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Statement and Significance of the Problem

The increased prevalence of patients with more complicated and debilitating conditions is ever increasing. The reason for this are many folds that are causing a new aspect of challenge for the nursing staff tending to tertiary care institutes. As the complications of the patient increase, there is also increased susceptibility of these patients to hospital acquired infections, acquired skin complications and medical complications due to errors by the hospital staff. These situations are even more complicated when related with the high awareness of patients regarding their rights and need for high quality health care.

The administration of healthcare institutes catering to these patients has developed various strategies to counteract these challenges. These strategies include quality control checks through planned support programs, patient’s health awareness and safety control and optimization of the healthcare staff to raise their standards of work through updated education and workshops.

One of the problems that these factors present is that of pressure ulcers, pressure sores or bed sores in immobile and elderly patients facing complicated acute illnesses or neurological deficit.  (Studies, 2003). These ulcers cause localized skin damage and erosion of the underlying tissue. They are not just common in the elderly, but studies show that 10% of all the individuals admitted to the hospital face this problem out which 70% are elderly  (Lyder, 2002). These pressure ulcers are a very painful and disturbing condition for the patient and his family and often mean that the patient would need more care beyond his regular stay in the hospital. This extension in stay for hospitals has severely increased the cost of treatment for pressure ulcers to be between 500 to 50,000 US dollars per ulcer. This price keeps increasing with the higher severity of the ulcer (Pompeo, 2001).

One of the key factors in controlling of these pressure ulcers is the role of the nursing staff in proper care and vigilance of the patients at high risk for this condition. For this the nursing staff needs to be well equipped with the most up to date scientific knowledge and practice to handle an issue so in commonality within the patients. Various studies suggest that the knowledge of nursing staff usually lacks the scientific basis and is based on myths, observations or experiences of others. (Zulkowski K, 2007) (Duimel-Peeters IGP, 2006). Internationally steps have been taken to optimize the knowledge of the nurses through various recommended guidelines, trainings and educational workshops to promote evidence based practice. (Rycroft-Malone J, 2000). A determination of the baseline factors of the knowledge and practices of nurses related to pressure ulcers can provide a starting point for designing a customized set of guidelines for the local nurses in order to handle this issue in a much optimal way.

Literature Review

The occurrence of a problem such as pressure ulcers is on a constant rise and is a major cause of pain and fatigue to the patients, not to mention the high costs of its treatment requiring the valuable time, facilities, equipment and skill of the healthcare staff.  (Jones, 2007).These ulcers develop due to any disturbance in the circulation of the patient due to external factors (Anton, 2005). Hence pressure ulcers are preventable when proper attention is paid to maintenance of the blood circulation through the variety of equipments and techniques. Jones et al, also states that 45% of these pressure ulcers are preventable. The key to these prevention techniques is to increase the knowledge and skill set of the nursing staff  (Jones, 2007).

Studies show that the group that is faced with the highest percentage of pressure ulcers are residents of nursing homes where the prevalence ranges between 1.9% - 23.9% (Hammett, 2007), followed by patients with injury to the spinal cord (Garber, 2002).  There is a vast amount of information available on the prevention these pressure ulcers encompassing pressure relief and removable of co morbidities. The techniques and skills documented regarding this prevention require the integral element of education to make the cycle complete, compensate for the shortfalls in the baseline knowledge and benefit the nursing community and society as a whole (Anton, 2005). Anton et al also stresses on this lack of knowledge within the nursing staff by presenting the case of the Turkish nurses who currently used practices which were obsolete 20 years ago.

Clinical and medical practice as a whole are facing the problem of limited knowledge (Gunningberg, 2001). Evidence based practice suggests that the nursing staff be aware of the latest updates and new knowledge regarding their practices, however, the real picture of this scenario is still not determined. This gap of knowledge and hence effective training should be assessed in an effective manner so that education programs and trainings can be custom tailored to compensate for this shortfall. Increase in the prevention knowledge of pressure ulcers within the nursing staff will in the longer run improve on the outcomes faced by the patients (Smith, 2009). One of the initial and most crucial steps in the prevention of pressure ulcers, as suggested by The National Pressure Ulcer Advisory Panel, is the correct staging of these pressure ulcers; however, studies show that this is the stage where the nurses lack the most in their knowledge and skill sets, hence leading to incorrect diagnosis  (Ayello, 2006).Knowledge assessment is an important step towards formulating an important strategy to counteract the problem of pressure ulcers in patients and this knowledge is lacking due to various factors. The studies previously carried out suggest that the reasons for this lack of knowledge include factors related to time, money and personal commitment on the nurses’ side and the increased nurse’s turnover causing lack of a consistent nursing education programs as the problem on the institute’s side  (Law, 2003).

The increased incidence of pressure ulcers has stimulated vigorous research into its prevention and treatment modalities (Ayello E. A., 2003). This has further increased the pool of knowledge available for the optimal treatment of pressure ulcers. This has increased the gap between the clinical practice of nurses and current knowledge regarding pressure ulcers. Various countries have successfully formulated guidelines for the nursing staff to follow in order to decrease this rising incidence of pressure ulcers, however,studies suggest that they are hardly followed  (Catania, 2007).

Previous studies on the knowledge of the nurses regarding pressure ulcers mention an increase in the knowledge from reading an article to attending a seminar on the topic (Gunningberg, 2001).  Pancarbo et al had also presented an interesting finding that knowledge regarding prevention of pressure ulcers decreased as the experience of nurses increased to up to twenty years.  He also said that RN with the certification and education higher than that of an LPN can assist in raising the bar o this baseline knowledge by sharing their education and skills with other team members (Pancorbo-Hidalgo, 2007).

            Beeckman et al found out that attending conference regarding wound treatment significantly increased knowledge of nurses regarding pressure ulcers compared to those who did not get many educational opportunities (Beeckman, 2008).

In light of the research reviewed above it is safe to say that providing knowledge and training to the nursing staff is the best way of combating the rising incidence of pressure ulcers, however, before planning any set of guidelines a determination of the baseline knowledge of the group under study is extremely important. Determining the current knowledge of the nurses regarding pressure ulcer care, treatment and prevention would help in designing a much effective educational program to prevent pressure ulcers.

Research Question

The aim of this study will be to answer the following research question:

  • How knowledgeable are registered nurses regarding the prevention and care of pressure ulcers?

Variables of interest include the RN’s knowledge which would be assessed using a questionnaire that the nurses would be required to answer after taking informed consent and explaining them that this questionnaire is only administered to check their baseline knowledge. Another variable is prevention and care of pressure ulcers, the knowledge of which would be assessed by administering the Pieper Pressure Ulcer Knowledge Test, which is a questionnaire previously used and validated for the determination of RN’s knowledge regarding pressure ulcers  (Pieper B, 1995).

Methodology

Study Setting

            This study will take place at a local nursing home where all the registered nurses working at that time would be asked to answer an administered questionnaire. The total number of nurses working there are 2RN, 3LPN and 3CNA. The nurses would participate at their own will and written as well as informed consent would be taken on the first page of the questionnaire.

Research Design

            This is a descriptive study design of the cross sectional type, where the data is collected at a single time from the nurses present at the hospital at the time of study (Burns, 2009). The reason for choosing this non experimental type of study design is that this types of studies are always needed to establish effective interventions. This means that experimental interventions are developed on the basis of non experimental research which describes the scope of the problem and the critical relationships between the relevant variables.

 Sample and Sampling Procedure

            A convenience sample would be used for this study. Selection would be based on the presence of the nursing staff at the days appointed for collecting data for this research. The sample size calculation would use the total number of nurses appointed at the selected nursing home and then adjust the α at 0.05 and β at 0.10 for the finite population (total number of appointed nurses at the nursing home) the required sample amount would be obtained. However, to account for errors in data obtained a 10% excess of the calculated sample size would also be included in the sample.

The inclusion criteria for the nurses participating in the study would include nurses who are registered and hence obtained a certain amount of certification, nurses working at the nursing home selected as the study setting. The exclusion criteria include nurses who are not registered, nurses working at hospitals other than the one under study.

Data Collection

            The data collection would be done based on the questionnaire known as the Pieper Pressure Ulcer Knowledge Test  which has a total of 46 questions with the options of true, false or I don’t know. This test is based on 3 parts the first one revolving around the concept of prevention, the second one regarding the staging of pressure ulcers and third regarding general would knowledge. The score is obtained by dividing the total correct answers with the total number of questions. This questionnaire is presented in Appendix 1.

The questionnaire would be distributed among the RNs of the nursing home, and they would be required to answer the questions on the spot. The questionnaires would be collected soon after they have finished answering it under the supervision of the researcher.

Data Analysis

            The data analysis would include entering the collected data into the statistical software SPSS. Descriptive statistics of mean, median, mode and range would be calculated on the collected data.

Strengths and Weaknesses

            This study would consist of a number of limitations which are better when described beforehand. The first one related to its sample is that of sampling procedure. We would be using a convenient sampling procedure where the ideal should be a random sampling procedure which we were unable to incorporate due to limitation of resources. Second limitation is that of extraneous variables like the years of experience of each nurse and level of academic performance and understanding of each nurse.

The external validity of this research will only pertain to the knowledge of nurses within the nursing home under study and would lack the generalizability of this study to the entire population. However, a focus on the local population of RNs and their knowledge levels would provide better grounds to design optimal intervention courses to educate them on issues related to pressure ulcers within the nursing home under study.

APPENDIX 1

Pieper Pressure Ulcer Knowledge Test

Please answer each of the following by placing a check mark for each question:

1.

Stage I pressure ulcers are defined as nonblanchable erythema

True

False

Don’t know

2.

Risk factors for development of pressure ulcers are immobility, incontinence, impaired

nutrition, and altered level of consciousness

True

False

Don’t know

3

All individuals at risk for pressure ulcers should have a systematic skin inspection at least once a week

True

False

Don’t know

4

Hot water and soap may dry the skin and increase the risk for pressure ulcers

True

False

Don’t know

5

It is important to massage bony prominences

True

False

Don’t know

6

A stage III pressure ulcer is a partial thickness skin loss involving the epidermis and/or dermis.

 

True

False

Don’t know

7

All individuals should be assessed on admission to a hospital for risk of pressure ulcer development

True

False

Don’t know

8

Corn starch, creams, transparent dressings (i.e.,Tegaderm, Opsite), and hydrocolloid dressings (i.e., DuoDerm, Restore) do not protect against the effects of friction.

 

True

False

Don’t know

9

Stage IV pressure ulcers are a full thickness skin loss with extensive destruction, tissue

necrosis or damage to muscle, bone, or supporting structure.

True

False

Don’t know

10

An adequate dietary intake of protein and calories should be maintained during illness.

True

False

Don’t know

11

Persons confined to bed should be repositioned every 3 hours.

True

False

Don’t know

12

A turning schedule should be written and placed

at the bedside.

True

False

Don’t know

13

Heel protectors relieve pressure on the heels

True

False

Don’t know

14

Donut devices/ring cushions help to prevent

Pressure ulcers.

True

False

Don’t know

15

In a side lying position, a person should be at a

30-degree angle with the bed.

True

False

Don’t know

16

The head of the bed should be maintained at the

lowest degree of elevation (hopefully, no higher

than a 30 degree angle) consistent with medical

Conditions.

True

False

Don’t know

17

A person who cannot move self should be

repositioned while sitting in a chair every two

Hours.

True

False

Don’t know

18

Persons who can be taught should shift their

Weight every 30 minutes while sitting in a chair.

True

False

Don’t know

19

Chair-bound persons should be fitted for a chair

Cushion.

True

False

Don’t know

20

Stage II pressure ulcers are a full thickness skin

Loss.

True

False

Don’t know

21

The epidermis should remain clean and dry.

True

False

Don’t know

22

The incidence of pressure ulcers is so high that

the government has appointed a panel to study

risk, prevention, and treatment

True

False

Don’t know

23

A low humidity environment may predispose a

Person to pressure ulcers.

True

False

Don’t know

24

To minimize the skin's exposure to moisture on

incontinence, underpads should be used to

Absorb moisture.

True

False

Don’t know

25

Rehabilitation should be instituted if consistent

with the patient's overall goals of therapy

True

False

Don’t know

26

Slough is yellow or creamy necrotic tissue on a

Wound bed.

True

False

Don’t know

27

 Eschar is good for wound healing.

True

False

Don’t know

28

Bony prominences should not have direct

Contact with one another.

True

False

Don’t know

29

 Every person assessed to be at risk for

developing pressure ulcers should be placed on

A pressure-reducing bed surface.

True

False

Don’t know

30

Undermining is the destruction that occurs

Under the skin.

True

False

Don’t know

31

 Eschar is health tissue.

True

False

Don’t know

32

Blanching refers to whiteness when pressure is

Applied to a reddened area.

True

False

Don’t know

33

A pressure relieving surface reduces tissue

interface pressure below capillary closing

Pressure.

True

False

Don’t know

34

Skin, macerated from moisture, tears more

Easily.

True

False

Don’t know

35

Pressure ulcers are sterile wounds.

True

False

Don’t know

36

A pressure ulcer scar will break down faster

than unwounded skin.

True

False

Don’t know

37

A blister on the heel is nothing to worry about.

True

False

Don’t know

38

A good way to decrease pressure on the heels is

to elevate them off the bed.

True

False

Don’t know

39

All care given to prevent or treat pressure ulcers

must be documented.

True

False

Don’t know

40

Vascular boots protect the heels from pressure.

True

False

Don’t know

41

Shear is the force which occurs when the skin

sticks to a surface and the body slides.

True

False

Don’t know

42

Friction may occur when moving a person up in

Bed

True

False

Don’t know

43

A low Braden score is associated with increased

pressure ulcer risk.

True

False

Don’t know

44

The skin is the largest organ of the body.

True

False

Don’t know

45

Stage II pressure ulcers may be extremely

painful due to exposure of nerve endings.

True

False

Don’t know

46

For persons who have incontinence, skin

cleaning should occur at the time of soiling and

routine intervals.

True

False

Don’t know

47

Educational programs may reduce the incidence

of pressure ulcers.

True

False

Don’t know

 

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