Assess the Level of Practice regarding Prevention of
Pressure Ulcer in bedridden patients among Nurses
Juby Rose Kuriakose1*, Akku Maria Sebastian2,
Annem Jose Mary2, Ashly Zacharia2, Dhundup Chodon2,
Manlian Kim2, Silpamol Jojo2, Jaimol Alex2
1Professor,
Department of Child Health Nursing, St. Philomena’s College of Nursing, Bangalore.
24th
Year B.Sc. Nursing Students, St. Philomena’s College of Nursing, Bangalore.
ABSTRACT:
Background: Pressure ulcers are the common
conditions among patients hospitalized in acute and chronic care facilities and
impose significant burden on patients, their relatives and caregivers. Now
days, pressure ulcers are recognized worldwide as one of the five most common
causes of harm to patients and preventable patient safety problem. It is also
increasingly described as an indicator of the quality of care provided by
health care organization. However, pressure ulcers are largely preventable. All
patients who are identified as being at risk should have a management plan to
prevent development of pressure ulcer, optimize healing, and prevent complications
of existing pressure ulcer. Objectives: 1. To assess the level of
practice regarding prevention of pressure ulcer in bedridden patients among
nurses. 2. To determine the association between pre-test practice scores of
nurses regarding prevention of pressure ulcer in bedridden patients with
selected sample characteristics. Methodology: The research design used
for this study was non – experimental descriptive design. The study was
conducted at a tertiary hospital in Bengaluru, Karnataka, India. Population
comprises of nurses (staff nurses and student nurses) working in a selected
hospital. The sample size selected for this study consists of 60 nurses (staff
nurses -24 and student nurses -36) who were working in medical, surgical wards
and Intensive Care Units (ICUs). Nurses providing care to the patients who are
bed ridden for more than 48 hours were included in the study. Non – probability
purposive sampling technique was used to select the samples. The tool used in
this study was socio-demographic profile of nurses (separate tool for staff
nurses and student nurses) and observational checklist to assess the practice. Result:
The overall practice scores of the 60 nurses revealed that 40(66.67%) had
good practice, whereas 20(33.33%) samples had average practice and none of them
had poor practice. Among of 24 staff nurses; 20(83.33%) had good practice,
whereas 4(16.67%) had average practice and none of them had poor practice. Out
of 36 student nurses; 20(55.56%) had good practice, whereas 16(44.44%) samples had
average practice and none of them had poor practice. It was found that among
socio-demographic variables none had association with the practice of staff
nurses and student nurses too. Conclusion: The study concluded that
continuing education programmes are needed to improve the practices of nurses.
Nurses must be motivated to provide back care and position change every second
hourly in bedridden patients.
KEYWORDS: Pressure
ulcers, Bedridden patients, Intensive Care Units (ICUs), Nurses.
INTRODUCTION:
Pressure ulcer is defined by the National Pressure Ulcer
Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP) as
“localized injury to the skin and/or underlying tissue usually over a bony
prominence as a result of pressure, or pressure in combination with shear
and/or friction.”1 An Average of approximately 50% of the
hospitalized individuals has mobility impairment. An immobilized individual is
at a greater risk of developing Pressure sore.2 Immobilization and
inactivity are frequently present in patient with involvement of
musculoskeletal and neurological systems and also among critically ill
patients.3 Prolonged bed rest and immobilization inevitably lead to
complications such as deep vein thrombosis, contracture, pulmonary embolism,
pneumonia, pressure ulcer, calculi, urinary tract infection, osteoporosis,
constipation, muscle atrophy, depression and psychosis.4 Pressure of
200 mm hg for 16 hours or 600 mm hg for
11 hours is required before bed sore to occur. The continuous pressure directly
affects tissue perfusion which leads to pressure ulcer.5
Every year the health system spends hundreds of thousands
of dollars treating pressure ulcers that can be prevented with a little basic
quality nursing care.6 Younger individuals who develop pressure
ulcers are males, compared to the increase in female gender in the elderly age
group. More than 1% of the total health budget is spent on treatment of pressure ulcers. Prevalence rates of
pressure ulcers are 4.7–32.1% in hospital and 8.5–22% in nursing home settings.
Studies show that in Indian setting, the prevalence rate reported is 4.94%.
During the first two weeks of admission alone, hospital acquired pressure
ulcers occur in 9% of hospitalised patients. An average length of extended
hospital stay for treatment of pressure ulcer is 13days.7
The presence or absence of pressure ulcers has been
generally regarded as a performance measure of quality nursing care and overall
patient health. On average, 60,000 people die each year worldwide due to
pressure ulcer related causes. The prevalence of pressure ulcers in European
hospitals ranges from 1% to 11% in medical wards and 4.7% to 66% in surgical
wards. A study conducted in the United States demonstrated that pressure ulcers
can be avoided by applying simple interventions like using risk factor
assessment scales and regular turning of the patient by the nurses or by the
nurse instructing a care taker.8
Poor knowledge and practice of nurses have its own
significant contribution for the higher prevalence of pressure ulcers. Nurses
and nursing care interventions play an important role in pressure injury
prevention across healthcare settings. However, pressure ulcers are largely
preventable. All patients who are identified as being at risk should have a
management plan to prevent development of pressure ulcer, optimize healing, and
prevent complications of existing pressure ulcer.9
NEED
OF THE STUDY:
Pressure ulcers are the common conditions among patients
hospitalized in acute and chronic care facilities and impose significant burden
on patients, their relatives and caregivers.10 Now days, pressure
ulcers are recognized worldwide as one of the five most common causes of harm
to patients and preventable patient safety problem. It is also increasingly
described as an indicator of the quality of care provided by health care
organizations. It has been estimated that the cost of treating pressure ulcer
is 2.5 times higher than the cost of preventing. In USA, pressure ulcers remain
a major health problem affecting approximately 3 million adults. A systematic
review of 31 studies found that pressure ulcers significantly limit many
aspects of an individual’s well-being, including general health and physical,
social, financial and psychological quality of life. So, the burden of pressure
ulcers goes beyond increasing health care costs to loss of life.11
Studies around the world have reported large differences
in pressure ulcer prevalence rates, varying from 4.7% to 22.9% in hospitals and
7.7% to 83.6% in nursing homes12. The prevalence of worldwide
pressure ulcers in the ICU remain high and are documented between 3% and 50%.13
Incidence rates of as low as 0.4% to as high as 38% have
been reported in the inpatient department while prevalence has been reported as
3.5% to 69%. In long term care facilities, the reported incidence is between
2.2% to 23.9% while in home care setting the incidence varies from 0 to 17%.14
Education and implementation of appropriate skin care
products and procedures like back care and pressure ulcer prevention protocols
may reduce the incidence of hospital acquired pressure ulcer. Educating the
care givers of chronically bedridden patient regarding the various aspects of
health care helps in improving recovery and it is significant.15
Awareness, Exercises, scrupulous nursing care and early rehabilitation,
interventions can prevent or minimize most of these complications without
pacing the patients in jeopardy.16
All staff nurses working in hospitals and health centres
should have access to qualitative and up-to-date information on best practices.
Timely education to staff nurses should be facilitated to prevent pressure
ulcer. Researchers have found that pressure ulcers are more in the bed ridden
patients in many hospitals. So in order to prevent occurrence of pressure ulcer
among bed ridden patients in our hospital as well as to know the level of
preventive practices among staff nurses we are conducting research study.
STATEMENT
OF THE PROBLEM:
A study to assess the level of practice regarding
prevention of pressure ulcer in bedridden patients among nurses of a selected
hospital, Bangalore.
OBJECTIVES:
1.
To assess the level of practice
regarding prevention of pressure ulcer in bedridden patients among nurses.
2.
To determine the association
between pre-test practice scores of nurses regarding prevention of pressure
ulcer in bedridden patients with selected sample characteristics.
HYPOTHESIS:
·
H1: There will be a statically significant association between pre-test practice scores of nurses regarding
prevention of pressure ulcer in bedridden patients with selected sample
characteristics at p<0.05 level.
MATERIALS
AND METHODS:
Research approach: Descriptive survey approach was adopted for this study.
Research design: Non-Experimental Descriptive survey design.
Setting: For this study selected tertiary hospital
in Bengaluru, Karnataka.
Population: Nurses
(staff nurses and student nurses) Sampling Technique: Non- probability
purposive sampling.
Sample Size: 60 nurses (Staff nurses -24 and
student nurses -36).
Nurses who were working in medical, surgical wards and
ICUs and those providing care to the patients who were bed ridden for more than
48 hours were included in the study.
Description of the tool:
Section I: Socio-demographic variables for staff
nurse consist of age, gender, educational qualification and years of work
experience. For student nurse consist of age, gender and course and year of study.
Section II: Observational checklist to assess the
practice regarding prevention of pressure ulcer in bed ridden patients among
nurses. It consists of 30 “yes” or “no” items. Each “yes” item carried
‛one mark’. The maximum score was 30. The score interpretation was done
as; good practice ≥75% (23-30 marks), average practice 51-74% (16-22
marks) and poor practice ≤50% (≤ 15 marks).
Method of data collection:
Written permission to conduct study was obtained from
authorities of hospital and college of nursing. Samples were selected based on
the inclusion and exclusion criteria. The data was collected during the months
of July-August 2017. Each sample was observed once to assess the practice.
After the completion of data collection, samples were informed regarding the
study
and demographic profile of nurses were obtained. Collected
data was coded, tabulated and analysed by descriptive (frequency, percentage,
range, mean, median and standard deviation) and inferential statistics (chi-
square test).
RESULTS:
Section I: Related to socio- demographic variables of
samples
Table No.1: Distribution of samples according to socio-
demographic variables of the staff nurses (n = 24)
|
Sample Characteristics
|
Frequency (f)
|
Percentage (%)
|
|
Age in years
20-25YRS
|
15
|
62.5
|
|
26-30YRS
|
8
|
33.33
|
|
31-35YRS
|
1
|
4.17
|
|
Gender
|
|
|
|
Male
|
5
|
20.83
|
|
Female
|
19
|
79.17
|
|
Educational qualifiation
|
|
|
|
GNM
|
12
|
50
|
|
B. Sc. Nursing
|
12
|
50
|
|
Years of work experience
|
|
|
|
<1YR
|
9
|
37.5
|
|
1-2YRS
|
6
|
25
|
|
>2YRS
|
9
|
37.5
|
The data represented in the above table shows that among
24 staff nurses majority 15(62.5%) were in the age group of 20-25 years. With
regard to gender, 19(79.17%) samples were females. Regarding educational
qualification, 12(50%) staff nurses had completed GNM and remaining 12(50%) had
finished B.Sc. nursing. With regard to years of work experience, 9(37.5%)
samples each had experience of <1 year and also >2years.
Table No.2: Distribution of samples according to socio-
demographic variables of the student nurses(n=36)
|
Sample Characteristics
|
Frequency(f)
|
Percentage (%)
|
|
Age in years
17-18YRS
|
12
|
33.33
|
|
19-20YRS
|
5
|
13.89
|
|
21-22YRS
|
19
|
52.78
|
|
Gender
|
|
|
|
Male
|
0
|
0
|
|
Female
|
36
|
100
|
|
Course and year of study
|
|
|
|
1 YEAR BSC
|
9
|
25
|
|
11 YEAR BSC
|
10
|
27.78
|
|
111 YEAR BSC
|
13
|
36.11
|
|
1V YEAR BSC
|
4
|
11.11
|
The data represented in the above table shows that out of
36 student nurses, majority 19(52.78%) samples were in the age group of 21-22
years. With regard to gender, all 36(100%) samples were females. With regard to
course and year of study, 13(36.11%) samples were studying 3rd year B.Sc. nursing.
Section II: Distribution of nurses according to
level of practice.
Table No.3: Assessment of the level of practice of
nurses regarding prevention of pressure ulcer in bed ridden patients (n=60)
|
Practice level
|
Category
|
Respondents
|
|
Frequency (f)
|
Percentage (%)
|
|
GOOD
|
≥75%
|
40
|
66.67%
|
|
AVERAGE
|
51-74%
|
20
|
33.33%
|
|
POOR
|
≤50%
|
-
|
-
|
|
TOTAL
|
|
60
|
100%
|
The data represented in the above table shows that out of
60 nurses; 40(66.67%) had good practice, whereas 20 (33.33%) samples had
average practice and none of them had poor practice.
Table No.4: Frequency and percentage distribution of
staff nurses according to level of practice regarding prevention of pressure
ulcer in bed ridden patients (n=24)
|
Practice level
|
Category
|
Respondents
|
|
Frequency
|
Percentage
|
|
GOOD
|
≥75%
|
20
|
83.33%
|
|
AVERAGE
|
51-74%
|
4
|
16.67%
|
|
POOR
|
≤50%
|
-
|
-
|
|
TOTAL
|
|
24
|
100%
|
The data represented in the above table shows that that
out of 24 staff nurses; 20(83.33%) had good practice, whereas 4(16.67%) had
average practice and none of them had poor practice.
TableNo.5: Frequency and percentage distribution of
student nurses according to level of practice regarding prevention of pressure
ulcer in bed ridden patients (n=36)
|
Practice level
|
Category
|
Respondents
|
|
frequency
|
percentage
|
|
GOOD
|
≥75%
|
20
|
55.56%
|
|
AVERAGE
|
51-74
|
16
|
44.44%
|
|
POOR
|
≤50%
|
-
|
-
|
|
TOTAL
|
|
36
|
100%
|
The data represented in the above table shows that out of
out of 36 student nurses; 20(55.56%) had good practice, whereas 16(44.44%)
samples had average practice and none of them had poor practice.
Section III: Scores of nurses according to the
level of practice:
Among 60 nurses, the range of practice score was 8, mean
23.4, median 23.5 and standard deviation score was 1.933
Section IV: Association between the practice scores
of staff nurses with socio-demographic variables:
Chi square value was calculated to find out the
association between the practice scores of the staff nurses (n=24) with socio -
demographic variables. The findings revealed that there was no significant
association between the practice scores of staff nurses regarding prevention of
pressure ulcer in bed ridden patients with selected socio- demographic
variables i.e. age - χ2
value of 0.483
(df- 1, chi square value-3.84, p>0.05), gender-χ2
value of 0.386 (df- 1, chi square value-3.84 , p>0.05) educational
qualification- χ2 value of 3.513 (df- 1, chi square value- 3.84,
p>0.05) and years of work experience - χ2 value of 0.533 (df- 1, chi
square value- 3.84, p>0.05) . Hence, it was concluded that among
socio-demographic variables none had association with the practice of staff nurses.
Association between the practice scores of student
nurses with socio-demographic variables:
Chi square value was calculated to find out the
association between the practice scores of the student nurses (n=36) with socio
- demographic variables. The findings revealed that there was no significant
association between the practice scores of staff nurses regarding prevention of
pressure ulcer in bed ridden patients with selected socio- demographic
variables i.e. age - χ2 value of 1.05 (df- 1, chi square value-3.84, p>0.05),
course and year of study - χ2 value of 1.896 (df- 3, chi square value-
7.82, p>0.05). With regard to gender, as all the 30 samples were females, so
association was not calculated. Hence, it was concluded that among
socio-demographic variables none had association with the practice of student nurses.
DISCUSSION:
The overall practice scores of the 60 nurses revealed that
40(66.67%) had good practice, whereas 20 (33.33%) samples had average practice
and none of them had poor practice. Among of 24 staff nurses; 20(83.33%) had
good practice, whereas 4(16.67%) had average practice and none of them had poor
practice. Out of 36 student nurses; 20(55.56%) had good practice, whereas
16(44.44%) samples had average practice and none of them had poor practice. It
was found that among socio- demographic variables none had association with the
practice of nurses (staff nurses and student nurses) too.
NURSING
IMPLICATIONS:
The nursing implications are discussed under nursing
practice, nursing education, nursing administration and nursing research.
Nursing practice:
·
As this study helps to assess the
level of practice regarding prevention of pressure ulcer in bedridden patients
among nurses, the findings helps to monitor performances of nurses.
·
It provides good opportunity to
train them to be more knowledgeable and skilful which indirectly reduces the
risk of pressure ulcer occurrences in bedridden patients.
·
Ward incharge or supervisor can
motivate the nurses to use Braden scale or any other appropriate tool as per
hospital practice on regular basis as practical utilization might be lacking.
·
The nurses can teach the
non-ambulatory patient’s caregiver about the back care and position change.
·
Additionally, protocols to guide
pressure ulcer care need to be developed and disseminated for use during care.
Nursing education:
Although this topic is already included in the curriculum,
student nurses must be motivated, periodically trained and reinforced to
deliver appropriate nursing care to prevent occurrences of pressure ulcer in
bedridden patients. Nurses must be instructed to practice at the bedside
exactly as what is taught to them.
Nursing administration:
·
The nurse administrator has a
significant role in updating the knowledge and skills of nurses regarding the
prevention of pressure ulcer through in- service programs.
·
The findings of the study could be
made useful by health care personnel holding administrative position to
formulate policies and protocol or modify the existing ones.
·
Quality control nurse can
frequently check the utilization of Braden scale or any other tool as per
hospital practice by the nurses to reduce the incidence of pressure ulcer occurrences.
Nursing research:
·
There is need to carry out
research based on the available risk assessment tools so as to identify
individuals prone to pressure ulcers so that prevention and management is predictable.
·
More researchers could be carried
out in this area on a larger scale which provides more scientific data which
could enhance the health care services rendered to bedridden patients.
·
Nurses need to be encouraged to
follow evidence- based practice rather than intuitive nursing decisions.
·
An experimental research can be
conducted among nurses to assess the knowledge, attitude and practice regarding
prevention of pressure ulcer in bedridden patients among nurses of a selected hospital.
CONCLUSION:
From the findings of the study, it was concluded that
majority of the nurses had good practice and none of them had poor practice.
Hospitals also need to devote more resources to prevent and manage pressure
ulcers. Professionals should also meet their responsibility to provide
perennial education to staffs and students regarding pressure ulcers and its
prevention in bedridden patients. Nurses must be motivated to provide back care
and position change every second hourly in bedridden patients.
ACKNOWLEDGEMENT:
Our special thanks go to the management of St.
Philomena’s college and hospital for permitting us to
conduct this study. We are thankful to all the participants of the study.
CONFLICT
OF INTEREST:
The authors declare no conflict of interest.
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Received on 03.04.2021 Modified
on 06.05.2021
Accepted on 29.05.2021 ©A&V Publications All right reserved
Asian J. Nursing
Education and Research. 2021; 11(4):475-480.
DOI:
10.52711/2349-2996.2021.00114