Introduction
Background information
During the last several decades, the problem of pressure sores in the intensive care units (ICU) did not receive the attention it deserved from scholars in the medical field. This is despite the fact that ICU patients are at high risk of developing pressure sores due to long periods of confinement to beds. Nevertheless, not all ICU patients end up with pressure sores, a fact that can be attributed to the implementation of effective prevention strategies.
On the other hand, in some cases, huge costs are incurred in preventing pressure sores among patients who are not at risk thereby necessitating an effective method of identifying patients who are at risk. It has been discovered that the development of pressure sores is not mainly attributed to poor nursing care as was originally thought. This is because the quality of nursing care over the past decades has improved tremendously and yet the problem of pressure sores still persists. As a result, it has been concluded that pressure sores are caused by multiple factors which are not taken into serious consideration by the medical practitioners.
Pressure sores “are also known by other terms such as pressure ulcers and decubitus ulcers,” (Lyder, 2003, p. 224). Pressure sores present themselves in different manners depending on their stage of development. For instance, they can develop as skin discoloration, skin abrasion, blister, and damage to subcutaneous tissue, damage to muscles, bones or supporting tissues (Lyder, 2003).
Area of practice
I have been working in an intensive care unit as a staff nurse for the last five years. The ICU takes care of eight patients at any given time. Since I began working there, I have witnessed the critical problem of pressure sores among the patients. Majority of the patients develop pressure sores within five days of admission. Pressure sores are a big problem to the ICU in that they increase the work load of the nurses and have negative outcomes on the patients. This paper proposes practice development as a way of reducing the incidence of pressure sores in the ICU.
Overview of the dissertation
The aim of this dissertation is to examine the problem of pressure sores among ICU patients. Although many studies have been written about pressure sores, the problem still persists. The dissertation proposes a preventive approach to pressure sores, specifically through continued monitor and positioning of patients. Section 2 is the literature review. The section will review a number of journal articles that have been written about prevention of pressure sores.
The journal articles chosen date between 2000 and 2010 and focus chiefly on pressure sores among ICU patients. Section 3 will examine practice development and what can be done to change the manner in which pressure sores are managed in my ICU. Section 4 will examine the planned change and the theories that will be used to support the change. Specifically the Kurt Lewin’s Three-Step Change Theory will be discussed and how this theory can be used to bring about successful change in the prevention of pressure sores in my ICU.
In addition, section 4 will examine how the proposed change will be evaluated to determine whether or not it is successful. The last section, section 5, will conclude the entire dissertation and will make recommendations as to what additional measures should be taken to address the problem of pressure sores in ICU patients.
Literature Review
Prevalence and incidence of pressure sores
Prevalence refers to “the total number of current cases in the entire population at any given time period,” (Gould et al., 2000, p. 165). On the other hand, incidence refers to the number of new cases of pressure sores in relation to the number of patients. Prevalence rates differ from one community to another and from one healthcare facility to another. The prevalence rate of pressure sores range between 0.43% and 0.86% in community healthcare centres; 2% and 20% in nursing homes; and 3% and 22% in hospitalized patients. The prevalence rates of pressures are greatest among patients with spinal injuries, ranging between 5% and 50%.
The incidence rates of pressure sores also differ from setting to another and range between 1% and 11% among hospitalized patients. It is sad to note that the greatest percentage of pressure sores develop within the first two weeks of admission (Gould et al., 2000).
Etiology of pressure sores
Pressure sores are mainly caused by pressure, shear or friction of the skin when it contacts a surface for a long time (Davies, 1994). When the skin comes into contact with a surface, compressive and shearing forces greater than a specified threshold and lasting for a particular time period will lead to tissue damage. However, the extent of tissue damage and the magnitude of the forces depend on tissue tolerance either to pressure or/and to tissue oxygen concentration. The magnitude of compressive force is influenced by the kind of surface that is used to support the patient, the posture of the patient and the body build of the patient.
The length of compressive force on the other hand is influenced by the ability of the patient to perceive painful stimuli and by the extent to which the patient is able to relieve himself from the painful stimuli. The magnitude of shearing force is also influenced by the type of support surface and the patient’s posture. Among ICU patients, the length and intensity of forces are adversely affected by the minimal activity, limited movement, skin maceration (due to sweating, incontinence or oozing wounds) and loss of sensory perception (due to ICU-related drugs such as sedatives) (Hill, 1992).
Consequences of pressure sores
The development of pressure sores has serious effects not only on patients but also on the health practitioners. Patients with pressure sores are negatively affected through pain, dysfunctionality, loss of independence, higher risks for developing infections and sepsis, as well as additional surgeries. All these factors translate into lengthy hospital stays, high costs of medical care and high mortality rates.
In a study conducted by Clough (1994), the results showed that ICU patients without pressure sores had a mortality rate of 15% while those with pressure sores had a mortality rate of 63%. However, the effect of pressure sores on mortality is not direct. This is because patients with critical illnesses are more at risk of developing pressure sores and more at risk of dying than their counterparts. Besides affecting patients, pressures sores also have a negative effect on the healthcare providers, especially nurses.
Pressure sores development increases the workload of nurses by almost 50% mainly due to prolonged hospital stay and the additional care required by patients with pressure sores. These factors also increase the costs incurred by hospitals or units that have patients with pressure sores. According to Lapsley and Vogels (1996), pressure sores increase the length of hospital stay by approximately eleven days.
The prolonged stay in turn increases the costs of hospitals by approximately 65% whereas an additional 25% of the costs are caused by extra nursing care. Other factors related to pressure sores which increase the costs of hospitals include the utilization of devices such as special mattresses and beds to manage the patients and additional medicines, dressings and diets required by the patients. Various researchers have found that the treatment of pressure sores is costlier for hospitals than prevention (Lapsley & Vogels, 1996; Waterlow, 1995).
Risk factors of pressure sores among ICU patients
The risk factors of the development of pressure sores are similar for ICU and non-ICU patients. Nevertheless, the risk factors are more intense among the ICU patients due to the nature of the patients. ICU patients have limited mobility and stay in one position for a long time unless the position is changed by nurses (Theaker et al., 2000). Thus, ICU patients are unable to change their positioning in bed resulting in high risk of developing long and intense pressures.
In addition to limited mobility ICU patients also engage in limited, if any, physical activity. Second, ICU patients are administered with drugs such as sedatives and anaesthetics, which reduce their sensory perceptions. As a result, such patients cannot feel pain resulting from pressure or friction and therefore they cannot react to such pain, for instance, by changing their position (Jiricka et al., 1995).
Third, ICU patients experience increased skin moisture resulting from excessive sweating, oozing wounds and/or faecal incontinence. The increased skin moisture increases the risk of developing pressure sores by approximately five times (Reuler & Cooney, 1981). Fifth, ICU patients have a higher encounter with excessive compressive, shearing and friction forces. This is because they are confined to bed for long periods of time. For instance, shearing forces occur when a patient is in need of repositioning. In addition, elevating the head and trunk of a supine patient to greater than 30 degrees makes the patient to slide downwards creating shearing forces on the heels and sacrococcygeal areas of the patient.
Prevention of pressure sores
Prevention of pressure sores is less costly than treatment. It is therefore important for nurses in the ICU to take measures that will prevent the development of pressure sores among the patients. A number of measures have been proposed and used in the ICU to prevent pressure sores. The main objective of prevention of pressure sores is to reduce high degrees and long periods of pressure. The most significant preventive measure is regular positioning of patients.
This requires nurses to create a log for each of the patients. The logs are then used to record each repositioning made on the patient. It is also important to record any changes in the patient’s condition, such as skin condition, after every repositioning. This helps in assessing the risk of the development pressure sores (Sollars, 1998). It is recommended that patients should be repositioned after every two or three hours, if their health condition permits it. The best method of repositioning ICU patients is the 30 degrees tilt, which does not involve any lifting of the patient and has no risk of damage caused by friction.
In addition, the 30 degrees tilt has lower pressure compared with the 90 degrees tilt. When placing patients on their backs, nurses should use the semi-Fowler position, with 30 degrees elevation of the head, trunk, and feet. Nurses should also pay close attention to pressure on the patients’ heel which can be reduced by putting a pillow beneath the lower legs. Other preventive measures include using special support surfaces such as special beds (such as air-fluidized beds), and pressure-reducing mattresses. Reducing excessive skin moisture and nutrition are also used to prevent pressure sores among ICU patients (Hampton, 1997).
Introduction to the literature review
A number of journal articles have been published on the problem of pressure sores. Unfortunately, majority of these studies focus on general hospital populations rather than on intensive care units patients. This is despite the fact that ICU patients are more at risk of developing pressure sores compared to patients in general hospitals. The number of literature focusing on pressure sores in ICU patients is relatively small.
This dissertation makes use of journal articles that focus on pressure sores in ICU patients, and which have been published between 2000 and 2010. The main aim of the literature review is to identify what has been done so far in the area of pressure sores in ICU patients, what preventive measures are being used to minimize the incidence of pressure sores among the ICU population, as well as to identify any gaps in clinical practice as far as preventing pressure sores among ICU patients is concerned. In addition to journal articles, the dissertation will also review national guidelines on the prevention of pressure sores.
A review of journal articles
Antle and Leafgreen (2001) conducted a study to examine the factors that influence the high increase in the number of patients with pressure sores and to develop a program that would reduce the incidence of pressure sores. The study was undertaken at an ICU of a 500-bed medical centre located in the Midwest. Before the study was done, the committee members convened and discussed their observations of clinical practice in the ICU. They observed that heel elevation was not a common practice and repositioning of patients was done irregularly. The ICU also did not use special support devices such as beds and mattresses. Antle and Leafgreen (2001) created a prevention program that consisted of two interventions. The first intervention involved the use of the Gaymar Sof-Care static air overlay as a support device for the participants.
The second intervention entailed the reposition of patients after every two hours. Specifically, a turning log was created for each of the participating patients on which documentation of repositioning was done. Failure to reposition a patient after the two hours required the nurse to document the reason behind the failure. The nurses were also told to shift the bodies of the patients who could not be repositioned so as to alter the pressure points.
Appropriate heel elevation was also done to ensure that the heels do not come into contact with the bed. The nursing staffs were educated about the project through posters and phone mail. These interventions were highly effective in the institution of study. A total of fifty patients took part in the study. During the period of study, 98 percent of the participants (49 patients) did not develop pressure sores. Only one patient developed a stage I pressure sore. Despite these impressive results, the researchers could not identify which of the interventions made the greatest impact or if it was a combination of the interventions.
Cantrell (2009), in her article, examines decubitus ulcers and how they can be prevented and managed. She argues that one of the most effective ways of preventing decubitus ulcers is to create awareness among the nurses through education and training programs. Specifically, she advocates teaching nurses how to identify changes in the skin of patients. Other measures include increasing the mobility of patients through turning them after every few hours, improving the nutrition, diet and fluids of patients, appropriate and adequate care of the skin to minimize moisture, as well as regular documentation of care of patients so as to identify any changes in the patients.
Ozdemir, Karadag and Doughty (2008) examined the problem of pressure sores in three Turkish ICUs. The aim of the researchers was to identify the extent of preventive measures implemented against pressure sores by the three ICUs. The study was based on the notion that the quality of care provided by nurses plays an important in the development of pressure sores. The researchers made use of a sample of 30 nurses, selected from a population of 126 nurses using stratified sampling technique.
The data used were collected from evaluation, questionnaire and observation forms as well as the Braden Scale. Prior to the beginning of the study, the patients under the care of participating nurses were examined and assessed for risk of pressure sores using the Braden Scale. Thereafter, the participating nurses were required to fill the demographic forms. The participants were then observed as they took care of the patients in the ICU units. However, observation was only done for cases which included patients who were at risk of pressure sores. In the end, a total of ninety observations were done; three observations for each of the thirty participating nurse.
The results from the demographic forms showed that four-fifth of the nurses were licensed practical nurses and 73.3 percent of them had worked in an ICU for the past two to four years. Only a small number of the numbers (16.7 percent) had participated in a training program on pressure sores and none of them had taken part in a scientific conference about pressure sores. A great majority of the nurses did not read habitually resources on pressure sores.
Moreover, only 13.3 percent of the nurses felt that their care of the ICU patients was sufficient in preventing pressure sores. The observation on the care of ICU patients revealed that many nurses did not implement adequate preventive measures against pressure sores such as assessing patients for risk of developing pressure sores, recording the assessment and positioning the patient. The conclusion made was that the inadequate care of ICU patients for the prevention of pressure sores was due to lack of education and training of nurses about pressure sores. The researchers therefore recommended that nurses working in ICU should undergo additional training that chiefly focuses on pressure sores, their prevention and care.
The significance of nurses’ knowledge in preventing pressure sores has also been examined by Tweed and Tweed (2008) who argued that effective prevention of pressure sores require the caregivers to have adequate knowledge about the problem. The study conducted by Tweed and Tweed aimed at evaluating the level of knowledge among ICU nurses as well as the effect of an educational program on nurses’ knowledge level.
This study was conducted in an ICU of a tertiary hospital, the Wellington Public Hospital, located in New Zealand. The study made use of all registered nurses of the ICU. The knowledge of the nurses was evaluated using written tests on three different occasions, namely: before being admitted in an educational program, two weeks after admission in the program and five months after the program. The educational program was administered by one investigator to small groups of nurses over a period of two weeks. The content covered by the education program included the etiology, risk assessment, risk factors, recording, prevention and management of pressure sores.
The results showed that the participants had high level of knowledge about pressure prior to the educational program. The level of knowledge further increased two weeks after the educational program but declined to baseline five months after the intervention. The reason given for this trend is that nurses and the organization may not attach great importance to pressure sores due to other more serious conditions affecting ICU patients.
The researchers therefore suggested that habitual learning is needed to avoid knowledge decay. Although the participants in this study had high knowledge levels about pressure sores, the researchers were cautious in linking the high levels of knowledge to practice. They argued that having knowledge does not necessarily mean that nurses put their knowledge into practice. Thus, practicing the knowledge is more important than having the knowledge by itself.
Reilly et al. (2007) argue that few studies have been published on pressure sores in the intensive care units. Even grimmer is the fact that fewer studies have focused on the prevention of pressure sores in the ICU. They argue that ICU patients are the most ill and dependent patients and therefore there is a need to understand pressure sores, their causes, etiology, and successful ways of preventing and treating them.
They argue that prevention is the best treatment of pressure sores and assert that there are various reasons which justify the fact that many pressure sores can be prevented. This is because at-risk patients can easily be identified before they develop pressure sores through risk assessment tools. In addition, there are various preventive measures which can be used for at-risk patients. Moreover, close follow-up can easily be done on the at-risk patients to identify any changes in their skin and functionality.
Reilly et al. (2007) further argue that there is need to use sound clinical judgment in choosing the magnitude and extent of preventive measures which are most appropriate for any given patient. These preventive measures include minimizing or eradicating the factors which lead to pressure sores such as friction, shear forces, poor nutrition, and incontinence. As earlier mentioned, the measures that can be used to reduce such forces include regular positioning of patients and use of special mattresses and beds.
Reilly et al. (2007) further asserted that the responsibility of reducing the incidence of pressure sores should not only rest on the nursing staff but also the healthcare facility. The healthcare organization can take various steps that can reduce the number of ICU patients suffering from pressure sores. For instance, the organization can create protocols for the prevention and treatment of pressure sores.
These protocols should be subject to regular assessment and evaluation to ensure that they are effective. Second, the organization should create quality improvement teams whose duty is to discuss and ensure that the measures put forth are used. Third, the organization should create education and training programs for the nurses and other healthcare practitioners to create awareness about pressure sores and how they can assess at-risk patients, and prevent and treat pressure sores. The organization should also provide devices and instruments that reduce the incidence of pressure sores such as pillows, cushions, and special mattresses and beds.
Quality improvement programs that make use of both staff education and technology are said to be effective in preventing pressure sores. New technologies in rehabilitation engineering such as passive standing can be used to enhance the mobility of immobile patients. Physicians in charge of patients with mobility problems should also be on look out for factors that constrain the ability of patients to change their positions.
This can be achieved by documenting the history of the patient, conducting physical assessment, making use of laboratory data and managing the highlighted conditions and risk factors. Other technologies include fluidization which makes use of warm air to reduce the development of pressure sores. Fluidized beds have been found to be very effective in reducing the development of pressure sores or deteriorating the already formed pressure sores. Unfortunately, such beds are very costly and impractical for the prevention of pressure sores among all at-risk patients (Reilly et al., 2007).
Shahin, Dassen and Halfens (2008) conducted a longitudinal study to examine the incidence of pressure sores and methods by which they are prevented and treated. The patients taking part in the study (a total of 121 patients from a university hospital and a general hospital) were assessed twice during the study: first when admitted at the ICU and second when they died or two weeks after admission if they were still in the ICU. The researchers collected their data using a questionnaire that contained demographic data, the occurrence of pressure sores, the stage of pressure sore, the location of the pressure sores, during, origin and the preventive measures used by the nurses.
The demographic data showed that 56.2% of the patients were male while 43.8% were female. The average length of hospital stay for all patients was seven days while that of patients with pressure sores was 9.5 days. The incidence rate was found to be 3.3%. The researchers also found that the greatest number (75%) of new pressure sores developed more than one week but less than two weeks after admission at the ICU, while 25% of the pressure sores developed within the first week of admission.
The researchers also found that the most commonly used preventive measures were: foam, standard and alternating air mattresses, skin inspection, mobilisation and massage. Nutrition and fluid intakes were used inadequately. The researchers concluded that pressure sores in ICU can be cured and prevented if the appropriate measures are taken such as regular assessment and inspection and the use of protective special devices such as foam mattresses (Shahin et al., 2008).
Elliott, McKinley and Fox (2008) argued that the incidence of pressure sores among ICU patients can be reduced if quality improvement programs are formulated and implemented. The main objectives of their quasi-experimental study were: enhancing the patients’ outcomes by minimizing the number of patients admitted in ICUs who develop pressure sores, highlighting the areas that need to be improved so as to prevent the occurrence of pressure sores and encouraging the utilization of pressure sores preventive methods in ICUs. The study was undertaken in a general ICU of a teaching hospital located in Sydney, Australia. Before the study, the patients taking part in the study were assessed for risk of pressure sores.
The reason behind this was to allow for assessing any improvements in pressure sores preventing after the intervention program. The baseline survey showed that majority of the patients had very high risk of developing pressure sores and yet they were not provided with special devices for preventing the sores. The nurses in charge of the ICU patients were also trained on risk assessment, documentation, skin inspection, and prevention measures.
The results showed that at baseline, the prevalence rates among the critically ill patients were very high, higher than international rates. After the intervention program (which consisted of the use of pressure-reducing devices), the prevalence rates declined significantly, from 50% to 8%. The intervention also “increased the use of pressure-relieving devices from 75% to 100%” (Elliot et al., 2008, p. 331).
The success of the intervention program was attributed to the multi-faceted approach used. The program involved the nurses in an education program that included not only interpersonal clinical instructions but also constant reminders, feedback on nurses’ performance and patients’ outcomes as well as the documentation of raw data on the prevalence rates on notice boards. The use of raw data was particularly effective on the education program because it enabled the nurses to witness first-hand the effect of various preventive measures on the incidence of pressure sores. This study also highlighted the significance of utilizing quality improvement tools such as the Plan-Do-Study-Act and of evidence-based practice. Most importantly, involving the nurses in the study equipped them with knowledge and skills thereby ensuring the sustainability of the intervention (Elliott et al., 2008).
A review of clinical and national guidelines
A number of clinical and national guidelines have been published on pressure sores across the globe. This dissertation will review two clinical guidelines and one national guideline. The Royal College of Nursing (2001) published a clinical guideline that gives recommendations on how the risk for developing pressure ulcers can be assessed and how pressure sores can be prevented. The first recommendation given is to identify those patients who a have risk of developing pressure sores. The assessment should be done by clinical personnel who have been appropriately and adequately trained to identify the risk factors. Assessment should also be done within six hours of admission. Patients who have been identified as not at-risk should be reassessed when any of their health conditions changes.
The second recommendation is that clinical judgment should not be superseded by any risk assessment tool. Therefore, risk assessment tools should only be used to complement clinical judgment and the tools should be tested for validity and credibility before being used. Third, the risk factors of the patient should be taken into consideration when conducting a risk assessment. Fourth, the skin of the patients should be inspected regularly depending on the changing conditions of the patients as far as deterioration or recovery is concerned. Documentation of any changes in skin condition should be done immediately. Fifth, devices for relieving and redistributing pressure should be used based on risk assessment and holistic individual assessment including for factors such as comfort and the overall health status.
The other recommendation given is positioning of at-risk patients depending on changes in the skin condition and individual needs rather than on rituals. Repositioning should also take into account other factors such as the comfort of the patient, support surface and health condition. At-risk patients should also be allowed to stay out of bed for less than two hours every day. In addition, positioning should be done in a manner that minimizes shearing, compression and friction forces. Each patient should have a documentation prepared by the nurse in which each repositioning made is recorded along with any observed changes.
Patients who are confined to chairs should be assessed by expert professionals and the appropriate seating positions established. Weight distribution, feet support and alignment of posture should also be considered for such patients. The last recommendation given is the education and training of health personnel. Specifically, the education and training programs should be inter-disciplinary in nature. Other recommendations given include good nutrition, management of incontinence and observing hygiene (Royal College of Nursing, 2001).
Similar recommendations have also been given in a guideline published by the Ministry of Health (2001) of Singapore. In addition to the recommendations discussed above, this guideline suggests that the skin of ICU patients should be cleansed on a regular basis and after soiling. “Warm water and mild cleansing agent should be used to reduce skin irritation and dryness,” (Ministry of Health, 2001). In addition, the skin should not be exposed to environmental factors such as cold which dry the skin. To counteract these environmental factors, dry skin should be moisturized. The guideline also warns against massage of areas that are at risk of developing pressure sores.
In Malaysia, guidelines on the assessment, prevention and treatment of pressure sores are found in APUAP Clinical Practice Guidelines for the Prediction, Prevention and Treatment of Pressure Ulcers. This is an alliance between the Australian Wound Management Association (AWMA) and neighbouring countries such as Malaysia, Singapore, New Zealand and others. These guidelines have had significant benefits to patients as well as healthcare organizations. They have improved the quality of care provided to patients by ensuring that patients receive adequate and timely care. They have also led to the discovery of less costly yet effective intervention measures thereby improving the quality of life of patients, reducing their mortality and morbidity rates and reducing the costs incurred by healthcare organizations.
Overview of the literature review
Various studies and clinical guidelines have been reviewed to identify the preventive measures that are used against pressure sores. Although the studies may differ from setting to setting, from country to country and from sample to sample, they are common in a number of ways. To begin with, the literature review has shown that prevention of pressure sores is a long process which begins by assessing the risk of ICU patients upon admission. The assessment should be done by qualified and trained clinical personnel using clinical judgment and risk assessment tools whose validity and credibility should be tested a priori.
Second, although there are many preventive measures, the most effective is regular repositioning of immobile patients so as to reduce pressure and to change the pressure points. Repositioning should however be done cautiously to minimize compressive, shear and friction forces. Nutrition and fluid intake as well as skin inspection and care have been shown to play an important role in the prevention of pressure sores. Most importantly, the literature review has highlighted the importance of nurses’ education and training in reducing the incidence of pressure sores. All the above measures cannot be implemented successfully if nurses do not have the knowledge about pressure sores or if they do not practice their knowledge.
Practice Development
Meaning of practice development
Practice development refers to “a systematic approach that aims to help practitioners and healthcare teams to look critically at their practice and identify how it can be improved,’ (McCormack et al., 2009, p. 93). The process of practice development deals with tangible plans and programmes and it also deconstruct and rebuilds a variety of patterns in the organization which help workers to have a clearer understanding of their organizational culture and responsibilities. Thus, the main goal of practice development is to create more successful working environment and culture that are driven by person-focused processes and systems (Carradice & Round, 2004).
The person-focused process of practice development is indeed one of its key features. Person-focused process puts emphasis on individuals by encouraging respect towards each individual, and holding each individual with high esteem. It involves respecting the rights of individuals and interacting with individuals in a manner that enhances their dignity, self-worth and autonomy. This is the core of the nursing profession and healthcare industry.
Quality health care depends significantly on the care givers, that is, the healthcare providers. It is the healthcare givers who build and maintain an environment and culture that promotes the caring of patients and their loved ones. Although healthcare practitioners play an important role in care giving, the organizations in which they work also affect the quality of care given to patients because the organizational system impacts directly on the healthcare practitioners (Garbett & McCormack, 2001).
Organizational culture is important in nursing and healthcare as a whole. Practice development helps to change organizational cultures by encouraging employees and their managers to critically examine their values and beliefs about patient care and to alter them in a way that promotes quality patient care. Healthcare teams are made to change their behaviours, procedures and systems in a way that promotes person-focused values (McCormack & Garbett, 2003).
Practice development facilitators help employees and managers to be aware of what should be changed and their roles in promoting continuous improvement. This requires reflection on the part of the employees and managers as well as an evaluation of proof from their practice. It also requires them to adopt evidence-based practice, to have consistency and to carry on with newly created initiatives (Unsworth, 2000). In order to encourage change in the workplace, practice development facilitators create processes that: engage staff in a continuous learning process; encourage staff to be in charge of their practice; incorporate active learning and create new knowledge, skills and culture.
Principles of Practice Development
There are nine major principles of practice development that are used to drive practice development in the nursing profession and other healthcare activities. The principles offer the benchmark by which any practice development activity should be carried out and thus separated from other activities. The first principle is person-focused culture which focuses on the quality of care accorded to clients and their families. This requires educating and empowering the staff so as to change their culture and mindset (Dewing, 2008).
The second principle is facilitation which makes use of practice development facilitators to create awareness among the staff about the required culture and change and to help them adopt the proposed change (Shaw et al., 2008). The third principle is authentic engagement in which practice development facilitators interact with others through reflexive engagement. The fourth principle entails incorporating personal characters and creativity with skills and wisdom.
This makes it easy for staff to critically analyze their practice and to find new solutions to problems as well as realize alternative viewpoints. Active learning is the fifth principle which entails a deep learning process that makes use of creative synthesis and a variety of learning approaches. It also incorporates the experiences of health providers and their clients, critical reflection and sharing experiences with others. This process requires openness on the part of the healthcare practitioners to the experiences of others (Titchen, 2004).
The sixth principle involves changing the practices of individuals and teams, specifically their cultures. Culture change is a critical focus area in practice development. Because practice development puts emphasis on persons, it requires individuals and organizations to shift their focus from the bottom line to individuals. The seventh principle is corporate strategy which involves aspects such as sustainability, feasibility and acceptability (McCormack et al., 2007).
Sustainability implies the ability of the staff and managers to continue on with the proposed change and new initiatives long after the practice development facilitators are gone. Feasibility implies the probability of the success of the proposed change or initiatives while acceptability means the willingness and readiness of the staff and managers to embrace the proposed change/initiatives. The eighth principle entails “utilising a set of processes, including skilled facilitation that can be translated into a specific skill-set required as near to the interface of care as possible” (McCormack et al., 2009, p. 94). The last principle entails evaluating practice using methods that are comprehensive, participatory and mutual.
Forms of knowledge used to support practice development
Practice development involves different types of knowledge. In shifting the practice in the ICU so as to reduce the incidence of pressure sores, different forms of knowledge will be used and integrated into the practice. The first knowledge is theoretical knowledge which is obtained through a logical thought process. The nurses will make use of nursing theories that exist in the literature to guide their practice development. Nevertheless, it is important not to blindly follow the theories but to use them cautiously and apply them individually to every case they have. The second knowledge is empirical knowledge which is obtained through research.
The ICU staff, especially the advanced nursing practitioners, will conduct research on the problem as well as critical review of prior research studies that have been conducted to examine the problem. The importance of such critical review is to provide solid evidence for the practice of positioning of patients so as to reduce the incidence of pressure sores. The third is practical knowledge, which originates from nursing practice and may be obtained either from logical thought or research, or both. Experiential knowledge is knowledge that is gained from the every-day experience of the ICU nurses.
This form of knowledge is important because patients differ from one to another and therefore what is applicable to one may not necessarily be applicable to another, even if the same practice is undertaken. Interpersonal knowledge is knowledge obtained from interactions of the ICU nurses with their colleagues, patients, patients’ families, and other professionals. The ICU nurses can learn a lot from the experiences of their colleagues and other professionals. In addition, the experiences of the patients and their families can go a long way in influencing their practice and enhancing the quality of care of their clients.
The last form of knowledge is rituals, which include the traditions of practice in the ICU. It is important for the ICU nurses not to do what has always been done just because it provides them with a comfort zone (Brooker & Nicol, 2003). The proposed change should be welcomed and tried out to examine if it will have a better effect on patient outcomes. The failure of the proposed change should also be seen as a stepping stone towards better and improved care techniques by the nurses.
Planning Change
As earlier discussed, a high incidence rate of pressure sores has substantial disadvantages to all parties of a healthcare organization. For the patients, pressure sores translate into deteriorating health condition, additional medical and surgery procedures, high medical costs, longer hospital stays and high rates of morbidity and mortality. For the healthcare practitioners, especially nurses, pressure sores imply longer working hours, higher work loads, and more fatigue. For the healthcare organization, pressure sores lead to higher costs incurred in purchasing more equipment for the patients such as special mattresses and beds which are costly.
Because of these reasons, this dissertation proposes several changes to be made in the intensive care unit so as to prevent the occurrence of pressure sores rather than manage or treat pressures after they develop. The main objective of the proposed change is to reduce the incidence of pressure sores in the intensive care unit from the current 9 percent to a minimum of one percent within a period of one year.
Continuing monitoring of intensive care unit patients
Prevention of pressure sores requires continuous monitoring of the patients’ skin condition. This entails checking for any changes in the patients’ skin condition, maintaining high standards of hygiene, managing skin moisture, and managing patients’ continence (Cullum et al., 1995). It has come to the attention of the supervisor that the nurses working in the ICU do not carry out continuous monitoring of patients’ skin condition. Specifically, nurses go for days before inspecting patients’ skin condition, and patients’ clothes and beddings are changed only twice a day despite the frequency of incontinence.
The main challenge facing the nurses in skin inspection and management of patients’ hygiene, moisture and continence is lack of adequate time due to work overload. To address this problem, the supervisor will buy moisture-absorbing and continence aids and train the nurses on how to use them. The nurses’ workload will thus be reduced and they will have adequate time to conduct skin inspection. In addition, to ensure that skin inspection is done regularly, the supervisor will introduce a recording mechanism through which nurses will be required to document the time, and the outcome of every patient’s skin inspection.
Positioning of patients
Besides regular assessment and continuing monitoring of patients, this paper also proposes positioning of patients as a preventive strategy. Individuals who have high risk of pressure sore development should be repositioned on a regular and frequent basis (Clark, 1998). It has come to the attention of the ICU supervisor that nurses are not aware of the importance of patients’ repositioning in reducing pressure sores.
Patient repositioning in the ICU is always done in a ritualistic manner, specifically after every three hours, irrespective of the differing degrees of risk among the patients. To address this problem, the nurses will be educated on the importance of patient repositioning, the different methods of repositioning and their suitability to patients differing conditions. In addition, once a patient is admitted to the ICU, he or she remains confined to his/her bed.
The nurses do not encourage mobility of the patients, which encourages the development of pressure sores. To address this problem, nurses will be directed to allow bed-ridden patients to stay out of their beds for at least two hours every day. To make the work of the nurses easier, the supervisor will create a schedule of the nurses that will state what time of the day and for how long the patients should be allowed to stay out of their beds. Repositioning should ensure that “prolonged pressure on bony prominences is minimised and bony prominences are kept from direct contact with one another” (Royal College of Nursing, 2001, p. 17). The change plan is shown in appendix A.
Theories and models of change
Introduction
In nursing, there are many different types of theories which are used to “understand, explain, predict or change nursing phenomenon” (Meleis, 2007, p. 45). These theories may have originated from other disciplines, other theories, nursing practice, and experiences of nursing, or nursing practice. The different theories used have different purposes and hence the use of any theory depends on the goal of the user (Burns & Grove, 2005). Change theories are used to guide and explain the change process that takes place in a nursing arena. This paper makes use of Kurt Lewin’s Three-Step Change Theory to guide the change in practice with regard to preventing pressure sores.
Kurt Lewin’s Three-Step Change Theory
The three-step change model was formulated by Kurt Lewis in 1951. According to Lewin, “behaviour can be seen as a dynamic balance of forces working in opposing directions,” (Marquis & Huston, 2008, p. 168). He argued that some forces enable change to take place because they guide the workers in the required direction. On the other hand there are some forces which deter change because they guide employees away from the desired direction. As a result, both the positive and negative forces should be assessed. The three-step change theory of Lewin can help to create a balance in the desired direction of the change
According to Lewin’s three-step theory, the first step in bringing about change is known as the unfreezing stage. This implies the unfreezing or undoing of the current state or the status quo. Unfreezing is a crucial stage in defeating the limitations brought about by individual opposition and or group conformity. This process can be attained through three strategies. The first strategy is to increase the driving forces that have the potential of directing behaviour away from the current state. The second strategy is to reduce the negative forces that hinder the movement from the current state to the desired state.
The third strategy is to combine the first two strategies; that is, using both positive and negative forces to drive change. There are some activities that can help in unfreezing the current situation and include: encouraging all those involved by making them ready for change, building trust and realizing for the necessity of the change, as well as playing an active role in identifying problems and discussing possible solutions with other team members (Ziegler, 2005).
Lewin’s first step of change can be used in bringing about change in the manner in which pressure sores are managed in the intensive care unit. To begin with, the nurse manager, acting as the key change agent, recognizes the necessity of doing things differently so as to reduce the incidence of pressure sores. Other preventive methods that have been used all along have not proved to be as effective as desired because the incidence rate is still high.
Once the nurse manager has recognized this need, she creates awareness among other nurses and together they brainstorm for possible solutions to the problem. They realize that the high incidence rate of pressure sores can be reduced through continuing monitoring of the patients’ conditions and regular repositioning of the patients. The unfreezing stage takes place when the proposed preventive methods of pressure sores are introduced in the entire organization thereby creating disequilibrium or distorting the status quo (Marquis & Huston, 2008).
The second stage in Lewin’s theory of change is referred to as the movement stage. Roussel and Swansburg (2006) argue that, “in this step, it is necessary to move the target system to a new level of equilibrium,” (p. 63). There are several strategies that can be used to achieve a new equilibrium level. The first strategy includes convincing other staff members that the current situation is not of merit to them, the clients and the organization. Another strategy is to encourage the staff to adopt a different perspective towards the problem and to work collaboratively to search for novel and appropriate information about the problem.
Lastly, the views and opinions of the staff should be discussed with the managers who are in support of the change. With regard to reducing the incidence of pressures in the intensive care unit, the nurse manager can use this stage by collecting information about the problem and possible solutions from other staff members and sources such as literature published on the same topic. This is especially important because it promotes the implementation of evidence-based practice (Utley, 2010). Once the solutions have been given and agreed upon, the nurse manager proceeds with the creation of a plan of action. The proposed solutions, in this case, continuous monitoring and regular repositioning of the patients, are then put into practice according to the plan.
The third stage in Lewin’s theory of change is referred to as the refreezing stage. This stage mainly entails undertaking activities that will ensure the sustainability of the change. It is implemented after the change has already taken place. Often, it is common for the old behaviours to be adopted again once a change has been implemented in an organization. This stage entails incorporating the novel values into the organizational culture.
Swansburg and Swansburg (1995) argue that “the purpose of refreezing is to stabilize the new equilibrium resulting from the change by balancing both the driving and restraining forces” (p. 251). One strategy that can be used to achieve sustainability of change is to reinforce new behaviours and make them part and parcel of the organizational culture through both formal and informal means, for instance, through legislations, processes and organization’s policies.
Sustainability is of critical importance because it addresses the issue of what would happen if the change agent is removed from the organization. It is important to note that the role of the change agent is time-limited and at some point he or she will have to terminate the change agent role. It is therefore important to implement strategies which will ensure that the employees of the organization will carry on with the proposed change once the change agent abandons his or her role.
This necessitates a collaborative approach to implementing the change implying that the staff members should be made part and parcel of the change right from the word go. It implies involving all staff members in discussing about the problem, sharing ideas and opinions about possible solutions and working together to implement the agreed-upon solutions.
This is effective in ensuring sustainability because the employees will feel appreciated and as a result they will view the change as their contribution rather than as a change that has been pushed down their throats. If the employees are not included in the change, they are more likely to view the proposed change with contempt and therefore negative forces – in the form of resistance and opposition – towards the change may outweigh the positive forces thus hindering the realization of the proposed change.
One important element of the refreezing stage is evaluation of results. In particular, once the change has been implemented in an organization, the organization needs to conduct evaluation or assessment to determine the success or failure of the change. Evaluation can be done monthly, quarterly, semi-annually or annually, depending on the needs of the clients, staff and organization. The importance of evaluation is that it can bring to light the challenges facing the change implementers as well as the strengths and weaknesses of the proposed change. This can help the organization to revise the proposed change if and when need arises (Ziegler, 2005).
With regard to reducing the incidence rate of pressure sores in the intensive care unit, the nurse manager, acting as the change agent, will work with the organization’s managers to incorporate continuing monitoring and regular repositioning of patients in the organization’s policies.
Other strategies will include organizing quarterly education and training workshops for the nurses as a way of reminding them about pressure sores, their causes, risk factors, what is required of them as far as preventing pressure sores is concerned, and how to best implement the newly proposed preventive measures. Besides using policies and education and training programs, educational resources such as posters will be placed in every intensive care unit. The posters will contain all the crucial information pertaining to pressure sores and their prevention. The posters will serve as strong reminders to the nurses about preventing pressure sores. As a result of all these strategies, the old status quo will be strongly done away with and the new status quo will be easily attained and sustained.
To determine the success, strengths and weaknesses of the newly implemented preventive measures of pressure sores in the ICU, evaluation will be conducted after every three months. The evaluation will include questionnaires to the ICU nurses in which the nurses will highlight their experiences with the new preventive measures. Secondary data will also be used, particularly, on the number of new critically ill patients who are admitted without pressure sores, development of pressure sores and the time frame of pressure sore development.
Overview of change theories
In sum, the Lewin’s three-stage change theory is about using forces to bring about change. There are two types of forces; positive and negative forces. Positive forces promote change while negative forces hinder change. Although both forces may exist in any given situation and at any given time, the success or failure of a proposed change depends significantly on which of the two forces is greater than the other. In order to reduce the incidence of pressure sores in ICU, the change agent, the nurse manager, should keep in mind that opportunities exist for the proposed change to be effective.
Likewise, negative forces towards the proposed change also exist in the form of hesitation, opposition and the unwillingness of the staff to leave their comfort zones for an uncertain destiny. It is therefore up to the nurse manager to increase and reinforce the positive forces so that they outweigh the negative forces. Only then will the organization be able to successfully adopt the new preventive methods of pressure sores.
Evaluation of change
The changes proposed above may be successful or not. This requires an evaluation to determine the extent to which the changes have been implemented, and whether or not they have been successful. The evaluation of the changes will be done based on a number of indicators (Maurer & Smith, 2005): the incidence rate of pressure sores, the quality of care accorded to ICU patients, the costs incurred in managing pressure sores, the length of hospital stay of ICU patients, the level of knowledge of nurses about pressure sores, and the amount of time spent by nurses in managing pressure sores.
Incidence rate of pressure sores
This indicator will be evaluated using secondary data. Specifically, the intensive care unit will compare the number of patients who developed pressure sores after admission before the implementation of the proposed changes with the number of patients who develop pressure sores after admission after the implementation of the proposed changes. If the incidence rate after implementation of the proposed changes is lower than before the changes were implemented, it would imply that the changes have been effective in reducing pressure sores, and vice versa.
Quality of care of ICU patients
The quality of care accorded to ICU patients will be another indicator measuring the effectiveness of the proposed changes. The quality of care will be measured by the amount of time and level of attention accorded to each patient. For instance, it can be measured by how often the nurses change the clothes and beddings of the patients after each soiling, whether or not they use continence management and moisture-reducing aids, how adequately they educate and train able patients on repositioning and inspecting their skin, and the frequency with which they document the skin inspection and repositioning on the logs.
Costs incurred by the ICU in managing pressure sores
As discussed earlier, pressure sores increase the costs of ICUs by necessitating them to purchase special equipments such as beds and mattresses, medication and additional medical procedures such as surgeries. The effectiveness of the proposed changes will be effectively measured by the amount of money spent by the ICU in managing pressure sores. The information will come from secondary data complied by the ICU.
Specifically, the ICU will examine the amount of money that was spent on ICU patients with pressure sores before the changes were implemented. This amount will then be compared with the amount spent on pressure sores after the changes were implemented. Any difference between these two amounts will reflect the success or failure of the changes. If the costs reduced after the implementation of the changes, it would imply that the changes have been effective in reducing pressure sores, and vice versa.
Length of hospital stay and time spent by nurses on the patients
Pressure sores increase the length of stay of ICU patients as well as the amount of time spent by the nurses on the patients. This is because of additional medications, treatments and procedures required by patients with pressure sores. The effectiveness of the proposed changes will also be evaluated by the average length of stay of patients admitted at the ICU. A shorter average stay after the implementation of the changes will imply the success of the changes and vice versa. Similarly, the effectiveness of the proposed changes will be measured by the average amount of time spent by the nurses on the ICU patients. A lower average amount of time spent by nurses would imply the success of the proposed changes and vice versa.
Level of nurses’ knowledge on pressure sores
Nurses’ knowledge on pressure sores is a critical element in reducing pressure sores. All the proposed changes cannot take place effectively if the nurses are not well educated and trained about pressure sores, their risk factors, risk assessment, prevention and treatment. This indicator will be evaluated through knowledge tests conducted on the ICU nurses. High scores on the tests will indicate the effectiveness of the proposed changes and vice versa.
Conclusion and Recommendation
Conclusion
Pressure sores are a major problem in the intensive care units. Persistently high prevalence and incidence rates of pressure sores indicate the failure of measures that have been put in place to address them. Pressure sores have serious consequences for the patients, nurses and the entire healthcare organization. Patients with pressure sores spend longer days in hospitals because they require additional treatments and procedures.
They are also more likely to die than their counterparts and have higher morbidity rates. Nurses spend more time and have high work loads when they have patients with pressure sores. The healthcare organization on the other hand incurs higher when it has patients with pressure sores due to the necessity of buying special equipments and undertaking additional and costly procedures.
This paper has proposed a preventive rather than a curative approach to dealing with pressure sores. It has examined what measures can be taken to prevent pressure sores before they even occur. The preventive approach is composed of three major strategies. The first strategy is continuing monitoring of the patient. Patient assessment should begin upon admission and should continue throughout the patient’s admission. The assessment should be done on the patients’ health/medical condition, risk factors and skin condition. The second strategy is regular and frequent repositioning of patients to redistribute patients’ weight and reduce pressure forces on the patients’ risk areas. Lastly, all these actions should be documented after each incident.
Recommendation
The outcome of the evaluation of the changes will determine the next action that should be taken by the intensive care unit. If positive outcomes are realized, it would imply that the incidence rate of pressure sores has been significantly reduced. In this scenario, the unit should continue implementing the changes. On the other hand, if negative outcomes are realized in the form of persistently high incidence rate of pressure sores, the unit should re-evaluate the changes to identify the weaknesses. The changes should then be revised in accordance with the needs of the patients and the organization.
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Appendix A: Continuing Monitoring and Positioning Plan
Continuing monitoring
- Purchase moisture-absorbing and continence aids, specifically absorbent and incontinence pads, which will be bought in bulk on a semi-annual basis.
- Train nurses on how to use the moisture-absorbing and continence aids
- Introduce skin inspection documentation mechanism through which nurses will document the time and outcome of skin inspection of every patient. Auditing will be conducted on a weekly basis to ensure that the nurses adhere to the documentation mechanism.
Positioning of patients
- Create awareness among nurses, through nurse education, on the importance of patient positioning in reducing pressure sores.
- Use pillows or wedges to reduce pressure on bony prominences.
- The frequency of positioning should be determined by the patients’ health condition and results of skin inspection
- Make frequent, small position changes.
- Direct nurses to allow bed-ridden patients to stay out of bed for a few hours.
- Create a schedule for the nurses that will state what time of the day and for how long the patients should be allowed to stay out of their beds. This will be audited on a weekly basis to ensure that it is strictly adhered to.