Nursing Interventions for Pressure Injury Prevention

HAPUs are a fundamental challenge in the American healthcare industry. The rationale behind this statement is that numerous people suffer from this issue (Padula et al., 2019, Hultin et al., 2019; Latimer et al., 2019). Even though the problem affects many patients, it is considered preventable, and multiple articles prove this point of view (Gray & Giuliano, 2018; Latimer, Gillespie, & Chaboyer, 2017; Lin et al., 2020). Many scholars try to address this problem by conducting studies to analyze the effectiveness of different interventions, including turning and repositioning, among others. However, the existence of the problem within the medical system means that there is still room for improvement. That is why the purpose of this DPI project is to determine if or to what degree the implementation of turning and repositioning every two hours would impact the HAPU incidence when compared to current practice among older hospitalized patients in a 23-bed unit in urban Arizona.

The literature review is necessary to identify and understand the findings related to the topic under investigation. As a result of this process, it can be possible to develop a well-documented argument regarding the selection of the project topic, formulate the clinical questions, and justify the use of the specific methodological approach. Consequently, the literature review is going to focus on what methods can be undertaken to study the problem, what interventions exist, and whether it is necessary to investigate the issue.

Since Chapter 2 should present much information, it follows a specific structure. The Background section presents a historical overview of the project, which is necessary to identify the existing gap that should be addressed to achieve practice improvement. Then, the Theoretical Foundations section introduces a nursing theory and a change theory that are necessary to identify variables, their relationship, and how they should be measured. Furthermore, the Review of the Literature heading presents the synthesis of the findings, and they are grouped into three themes. They are The Use of Repositioning and Turning, Turning and Repositioning with Other Interventions, and HAPUs in the Healthcare Industry. Each theme is then divided into smaller subthemes that contribute to a better understanding of the literature. Thus, the Project Methodology section provides the rationale for selecting a quantitative approach, while the Project Design heading justifies the use of a quasi-experimental study.

The DPI project should undertake a thorough literature review to analyze the existing information. It is reasonable to search professional databases to find credible and timely literature on the topic. That is why a suitable approach is to use Google Scholar since this service provides simultaneous access to multiple resources, including PubMed, Cochrane, EBSCO, BMJ, CINAHL, and others. The following keywords and their various combinations are used to identify the required sources of information: pressure injuries, turning and repositioning, and two hours. The search results are limited to the studies that are published not earlier than in 2017 to ensure that the DPI project deals with the most recent literature. The identified articles are included in the project based on their abstracts. As a result, a set of 50 credible and reliable studies are selected for this literature review.

Background

Pressure injuries affect multiple patients, and it is impossible to deny that some improvements are needed. Ricci, Bayer, and Orgill (2017) admit that “the overall pressure injury prevalence rate described in 1999 for acute care facilities was 14.8 percent” (p. 275e). Simultaneously, the 2009 International Pressure Ulcer Prevalence Survey revealed approximately the same results irrespective of some improvement measures (Ricci et al., 2017). Simultaneously, Li, Lin, Thalib, and Chaboyer (2020) indicate that the current HAPU prevalence is 12.8%, while the incidence rate is “5.4 per 10,000 patient-day” (p. 2). These findings demonstrate that a gap exists because no significant improvements have occurred over more than 20 years in the sphere of addressing pressure injuries.

It is necessary to focus on what intervention should be used. Multiple sources state that turning and repositioning are traditional approaches to the problem (Atkinson & Cullum, 2018; Gaspar, Peralta, Marques, Budri, & de Matos, 2019; Mäki-Turja-Rostedt, Stolt, Leino-Kilpi, & Haavisto, 2019). Some researchers also focus on various repositioning intervals, and they show mixed results. Thus, Courvoisier, Righi, Béné, Rae, and Chopard (2018) and Pechlivanoglou et al. (2018) admit that 2- and 3-hourly interventions are more effective. However, while Jocelyn Chew, Thiara, Lopez, and Shorey (2018), Sharp, Moore, and McLaws (2019), and others identify no differences between 2-, 3-, and 4-hourly intervals. These findings reveal strong evidence for using the intervention, turning and repositioning every two hours, to determine its effectiveness.

Theoretical Foundations

Human caring nursing theory is used in this DPI project to identify how 2-hourly turning and repositioning can be associated with reduced HAPU incidence. Jean Watson (2018) proposed this theoretical framework by highlighting how to improve positive outcomes during human-to-human caring moments. Wei and Watson (2019) also indicate that the theory relies on practice, research, and theory-based education to ensure that any proposed intervention is suitable and can help patients achieve better health outcomes. This theory denotes that successful results can only be achieved if a medical practice is backed theoretically.

In addition to that, the DPI project focuses on a specific change theory. It refers to Kurt Lewin’s (1951) change management theory that is typically used for numerous quality improvement projects. This framework implies that patients change their behavior under the influence of driving or positive forces that affect individuals from outside (Lewin, 1951). This information suggests that it is necessary to provide patients with external support to ensure that they can overcome some challenges.

The change model above implies that the DPI project will rely on specific steps to measure the variables. Firstly, it is necessary to improve patients’ knowledge about the problem and its possible solutions. In this case, the findings from Ricci et al. (2017), Li et al. (2020), Courvoisier et al. (2018), and others are helpful. This information justifies the use of turning and repositioning and HAPU incidence as the project variables. Secondly, it is reasonable to implement a change by subjecting patients to specific interventions. One can suppose that applying the chosen change theory is appropriate to answer the identified clinical question.

Review of the Literature

This section presents synthesized evidence for three broad areas. Each of them provides information that is sufficient to understand the scope of the given DPI project. The literature review collects and analyzes findings from 50 credible and reliable sources. It is worth admitting that most of these sources were published within the last five years, which indicates that the DPI project relies on timely data.

The Use of Repositioning and Turning.

The first theme refers to the use of repositioning to address pressure ulcers. Considering the DPI project topic, it is not a surprise that it is necessary to identify what scientific studies state about the effectiveness of this method. The given theme will try to explain whether this intervention is suitable to address the issue, how to maximize its benefits, how it affects various groups of patients, and what techniques are used.

Affecting Pressure Ulcers

The first subtheme focuses on whether it is justified to rely on turning and repositioning in reducing the pressure injury prevalence among older patients. The articles of this group try to explain what pressure ulcer prevention measures can be used and which of them are the most effective. These include the studies by Atkinson and Cullum (2018), Gaspar et al. (2019), Mäki-Turja-Rostedt et al. (2019), Latimer et al. (2017), and Lin et al. (2020). The following information will comment on the peculiarities of these sources.

The article by Atkinson and Cullum (2018) is an analysis of 38 systematic reviews from the Cochrane Library and PubMed. The authors focus on existing ways to prevent and manage pressure injuries. This source reveals that turning and repositioning are among the practical HAPU prevention approaches. However, the scholars admit that further research is needed to identify the most appropriate management strategy to protect the population from this health condition.

The study by Lin et al. (2020) is another systematic review that synthesizes 21 peer-reviewed articles from popular medical databases. These scholars conclude that many quality improvement initiatives can be used while turning and repositioning are among them. With this, Lin et al. (2020) fail to compare the effectiveness of various interventions or state how it is possible to avoid them. That is why the scholarly source highlights the necessity to undertake future high-quality research on the topic.

Gaspar et al. (2019) focus on the EBSCO host, PubMed, and Web of Science databases to identify 26 relevant articles. The study demonstrates that repositioning is a widespread intervention, but it fails to present significantly positive results when used in isolation. The authors rely on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to find that it is reasonable to use repositioning with technology to maximize its potential advantages.

Mäki-Turja-Rostedt et al. (2019) focus on 18 pieces of research from PubMed (MEDLINE), CINAHL, Web of Science Core Collection, Scopus, Cochrane Wounds Group Specialized Register, and Cochrane Central Register of Controlled Trials databases. These authors support the findings by Gaspar et al. (2019) since they also highlight that repositioning fails to produce positive outcomes when it is the only intervention. Thus, it is necessary to implement additional interventions to prevent pressure injuries.

Regarding this subtheme, Latimer et al. (2017) is the only study that is not a systematic review. It is an observational study with 241 participants to investigate the issue of HAPUs in an Australian medical unit. These scientists claim that repositioning is the most frequent and often the only intervention in this context. That is why it is reasonable to organize additional studies to identify whether it can result in positive health outcomes for patients.

In summary, this subtheme is represented by qualitative methodologies, predominantly by systematic reviews. The findings are relevant to the DPI project since they reveal that turning and repositioning are widespread HAPU prevention methods, while the data on their effectiveness are mixed. The description of the DPI project’s independent variable reveals a gap in the current research field because it is rational to analyze the issue by using a quantitative methodology.

Repositioning and Turning Intervals

The second subtheme draws attention to the fact that there are different repositioning intervals. It refers to 2-, 3-, and 4-hourly repositioning techniques that are currently used in hospitals. Since there are a few options, it is necessary to identify how they affect pressure injury incidence. In other words, the articles from this subtheme will try to answer whether there is a significant difference between the possible repositioning intervals.

A modified Delphi study by Lovegrove, Fulbrook, and Miles (2020) presents synthesized evidence regarding how often it is necessary to reposition and turn patients. Sixty-seven panel members were identified and questioned regarding the issue under analysis. The scholars admit that patients should be repositioned at least every two, three, or four hours. This information presents the overall conclusion but fails to compare and contrast the intervals.

A cross-sectional prevalence study by Courvoisier et al. (2018) focuses on 2,671 patients to identify and compare the effectiveness of various intervals. These intervals are considered independent variables, while HAPU incidence represents a dependent one. Thus, the scholars have determined that 2- and 3-hourly intervals are more effective than 4-hourly ones. It demonstrates that a higher intervention frequency leads to improved health outcomes for patients suffering from HAPUs.

The cost-effectiveness analysis by Pechlivanoglou et al. (2018) considers the issue from a public payer perspective. These scientists deal with the data from a clinical trial to compare financial affairs associated with 2-, 3-, and 4-hourly repositioning approaches. The findings reveal that turning and repositioning patients every three hours is considered the most cost-effective approach. Furthermore, this approach is helpful when it comes to assessing the HAPU incidence.

The article by Avsar et al. (2020) is a systematic review and meta-analysis of 16 randomized controlled trials. This fact denotes that the given study deals with quantitative data to arrive at reliable conclusions. Thus, the scholars admit that more frequent repositioning intervals lead to reduced HAPU incidence. However, the authors also argue that their findings should be interpreted with caution since further research is necessary to test the results.

Simultaneously, a retrospective cross-sectional study of 80 individuals by Sharp et al. (2019) offers contradictory findings. The researchers analyze the participants’ medical records to identify how, when, and why they suffer from pressure ulcers. The results are worth considering because they demonstrate that almost one-third of the sample size had a HAPU irrespective of 2-hourly repositioning. This information allows for concluding that a frequent turning and repositioning interval is not effective when used in isolation.

A systematic review by Jocelyn Chew et al. (2018) focuses on ten scholarly articles, and three independent researchers analyze them and synthesize the data. This approach demonstrates that even though some of the studies highlight the effectiveness of turning and repositioning, none of them presents any significant difference between intervals under analysis. These results make the authors suggest that it can be reasonable to implement a multifaceted intervention, including repositioning and specific mattresses.

This subtheme provides the findings that are essential for the DPI project. It refers to the fact that there exists a need to undertake a quality improvement project because there is insufficient evidence that any of the repositioning frequencies is substantially better than the others. Simultaneously, the use of various methodologies demonstrates that it is possible to apply multiple approaches to investigate the issue; however, a quantitative method can produce more reliable results.

Repositioning and Turning for Patients with Specific Health Conditions

It is sad to say that pressure ulcers are usually comorbidities that develop against the background of other diseases. Typically, this health issue is the most acute for individuals who spend much time in prone or sitting positions. That is why it is reasonable to identify research pieces that would make it clear whether turning and repositioning are helpful for people with particular health conditions.

Aljezawi and Tubaishat (2018) try to answer whether turning and repositioning are effective for cancer patients. A multicenter, cross-sectional prevalence study of 110 patients used a quantitative methodology to analyze the impact of 2-hourly repositioning on protecting such individuals from the health issue under analysis. The scholars conclude that irrespective of short frequency, this intervention does not guarantee that pressure injuries will not develop in cancer patients.

Chitambira and Evans (2018) assess the effect of repositioning for stroke patients with pusher syndrome and conduct a quality improvement initiative with 140 adults. The researchers draw attention to 2-hourly repositioning and placing of pillows. This article supports the claim that repositioning becomes more effective when it is used together with an additional intervention. Since the study focuses on a short intervention period, the authors highlight the necessity to organize further research on this topic.

Gray and Giuliano (2018) reveal that there is a robust correlation between pressure injuries and incontinence-associated dermatitis (IAD). A descriptive and correlational analysis of 5,342 adults demonstrates that an increased HAPU prevalence is found when it comes to focusing on IAD patients. The authors also highlight that traditional prevention measures, including repositioning and turning, are not sufficient to protect the population from the given health condition.

Mussa et al. (2018) focus on pressure injuries among patients with an endotracheal tube (ETT). A retrospective, pre-post intervention study indicates that a more frequent repositioning leads to some improvements, but they are not statistically significant. The authors prove it by analyzing data of 61 members from the pre-intervention group and 81 individuals from the post-intervention group. This finding demonstrates that it is not possible to rely on repositioning and turning to protect patients with ETTs from HAPUs.

Eren, DeLuca, and Kirshblum (2020) consider what results turning and repositioning offer to patients with spinal cord injury. The authors do not implement any interventions but interview such individuals regarding whether they rely on the intervention. The findings demonstrate that almost half of the 86 respondents fail to turn regularly, irrespective of the fact that they are aware of this action. That is why it is not a surprise that patients with spinal cord injury are subject to HAPUs.

This subtheme has a particular meaning for the entire project. Firstly, it proves that pressure injuries are a widespread problem that requires specific interventions. Secondly, the subtheme has revealed that individuals with particular health conditions are more subject to suffering from the given issue because they spend much time in sitting and prone positions. It indicates that turning and repositioning can only be effective for patients who do not suffer from additional issues.

Turning and Repositioning Techniques and Approaches

The fourth subtheme refers to the idea that various repositioning techniques and approaches to this intervention can lead to better patient outcomes. Repositioning and turning effectiveness is supposed to increase when medical professionals follow specific strategies to make decisions and take action. That is why the articles of this subtheme try to address appropriate research questions as to how it is possible to maximize repositioning effectiveness.

The study by Krapfl, Langin, Pike, and Pezzella (2017) is a literature review that has searched three databases, including CINAHL, EMBASE, and PubMed, to identify relevant articles. As a result, the scientists have extracted five research pieces that focused on the effect of incremental positioning. The findings demonstrate that this approach leads to certain changes regarding gravitational equilibrium, but this fact does not result in a reduced number of pressure injuries.

Oomens, Broek, Hemmes, and Bader (2016) selected 14 volunteers and analyzed magnetic resonance imaging (MRI) of their sacral areas. It was necessary to determine how tilting would affect individuals’ skin. The participants in a supine position demonstrate the highest strains in the muscle and fat. That is why the scholars insist that a tilting angle between 20º and 30º is optimal since it protects individuals from pressure injuries in their sacral areas.

Sving, Högman, Mamhidir, and Gunningberg (2016) conducts a quasi-experimental, pre- and post-test study of 506 patients. The scientists implemented different turning schedules and assessed their impact on participants’ health. The analyzed findings demonstrate that turning schedules are not effective when used in isolation. This information indicates that it is necessary to use repositioning and turning together with additional interventions to ensure that the HAPU incidence is addressed.

A laboratory study by Wiggermann, Zhou, and McGann (2021) assesses the effectiveness of three repositioning aids, including turn and position glide sheets, pair of friction-reducing sheets, and air-assisted transfer devices, for three participants. This research demonstrates that these aids are typically insufficient to mitigate the risk of traumas. Consequently, it is not rational to rely on the interventions above to protect individuals from pressure injuries.

The findings of the given subtheme support the overall tendency that has been identified throughout the theme exploration. It relates to the fact that there is controversial evidence regarding the effectiveness of repositioning and turning in preventing pressure ulcers. These four studies have demonstrated that the same is true for various repositioning techniques and approaches. Even though the findings are controversial, it is possible to extract one typical issue. Many articles demonstrate that managing pressure injuries is a complex task that requires a comprehensive approach.

A concluding paragraph of this theme presents the synthesized information. Each of the articles implies some limitations that deserve attention. Relatively small sample size is a limitation for some articles (Avsar et al., 2020; Mäki-Turja-Rostedt et al., 2019; Lin et al., 2020; Jocelyn Chew et al., 2018; Mussa et al., 2018; Eren et al., 2020; Krapfl et al., 2017; Oomens et al., 2017; Sharp et al., 2019; Wiggermann et al., 2021). The reliance on relatively outdated sources is a limitation of a different group of articles (Atkinson & Cullum, 2018; Latimer et al., 2017; Courvoisier et al., 2018; Pechlivanoglou et al., 2018; Lovegrove et al., 2020; Aljezawi & Tubaishat, 2018; Chitambira & Evans, 2018; Gray & Giuliano, 2018; Sving et al., 2016). The study by Gaspar et al. (2019) is limited since it does not imply coding to ensure an unbiased review of the articles. The studies’ strengths refer to the fact that the findings are consistent and reliable.

Since the articles above represent a single theme, it is not a surprise that they focus on similar variables. All of them focus on what effects turning and repositioning can produce. The research pieces under analysis have provided some controversial findings. For example, Atkinson and Cullum (2018) and Latimer et al. (2017) admit the effectiveness of turning and repositioning, while Gaspar et al. (2019) and Mäki-Turja-Rostedt et al. (2019) state that their effect is limited. The same is found with repositioning intervals because Courvoisier et al. (2018) highlight the effectiveness of 2- and 3-hourly repositioning, while Jocelyn Chew et al. (2018) do not admit any statistically significant difference between them. This information reveals that it is reasonable to conduct a quantitative study to fill the gap regarding the effectiveness of 2-hourly repositioning. The following theme will comment on the use of turning and repositioning with other interventions to assess whether this approach is more effective.

Turning and Repositioning with Other Interventions

According to the information above, it is not a surprise that Theme 2 refers to the use of repositioning and turning with other interventions to combat pressure injuries. This topic is requested in the research field, and scientists do their best to assess various additional measures’ effectiveness. The possible interventions include the use of mattresses and pillows, continuous bedside pressure mapping systems, and electronic devices. Seventeen articles represent the given theme and are subdivided into appropriate subthemes.

The Use of Continuous Bedside Pressure Mapping (CBPM) Systems

The first subtheme addresses the issue that repositioning charges nurses with responsibility. It relates to the fact that many individuals forget to move to avoid pressure injuries because of various reasons. That is why it is nurses’ task to either remind them of the necessity or to reposition the patients by themselves. In this case, medical professionals need assistance to cope with the assignment successfully, and CBPM systems can be helpful in this case. These systems help nurses determine when patients start experiencing excessive pressure and when it is necessary to reposition them.

The work by Gunningberg, Sedin, Andersson, and Pingel (2017) is a pragmatic randomized controlled trial of 190 patients, including control and intervention groups. CBPM systems were applied to the intervention group to test whether the given intervention has the potential to protect older patients from pressure injuries. The authors conclude that the application of the CBPM systems does not lead to any significant improvement regarding pressure injury incidence. It means that further research is necessary to test whether the blinded intervention will have the same impact on patient health.

Simultaneously, Gunningberg and Carli (2016) have conducted a prospective and quantitative study of 19 registered nurses and 33 assistant nurses, where the medical professionals assessed the effectiveness of CBPM. This approach allows the researchers to find that healthcare professionals highly appraise the instrument, stating that this intervention leads to optimized repositioning, which is helpful to reduce pressure ulcers. Further research is necessary to investigate the patients’ perception of CBPM systems.

Hultin et al. (2019) offer a qualitative, descriptive study of 31 orthopedic patients who are 65 years old and higher. They participated in semi-structured interviews, and their answers were subject to qualitative content analysis. This approach allows for identifying that the CBPM system increases adults’ awareness of pressure injuries and the necessity to prevent them. It denotes that this instrument is significant for patients to make them more engaged in HAPU prevention measures.

The given subtheme demonstrates that both medical professionals and patients positively assess the use of CBPM to prevent pressure injuries. This instrument implies some benefits because regular notifications of the necessity to change the patients’ position are convenient for all the stakeholders. Qualitative methodologies produce these results, while a randomized controlled trial by Gunningberg et al. (2017) does not identify reduced HAPU incidence. Further research implying a blind intervention is necessary to find the actual effect of CBPM systems. These findings reveal that this topic is considered using different methodologies, meaning that the given DPI project is not interested in addressing this topic.

Using Mattresses and Pillows

This subtheme considers whether specific mattresses and pillows are sufficient to reduce pressure on individuals’ skin and protect them from pressure ulcers. Six studies are analyzed, including the works by Jiang et al. (2020), Powers (2016), Sauvage et al. (2017), Alshahrani, Sim, and Middleton (2021), Bai, Liu, Chou, and Hsu (2020), and Bambi, Yusuf, and Irwan (2020). These pieces of research try to answer research questions of whether mattresses and pillows increase turning and repositioning effectiveness in reducing the pressure ulcer incidence and mattresses of what type are better.

Jiang et al. (2020) have conducted a multicenter, open-label, and comparative study with 1,204 participants. This fact has allowed the researchers to compare the effectiveness of viscoelastic foam and air pressure redistribution mattresses. The researchers mention that the viscoelastic foam and air pressure redistribution mattresses are effective pressure injury prevention methods, but there is no significant difference between the two. According to the authors, further research is necessary to assess the mattresses’ effect for different repositioning intervals.

Powers (2016) has selected 59 participants and investigated whether the standard of care (SOC) using pillows is better than a patient positioning system (PPS) in a nonrandomized study. The scholar states that the use of pillows is not sufficient to reduce the pressure injury prevalence. It is reasonable to conduct a randomized study to investigate the given issue and identify what additional measures are necessary to solve the problem.

Simultaneously, a literature review by Bambi et al. (2020) deals with randomized controlled trials and prospective cohort studies. The scholars analyze four studies that fit their inclusion criteria. They insist that the use of 30º repositioning cushions reduces interface pressure, which, in turn, leads to a reduced incidence of pressure ulcers in healthcare facilities. It is possible to claim that these results are reliable and credible since the authors deal with a high level of evidence.

The article by Sauvage et al. (2017) is a randomized, controlled, superiority, parallel-group, open-label, multicenter study of 76 patients. The scientists have compared the effectiveness of alternating pressure air mattresses (APAM) and viscoelastic foam mattresses (VFM). The authors admit that the APAMs are more effective compared to the VFMs. It is reasonable to involve a larger sample size to test the reliability of these results and consider their generalizability.

Alshahrani et al. (2021) offer a systematic review of randomized controlled trials, quasi-experimental designs, case series, and cross-sectional studies. Analysis of 14 articles demonstrates positive outcomes of using specific surface support in addition to repositioning. This information allows for concluding that there is a robust connection between the reduced HAPU incidence and a multifaceted intervention. However, the authors assess the level of evidence as moderate or low, meaning that further research is necessary.

An observational prospective cohort study by Bai et al. (2020) compares the effectiveness of non-pressure redistributing foam mattresses and pressure redistributing ones. The sample size of 254 participants was divided into experimental and control groups with 127 members in each. The authors indicate that the use of pressure redistributing mattresses leads to a significantly reduced risk of pressure injury occurrence. These findings allow for concluding that the combination of this intervention with repositioning can lead to better outcomes.

The results of this subtheme are of significance for the major theme and overall project. The articles demonstrate that pillows, as well as viscoelastic foam and air pressure redistribution mattresses, can cope with the task. In addition to that, the subtheme indicates that APAMs are better at decreasing the incidence of pressure ulcers among older patients. It means that the research field agrees that regular repositioning can be more effective if patients use specific mattresses that reduce pressure on individuals’ skin and muscles.

Additional Electronic Devices

This subtheme refers to the issue that appropriate electronic devices can improve the effect of repositioning and turning to reduce pressure injury incidence. This topic is addressed by a few relevant and timely studies that represent different methodologies. The studies try to answer the research question of whether various electronic devices, including automatic repositioning systems, wearable patient sensors, accelerometers, and others, can decrease the incidence of pressure injuries.

Edger (2017) conducts a prospective before-and-after study with 717 patients to test a repositioning device’s impact. The author also focuses on the cost-effectiveness of the given intervention. This repositioning device reduces the pressure injury incidence from 1.3% to 0%, while the return on investment accounts for more than $16,000 (Edger, 2017, p. 236). This information reveals that the tool under analysis maximizes the repositioning and turning advantages.

Knibbe et al. (2018) assess the effect of an automatic repositioning system on 13 patients over four weeks to analyze how an automated repositioning system can influence their skin. The authors admit that an automatic repositioning system leads to recovery from pressure ulcers. This article is another research piece that supports the idea that the combination of turning and repositioning with additional technological tools is beneficial for patients.

Minteer et al. (2019) analyze two sensor devices that imply no contact with the patient skin to track ten individuals’ movements. The scholars organize a specific experiment to assess this tool’s effectiveness. The study reveals that the sensor devices accurately track patient movements. This finding allows for concluding that medical professionals can rely on these devices to monitor if patients engage in regular repositioning and address this situation if some inefficiencies exist.

The study by Pickham et al. (2019) is a randomized clinical trial that includes 1,312 participants divided into control and experimental groups to evaluate the use of a wearable patient sensor. The experiment demonstrates that the tool under analysis is helpful since it makes patients change their positions every two hours. This approach results in the fact that the article offers arguments to support the effectiveness of 2-hourly repositioning.

Richardson et al. (2017) conduct a quality improvement program that took place in four adult critical care units with 88 beds in total to test the use of technical and non-technical interventions. The study reveals that wearable sensors lead to lower pressure ulcer rates. In particular, the authors claim that the HAPU incidence reduced by 63% over four years (Richardson et al., 2017, p. 433). Consequently, it is rational to rely on devices to address HAPUs.

Duvall et al. (2019) assess the effectiveness of the E-scale monitoring system for preventing pressure injuries among ten participants. The study reveals that the tool under analysis is capable of identifying patient movements with an increased level of accuracy. It denotes that the E-scale system can be considered a helpful instrument for healthcare professionals to monitor bed movements and promote them among patients when required.

A study by Yap et al. (2019) follows a mixed-method, pre- and post-test design. The scholars focus on 44 resident and 38 staff participants to identify whether a patient monitoring system can increase repositioning compliance. The study results demonstrate that this approach can increase the effectiveness of 2-hourly repositioning among nursing home residents. Consequently, this electronic device implies essential advantages that make it a helpful tool in preventing HAPUs.

Stinson et al. (2018) analyze the findings of two recent articles with at-risk cohorts, including 21 participants in total. The study assesses the use and impact of accelerometers and interface pressure mapping systems. It is the only study that fails to highlight the positive effects of using electronic devices. The scholars admit that accelerometers and interface pressure mapping systems are not effective in preventing pressure injuries.

The studies of this subtheme demonstrate that the use of electronic devices can improve the effectiveness of repositioning in combating pressure ulcers. Even though some research pieces may not identify positive outcomes, most articles reveal that medical professionals and establishments should make an effort to choose the most suitable interventions. These findings show a consistent set of literature that proves the effectiveness of using electronic devices to manage HAPUs.

The articles from this theme have certain limitations that deserve attention. Firstly, some studies are limited because they focus on small sample sizes (Hultin et al., 2019; Sauvage et al., 2017; Powers, 2016; Alshahrani et al., 2021; Bambi et al., 2020; Knible et al., 2018; Minteer et al., 2018; Stinson et al., 2018; Duvall et al., 2019; Yap et al., 2019). Secondly, other studies are narrow-focused, meaning that their results cannot be generalized (Gunningberg & Carli, 2016; Gunningberg et al., 2017; Jiang et al., 2020; Bai et al., 2020; Edger, 2017; Pickham et al., 2019; Richardson et al., 2017). That is why the scholars make specific efforts to ensure that these limitations are addressed. Some of them rely on reputable review guidelines (Alshahrani et al., 2021; Bambi et al., 2020), while others invest in following scientific principles to increase the level of evidence.

These results support the findings of Theme 1 that turning and repositioning are effective when used with additional interventions. It denotes that there is no gap in this area, meaning that the scientific processes of the DPI project should focus on turning and repositioning in isolation. Quantitative articles from Theme 2 demonstrate that this methodology can provide the required information to identify the effectiveness of quality improvement initiatives. The following section will determine how it is possible to affect HAPUs.

Pressure Injuries in the Healthcare Industry

Theme 3 presents the most generalized information on pressure ulcers and includes the smallest number of articles. This theme is necessary for the given project because it allows for understanding common concepts of how health care can address the issue and what challenges the problem brings to the medical industry. That is why 13 studies comment on how pressure ulcers develop, what nurses think of this problem, and what the first essential phenomenon to start combating pressure injuries is. Since this theme offers generalized data, it will be presented in a concise form.

HAPU Development

Since the DPI Project aims to assess the effectiveness of various pressure ulcer prevention and management methods, it is impossible not to draw attention to the theoretical background of this medical condition. It is a complex issue that implies an adverse impact on numerous patients. That is why it is necessary to understand how pressure injuries emerge. The researchers attempt to answer the question of what prerequisites lead to pressure ulcer development.

The study by Greenwood and McGinnis (2016) is a literature review of 32 root cause analyses to identify many HAPU risk factors, including mobility, nutrition, skin condition, and others. Latimer et al. (2019) conduct a prospective correlational study and stipulate that age and comorbidities are essential pressure ulcer prerequisites. In their systematic review and meta-analysis, Li et al. (2020) identify global HAPU incidence and state that people of various ages and genders suffer from the problem. An evidence-based article by Ricci et al. (2017) also reveals that versatile causes lead to the HAPU development.

A retrospective longitudinal cohort study by Wang et al. (2020) focuses on an Australian context and concludes that some medical tools, including a C-collar, can contribute to HAPUs. Simultaneously, a retrospective descriptive article by Cox, Roche, and Murphy (2018) argues that immobility and septic shock are among the most common pressure ulcer risk factors. Pittman, Beeson, Dillon, Yang, and Cuddigan (2019) offer another descriptive retrospective study highlighting that HAPUs can be preventable and unpreventable. The unavoidable HAPU occurs among patients with bowel management devices (Pittman et al., 2019). Irrespective of this fact, a cost-utility analysis by Padula et al. (2019) reveals that pressure ulcers should be prevented even though many conditions contribute to them.

These details demonstrate that pressure injuries represent a severe issue in the health care industry. Numerous patients suffer from them, and many factors cause these injuries. Thus, this subtheme is useful to understand that it is necessary to find a practical solution to the issue. That is why when a medical organization intends to minimize pressure injury incidence, it should implement a comprehensive and evidence-based approach to affect the problem.

Nurses’ Perceptions

When it comes to preventing or managing pressure ulcers, it is challenging to overestimate medical professionals’ role in achieving the desired outcomes and reducing the pressure injury prevalence. Nurses and others are responsible for turning patients or promoting them not to stay in one position for an extended period of time. Studies from this subtheme pose the research questions of what nurses think of a turning and repositioning approach.

The article by Gunningberg, Bååth, and Sving (2018) is a descriptive study of 50 medical professionals who participate in semi-structured interviews. The authors claim that nurses highly appreciate the use of pressure mapping systems to stimulate the repositioning and turning of patients. Simultaneously, Hommel, Gunningberg, Idvall, and Bååth (2017) conduct qualitative semi-structured interviews of 39 participants. This article shows that nurses believe that regular turning is an effective intervention to reduce pressure injury prevalence. A qualitative, exploratory, descriptive study by Garrigues, Cartwright, and Bliss (2017) shows that nursing students are aware of multiple prevention measures and positively appraise them.

This subtheme demonstrates that the issue of pressure injuries gathers the attention of multiple medical professionals. They understand the importance of the problem and have some opinions concerning the current interventions to improve the situation. The three articles have revealed that nurses and other medical staff positively assess regular turning and pressure mapping systems. They admit that these actions can improve patient outcomes and help them avoid pressure ulcers.

Training

It is necessary to state that nurses’ qualifications and skills can influence whether patients are at risk of having pressure injuries. Two articles of this subtheme address this topic and focus on nurses’ training. Thus, the researchers pose the question of whether written guidance is an effective method to reduce the incidence of pressure ulcers. These findings can demonstrate whether there is a connection between nurses’ training and repositioning.

Woodhouse, Worsley, Voegeli, Schoonhoven, and Bader (2019) conduct a pre-test post-test study with twelve participants. They argue that giving specific guidance to nurses makes them follow more effective turning practices. A cross-sectional prevalence study by Hödl, Eglseer, and Lohrmann (2019) demonstrates that nurses should be trained in risk assessment to identify what patients should get more attention to ensure that turning and repositioning lead to health benefits.

This subtheme reveals that training occupies an essential place in addressing HAPUs. When it comes to implementing turning and repositioning interventions, specific systems increase the staff’s compliance with the required actions. These findings are helpful for the given DPI project since they denote that the guidance to reposition or turn patients every two hours can help medical professionals mobilize their efforts to follow the prescription.

In Theme 3, the limitations of the articles are small sample sizes and work with outdated references. However, this section offers essential information for the DPI project. It relates to the fact that the literature review comments on HAPU risk factors, how medical professionals can address the situation, and what factors are necessary to achieve positive outcomes. This information introduces the appropriateness of undertaking the DPI project.

Project Methodology

A quantitative methodology is the most appropriate for the given DPI project. The rationale behind this statement is that it relies on numerical data, and this approach is necessary to identify the incidence of a particular phenomenon. Creswell and Creswell (2018) explain that the main benefit of this approach is that it allows for conducting an experiment to collect and analyze the data. Bell, Bryman, and Harley (2018) admit that this methodology applies different statistical tests, including t-test, which increases the reliability of the obtained results. Simultaneously, Rutberg and Boukidis (2018) stipulate that a quantitative method is appropriate when it is necessary to answer a clinical question to achieve quality improvement. Since the DPI project’s clinical question focuses on HAPU incidence, it is not a surprise that the quantitative methodology is the most optimal option.

One should also explain why the quantitative methodology is the best choice for the DPI project compared to other approaches. On the one hand, a qualitative method is not appropriate since it is used to identify new perspectives regarding a phenomenon under analysis (Creswell & Creswell, 2018). The DPI project is based on the existing knowledge about pressure injuries, meaning that this approach is not required. On the other hand, a mixed methodology is not suitable since it combines both qualitative and quantitative methods (Creswell & Creswell, 2018). Thus, the drawbacks of the qualitative method have been identified above, while a mixed approach is not also relevant since it can be time-consuming. It demonstrates that the quantitative methodology is the best approach since it is feasible for the DPI project and contributes to an increased clinical relevance because it focuses on the credible measurement of numerical data.

Project Design

The DPI project uses a quasi-experimental design to answer the clinical question. The reason for selecting this approach is the necessity of applying the intervention (turning and repositioning every two hours) and identifying whether it leads to improved outcomes (reduced HAPU incidence). Thus, the given design is relevant because Rutberg and Boukidis (2018) state that it allows for assessing the intervention’s effectiveness for experimental and control groups. Siedlecki (2020) also admits that case studies, descriptive, and correlational designs are not appropriate since they are less practical compared to the selected approach. Thus, it is necessary to stipulate that the quasi-experimental design is ideally aligned with the quantitative methodology.

The discussion of the DPI project design should devote sufficient attention to data collection and work with the project variables. The dependent variable that is the intervention is the use of repositioning and turning every two hours. This term stands for actions and efforts to make hospitalized patients change their postural positions. Nurses should ensure that the study participants follow the prescribed schedule. The independent variable refers to a HAPU incidence rate that is measured by focusing on the number of patients who develop pressure injuries during their hospital stay. The data for the independent variable is collected by analyzing electronic health records after the end of the intervention process. This discussion proves the statement by Rutberg and Boukidis (2018) that the non-experimental design is suitable for this DPI project. Thus, one can stipulate that the selected project design is appropriate to answer the clinical question.

Summary

Chapter 2 presents essential information for the whole DPI project. Ricci et al. (2017) and Li et al. (2020) show that HAPUs have long been a critical challenge in the healthcare industry, meaning that interventions are necessary. Watson’s (2018) nursing theory and Lewin’s (1951) change management theory explain that it is possible to address the issue by focusing on human-to-human caring moments to modify patients’ behavior. The literature review has revealed a science gap, and the DPI project purpose is aligned with it. Simultaneously, the review has demonstrated that many scholarly and evidence-based articles prove the effectiveness of turning and repositioning when used together with additional interventions. This statement implies that it is necessary to conduct a quantitative study to identify the impact of 2-hourly turning and repositioning without any additional aids. That is why the DPI project is a quantitative quasi-experimental study. Chapter 3 presents methodological details of the DPI project so that other scholars can understand and easily replicate all the project steps.

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