Ninety-seven percent of respondents confirmed that PIs occur in their work environments. Only 3% reported no PIs in their facility, and 37% rated PIs as a frequent occurrence (Figure 3). Most of the respondents (91%) were part of a team involved in treating PIs.
Of the 590 participants, 90% were aware of PI prevention, using devices and related technologies. Between 80% and 90% used offloading or pressure redistribution devices including prophylactic dressings to prevent PIs, but only 20% instituted measures to address the skin microclimate for the prevention of moisture-associated skin damage (Table 1).
Over three-quarters of the respondents (77%) reported using one or more PI prevention protocols in their facilities (Table 2). Fifty-four percent of respondents reported that their facilities have a surveillance system to track PI rates and, of those, 44% collected data monthly (Figures 4 and 5).
With an aging population and increased prevalence of chronic diseases, PIs continue to be a common problem. This survey focused on three main areas:
- attitudes (are PIs an issue?)
- knowledge (awareness of PI prevention devices)
- practices (implementation and monitoring of prevention protocols)
Best practice guidelines have been developed to outline evidence-based interventions for the prevention and treatment of PIs.10 Although most respondents were aware of PI prevention measures, it remained unclear how protocols and prevention strategies were implemented to curb the growing concern around PIs. Survey results indicated that 90% of respondents were aware of the need to implement PI prevention protocols, but 23% confirmed that there is no standard prevention protocol in place at their facility. Further, only 50% of those who completed the survey monitor PI prevalence on a regular basis in their workplace. These findings indicate a disparity between the need to implement evidence-informed protocols/guidelines and the resources available to systematically monitor the scope of PIs.
There are three main barriers to effective and optimized PI care: organizational, provider, and patient barriers.
According to the Registered Nurses’ Association of Ontario, barriers to effective PI treatment include high nurse-to-patient ratios, resource constraints, and insufficient integration of best practices into organizational structures and processes.10 This survey indicates that, contrary to best practices, 28% of respondents confirmed that PI rates were not being tracked in their facilities, and 23% of respondents were not following a standardized prevention protocol. Lack of organizational support is frequently cited as a barrier to implementation, even when healthcare professionals display positive attitudes, adequate knowledge, and the desire to employ best practices.10 Further, approximately 15% of respondents do not have access to specialty surfaces and other offloading devices. Seventy-five percent of respondents lacked the tools (barrier creams/ointments, containment products, etc) required for microclimate management.
Skin that is exposed to fecal incontinence and moisture is susceptible to breakdown. The term moisture-associated skin damage has been introduced to describe a spectrum of skin damage resulting from prolonged exposure to a variety of moisture sources, including wound exudate, sweat, urine, mucus, and other bodily fluids.11 Overhydration of the skin causes the stratum corneum to swell and stretch, weakening the connections between epidermal cells and collagen fibers. Increased permeability and disruption of the normal barrier function render the skin more susceptible to irritants and mechanical damage.11 In a recent systematic review and meta-analysis, Beeckman et al12 confirmed that individuals with bowel and bladder incontinence and related incontinence-associated dermatitis are 4.99 times more likely (95% confidence interval, 2.62–9.50) to develop PIs than those who are continent. Prevention and treatment of moisture-associated skin damage may encompass a variety of options including specialized equipment or surfaces, incontinence products, customized linen and fabrics, dressings, and skin cleansing agents, in addition to topical application of barriers and moisturizers to protect or strengthen the skin. Management protocols are increasingly difficult to implement because treatment needs are extremely individualized and must be based on the frequency of incontinence and amount of moisture.12
In addition, 40% of respondents indicated that they do not have access to prophylactic dressings despite recent literature supporting prophylactic dressings as an important means for preventing certain PIs.13,14 In 2009, as a result of collaboration between the National Pressure Ulcer Advisory Panel and the European Pressure Ulcer Advisory Panel, the first edition of the Clinical Practice Guideline on the prevention and treatment of PI was published.15 More recently, the Pan Pacific Pressure Injury Alliance has worked with both of these organizations to produce a second edition of the Guideline that includes updated recommendations and research summaries, plus a number of new sections on emerging fields of interest.16 One such new section includes the following recommendation: “Consider applying a polyurethane foam dressing to bony prominences (eg, heels, sacrum) for the prevention of pressure ulcers in anatomical areas frequently subjected to friction and shear.”16 The results of four clinical studies are cited in support of this recommendation, three of which investigated the efficacy of multilayer foam dressings.13,16–18 In 2014, the recommendations of a consensus panel on the use of prophylactic dressings as an adjunct to PI prevention strategies were published.17,18 The use of prophylactic polyurethane foam dressings as a component of standard prevention measures has been an area of growing interest.14,17–19
In 2012, the Registered Nurses’ Association of Ontario10 identified barriers that impede bedside care for patients living with PIs. Barriers include challenges in (or lack of) continuity of care, resource discrepancies between healthcare settings at transition of care, inexperienced providers, heavy clinical workload, clinician inexperience with routine PI care, and lack of access to pressure redistribution surfaces or devices required to prevent PIs or improve healing outcomes.9
In general, attitude and knowledge toward prevention and management of wounds such as PI are poor. Suen et al20 documented that only 3% of the medical students (n = 39) who participated in their study were able to correctly identify a PI. Some students believed that PI care was ineffective and a lower priority than other areas of care.
Knowledge and attitude have a significant impact on the quality of wound-related care. Demarré et al21 documented that PI care and adherence to best practice recommendations were predicted by knowledge and attitude in a sample of 145 nurses. A systematic review conducted by Suva et al22 on PI care-related education determined that a lack of PI assessment and management knowledge by healthcare professionals is a prevalent issue.22
Anissimova et al23 conducted a scoping review examining the potential impact of advanced wound care education for healthcare providers on patient clinical outcomes. They located a total of eight studies: seven articles focused on nurses with a specialization in wound healing, and one study evaluated chiropodists with advanced training in wound care. Despite the paucity of high-quality evidence, provision of wound care by knowledgeable clinicians with advanced training or education has been linked to improved wound healing, cost-effectiveness, low wound recurrence, and high morale in wound care practices.23
Long-term adherence to recommended preventive and self-care measures by patients at risk for PI remains suboptimal. For example, in a survey of people with spinal cord injuries in the Netherlands, fewer than 50% of their participants performed pressure-relief maneuvers on a regular basis.24
Self-management to prevent PI is not an easy task, requiring ongoing skin surveillance and lifelong behavioral/lifestyle modifications sustained by high levels of motivation and vigilance.8 Although not assessed in this study, patient-related barriers that impede care and treatment of PIs are integral factors related to prevention.
Patient-related barriers can be divided into two sections. For those at risk for PIs, barriers include a lack of PI awareness and lack of appropriate resources. For family and other caregivers, barriers include a lack of PI awareness, lack of knowledge and skill to effectively provide care, and lack of support resources.8
Patient surveys of the Canadian populations should be completed to gain a greater understanding of the knowledge, attitudes, and practices of patients and their family/caregivers in relation to PI prevention. To optimize PI prevention, emerging evidence highlights a need to shift the chronic disease management paradigm away from traditional disease-centered care to patient engagement and self-management. As eloquently defined by the Health Council of Canada, self-management support is “the systematic provision of education and supportive interventions, by healthcare staff (and others), to increase patients’ skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting, and problem-solving support.”25
- Healthcare facilities should implement best practices and ensure that healthcare professionals have access to devices for offloading and preventing/managing PIs.
- Healthcare professionals should be provided ongoing education and mentoring pertaining to the prevention and management of PIs.
- Patient surveys of the Canadian population should be completed to gain a greater understanding of the knowledge, attitudes, and practices of patients and their family/caregivers in relation to PI prevention.
Evidence-informed strategies to promote skin health and reduce the incidence of skin breakdown are integral to safeguard patient safety, quality of care, and judicious use of healthcare resources. The findings from this survey have highlighted a disconnect between Canadian healthcare professionals’ awareness of PIs and the implementation of best practices for the prevention of PIs. It is evident that, although the majority of respondents were aware of PIs and of treatment protocols, barriers still exist that impede optimized care and treatment.
Canadian healthcare professionals and organizations need to prioritize the prevention of PIs along with their management in a coordinated effort to drastically reduce the prevalence and incidence of these highly preventable wounds among Canadians. It is therefore imperative that healthcare professionals identify barriers to preventing and managing PIs appropriately in their workplaces. Once identified, healthcare professionals must work at all levels to remove these barriers and ensure patients are safeguarded against the serious complications of PI development.
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18. Black J, Clark M, Dealey C, et al. Dressings as an adjunct to pressure ulcer prevention: consensus panel recommendations. Int Wound J 2015;12(4):484–8.
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in trauma and critically ill patients: the border trial. Int Wound J 2015;12(4):302–8.
20. Suen W, Parker VA, Harney L, et al. Internal medicine interns' and residents' pressure ulcer prevention and assessment attitudes and abilities: results of an exploratory study. Ostomy Wound Manage 2012;58(4):28–35.
21. Demarré L, Vanderwee K, Defloor T, Verhaeghe S, Schoonhoven L, Beeckman D. Pressure ulcers
of nurses and nursing assistants in Belgian nursing homes. J Clin Nurs 2012;21(9-10):1425–34.
22. Suva G, Sharma T, Campbell KE, Sibbald RG, An D, Woo K. Strategies to support pressure injury best practices by the inter-professional team: a systematic review. Int Wound J 2018;15(4):580–9.
23. Anissimova V, Brittain M, Loundes DA, Woo K. Scoping review of clinical outcomes related to advanced training in wound care. Surgical Technol Int 2018;33:67–73.
24. van Loo MA, Post MW, Bloemen JH, van Asbeck FW. Care needs of persons with long-term spinal cord injury living at home in the Netherlands. Spinal Cord 2010;48(5):423–8.
Keywords:Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
attitude; Canada; health professionals; knowledge; online survey; practice; pressure injuries; pressure ulcers