Despite the intention to provide non-ambulatory patients with the best services, a modern healthcare system is hardly perfect. This group of people faces several challenges that contribute to their health and quality of life. The growth of pressure ulcer risks is one of the main concerns due to several reasons. Some people believe that pressure ulcers introduce a serious health problem that is rooted in poor nursing care.
However, experts’ opinions and observations show that the development of such injuries is explained by a failure of the entire system. In this project, attention will be paid to pressure ulcers, their clinical characteristics, preventive measures, and the already existing treatment methods. The reduction of pressure ulcers among non-ambulatory old patients is the goal that has to be achieved within hospitals and other medical facilities globally. Using reliable studies and valid findings, two significant interventions will be compared within the frames of this evidence-based practice (EBP). In nursing care, many myths about the effectiveness of different practices exist, and this EBP project focuses on the reduction of pressure ulcers using either two-hourly turning or using pressure mattresses.
The rationale for Choosing a Clinical Question
Many professional organizations work hard to provide populations with the best care services. The concept of aged or elderly care is frequently applied to specify help to be offered to older people who can no longer stay independent due to physiological changes (Orellana et al., 2018). Pressure ulcers create a serious health problem among non-ambulatory old patients (Sharp et al., 2019). They are characterized by localized skin injuries and underlying tissues that result from regular pressure (Jiang et al., 2020).
Although the signs of pressure ulcers have already been properly identified in many studies, treatment and prevention plans require additional research and improvements. Sharp et al. (2019) discovered that about 91% of non-ambulatory residents were at risk of pressure ulcers, and 34% of them died with at least one bedsore. Taking into consideration such numbers, it is necessary to find out if it is possible to reduce the frequency of such traumas and help old patients. Instead of thinking if pressure ulcer risks grow because of nursing errors or the holes in a healthcare system, options must be defined, evaluated, and compared to understand how to protect the vulnerable population.
The main goal of this EBP project is to understand how to reduce the risks of pressure ulcers among non-ambulatory old patients. The importance of this work is to not only find the answer but also understand how to promote safe health standards for people within a particular system. During the last several decades, pressure ulcers, also known as decubitus ulcers or bedsores, put millions of people at risk of painful death (Jaul et al., 2018). This problem has already gained a global status because the number of aging populations continues growing.
Predictions about how the situation with pressure ulcers can be changed are hardly positive. According to the Organizational for Economic Co-Operation and Development (as cited in Beeckman et al., 2019), in the middle of the 20th century, individuals under 80 years constituted about 1% of the population. In the middle of the 21st century, a 10% increase is expected (Beeckman et al., 2019). In many countries, the 2-hourly turn has already become a common practice, with its evident benefits and specific harms to patients (White et al., 2018). In this project, the assessment of this intervention will be developed regarding the threats and advantages of pressure mattresses as a multidisciplinary responsibility among hospital employees.
Considering the goals and main problematic areas of the chosen topic, a properly structured question has to be introduced. In this work, the answer to the following PICOT question must be given, “In non-ambulatory old patients, will 2-hourly turning compared to pressure mattress usage reduce the risk of pressure ulcer within two months?”. There are five main aspects of analysis:
- P – Patients – non-ambulatory old patients;
- I – Intervention – two-hourly turning;
- C – Comparison – pressure mattress usage;
- O – Outcome – to reduce the risk of pressure ulcer;
- T – Time – two months.
To answer the offered question, the e-library of the University of Sharjah will be used. The main keywords include “pressure ulcers”, “prevention”, “mattress”, and “turning”. All these words may be combined in different ways, with “pressure ulcers” or “bedsores” being added each time. The search is limited to the sources published in peer-reviewed journals within the last two years. As soon as an article that meets the initial characteristics is found, the availability of its full text has to be checked. It is not enough to use abstracts for this kind of work.
Summarization and Synthesis of the Journal Articles
There are many reasons for older people to spend some period in hospitals and receive professional. Sometimes, patients need long-term care, and nurses have to apply their best skills and knowledge to predict complications. Nowadays, pressure ulcer incidence and prevalence remain high (up to 20%) in many regions (Knibbe et al., 2018). Millions of patients who stay immobile or lack regular physical activities suffer from bedsores. Sharp et al. (2019) underline that sometimes this condition develops deep in the body, and nurses are not able to identify evident signs of skin injury. Therefore, the task of the hospital staff is not only to treat patients and identify the symptoms but also to take action to prevent decubitus ulcers and avoid unpredictable complications.
Symptoms of Pressure Ulcers
An old person, as well as any other non-ambulatory patient, is at risk of developing pressure ulcers because of constant pressure on the body or its part, the friction of the skin against bedding, or shear. Skin injures are frequently observed in such areas as the back, shoulders, hips, and heels, and people are offered protective cushions or mattresses (Beeckman et al., 2019; Jaul et al., 2018). According to the Clinical Practice Guidelines, nurses are responsible for regular observations and physical examinations for skin condition changes or swelling (as cited in Sharp et al., 2019). Such vital signs as body temperature and blood pressure should be evaluated as well, even if no physical changes occur (because bedsores may be originated inside the body first).
Threats of Maltreatment
Frail old patients have to be carefully treated, and nursing care presupposes the necessity to investigate the impact of comorbidities. Aging, by its nature, is a critical risk factor for patients, either physically active or immobile. If bedsores remain unrecognized or poorly treated, Jaul et al. (2018) introduce several complications like sepsis, anemia, and changes at the cellular level. Cancer and bone diseases are rare among people with pressure ulcers, but their possibilities cannot be neglected to prove the importance of preventive interventions in the form of repositioning (turning). Sometimes, older patients are not ready to accept their dependence on other people and try to take steps and reduce their immobility-related complications.
In this case, nurses have to restrain patients physically for their safety and healing (Sharp et al., 2019). In addition to professional health care, daycare hospitals aim at providing people with a sense of dignity and respect in communities using rehabilitation and support (Orellana et al., 2018). Numerous physiological and psychological complications are associated with bedsores, and the reduction of skin injuries might provoke the elimination of new health problems.
Prevention of Bedsores
Researchers around the globe are involved in the discussion of preventive techniques for nurses who work with non-ambulatory patients. They introduce 4- and 2-hour repositioning combined with different types of mattress redistribution (Jiang et al., 2020; Sharp et al., 2019). Orellana et al. (2018) investigate the worth of education activities and support services for old patients. However, Knibbe et al. (2018) find out that repositioning systems are not associated with skin problem reduction. There are many opposing points of view about the effectiveness of repositioning and the use of special mattresses for in-hospital care. For example, White et al. (2018) admit that turning as a single practice cannot do serious harm to old patients, but if caregivers use inappropriate techniques or set poor time limits, negative outcomes may occur. Finally, there is no definite opinion if it is reasonable to combine several preventive techniques to make sure that bedsore prevalence is under control.
The analysis of recent peer-reviewed articles, discussions, and studies shows that the question of pressure ulcer prevention is still open and needs additional research and explanations. Patient safety, threats of chronic diseases, and aging are the factors that influence the quality of care that people receive today. Bedsores should not create problems in the modern healthcare system, and it is time for nurses to solve the existing literature gap and formulate a clear attitude toward 2-hour turning to reduce skin-related injuries.
Methodology and Modification of Current Practice
In this EBP project, two-hourly turning is the main intervention for analysis and the identification of its impact on pressure ulcer occurrence. As the PICOT question contains the necessity to compare this practice with pressure mattress distribution, the necessary materials include several mattresses (one particular type is preferable) and beds for old patients. Regarding modifications of current practice in the light of the found evidence, it is planned to work with nurses and patients of one hospital. A turning procedure includes direct cooperation and contact between nurses and patients.
Although a final sampling choice depends on the actual number of beds and non-ambulatory patients in the hospitals, this project should have at least 40 participants (20 patients for an experimental group and 20 patients for a control group). Additional inclusion criteria are at least two certified nurses to work with older adults, a hospital’s willingness to participate in the study, and approval from an ethics committee. Although it is desired to find patients with no chronic conditions, old age is usually a preventive factor. Therefore, it is important to mention what comorbidities every individual has at the moment of the study.
As soon as the participants are chosen and informed about the goals and the offered interventions, the intervention has to be implemented. During the next two months, non-ambulatory old patients (an experimental group) will be turned with an interval of two hours. The nurses have to study the guidelines and techniques and follow them properly (a researcher develops a list of evidence-based requirements).
To promote effective and non-biased measurement, the nurses check every patient and report on skin problems during the study. As a part of the quantitative method, a Braden Scale is recommended for the evaluation of pressure ulcer risks (Jiang et al., 2020). The condition of the skin is described before and after the intervention as a part of qualitative content analysis. In two months, all the patients are observed by a researcher to make conclusions and gather enough information about the offered techniques.
Following the recommendations and requirements, the present project will be a comparative study conducted in one daycare hospital where non-ambulatory patients are treated for at least two months. It aims at determining the impact of the offered variables (2-hourly turning and a pressure mattress) on the reduction of bedsores among old patients who are physically inactive. Two groups of individuals stay in hospitals under similar conditions. The results of interventions are compared to prove if 2-hourly turning is more effective than the distribution of special mattresses.
Focusing on the main tasks and the background information, the major barriers in this EBP could include the lack of experience in research practice, poorly developed communication skills, and unpredictable challenges in administrative work. Any research requires time and a plan, and this practice is based on the necessity to implement the intervention, invite people, and analyze their data and reports.
Poor communication could hinder the progress because of the impossibility to explain what goals are set, and why the offered steps are taken. People should understand why their participation is critical for the study, and the task of the researcher to stay informative, confident, and supportive. Finally, not all patients and nurses are eager to share their problems and intentions with novice researchers. Therefore, problems in administrative work cannot be ignored, and participants’ loads should be properly weighted.
Despite the existing barriers and potential problems, pressure ulcers among old patients remain a serious problem. Many medical workers are interested in the reduction of skin injuries because of limited physical activities and movements. The intention of a researcher to find the most effective solution could promote the creation of a safe working environment and a motivated culture. Access to reliable evidence and the opinions of people helps choose the right steps in the intervention. Finally, the establishment of a supportive team with a strong leader and peers enhances the chances to achieve success in this modification. Independent achievements have to be underlined, but cooperation is a core element of this EBP journey.
In general, it is expected to prove that 2-hourly turning is associated with positive changes among old patients. Pressure ulcers remain a serious health problem in hospitals, and the governments of many countries pay special attention to the attempts made for finding a solution. The environment under which older adults receive treatment and care determines their future psychological and physical conditions. The role of nurses in this intervention cannot be ignored because much depends on how well an employee understands duties, communicates with patients and their families, and supports professionally and individually.
Bedsores are dangerous for people of different ages, but older patients may also have some chronic diseases or disabilities that change their lives. Therefore, the reduction of pressure ulcers is a minimal and obligatory step in the development of treatment plans for non-ambulatory patients. The condition of the skin has to be regularly checked to predict sepsis, anemia, and other complications, and bedsore incidence can be controlled using 2-hourly turning.
In this EBP journey, I got a good opportunity to develop and improve several skills. On the one hand, I learned how to work with a database, search the necessary material, and choose correct research questions. On the other hand, I strengthened my research position and contributed to the discussion of the importance of healthcare interventions in modern practice. Although it was challenging to identify the main goals and possibilities, reading peer-reviewed articles and studies turned out to be a helpful activity.
I realized that the success of an EBP project depends not only on personal qualities and available material but on the establishment of administrative and collaborative standards. It is impossible to create a study and prove the urgency of intervention alone, and I, as a nurse researcher, have to address other experts for help, relying on their experiences and knowledge. My work is not over, and I am ready to discover some new aspects of the chosen practice and investigate pressure ulcer treatment, comparing available methods and their outcomes.
Beeckman, D., Serraes, B., Anrys, C., Van Tiggelen, H., Van Hecke, A., & Verhaeghe, S. (2019). A multicentre prospective randomised controlled clinical trial comparing the effectiveness and cost of a static air mattress and alternating air pressure mattress to prevent pressure ulcers in nursing home residents. International Journal of Nursing Studies, 97, 105-113. Web.
Jaul, E., Barron, J., Rosenzweig, J. P., & Menczel, J. (2018). An overview of co-morbidities and the development of pressure ulcers among older adults. BMC Geriatrics, 18(1), 1-11. Web.
Jiang, Q., Liu, Y., Yu, H., Song, S., Li, G., Liu, H., Song, S., Li, G., Liu, H., Zhou, Y., Zhu, Y., Jia, J., Huang, Y., & Wang, J. (2020). A multicenter, comparative study of two pressure-redistribution mattresses with repositioning intervals for critical care patients. Advances in Skin & Wound Care, 33(3), 1-9. Web.
Knibbe, N. E., Zwaenepoel, E., Knibbe, H. J., & Beeckman, D. (2018). An automatic repositioning system to prevent pressure ulcers: a case series. British Journal of Nursing, 27(6), 16-22. Web.
Orellana, K., Manthorpe, J., & Tinker, A. (2018). Day centres for older people: a systematically conducted scoping review of literature about their benefits, purposes and how they are perceived. Ageing & Society, 40(1), 73-104. Web.
Sharp, C. A., Moore, J. S. S., & McLaws, M. L. (2019). Two-hourly repositioning for prevention of pressure ulcers in the elderly: Patient safety or elder abuse? Journal of Bioethical Inquiry, 16(1), 17-34. Web.
White, R., Swan, J., Downie, F., Clark, M., & Schofield, A. (2018). Pressure ulcers prevention: Mobility matters but does turning work? Wounds UK, 15(4), 16-19.