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Professionals’ Knowledge, Attitudes, and Practices Related to Pressure Injuries in Canada

LeBlanc, Kimberly, PhD, RN, WOCC (C), IIWCC; Woo, Kevin, PhD, RN, NSWOC, FAPWCA; Bassett, Katie, BA; Botros, Mariam, DPM

Advances in Skin & Wound Care: May 2019 - Volume 32 - Issue 5 - p 228–233
doi: 10.1097/01.ASW.0000554444.52120.f6
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BACKGROUND: Pressure injuries (PIs) represent a significant burden on the healthcare system and have a negative impact on the quality of life of those affected by these wounds. Despite best practice guidelines and other protocols to help healthcare facilities prevent PIs, the prevalence of PIs in Canada across all healthcare settings is concerning.

OBJECTIVE: To describe the pattern of PI prevention and identify national priorities and opportunities to address PIs.

METHODS: A descriptive, cross-sectional, online survey was created between August and December 2017 to explore Canadian healthcare professionals’ knowledge, attitudes, and practices related to PIs.

RESULTS: In total, 590 surveys were completed. Eighty-five percent of respondents confirmed that PIs occur in their work environments, and 29% claimed PIs are a frequent occurrence. Most of the respondents (91%) confirmed that they were part of a team that treats PIs. Of the 590 participants, 90% confirmed that they are aware of PI prevention devices and technologies. Between 80% and 90% attest to using offloading devices including prophylactic dressings to prevent PIs, but only 20% instituted measures to address moisture-associated skin damage.

CONCLUSIONS: The findings from this survey have highlighted a disconnect between Canadian healthcare professionals’ awareness of PIs and the implementation of best practices for PI prevention. It is evident that, although the majority of respondents were aware of PIs and related treatment protocols, barriers still exist that impede optimized care and treatment.

In Ontario, Canada, Kimberly LeBlanc PhD, RN, WOCC (C), IIWCC, is Chair, Wound Ostomy Continence Institute, Ottawa; Kevin Woo, PhD, RN, NSWOC, FAPWCA, is Associate Professor, Faculty of Health Sciences, Queen’s University, Kingston; Katie Bassett, BA, is Communications Specialist, Wounds Canada, North York; Mariam Botros, DPM, is Executive Director, Wounds Canada, and Director, Diabetic Foot Canada, North York.

Acknowledgments: The authors declare that this study was financially supported by an unrestricted grant from Mölnlycke Health Care. The authors have disclosed no other financial relationships related to this article. Submitted September 4, 2018; accepted in revised form November 26, 2018.

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INTRODUCTION

Pressure injuries (PIs), also called pressure ulcers, are areas of localized damage to the skin and underlying soft tissue, usually developed over a bony prominence or caused by a (medical) device.1 According to the National Pressure Ulcer Advisory Panel, PIs are caused by excessive or prolonged pressure and often in combination with shear.1 Individuals with mobility-limiting conditions or acute and chronic illness requiring hospitalization are at heightened risk for PIs.1 In addition, older adults are more vulnerable to age-related skin changes including loss of skin elasticity, reduced subcutaneous tissue, and compromised blood flow.2

Pressure injuries represent a significant burden on the healthcare system and have a negative impact on quality of life. Patients who develop hospital-acquired pressure injuries (HAPIs) experience longer hospital stays and are more likely to need long-term care (LTC) following hospitalization.3 People with PIs often suffer from social isolation, loss of independence, depression, persistent pain, and recurrent infection.4 As such, PIs have been linked to a number of adverse patient outcomes including prolonged care episodes, decline in physical functioning, and death.5,6

Despite best practice guidelines and other protocols to help healthcare facilities prevent PIs, the prevalence of PIs in Canada across all healthcare settings is of pressing concern. Graves and Zheng3 conducted a comprehensive review of available epidemiologic evidence (based on 38 studies conducted in 11 countries) for prevalence and incidence of chronic wounds.3 Of all chronic wounds, the prevalence of PIs was the most common in 1.1% to 26.7% in hospitals, 6% to 29% in community care settings, and 7.6% to 53.2% in LTC facilities.3 In Canada, PI prevalence is estimated to be 26% across healthcare sectors.7 Among individuals with a PI in LTC, the prevalence of multiple concurrent PIs was 72%, and, in terms of incidence, over 25% of PIs in LTC developed within 1 week postdischarge from an acute care facility.7 In critical care settings, HAPI prevalence was reported to be between 14% and 42% in ICUs and the incidence to be 12% to 66% in intraoperative settings.7 Despite regulatory and legislative efforts to reinforce prevention, PI rates have not been significantly reduced across Canada when compared with other countries.7

More than 70% of PIs are preventable, making PI prevention an important focus of care for patients across all care settings.4 Canadian best practice documents outline prevention strategies that include risk assessment, consistent turning and repositioning, careful use of therapeutic surfaces, moisture management, and nutrition support.8 In Ontario, Canada, in 2013, stage 2 HAPIs were estimated to cost Can $44,000, and stage 4 HAPIs up to Can $90,000.9 Despite these high costs and provincial government funding for PI treatment, available resources for PI prevention are inadequate.8 Given the healthcare system’s current financial constraints, healthcare settings should make a concerted effort to focus on PI prevention over treatment.

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Objective

Deficiencies in current PI research in Canada create an impetus for this study to describe PI care across the continuum of care. The purpose of this survey was to explore healthcare professionals’ knowledge, attitudes, and practices related to PI prevention in Canada. A survey of specific questions was designed to identify the extent to which prevention protocols were adopted and applied and to examine existing technologies and devices used to prevent PIs.

An overarching goal was to describe patterns in clinical practices to prevent PI and identify national priorities and opportunities to improve PIs. The researchers aim to inform decision-makers about the barriers and challenges to implementing PI prevention across various sectors, professional groups, and geographic locations.

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Research Questions

  1. What is the level of knowledge pertaining to prevention of PIs in Canada?
  2. What prevention protocols are used in practice?
  3. What technologies or devices are used routinely to implement prevention protocol?
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METHODS

A descriptive, cross-sectional, online survey was created between August and December 2017 to explore Canadian healthcare professionals’ knowledge, attitudes, and practices related to PIs. The data collection tool for the survey was designed specifically for this study by the research team. Three wound care nurses associated with Wounds Canada (www.woundscanada.ca) reviewed the survey for its face validity and the appropriateness of its questions. A sample group of 10 healthcare professionals was asked to assess the survey for readability, phrasing, color choice, physical layout, and question sequence. Revisions of the survey were made based on feedback from these groups. The final tool consisted of binary questions and 10 Likert-type scales.

A convenience sampling method was used to disseminate the link to the online survey to healthcare professionals known to Wounds Canada. Participants were also invited to participate via advertisement by product manufacturers. Participants were asked to complete the anonymous, online, self-administered survey. Completed surveys were directly downloaded to the SurveyMonkey server. All participant identifiers were removed prior to the research team’s data download.

Ethical approval was obtained from the Queen’s Health Sciences Research Ethics Board. Sample size (n = 383) was calculated a priori to ensure the study was adequately powered. Data analysis was completed using SPSS version 24 (IBM Corp, Armonk, New York). Descriptive statistics were used to provide summaries of demographics and question responses.

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RESULTS

In total, 590 surveys were completed. Respondent employment was distributed primarily among LTC, acute care, and community care (Figure 1), and the number of employees per participating organization ranged from fewer than 25 to more than 250 (Figure 2). The majority of respondents (90%) were nurses (registered nurse, registered practical nurse, or licensed practical nurse), 3% were physicians, and 7% were allied health professionals (physiotherapist, chiropodist, occupational therapists).

Figure 1

Figure 1

Figure 2

Figure 2

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.

Figure 3

Figure 3

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).

Table 1

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).

Table 2

Table 2

Figure 4

Figure 4

Figure 5

Figure 5

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DISCUSSION

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.

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Organizational 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

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Provider Barriers

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

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Patient Barriers

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

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Recommendations

  1. Healthcare facilities should implement best practices and ensure that healthcare professionals have access to devices for offloading and preventing/managing PIs.
  2. Healthcare professionals should be provided ongoing education and mentoring pertaining to the prevention and management of PIs.
  3. 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.
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CONCLUSIONS

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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REFERENCES

1. National Pressure Ulcer Advisory Panel. NPUAP Pressure Injury Stages. 2016. www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages. Last accessed January 18, 2019.
2. Ayello E. CMS MDS 3.0 Section M skin conditions in long-term care: pressure ulcers, skin tears, moisture-associated skin damage update. Adv Skin Wound Care 2017;30(9):415–29.
3. Graves N, Zheng H. The prevalence and incidence of chronic wounds: a literature review. Wound Pract Res 2014;22(1):1–19.
4. Woo KY. Exploring the effects of pain and stress on wound healing. Adv Skin Wound Care 2012;25(1):38–44.
5. Bååth C, Idvall E, Gunningberg L, Hommel A. Pressure-reducing interventions among person with pressure ulcers: results from the first three national pressure ulcer prevalence surveys in Sweden. J Eval Clin Pract 2014;20(1):58–65.
6. Brem H, Maggi J, Nierman D, et al. High cost of stage IV pressure ulcers. Am J Surg 2010;200(4):473–7.
7. Canadian Institute for Health Information. Canadian Hospital Reporting Project Technical Notes-Clinical Indicators. 2013. Ottawa, ON, Canada. https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC2320. Last accessed January 18, 2019.
8. Norton L, Parslow N, Johnston D, et al. Best practice recommendations for the prevention and management of pressure injuries. In: Foundations of Best Practice for Skin and Wound Management. A Supplement of Wound Care Canada 2017. www.woundscanada.ca/docman/public/health-care-professional/bpr-workshop/172-bpr-prevention-and-management-of-pressure-injuries-2/file. Last accessed January 18, 2019.
9. Chan B, Leraci L, Mitsakakis N, Pham B, Krahn M. Net costs of hospital-acquired and pre-admission PUs among older people hospitalized in Ontario. J Wound Care 2013;22(7):341–6.
10. Registered Nurses’ Association of Ontario. Toolkit: Implementation of Best Practice Guidelines. 2nd ed. 2012. https://rnao.ca/bpg/resources/toolkit-implementation-best-practice-guidelines-second-edition. Last accessed January 18, 2019.
11. Gray M, Black JM, Baharestani MM, et al. Moisture-associated skin damage: overview and pathophysiology. J Wound Ostomy Continence Nurs 2011;38(3):233–41.
12. Beeckman D, Campbell J, Campbell K, et al. Proceedings of the Global IAD Expert Panel. Incontinence Associated Dermatitis: Moving Prevention Forward. Wounds International 2015. www.woundsinternational.com/resources/details/incontinence-associated-dermatitis-moving-prevention-forward. Last accessed February 6, 2019.
13. Byrne J, Nichols P, Sroczynski M, et al. Prophylactic sacral dressings for pressure ulcer prevention in high risk patients. Am J Crit Care 2016;25(3):228–34.
14. Brindle CT, Wegelin JA. Prophylactic dressing application to reduce pressure ulcer formation in cardiac surgery patients. J Wound Ostomy Continence Nurs 2012;39(2):139–42.
15. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel. International Guideline: Pressure Ulcer Treatment Technical Report 2009. www.npuap.org/wp-content/uploads/2012/03/Final-2009-Treatment-Technical-Report1.pdf. Last accessed January 18, 2019.
16. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Haesler E, ed. Perth, Australia: Cambridge Media; 2014.
17. Walsh NS, Blanck AW, Smith L, Cross M, Andersson L, Polito C. Use of a sacral silicone border foam dressing as one component of a pressure ulcer prevention program in an intensive care unit setting. J Wound Ostomy Continence Nurs 2012;39(2):146–9.
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.
19. Santamaria N, Gerdtz M, Sage S, et al. A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers 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: knowledge and attitude 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.
25. Kitts J, Beaton B, Cook C, et al. Self-management support for Canadians with chronic health conditions: a focus for primary health care. 2012. www.selfmanagementbc.ca/uploads/HCC_SelfManagementReport_FA.pdf. Last accessed January 18, 2019.
Keywords:

attitude; Canada; health professionals; knowledge; online survey; practice; pressure injuries; pressure ulcers

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