Conducting A Qualitative Descriptive Study On Pressure Ulcer Prevention

Background

Discuss About The Conducting A Qualitative Descriptive Study?

Pressure ulcers, or commonly called pressure sores or bedsores, is the clinical condition in which the patient suffers a localised damage to the skin or the underlying tissue due to pressure and shear or friction. The areas prone to suffer such conditions are sacrum, heels, coccyx, knees, elbows, and back of the cranium. This condition attributes to a number of other ailments such as bladder distension, autonomic dysreflexia, bone infection,  amyloidosis, pyarthroses, urethral fistula, sepsis, anaemia and gangrene. These conditions cause considerable suffering to the patient as some are life-threatening. In addition, treatment of these conditions increases the burden of healthcare costs and inconvenience is suffered by the healthcare professionals alike (Coleman et al. 2013). Pressure ulcer in hospitalised patients continues to be a serious economical and clinical challenge across the clinical centres. The magnitude of the problem has increased in the recent past due to increasing number of patent admissions and ageing population (Bååth et al. 2014). Clinical audits of pressure ulcer prevention is a chief strategy to identify the patterns of pressure ulcer within the setting, that is ‘hot-spots’, to aid in the allocation of the resources and to assist with the proper and timely development of prevention strategies (Coleman et al. 2014).

The present paper is a proposal for clinical audit in the area of pressure ulcer prevention. The audit cycle would aim to be a suitable framework for understanding the need of bringing about changes in practice related to pressure ulcer prevention guidelines. Quality improvement process has to initiate with an audit. It would be a continual dynamic process that would result in quality improvement for both nurses and patients.

Pressure ulcers are suffered by hospitalised patients due to unrelieved pressure disrupting the blood supply to the capillary network, restricting the flow of blood and making the tissues deprived of nutrients and oxygen. It is a common problem and leads to a number of medical complications, increased hospital stay and readmissions. Pressure sores are key reasons for significant morbidity and under certain cases mortality. This clinical complication is considered as a preventable complication, and there are a number of measures available to achieve so (Gunningberg et al. 2015). The financial burden of pressure ulcers on care services is immense, and it is likely that with the ageing population of Singapore, the prevalence rate of this issue would rise. Nurses are to encounter number of similar cases while working in a healthcare setting, including ICU. The health department of Singapore is taking initiatives to combat the augmented challenge and coming up with guidelines that can bring positive changes in management practices (Low, Vasanwala and Tay 2014). Though the present protocols used by the hospital might be fairly abiding by the set guidelines present, there is always a scope of improvement in the near future. Recommendations can be brought into focus that deals with risk assessment, nutritional supplementation, skin care, pressure redistributing support surfaces, and multi-component interventions. The audit would serve this purpose of bringing change in practice.

Purpose of the audit

The aim of the present audit is to identify the contributing factors and preventive measures that impact pressure ulcer prevalence in healthcare setting of Changi General Hospital (CGH), specifically the ICU setting. The results of the audit would be valuable in bringing about substantial change in the approach to management of pressure ulcer in the setting.

The standard criteria against which the practice will be evaluated are National Institute for Health and Care Excellence (NICE) guidelines for pressure ulcer prevention. NICE develop performance metrics and quality standards for providing public health and commission in social care services. It provide guidelines for prevention, risk assessment and treatment of pressure ulcer and aims at reducing the pressure ulcer numbers in secondary and tertiary care settings like primary, community and emergency departments (Stansby et al. 2014).

The key guideline for risk assessment is to evaluate the sensation, mobility, and nutritional deficiency, ability for repositioning and cognitive impairment. This measures the level of pressure ulcer risk in adults according to NHS guidelines. There should also be documentation of any previous pressure ulcer and their ability to reposition themselves on their own. There should not be any massaging or rubbing of skin for the pressure ulcer prevention. In case of adequate nutritional intake, there should not be any kind of additional nutritional intake in that case. NICE also recommends that intravenous or subcutaneous fluids should not be given for the prevention of pressure ulcer in adults in case of adequate hydration status.

Adults who are at high risk for developing a pressure ulcer are being evaluated by a trained professional undergo a skin assessment. This assessment takes into consideration any kind of discomfort, pain when the skin is being checked. The integrity of skin is assessed at the pressure areas, any kind of discoloration or variations in moisture, firmness and heat. The skin si also assessed for the oedema, incontinence, inflamed or dry skin. 

The care planning is done according to the outcome of skin and risk assessment. There are certain considerations made for the high risked individuals like need for additional relief of pressure at risk sites, ability for repositioning and mobility. Patient preference and other co-morbidities are also assessed for care planning.

Repositioning is done for the high-risked individuals to change position every six hours. The repositioning should be done frequently and those who are unable to reposition themselves, appropriate assistance are used and documented. The high-risked individuals should be encouraged to change their position frequently and documented. 

Audit Standards

For the prevention of pressure ulcers in adults, NICE recommends high-specification foam mattresses for patients who are at risk for pressure ulcer development. Comfortable cushion can also be used made of resilient foam for the positioning and optimal stabilization. They recommended that the best way to prevent pressure ulcer is to keep the patient clean. These foam mattresses and cushions help to redistribute the pressure and provide equivalent pressure. Seating needs are also required for patients who have prolonged sitting periods.

For high risked adults, there is also barrier preparation consideration for the prevention of skin damage that are at high risk like developing incontinence associate dermatitis or moisture lesion. These are identified through skin assessment guidelines (Neilson et al. 2014).

Pressure ulcers are very common among ICU patients as they are ventilated, sedated or bedridden for long periods. It is one of the common complications that is observed among the ICU patients as they have limited mobility (Cox 2011). They are severe patients and are at high risk for inadequate nutrition, hydration and use of special medicine. They are critically ill and due to limited movement, there are accumulated pressure and risk increases for pressure ulcers among them. Therefore, keeping in mind the incidence of pressure ulcers, the audit will be undertaken in ICU setting in a private hospital in Singapore. The geriatric population in the ICU setting are at risk for developing pressure ulcers as they have limited mobility and so the auditing will be done among this targeted population.

As the nurses, perform the dressing for the pressure ulcers, therefore the registered nurses working in the ICU setting will be audited. They are aware of the pressure ulcer prevention guidelines and perform the dressing among geriatric population. Therefore, the registered nurses will be audited regarding the pressure ulcer prevention.

Around 10 registered nurses who perform wound dressings in the ICU setting among the geriatric ward will be included in the audit. It is important as they observe the patient skin and does assessment for the patients. As they document the process of wound dressing, risk and skin assessment along with repositioning interval, care planning and provide assistive devices that are being used, these clinical documents can also be used as reference.

The sample recruitment is done in the ICU setting in a private hospital in Singapore. As the registered nurses are able to perform the wound dressing in older aged patients in ICU setting, a convenient sample of around 10 registered nurses will be selected based on the ward roster. Familiarization trail will be conducted prior to sample recruitment so that the registered nurses are made aware of the objectives of the audit.

Population

In this audit, qualitative data will be evaluated for better understanding of the issue. Information regarding number of geriatric patients admitted at the ICU ward of the hospital who is at risk of developing pressure ulcers and who has not underwent  pressure ulcer risk assessment on admission will be noted. The frequency of skin assessment that is conducted in the hospital will also be taken into consideration. Additional data relevant to care planning of patients with pressure ulcers will be procured. Further, repositioning data in conjunction with the available pressure redistributing equipments will be taken into account for further data analysis. Demographic information relevant to the patients will be recorded encompassing age, gender, condition and others. All the data will be recorded in the form of open-ended questions as described in questionnaire that will be circulated among the attending Registered Nurses who are appointed at the ICU ward of the hospital. The series of questions will be printed in the questionnaire and the responses obtained from the intended audience will be recorded through the interview process (Patten 2016). One-to-one interview will be conducted with the Registered Nurse for the purpose of collecting pertinent data in line with the topic of investigation. The responses obtained from the respondents will be recorded for future analysis and transcribing the data into meaningful form. Specifically the semi-structured interview will be performed as a qualitative method of investigation comprising of pre-determined set of open-ended questions having scope of exploration for specific themes for the researcher (Liamputtong 2013).

For the audit study, definite qualitative data analysis method will be employed to derive meaningful data. Common responses with respect to the feedback of Registered Nurses to the open-ended questions will be scrutinized to obtain relevant information. Thematic analysis, a popular and reliable mode of qualitative data analysis will be incorporated specifically for recording the patterns within data. Definite and appropriate examination and recording pattern will be employed for recognizing the patterned meaning across a dataset (Vaismoradi, Turunen and Bondas 2013). Hence, answering to the definite research question as in this case the issue of pressure ulcer prevention in geriatric patents will become easier. Further, in course of the audit process endeavors will be streamlined to identify the examples among the wide spectrum of responses to open-ended questions in the questionnaire. Identification of the themes associated with the interview data will be performed by transcribing the recorded data. Inclusion of the wide variety of needs and requirements specific to the audit process will be maintained through thematic analysis (Braun and Clarke 2014). Data analysis will resort to transcribing the data obtained and then subjecting it to thematic analysis for procuring the most relevant and valid research findings. The broader themes related to the questions intended for risk assessment; skin assessment, repositioning, pressure redistributing equipments and care planning will be obtained in course of the data analysis process.

Successful completion of any research study requires abidance to certain ethical and legal guidelines. In basic research, emphasis has been laid to follow the guidelines and dictums as laid out by the concerned authority to maintain the ethical and legal decorum in performing the study. In this audit study, prior to commencement of the project necessary approval will be sought from the Director of Nursing to proceed with the audit in the ICU ward clinical setting of the hospital in Singapore. Once, permission and confirmation is received from the authoritative body, necessary arrangements will be made for proceeding with the audit objectives. It will be taken care of so that no coercive or unfair methods are adopted in collecting requisite information from the intended audience (Best and Kahn  2016). A familiarization trial will be conducted with the Registered Nurses before requesting them to answer to the questionnaire. Efforts will be taken to allay all their queries and apprehensions related to the audit so that the purpose of the audit may be clearly explained to them. This will ensure mitigation of ambiguities or confusions if any related to the audit. The responses obtained from the Registered Nurses will be kept in the custody of the principal investigator with secured password in the laptop. Further, confidentiality and reliability of the data procured from the audit will be maintained to safeguard the information (Neuman and Robson 2014). Under no circumstances, the data will be leaked to any unauthorized persons. Information obtained through the audit will be used for no other purpose other than academic one. Moreover, the NICE guidelines for pressure ulcer prevention will be diligently followed to perform the audit lawfully.

References

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