Nurses' use of water‐filled gloves in preventing heel pressure ulcer in the University College Hospital, Ibadan, Nigeria

Abstract

This cross‐sectional descriptive survey examined use (knowledge, perception and practices) of water‐filled gloves (WFGs) by nurses in the prevention of heel pressure ulcer (PU) in the University College Hospital (UCH), Ibadan, Nigeria. Participants were 250 purposively selected nurses working in the Neurosciences and Surgical units. Quantitative data were generated through the administration of a semi‐structured questionnaire, whereas the qualitative data were collected through in‐depth interview. Hypotheses were tested using chi‐square analysis at a significance level of 0.05, whereas the manual content analysis was used to analyse the qualitative data. Results showed that a significant number of nurses at UCH, Ibadan, were knowledgeable about WFGs and actually used them in their clinical practice. Years of experience in clinical practice was found to be significantly related to knowledge and use of WFGs in heel PU (X ² = 41·677; DF = 5; P = 0·001). Nurses with adequate knowledge of risk factors in the development of PU used WFGs more than those who were not aware (X ² = 44·907; DF = 3; P = 0·009). Nurses' perception about WFGs was also significantly related to its use (X ² = 4·527; DF = 1; P = 0·033). Although knowledge level and perception of WFGs and its use by nurses was fairly adequate, continuous education for practicing nurses should be encouraged in resource‐limited settings.

INTRODUCTION

Globally, maintaining skin integrity and preventing pressure ulcers (PUs) have traditionally been the responsibility of nurses when caring for hospitalised patients as shown in a study in the same setting few years ago (1). Today, the proportion of emerging admission of critically ill patients continues to rise as seen in the University College Hospital (UCH), Ibadan, where nurses work under a high pressured environment that exposes the vulnerable or at‐risk patients to tissue breakdown. This problem is compounded by global nursing shortage. Developed countries, such as UK, have a proportion of 1 nurse per 1000 people, whereas developing countries, such as Nigeria, have 1 nurse to 10 000 people (2). They further stated that this is not just a ‘problem for nursing but a health system problem, which undermines health system effectiveness'.

With the introduction of clinical governance, the prevention and management of PUs resurfaced as an issue and was identified as a priority by the National Institute for Clinical Excellence (3). PUs that were once viewed as an inevitable consequence of being infirm and bedridden are now seen much as an indicator of the quality of care provided (4). In line with this, it is asserted that today, the presence of PUs in hospitalised patients has been identified as a quality indicator in health care, thereby posing a great challenge for nurses when caring for hospitalised patients who are at risk of developing PU (5).

The incidence of heel PU is increasing and the heels are the second most common site for the development of PUs after the sacrum (6). Heel PUs appear to be a significant problem among critically ill patients and older people, particularly those who have sustained a fractured hip or who are nursed in long‐term care facilities. This may be because of a complex interplay of intrinsic and extrinsic factors such as age‐related diseases, tissue geometry, duration of immobility and ineffective pressure relief. Whatever the underlying cause, heel pressure damage may adversely affect mobility and may result in significant disability and morbidity 7, 8, 9. Literature reviewed indicated that majority of PUs occur over the lower part of the body and, in particular, over the sacrum and the heels because the skin in these regions bear weight not only of the part directly above it but also of other parts that are not adequately supported, however, any area of the body can develop pressure‐induced ischaemia 10, 11. Also, most PUs can be prevented and various preventive measures are being used in nursing practice to address the prevention and treatment of PUs in a more systematic way (11). Thus, in developed countries, there are ‘high tech’ devices such as alternating pressure mattresses/overlays, air fluid beds, low‐air‐loss beds and ‘low tech’ devices such as water‐filled mattresses, air filled mattresses and gel‐filled mattresses/overlays used in the prevention/treatment of PUs and so on.

In Nigeria, the cost implication of high technology that is found to be effective is not affordable, thereby posing a challenge for nurses in the prevention and management of PUs. Nurses at UCH, Ibadan, realised the need for interventions to prevent tissue breakdown in the heel areas by the use of pressure‐relieving aid such as water‐filled gloves (WFGs). WFGs are commonly recommended as they are inexpensive and easy to maintain and meet most of the characteristics of pressure‐relieving aids such as portability, ease of use, acceptability to patients and cost‐effectiveness (12). Although the use of WFGs as pressure‐relieving devices is practiced widely, there is a lack of evidence regarding its use and further investigations are required (13). The conservation model by Myra Estrin Levine provides a conceptual background for the study (14).

According to the Nursing and Midwifery Council Code of professional conduct, ‘Practitioners have a responsibility to deliver care based on current evidence, best practice and where applicable, validated research when it is available’(15). This necessitates the researchers' intent to investigate nurses' use as a reflection of their knowledge, perception and practices of WFGs in preventing heel PU in UCH, Ibadan, Nigeria.

METHODS

This is a descriptive study designed to examine the use of WFGs by nurses in the prevention of heel PU among patients in UCH, Ibadan, the first Teaching Hospital in Nigeria, established in 1957. All that is required is a latex glove filled with 200–250 ml water, a second ingredient, and tied at the tip once filled with a rubber band. Purposive sampling was used to select nurses from the Neuroscience and Surgical units of the hospital because they are in a position to use WFGs on patients who are vulnerable to tissue breakdown of the heel. All the available and willing nurses in the inpatient wards of the two units and who met the inclusion criteria constitute the study participants. They were 250 in number and the instruments used for data collection were questionnaire and in‐depth interview. The 32‐item questionnaire consists of five sections: sociodemographic characteristics, knowledge of nurses on the use of WFGs, use, perception and criteria for the use of WFGs, and it was administered face to face. Qualitative data were collected through in‐depth interview using an interview guide. Permission to conduct the study was obtained from the Joint University of Ibadan and University College Hospital (UI/UCH) Ethical Review Committee. A certification letter of approval with number UI/EC/07/0120 was given. Data were analysed using Statistical Package for the Social Sciences version 12 computer programme. Chi‐square statistics was used to test the association of relationship, whereas the responses from qualitative data were sorted and analysed using content analysis.

RESULTS

The age group 26–30 years had the highest frequency of 72 (28·8%). They were predominantly females, 248 (97·2%), with only 21 (8·4%) respondents having Bachelor of Nursing Science (Table 1).

Table 1.

Respondent' sociodemographic characteristics

Variable	Level	Frequency	Percentage
Age	No response	6	2.4
	21–25	18	7.2
	26–30	72	28.8
	31–35	49	19.6
	36–40	50	20.0
	41–45	32	12.8
	46+	23	9.2
	Total	250	100.0
Gender	No response	5	2.0
	Male	2	0.8
	Female	243	97.2
	Total	250	100.0
Highest educational qualification	No response	30	12.0
	Registered Nurse	21	8.4
	Registered Nurse/Midwife	147	58.8
	Diploma in Nursing	21	8.4
	Bachelor Nursing/Science	21	8.4
	Others	10	4.0
	Total	250	100.0

As shown in Table 2, 52 (20·8%) respondents did not know what WFGs are. Majority, 157 (62·8%), of the respondents showed that training on the use of WFGs was not part of their training in school (Table 3), while 32 (12·8%) have never used it in spite of its availability and common use as submitted by a nurse in one of the wards:

Table 2.

Respondents' view on what WFGs are

Responses	Frequency	Percentage
No response	52	20.8
Glove used for patients likely to develop pressure area	25	10.0
To prevent ulcer over bony prominence	29	11.6
Water glove to prevent pressure sore	55	22.0
Sterile or conform glove filled with water and tied to prevent pouring away and place under heels	68	27.2
Glove filled with water to prevent ulcer at pressure point	14	5.6
Latex gloves filled with water	6	2.4
Its used to aid circulation thus preventing ulcer	1	0.4
Total	250	100.0

WFGs, water‐filled gloves.

Table 3.

Where respondents obtained their training on WFGs

Variable	No		Yes
	Frequency	Percentage	Frequency	Percentage
Use of WFGs as part of training in school	157	62·8	93	37·2

WFGs, water‐filled gloves.

Presently, there are about six patients in my ward who are on Water Filled Gloves. We always have patients who are vulnerable to heel pressure ulcer and Water Filled Gloves is the commonest means of pressure relieving device used here.

Majority of the respondents, 97 (28·8%), met other nurses using WFGs and joined. They did not know whether it was the hospital policy (4, 5).

Table 4.

Respondents' years of use of WFGs

Years of use of WFGs	Frequency	Percentage
1–5	211	84.4
6–10	34	13.6
11+	5	2.0
Total	250	100

WFGs, water‐filled gloves.

Table 5.

View on whether the use of WFGs is hospital/managerial policy

Response	Frequency	Percentage
No response	14	5.6
No	76	30.4
Yes	63	25.2
I don't know	97	38.8
Total	250	100.0

WFGs, water‐filled gloves.

Physical examination and risk assessment on patients were carried out by 147 (58·8%) respondents before use of WFG (Table 6). Information from the in‐depth interview shows a central view that the use of WFGs should be:

Table 6.

Showing when WFGs are commenced on patients

Response	Frequency	Percentage
On admission into the hospital	72	28.8
After physical examination and risk assessment	147	58.8
When patient's condition changes	31	12.4
Total	250	100.0

WFGs, water‐filled gloves.

immediately on admission into the wards, and as soon as physical examination has been carried out; if the patient is found to be vulnerable to heel pressure ulcer; there should be no delay so that the development of the tissue breakdown can be prevented.

Results from Table 7 indicate that 89 (35·6%) respondents said it is safe, effective, and can be used by all, whereas 20 (8·0%) respondents did not have any reason for the use of WFGs.

Table 7.

Reasons for preferred use of WFGs

Response	Frequency	Percentage
It is safe, effective and can be used by all	89	35.6
practiced on some wards	22	8.8
Affordable/cheap/easily available	80	32.0
No response	20	8.0
It soothes the heels and encourages circulation	39	15.6
Total	250	100.0

WFGs, water‐filled gloves.

To buttress this point, an interviewee reported that

Water filled gloves are effective in relieving heel pressure ulcer and have decreased the number of inpatients with Heel pressure ulcer in this unit. Moreso, they are cheap; can easily be applied by anybody and are cost effective.

Nearly all the 248 (99·9%) respondents indicated that para/quardriplegia was a criterion for the use of WFGs (Table 8). This table is supported by data from the qualitative instrument in which most of the interviewees maintained that:

Table 8.

Respondents' view on criteria for use of WFGs

Response	No response	%	No	%	Yes	%
Oedema of the lower limb	10	4.0	56	22.4	184	73.6
Restricted movement of lower limb	0	0.0	10	4.0	240	96.0
Motor/sensory deficit in lower limb	24	9.6	6	2.4	220	88.0
Peripheral vascular disease	44	17.6	20	8.0	186	74.4
Congestive heart failure	44	17.6	71	28.4	135	54.0
Incontinence of faeces/urine	9	3.6	132	52.8	109	43.6
Excess/fidgety movement of lower limbs	10	4.0	186	74.4	54	21.6
Aged patients	21	8.4	74	29.6	155	62.0
Chronically ill	0	0.0	34	13.6	216	86.4
Unconscious patient	0	0.0	220	88.0	30	12.0
Patient with skeletal traction	0	0.0	245	98.0	5	2.0
Para/quadriplegia	0	0.0	2	0.8	248	99.2

WFGs, water‐filled gloves.

Heel pressure ulcers appear to be a significant problem among critically ill patients and older people; particularly those who have sustained a fractured hip or who are nursed in long term care facilities.

It appears that the respondents are mostly interested in clinical condition of the patients as the criteria for deciding when to use WFGs.

Table 9 shows that 188 (75·2%) respondents agreed that WFGs have contributed immensely to the reduction in the incidence of heel PU in their wards, while 33 (13·2%) disagreed.

Table 9.

Respondents' view on whether WFGs reduce the incidence of heel pressure ulcer

Response	Frequency	Percentage
No	33	13.2
Yes	188	75.2
I can not say/I don't know	29	11.6
Total	250	100

WFGs, water‐filled gloves.

Majority of the participants estimated that the use of WFGs is contributory to 21–40% reduction in heel PU.

DISCUSSION

The implication of age of respondents in this study was made apparent by the fact that the older nurses tend to believe more in their own knowledge and experience and thus were more assertive, matured, self‐reliant and capable of personal and professional empowerment; they would be more likely to know symptoms and likely signs that a patient may develop PU than younger nurses. Also, most of the nurses were females (97·2%). This finding is in agreement with the literature about preponderance of females in nursing profession 16, 17, 18. These authors also asserted that majority of nurses knew the importance of education and are advancing in their academic pursuits in order to stay competitive in the health care industry and be able to meet up with the changing societal needs and patients' demands; however, only 21 (8·4%) respondents had the first University degree.

Nurses who have been in practice for 11 years and above preferred the use of WFGs as against those with less years of practice (1–10 years). That is, the more experienced the nurse is, the higher the use of WFGs and vice versa. This implies that nurses who are new in the field were not conversant with the use of WFGs for the prevention of heel PU as no training was given while in school. Also, nurses who have spent many years in service are already used to the conventional methods. This is in support of Watson (19), who maintained that unless a nurse learns from experience, the learning is not good. He asserts that experience is usually measured quantitatively in terms of time, whereby it would be better to look at experience qualitatively in terms of the quality of experience and the amount of learning that takes place.

About 21% of nurses in UCH have no knowledge of WFGs. This is understandable given that, of the 79·2% who reported knowing the meaning of WFGs, majority (62·8%) did not receive any training about it while in school. Similarly, majority of the respondents reported not having used it during any of their training. This is contrary to Dealey (20) who proposed that the training and education of nurses and health care professionals should form an integral part of any PU prevention strategy. Also, findings from observational studies suggested that educational programmes and training may reduce incidence and prevalence of PU development 21, 22, 23. For the 97 respondents who had training about or had ever used WFGs, results showed three sources of their training, namely, while in the school of nursing (40·6%), workshops (34·4%) and during clinical practice (15·0%). This finding is in consonance with other authors who found lack of education of nurses as one of the many factors that may predispose the patients to the formation of PUs. Similarly, they explained that in order for nurses to be effective, they must have a sound knowledge base so that they can make an informed decision 24, 25, 26. Nurses need knowledge and skills relating to the cognitive process of problem solving in order to successfully prevent the occurrence of PU. Many studies looking primarily at clinical decision making have found that nurses use intuition and experience as a basis for their decision, which does not make it scientific and as such lacks basis for clinical decision making 19, 26.

Similarly, findings from the in‐depth interview showed nurses' willingness to receive additional training on WFGs. The emerging theme from the question on what can be done to improve nurses' knowledge and skills about WFGs is that:

Continuous training through workshops would be beneficial. This is because since WFGs is not taught in schools of nursing, nurses can benefit from attending conferences, clinical meetings and seminars specifically designed to enlightened them on the benefits and use of WFGs. This can be organised for different cadre of nurses at different period to facilitate their competency in the use of WFGs.

This supports the observation of the Agency for Health Care Policy and Prevention that increasing people's awareness about PU risk assessment and prevention through a well‐coordinated and structured educational programme is more likely to result in benefits for patients than providing no programme, as the effectiveness of educational programme is currently lacking a reliable research base (27). Majority of the nurses used WFGs on patients after physical examination only, without risk assessment and mainly to those patients vulnerable to developing heel PU. This is contrary to Stanton's (26) opinion that the way in which nurses decide which pressure‐relieving equipment intervention to choose should be based on the use of clinical judgement, risk assessment tools and practice guidelines. The efficacy and effectiveness of interventions, such as the provision of pressure‐relieving equipment, must be based on appropriate methodologies and research, unfortunately, Clark (28) argues that this is currently not the case. Evidence‐based care seeks to direct the nurse towards interventions to provide real benefits to the patient, while disregarding any ineffective strategies and interventions (28).

Moreover, it is important to note that the use of risk assessment tools must only be relied on in situations where they are available, and nurses must have been adequately trained on their proper usage. Data also showed that the respondents preferred WFGs for heel PU than other methods because it is safe, effective, can be used by anybody, affordable and easily available. Similarly, information from the qualitative instrument showed that nurses favour the use of WFGs. For example, an interviewee said:

WFGs, could be applied by patients' relatives or carers in the absence of nurses. Easily available and affordable as compared to high and low tech devices such as water and gel mattresses, that are too costly and not easily available or limited in number when available.

This also confirms another finding which stated that WFGs are commonly recommended as they are inexpensive and easy to maintain (29). Also, during the in‐depth interview, most of the interviewees mentioned other characteristics of use of WFGs which include ‘aiding of circulation, soothing the affected area and relieving pain’. Eighty percent of the participants preferred WFGs to other methods for heel PU. This is in line with other findings that pointed out that perception can be affected by many factors such as values acquired through education, culture, age and past experiences and also by emotional status, religion and socioeconomic level of the individual (12). George (30) reported that nurses can and do use influence of perception and interpersonal relationships to assist clients to work towards health.

Similarly, 75·2% agreed that WFGs have helped in reducing incidence of heel PU (Table 9). In fact, according to Table 10, 40·8% (23·6% and 17·2%) comprising 59 and 43 nurses, respectively, agreed to 41·0% and above estimation reduction in heel PU. It is noteworthy to mention that the rating indicates not much success. This is in line with the study conducted by Lockyer cited in Collier (31), where he reported that although the use of WFGs provided a degree of pressure relief, it was insufficient to achieve the therapeutic pressure of below 32 mmHg and was also easily displaced by slight movements (31). Although it is difficult to depend on the rating of nurses based simply on their perception, success or failure of WFGs in prevention of heel PUs is difficult to ascertain.

Table 10.

Estimated reduction in incidence of heel pressure ulcer with the use of WFG

Estimate in percentage (%)	Frequency	Percentage
<20	83	33.2
21–40	65	26.0
41–60	59	23.6
61–80	43	17.2
Total	250	100

WFG, water‐filled glove.

CONCLUSION AND RECOMMENDATION

In a country in which poverty and poor health policies make it hard for both patients and health caregivers to reap the benefit of sound health care system, the findings of this study are of serious implications. First, it is of concern that the training programme for nurses does not include the most easily affordable tool of managing heel PU in a poor resource country such as Nigeria. Heel PUs appear to be a significant problem among critically ill patients and older people. This is especially more striking in view of the fact that it is a common problem among the bed ridden and chronically ill patients, and the cost implication of high technology that is found to be effective is not affordable in the hospitals. Therefore, knowledge of pressure‐relieving aid, which could be gained easily and be of benefit to patients, is being left out in the training programme of health care providers, while patients suffer with the problem and are charged high fees for other methods that are more costly.

Based on the findings of this research, the researchers thereby recommend that nurses need to make a deliberate and personal effort to update their knowledge in current standard and practices in the area of heel PU prevention. Also, the hospital management should put in place a hospital practice guideline/institutional policy on the use of WFGs in the prevention of heel PU.

Suggestions for future research include determining the effect of WFGs on heel pressure sore prevention involving teaching hospitals more in resource‐limited settings and using experimental or quasi‐experimental design.

ACKNOWLEDGEMENTS

The researchers appreciate the untiring efforts of nurses in Neurosciences and Surgical units of UCH for their active participation during data collection for this study.