OVER 8 YEARS AGO, we conducted a wound care survey and reported the results in Nursing2005.1 Because wound care evidence and practice has continued to change, we invited you to participate in an updated version of that survey to gather data on current nursing practice in skin and wound care and wound prevention. We want to thank the 647 nursing colleagues who took the time to answer this confidential and anonymous survey. This is a similar response rate to the previous 2005 wound survey.1 (See Respondent profile for an overview of nurses responding to this survey.) We also appreciate the supplementary comments many nurses contributed.
We were encouraged that more nurses responded correctly about making sure there was an adequate blood supply before initiating moist wound healing for healable wounds. Being able to correctly categorize a wound as healable, maintenance, or non-healable is an important concept that we are delighted is understood by more nurses.2 The findings suggest that nurses want more education about skin and wound care in both their basic education and in their ongoing education once they are in practice.
Given the new knowledge regarding skin tear practices and the difficulties in differentiating between the stages of full-thickness pressure ulcers, we believe that these findings can provide some support for the importance of helping nurses understand correct wound etiology and classification.
The following pages include the results from both the 2005 and the 2012 surveys so the data can be compared. We discuss responses to each survey question, including evidence-based rationales for the correct or preferred answers, which are highlighted in green. No data from 2005 are provided for some questions because they weren't asked in that survey. Percentages don't always add up to 100% due to rounding.
1. Moist wound therapy is the gold standard for management of most chronic wounds but not for wounds without adequate vascular supply.
As with the 2005 survey results, most nurses know that moist wound healing using appropriate dressings is indicated for wounds that are healable. The literature supports that healable wounds should be 30% smaller in surface size by week 4 of a treatment regimen.2 The goal of care shifts for wounds that aren't healable because the vascular supply is inadequate or the patient/family doesn't adhere to the treatment plan.2 Wounds without adequate vascular supply/blood inflow should be kept dry, in contrast to the principle of moist wound healing. These wounds may need a dressing that provides protection and moisture reduction until vascular reconstruction is performed.2,3
2. People with diabetic neuropathy who have a foot ulcer can have pain.
Most nurses answered this question correctly. Due to abnormal sensory input, patients with neuropathy often describe the pain as burning, stabbing, or shooting.4 Pain in a neuropathic foot needs to be explored as it could indicate that an underlying infection, such as osteomyelitis or Charcot foot, is developing.4
3. Length, width, and depth measurement should be a part of wound documentation.
Wound measurement is an important component of a wound assessment and also an indicator of the progression of or lack of wound healing. As noted above, the literature indicates that a healable wound should be 30% smaller in surface area in 4 weeks.2 Recent changes in the Centers for Medicare and Medicaid Services (CMS) regulations for long-term care (MDS 3.0),5 long-term-care hospitals (LTCH) on the LTCH CARE data set,6 and in-home care on the Outcome and Assessment Information Set (OASIS-C)7 require documentation of pressure ulcer length, width, and depth.
4. The Braden Scale is used to assess a patient's potential to develop a vascular ulcer.
A greater percentage of nurses responding to the current survey answered this question correctly than nurses responding to the earlier survey. We don't know if this is because nurses have more knowledge, or if nurses were more careful in reading the word vascular as the type of ulcer. The Braden Scale is used only for pressure ulcer risk assessment, not vascular wounds. Another factor may be the increased emphasis on pressure ulcer risk assessment since 2008, when hospital-acquired pressure ulcers were no longer reimbursed by CMS. Since the 1980s, the Braden Scale has been recognized as a research validated tool that has been used to assess a person's risk for developing a pressure ulcer. It can't be used to assess risk for a vascular ulcer.
The Braden Scale contains six subscales (sensory/perception, moisture, activity, mobility, nutrition, and friction/shear), which are summed for a total score to identify the level of risk.8 However, clinicians also need to address any low subscale scores in the patient's plan of care. In its definition of a pressure ulcer, the National Pressure Ulcer Advisory Panel (NPUAP) states that “a number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated,”9 so all the risk factors for pressure ulcers may not be captured on the Braden Scale.
Use the Braden Scale in conjunction with a comprehensive assessment of the patient that includes other risk factors, such as medications (especially steroids), comorbidities, diastolic BP below 60, and history of a pressure ulcer, that can put the patient at risk for a pressure ulcer.8,10 Some evidence suggests that skin temperature may be an indicator of pressure ulcer risk.11–13
In addition, certain risk factors may be more important in some care settings than others. For example, decreased mobility and bowel incontinence were predictors of pressure ulcer risk in a study of home-care patients (n = 5375) based on OASIS-C data, with a finding of 1.3% incidence of pressure ulcers.14
5. Classic signs of infection may not be present in patients with chronic wounds or in those who are immunosuppressed.
Once again, most nurses who responded knew that the classic signs and symptoms of infection (erythema, heat, edema, pain, and purulent exudates) may not be present in patients with a chronic wound who are immunosuppressed.
6. Wet-to-dry gauze dressings are best to treat clean granulating chronic wounds.
A slight majority of nurses responded correctly to this question in 2012, which is lower than the 63% who responded correctly in 2005. We're curious as to why this time, a smaller percentage of nurses got this right and wonder if the way the question was worded was a factor. Wet-to-dry dressings don't maintain a moist wound-healing environment when the dressing dries out. Generally avoid the use of wet-to-dry gauze dressing for clean granulating chronic wounds because removing the dry dressing from the wound pulls out newly deposited granulation tissue in the wound bed. Even though moist wound healing has been the treatment of choice for over 20 years, many healthcare providers still prescribe wet-to-dry gauze treatment.
A type of mechanical debridement, wet-to-dry dressings should be used only in wounds that have necrotic or slough-type of debris/tissue. The removal of wet-to-dry dressings is very painful, as the dried dressing adheres to the tissue and causes pain when it's removed.15 This is one reason that CMS recommended limiting the use of wet-to-dry dressings in its Guidance to Surveyors for Long Term Care Facilities.16
7. Skin tears are best treated using an adherent dressing.
Most nurses know that adherent dressings aren't indicated to treat skin tears as they could damage healing skin during removal. A skin tear is an acute wound that can be of partial- or full-thickness insult.17 The dressing of choice is one that's nonadherent, protects the fragile skin, and can be left on for several days and removed without further damage.17,18
Skin tears are often overlooked. The International Skin Tear Advisory Panel (ISTAP) has published an important review of the literature regarding skin tear prevention, assessment, and treatment recommendations17,18 along with a new validated simplified classification system.19 The panel has provided many helpful resources on the ISTAP website, www.skintears.org.
8. All patients at risk for pressure ulcers should be turned and repositioned every 2 hours.
Most nurses got this wrong! We didn't mean this to be a difficult question; rather, we wanted to ask this question to highlight a change in practice. In the past, turning and repositioning patients every 2 hours was the standard, but this “one size fits all” time interval for repositioning is no longer considered appropriate by the NPUAP and some researchers. New research has provided support for repositioning recommendations from the NPUAP that take into account the type of mattress or support surface that a patient is on and how patient characteristics must be considered when developing an individualized repositioning time schedule. Their recommendation that “repositioning frequency should be influenced by the support surface used” was at A level for strength of evidence.20 (See Rating the strength of the evidence.)
Furthermore, they state that “an individual should be repositioned with greater frequency on a non-pressure-redistributing mattress than on a viscoelastic foam mattress. The repositioning frequency should depend on the pressure-redistributing qualities of the support surface.”20 At C level of evidence is the NPUAP recommendation that when treating pressure ulcers, “provide a support surface that is properly matched to the individual's needs for pressure redistribution, shear reduction, and microclimate control.”21 For example, some patients with multiple comorbidities at very high risk may need to be turned and repositioned every hour, while others at lower risk may need to be turned only every 3 or 4 hours.
9. Stage I pressure ulcers are easily identified in people with darkly pigmented skin.
Once again, nurses correctly reported that identifying stage I pressure ulcers in darkly pigmented persons isn't easy. Relying on color as the only indicator for risk shouldn't be current practice. The NPUAP stage I definition alerts clinicians to look at other factors beyond color: “Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.”9 Including skin palpation and temperature assessment for detecting a stage I pressure ulcer in this patient population may be indicated.
10. Topical enzymes are effective for removing necrotic tissue in chronic wounds.
A lot has changed regarding enzymes since we first asked this question in 2005, especially since the FDA removed all papain urea products from the market in the United States. Some respondents told us that they don't use enzymes as a method of wound debridement in their care setting. This could account for the lack of knowledge regarding topical enzymes in clinical practice. Currently in the United States, only one type of enzyme has been available after the FDA pulled the other type off the market.
An enzymatic debrider is a safe and effective way to remove necrotic tissue, but it does take longer to chemically work than a scalpel or surgical debridement. The use of enzymatic debriding agents requires daily dressing changes.22
Remember that an enzyme is a drug, so it must be prescribed by a healthcare provider licensed in your state or province to prescribe. As with any drug, you must follow the manufacturer's information for administering the drug and your facility's medication administration policies and procedures.
11. My facility has a policy for how often a wound assessment should be completed and documented.
Of course nurses know that wounds needed to be documented. A wound assessment is an important component of care; it's a picture of the wound's current status and progress. We're glad that most respondents work in a facility that has a policy for the frequency of wound assessments.
A general rule for most facilities and practice sites is to assess on admission and then at least weekly thereafter. Most definitely reassess if you note a change or deterioration in the wound. Assessments guide treatment decisions, so be sure to communicate this information to other healthcare providers and nursing colleagues, especially those who are determining the patient's plan of care, such as the wound care team.23
12. A pressure ulcer with full-thickness tissue loss is staged/classified as: Stage I, Stage II, Stage III, or Stage IV.
Most respondents know that the NPUAP classifies stage III and Stage IV pressure ulcers as full-thickness tissue loss. The difference between a stage III and stage IV is that bone, muscle, and tendon are visible or palpable in a stage IV ulcer but not in a stage III ulcer. NPUAP classifies stage II as partial thickness.9
13. I can identify the six stages of pressure ulcers in my patients.
We're intrigued by the drop in the percentage of correct responses in this survey compared with 2005, when pressure ulcers were categorized into four stages. The comments that you provided gave us some insights as to how the wording of the question may have influenced your responses. We weren't sure if this reflected confusion about the six stages of pressure ulcers or about differentiating the stages. Some of you mentioned that you weren't aware that the NPUAP now has six stages or categories of pressure ulcers. Four stages have numbers (I-IV) and the others word labels (unstageable/unclassified depth unknown, and suspected deep tissue injury depth unknown).9
14. Pressure redistribution products (such as specialty beds, mattresses, or chair cushions) are used in my facility to prevent pressure ulcers.
Because the primary force behind pressure ulcer occurrence is pressure, using products to redistribute pressure should be part of the pressure ulcer prevention plan for patients at risk for pressure ulcers.20 A good rule of practice is to be aware of what your patient is lying or sitting on.
15. Wound culture specimens are obtained in my facility by the following methods. (Check all that apply.)
Wound culture practice has remained constant since 2005, but these results demonstrate the wide variation in how cultures are performed. Tissue biopsy and fluid aspiration cultures aren't typically performed by nurses except for advanced practice nurses who are licensed to do so. Infection can be diagnosed with a bacterial swab that helps identify resistant organisms or serves as a guide to antimicrobial therapy. Swab cultures can be effective if the wound bed is debrided and cleansed and the culture specimen taken from healthy tissue.24 We don't know how many respondents don't perform wound cultures, and it was a good suggestion to include that question in the next survey.
16. Nurses in my facility wear sterile gloves for dressing changes on chronic wounds.
Patient risk factors and wound type can influence the choice of sterile versus clean gloves, and the survey findings are consistent with common practice. Sterile gloves are generally used in combination with a sterile field and sterile instruments when a sterile dressing needs to be applied. Clean gloves are appropriate for the care and treatment of patients with chronic wounds, for patients not at risk for infection, and for routine dressing changes.25
17. Compression wrap/bandaging multilayer system/dressing is the gold standard for treating venous ulcers.
18. I know how to apply a compression wrap/bandaging multilayer system/dressing.
Because questions 17 and 18 are related, we've included our discussion about the findings together. In 2012, a slightly lower percentage of nurses indicated that they knew how to apply compression wraps/bandages than in the previous survey. In order to clarify if this reflects a lack of ability in performing this skill or a lack of awareness of the role of compression in the care of patients with a venous leg ulcer, we included the question about compression being the gold standard. We're encouraged that most nurses got this correct. Results of the Cochrane library review underscore the importance of compression in healing venous leg ulcers as review of eight randomized controlled trials (RCTs) revealed better patient-healing outcomes in patients treated with compression therapy compared with those without compression.26 The type of compression used might also make a difference. One RCT reported better healing with two-component elastic systems versus no elastic component, another RCT revealed better healing with three-component elastic systems versus no elastic component, another found no difference, and five RCTs reported faster healing with four-layer systems compared with short stretch bandages.26
Now that we've reviewed why compression is a gold standard in treating venous ulcers, let's examine how nurses felt about their competence in applying compression bandaging systems. Results here varied by setting and nursing role. Because many patients with venous leg ulcers are treated in the home healthcare/community health or wound clinic setting, it was no surprise that most nurses from these settings answered yes (91%, n = 104 and 97%, n = 29, respectively). Most nurses working in both these settings also said they knew how to apply compression wraps/bandaging systems: 81%, (n = 92) in home healthcare/community setting and 80% (n = 23) in the wound care clinic setting. While fewer nurses working in long-term-care settings knew that compression wraps/bandaging is the gold standard for care (69%, n = 95), more of them (76%, n = 104) responded that they knew how to apply them. More hospital nurses (73%, n = 201) knew that compression wrap/bandaging systems are the gold standard for treating venous ulcers but fewer reported that they knew how to apply them (54%, n = 149). We believe that this is an opportunity for ongoing education for nurses, including assessment of their performance competency.
19. The following are routinely used to clean chronic wounds in my facility. (Check all that apply.)
We're very happy to see that a great majority of respondents use saline or a wound cleanser for their practice. Wound cleansing is a process for removing debris and contaminants from the wound bed. Often cleansing with normal saline isn't aggressive enough; a wound cleanser is then the product of choice. Toxic antiseptic agents such as povidone-iodine are still contraindicated in most wound care practices for clean granulating wounds.24 Education of all healthcare providers is still needed.
20. Nurses are licensed in my state or province to do minor surgical debridement.
In both survey years, a substantial minority of nurses didn't know whether nurses in their jurisdiction were permitted to perform minor surgical debridement. We hope that this question has inspired them to find out.
Surgical or sharp debridement is the removal of necrotic tissue from a wound bed. You must be a licensed healthcare professional in your state or province to perform this procedure. Review the nurse practice act in your jurisdiction if you're not sure. When in doubt, don't debride any tissue from a wound bed.22
23. Skin assessment is part of my daily/shift nursing assessment for all my patients.
It's great to have the evidence that most nurses are including skin assessment as part of their practice. Hospital nurses (n = 262) and hospice nurses (n = 98) reported the highest percentages (95% for both). Home health was next with 90% (n = 102), followed by long-term care at 72% (n = 98).
A skin assessment involves inspection and palpation of the skin over the patient's entire body. It's more than determining whether skin is dry and intact. Also look for abnormal moles, lesions, erythema, or ecchymoses, and document your findings.27
24. A computerized wound assessment tool is used in my facility.
Because of the push for electronic health records, we weren't surprised by the increase in the percentage of respondents who now use computerized wound assessment tools. Respondents working in home healthcare/community health (68%, n = 77) and hospitals (61%, n = 170) were most likely to be using computerized tools; those working in long-term care (34%, n = 46) and hospice (33%, n = 7) were least likely to be using them. Computerized wound assessment tools are the wave of the future as regulatory compliance becomes a reality.
25. Do you know your facility's pressure ulcer incidence rate?
26. Do you know your unit's pressure ulcer incidence rate?
Because questions 26 and 27 are related, we'll discuss the results for these two questions together. We were very interested in knowing your responses to this question, given all the CMS regulations regarding pressure ulcers that have been established since the last survey in 2005. For example, since 2008, hospitals are no longer reimbursed for expenses related to pressure ulcers that occur during a hospitalization.28 In addition, CMS patient/resident assessment forms have been revised as to information regarding pressure ulcers.5–7,29 Given that pressure ulcers are seen by the National Database of Nursing Quality Indicators as a nurse-sensitive indicator,30 and that some nurses participate in their facilities' pressure ulcer prevalence and incidence survey data collection, we wondered how the results of those efforts are disseminated throughout healthcare facilities. So we looked at responses in more detail by type of facility.
The percentage of nurses working in long-term care and hospitals responding yes to knowing their facility's rate was 44% and 41%, respectively, higher than nurses in home health/community health (20%) or hospice (29%). When it came to knowing a specific unit's pressure ulcer incidence rate, the same overall pattern was apparent, with nurses from long-term care and hospitals responding yes to knowing their unit's rate at 42% and 46%, respectively. The percentage of nurses who knew their own unit's pressure ulcer rate was less than for facility rate among nurses working in home health/community health (18%) and hospice (14%).
Sorting the data to better understand the implications, we looked at nurses' responses by current position. It was no surprise that for both facility and unit incidence rates, the yes responses were higher for charge nurse/assistant nurse manager (33% for facility, 37% for unit), manager/supervisor (51%, 52%), and advanced practice nurses (70%, 60%) than for clinical nurses (25%, 30%). We see this as an opportunity for management to be creative in educating and communicating to all staff the pressure ulcer incidence rate, not only in their facility but also on nursing units.
27. I received sufficient education on chronic wounds in my basic nursing-education program.
Once again, the number of years of nursing experience may have influenced responses. The more experience a nurse had in nursing, the less likely he or she was to respond yes to this question:
* 2 to 3 years, 47%
* 4 to 5 years, 42%
* 6 to 10 years, 43%
* 16 to 20 years, 32%
* over 20 years, 23%.
As we suggested in 2005, either nursing education has improved in covering wound care content, or “our collective memory about our educational experience has dimmed, or you don't know what you don't know until you've had some experience.”1 Masters of science-prepared nurses had the highest percentage (79%) of no responses.
Nurses offered several comments about their perceived lack of sufficient education on chronic wound care in basic nursing education programs. As far as work setting, more nurses in home healthcare/community care (43%) answered yes, compared with those in long-term care (33%), hospitals (29%), or hospice (29%). More clinical nurses (39%) and charge nurse/assistant nurse managers (36%) answered yes compared with manager/supervisors (22%) or advanced practice nurses (5%). Once again, we see this as an opportunity to enlighten educators about the importance of including this content in the nursing curriculum.
Nurses also had a lot to say about the importance of continuing education, especially for all shifts and for other disciplines besides nursing. (See What nurses had to say.) Fortunately, many national and regional conferences and symposiums on wound care are available for nurses to help them acquire the knowledge and most current evidence in this specialty area.
28. I'm comfortable in making recommendations to practitioners on appropriate wound dressings for my patients.
As in 2005, with age and experience more nurses expressed confidence all or most of the time. Among age groups, the highest percentage answering all the time or most of the time were nurses over age 65 (24% and 47%, respectively). Nurses ages 51 to 65 were next, with 17% responding all the time and 41% most of the time. In comparison, in the youngest age group, those ages 21 to 30, only 6% responded all the time and 28% responded most of the time. The pattern of percentages was the same when data were analyzed by years of experience in nursing.
Once again, we're not sure if these responses reflect experience, age, or, as we speculated in 2005, “interdisciplinary communication issues rather than lack of confidence in wound care experience.”1
29. Does your practice setting have a designated wound care team?
34. Are you a wound care team nurse?
We added questions 29 and 34 to the current survey to see how many respondents had access to a wound care team or were working as a wound care team nurse. Most pressure ulcer clinical guidelines and algorithms agree that pressure ulcer prevention and treatment is best managed when feasible by an interdisciplinary wound care team,31 so it's wonderful that almost two-thirds of respondents said their facility had a designated wound care team and nearly a quarter were on the team! The responses varied by care setting, with long-term care (77%) and hospital (75%) having the most yes responses, followed by hospice (38%) and home healthcare/community health (32%) with the least.
Skin and wound care is a nurse-sensitive quality measure, so we're grateful that so many nurses responded to this survey. Because this was a nonrandomized self-selected small sample size of nurses who read this journal, there are limitations to our findings, which can't be generalized to all nurses. It does, however, give us some insights into how nurses perceive their knowledge and skills in this specialty area. While more research is needed, survey results suggest that nurses want more education in both their basic nursing education and continuing education programs.
Accurately staging pressure ulcers is important not only from a CMS regulatory perspective, but also from a clinical one. Given the growing number of older adult patients and the potential for more patients with venous disease and ulceration, knowing the importance of compression therapy and how to apply compression wraps/dressings will be an essential nursing skill. These survey results reveal the need for more education about wound care for both nursing students and clinical nurses.
RATING THE STRENGTH OF THE EVIDENCE32
The NPUAP wound care recommendations are categorized as follows according to the strength of the evidence supporting them.
Supported by direct scientific evidence from properly designed and implemented controlled trials on pressure ulcers in humans (or humans at risk for pressure ulcers), providing statistical results that consistently support the guideline statement (Level 1 studies required).
Supported by direct scientific evidence from properly designed and implemented clinical series on pressure ulcers in humans (or humans at risk for pressure ulcers), providing statistical results that consistently support the recommendation (Level 2, 3, 4, 5 studies).
Supported by indirect evidence (such as studies in normal human subjects, humans with other types of chronic wounds, animal models) and/or expert opinion.
WHAT NURSES HAD TO SAY
A persistent theme in nurses' written comments was the need for more education for practitioners in all settings and at all levels. Here's a sampling.
* Wound care isn't really covered in nursing school.
* Students need more education; nurses need reviews and updates.
* I work part time in a small rural hospital, where we don't have the luxury of a wound care team or CWOCN. Many times the physicians are not up-to-date on current wound care practices either and look to nurses for recommendations.
* One of our greatest challenges is the education of surgeons and primary care physicians in our area to stop using wet-to-dry dressings, stop using Dakin solution, and stop using hydrogen peroxide!
* I started a lunch and learn program for nurses on wound and ostomy care at the last two facilities where I worked. It was received and attended very well.
* Previously I was a case manager in home health and I found that although home health nurses exhibited confidence in their ability to perform wound care, in reality they didn't always know the best way to treat a wound. Neither my LPN program nor my RN program provided much education on wound care.
* The home health agencies I've worked for don't include enough education on wound care in orienting new home health nurses and foolishly try to limit newer wound care applications and encourage the use of simple gauze dressings because they feel this is less costly.
* I'd like to see more educational opportunities open up to LPNs who are in supervisory roles within the long-term-care industry and are the main wound care providers.
* In hospice, our goal is not to heal the wounds. Our goal is to treat/prevent wound-related pain, prevent new ulcers (if possible), and maintain current wounds. I wish there were more education related to fungating cancer wounds.
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