INTRODUCTION:
The prevalence rate of pressure ulcer is very high among patients so excellent tools are needed for the effectiveness of adherence of guidelines related to pressure ulcer. Evidence based practice is widened term which is in accordance with person self clinical skills, that consist of evidence develop from projects of quality improvement, patients comprehensive physical examination (Bernadette, 2010). There are specific recommendations in the guidelines for pressure ulcer prevention so it is essential to provide best evidence so that will be more effectiveness of guidelines of pressure ulcer prevention on patients.
The purpose of this report is to review the best practices for adherence of pressure ulcer prevention guidelines. So that there will be better relevancy of guidelines in clinical practice. It is hoped that conclusions possibly will be represented to present suggestions on the ways for further improvement of guidelines.
BACKGROUND AND METHODOLOGY OF THE STUDY:
BACKGROUND OF THE STUDY:
For the treatment and proper prevention of pressure ulcer, guidelines act as a basic measurement. The guidelines consist of well organized framework that includes all the aspects for caring the patients on best evidence practice (Chaves, 2010).
Nowadays, every care is provided in accordance with the evidence based practice guidelines, also guidelines and standard preventive measures act as significant tools for providing best care to the patients. Such tools are also beneficial in improving the quality of life of patients. The outcome of applying this standard tool is very effective in preventive pressure ulcer (Chaves, 2010).
Moreover the same result was shown by, study that was conducted in the paediatric ward on critically ill children who were suffering from pressure ulcer and were having improper skin integrity. This study shows that after the care of skin in accordance with guidelines of pressure ulcer prevention within few days positive result was found shows early recovery (Butler, 2007).
The guidelines for pressure ulcer prevention consist of suggestions and various measurements so that early determination of high risk patients can be done and measures in these guidelines are helpful in preserving and improving the capacity of patients to endure pressures (Saliba, 2003). Moreover the life improvement programmes on adherence of pressure prevention guidelines reveals that effect of applications of majority of measures and resources improve drastically. Use of elastic foam mattress, water mattress and cushion, floating heels, daily skin observation, repositioning are very beneficial (Paquay et al, 2010).
However various patients oriented studies shows that the measures that were taken for the improvement of life is not in accordance with the evidence based guidelines of pressure ulcer prevention and use of various studies shows that very low standard pressure ulcer preventive measure which does not have any impact on the improvement of condition of patients, this is because of lack of knowledge regarding guidelines of pressure ulcer prevention (Baier et al, 2003).
Also study conducted in emergency department shows that there were only less number of patients that were aware of guidelines of pressure ulcer prevention (Gauld et al, 2000). Also many home care centres gave education to the patients in regarding pressure ulcer guidance still there were few homecare centres that provide material of teaching to patients. This is because of lack of appropriate education to the patients regarding guidelines and also there were no trained nurses that can provide effective education to the patients for preventing pressure ulcer (Bergquist, 2005).
LITERATURE SEARCH METHODOLOGY:
The broad search has been done to include all the aspects essential for the adherence of prevention of pressure ulcer in various clinical practice settings (Benbow M, 2010).
The various data base has been investigated for this report were British Nursing Index, Cinahl Plus, Academic Search Elite, E-Journals, The Allied and Complementary Medicine, Medline, PsycINFO, Cochrane Library. These data bases are based on the efficiency of pressure ulcer prevention in various health care settings. Search articles were limited to full text that is peer reviewed journals; publication date selected was from 2000-2010. The various search terms used to get adequate articles on current data bases were: best practice, pain assessment scale, assessment, strategies, primary research, management and guidelines, clinical practice, adherence, recommendations and nurses.
Initially on searching near about 1425 articles were found including all types of articles. It is very difficult to get relevant information from this broadened search after that search was only limited and comes to 435 articles. Majority of studies were secondary articles. Exact keywords were used appropriately for further refined the study after reading abstract of studies 8 research articles were selected and various general articles were selected such as reviews, qualitative studies, quantitative search articles and audits.
There are various barriers in application of guidelines for prevention of pressure ulcer such as attitude, beliefs, behaviour, knowledge of nurses, shortage of staff, lack of time, work overload. By the removal of these barriers practical application of guidelines can be effective in treating patient (Benbow M, 2010).
EVIDENCE: STAFF ATTITUDE AND BEHAVIOUR:
The cross-sectional survey was carried out on staff nurses from the urban area working within acute setting care to determine the attitude and behaviour of staff nurses regarding prevention of pressure ulcer (Moore Z, & Price, 2004). Survey is beneficial in knowing the data associated with the dissemination and establishment of relationship between the variables (Denise, 2008). Moreover, information can be gathered from staff nurses in a single moment through survey (Donald, 2009). The design chosen to perform research was questionnaire. The attitude of nurses was assessed on the basis of this questionnaire. Staff nurses (n= 300) were chosen from the six acute care hospital on the basis of random sampling.
Data interpretation from this study shows that attitude of nurses about the guidelines for prevention of pressure ulcer is positive but the optimistic attitude of nurses is not clinically applicable due to shortage of staff and lack of time. However only positive attitude should not be consider, there are various other factors that influence the behaviour of staff nurses to clinically follow the preventive measures such as education level of staff nurses. Still appropriate behaviour is consider significant and best practice that staff nurses must followed for proper implementation of preventive measures also importance must be given to education factor that dramatically effects the patient care.
This same result is also supported by other studies of assessing behaviour and attitude given by (Källman et al, 2009)
The other study that also supports the influence of attitude and behaviour is the study that has been conducted to determine the attitude and beliefs of health care nurses in nursing home care centre in Dutch. The study was intended to impact of attitude and beliefs, also the various other issues related to prevention of pressure ulcer in accordance with the guidance (Buss, 2004).
A qualitative approach was chosen for study. This exploratory study was conducted on (n= 18) health care workers from five nursing care homes using semi structure research design.
The statistical interpretation shows that nurses that all the nurses taken in a study not have positive attitude towards not with the guidelines for the pressure ulcer prevention. There education regarding preventive measure was based on the old traditions not on the current recommendations of guidelines. The other belief of the nurses was that prevention of pressure is not a big matter to deal with although it has high prevalence rate and also the care they provide was insufficient for effective care of the pressure ulcer patients
EVIDENCE: KNOWLEDGE LEVEL OF STAFF
The survey was conducted with the aim that to determine the effect of knowledge and experience pattern of staff nurses regarding pressure ulcer treatment guidelines. This is the cross sectional survey that was carried among registered nurses and nursing assistant to find out the effective knowledge of staff nurses regarding guidelines and also to identify the various barriers that affects the care in accordance with the guidelines. Design chosen for the study was descriptive and data collection tool was questionnaire which consists of 230 questions were given and only 154 forms were returned.
Sample size chosen whose 20 registered nurse and 20 nursing assistant nurses, and were selected in random manner, the nurses chosen was having experience of 10 years.
Interpretation of the result reveals all the staff members were familiar with the providing guidelines of preventive measures. They have education of preventive measures and they know various risk factors for occurrence of pressure ulcer. However knowledge level of nursing assistant was less as compared to that of registered nurses. The 32% of the total sample received education programs on pressure ulcer guidelines. They have shown excellent knowledge regarding preventive measures (Källman, U, & Suserud, B 2009).
However there are various studies that show that there is lack of knowledge of nurses regarding pressure ulcer preventive guidelines. One of such study is the experimental study conducted to know the nurses information to relate to risk assessment tools guidelines in nursing care homes(Gunningberg, L 2001).
The design of the study was descriptive. Sample chosen was 60 registered nurses and 58 nursing assistant and data collection tool was questionnaire. The questionnaire was hand over to all the 60 RNs and NAs and 68% of RNs and 76% of NAs completed the form. The 82% of the total staff was women.
The interpretation of the result shows 26 of registered nurses out of 41 responded that they follow risk assessment tool every time whereas 15 RNs use that tool very rarely and they have insufficient knowledge regarding that. In case of NAs 33 were using that tool each time and 10 rarely and 1 NA never used that tool because of lack of knowledge. So it is confirmed that risk assessment and treatment of patient was in accordance of guidelines because of the poor nurse′s knowledge (Gunningberg, L 2001).
EVIDENCE: LACK OF CLINICAL PRACTICE
The other quantitative study was done on Spanish nurses to determine the level of using current pressure ulcer preventive guidelines and also the application of these guidelines in clinical practices (Pancorbo-Hidalgo, 2007)
This experimental study is conducted on licensed practice nurses and also the registered nurses in various settings such as elderly home care centres, primary health care centres and hospitals. Data was collected by questionnaire tool in the year 2001 to 2002. 2006 nurses were included in the study and were selected on the basis of cluster randomized sampling.
The data analysis of the study shows that 36. 9% of the response was given and percentage of knowledge was 79. 1% and management intervention was 75. 9%. However the interventions in the clinical area were only 68. 1%.
The score of knowledge related to guidelines is 79. 1%. although staff nurses are well experienced and know that how to prevent the pressure in accordance with the guidelines still the score for application of these guidelines in clinical practice area by is very low, instead of having knowledge they are not applying the guidelines in clinical areas due to the influence of various factors such as overburden of work, lack of proper staff patients ratio (Pancorbo-Hidalgo, 2007)
Moreover the other study also shows that there is lack of practice of pressure ulcer preventive guidelines by nurses. The main aim of the study was to determine to determine the applications of guidelines in the clinical practice areas. The research method used was descriptive and exploratory which was done to identify the utilization of guidelines in clinical areas. The approach used was cross-sectional survey used in the study was conducted on Greek nurses and this sample was taken from the military hospital. Very few military nurses were chosen in the study. This small sample can provide valid result. Data collection tool selected was questionnaire. Nurses gave response regarding barriers that comes in the way for the intervention of guidelines in the clinical practice areas such as lack of staff, due to appropriate equipment, non cooperation with other health care workers, lack of knowledge of guidelines of pressure ulcer prevention, overcrowded departments, lack of understanding the appropriate literature, non familiarity with the present pressure ulcer, lack of time, communication barriers such as lack of interpersonal relationship with patients (Panagiotopoulou, K, & Kerr, S 2002).
BEST PRACTICE:
Instead of availability of various research based guidelines on evidence basis, the actual practices of these guidelines are not appropriate. The basic feature to the prevention of pressure ulcer is the adequate interventions according to the requirement of the patient. As the incidence of pressure ulcer is going on rising so therefore the prevention of pressure must be taken into account in proper manner. The nurse practitioners play a vital role in providing the care to the patient with pressure ulcer. The proper involvement of the nurse in providing care is according to the guidelines is very necessary. So clinical practice of the nurses in providing care is considered is the best practice Moreover if evidenced based practice barriers are removed then high quality effective care can be provided (Bernadette, 2010). If the nurses have appropriate knowledge regarding guidelines but does not adequately applied this practice in caring of the patients then there is no usage of having such type of knowledge. Nurse if provide care to the patients in accordance with the standard guidelines then there will automatically decrease in rate of pressure ulcer prevalence. So poor skin examination, finding the risk factors, doing the proper risk assessment is significant to prevent the pressure ulcer. Proper attention should be paid to each patient and periodically examine the condition of the patient. So overall barriers for clinical practice of guidelines should be removed for the effectiveness of the care such as proper interpersonal relationship should be maintained by the nurse with the patient and required need should be fulfilled in accordance with the guidelines of pressure ulcer prevention.
DISCUSSION
Evidence based practice act as an approach that allow nursing practitioners to attain the maximum level of care by fulfilling the various needs of the patients. The pressure ulcers are one of the most serious conditions that must be taken into account in right time. High incidence of the pressure ulcer is mainly due to the underreporting of condition of the patient by the nurses. If the treatment is provided according to the guidelines then the risk factors can be identified at early stages and further deterioration of condition should not take place. The supportive evidence of guidelines is beneficial in the holistic care of the patients. Such as if the nurses have adequate knowledge regarding the guidelines such early skin assessment, provision of cushions, therapeutic devices and follow all the basic guidelines for care of the patient. Education programs by the nurses to the Patients are beneficial. However in the studies it is determined even if the nurses have appropriate knowledge even then they are not providing care to the patients. Therefore nurse must be oriented towards her responsibility in providing care and also findings have shown that some of the nurses have negative attitude towards care of the patient. Therefore appropriate nurses education, positive attitude and good beliefs of the nurses, and provision of their knowledge in the clinical practice of the guidelines in accordance with the standard pressure ulcer guidelines plays a key role in the care of patient.
LIMITATIONS:
There are various drawback of the report of the research outcomes. All the pre set parameters were in accordance with the research study but as the research topic is much widened so a large varieties of approaches have been used so that search can be obtained appropriately in accordance with the research topic. However by applying various types of articles such as systematic review, primary research, audits, survey the result cannot be appropriate. Moreover as it is the report, for reviewing literature all patients in large number of hospitals take place not only in the specific hospital. This may lead to inaccuracy of the result. Also there is no specific age group was selected for conducting research. All types of nurses are selected for review such as practioners, registered nurses; nursing assistants are taken in the study. Sample size taken in different articles for appraisal is not definite. In some researches small sample was taken and in some large sample was chosen. The evidence used for this appraisal was only act as an image of the most probable reason for the insufficient utilization of guidelines of pressure ulcer prevevention. The information gather mainly with the help of questionnaire, the data might not be correct . Only focus is on nurse′s knowledge and lack of practice by nurses are the main themes of the review, the other components like various education programs must be carried out to support the study further. Also the emphasis was given on nurses for following the guidelines, so complete health team must be consider as every ones responsible for the provision of quality of care.
CONCLUSION:
This report shows that the different ways so that patient becomes capable of following the guidelines of pressure ulcer prevention. The guidelines consist of the basic standardized tool that is beneficial for the care of pressure ulcer. But there are some barriers for using these guidelines. This study explores some of the evidence based supportive measure to improve the proper utilization of these guidelines such as attitude and behaviour, clinical practice and knowledge. All these components are necessary in the provision of care to the patient. This report reveals the appraisal of the various articles like impact of knowledge; attitude, behaviour, and clinical experience are taken. Appraisal of these articles shows that nurses have good education level and their attitude and beliefs are also positive however lack of practice instead having knowledge of guidelines leads to the deteriorate the condition of the patient. So staff must be actively involved in the patient care and provide best care to the patient for preventing pressure ulcer.
Therefore for following the guidelines, the probable barriers that comes in the way should be regularly determine in providing evidence based care to the patient. This study helps in discovering that significant strategies for the utilization of guidelines. The result of this study suggests that in future the guidelines for the pressure ulcer prevention must be managed properly. The various educational programmes for the nurses as well as for the student nurse must be provided by the specialist so that all the barriers can be removed in provision of guidelines and also this will father leads to decline in level of pressure ulcer prevalence.
