Literature Synthesis for the Proposed Intervention
Providing safe and quality patient care should be a universal objective for health care professionals. As a result, health care professionals should engage in quality improvement practices that help to achieve better outcomes, such as high care quality and optimal safety in health care settings (Oldland et al., 2020). Direct practice improvement (DPI) projects offer nurses an opportunity to improve patient care outcomes by translating scientific evidence into clinical practice. Scientific evidence for nursing research should be high-level, current, and relevant to the clinical problem (Saeed et al., 2018). Its objective should be guiding nurses in practice change to improve excellence in outcomes. The purpose of this paper is to synthesize the literature for the proposed intervention.
Clinical Issue and Problem Statement
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Patients visit critical care settings with a myriad of severe illnesses and conditions. While receiving care for their conditions, patients in critical care settings are at a high risk of developing pressure ulcers. Susceptibility ranges from 12% to 32.7% and varies with illnesses, treatment methodologies, and the length of hospital stay (Cox et al., 2022). Old and debilitated patients are at high risk, and patient-centered interventions are vital in all health care settings. Other risk factors include immobility and incontinence (Gray & Giuliano, 2018). Understanding the risk and the implications of pressure ulcers on patients’ health are instrumental in developing evidence-based solutions.
Health care settings have a professional and ethical mandate to provide quality, safe, and cost-effective care. Pressure ulcers are detrimental to patient care since it impairs a patient’s overall functioning and quality of life. Health research demonstrates that pressure ulcers are a significant cause of extended hospitalization, high health care costs due to the need for bed rest, and increased care burden on patients and families (Rutherford et al., 2018; Lavallée et al., 2019). Pain, functional impairment, and distress can intensify mental pressure, causing depression. Pressure ulcers also increase patient mortality, and the risk of death is high among elderly patients (Song et al., 2019). The practicum site relied on standard pressure ulcer prevention care. Due to its effectiveness, a preventive care bundle for pressure ulcers was proposed to reduce the incidence of pressure ulcers.
Health care research on the effectiveness of preventive care bundles for pressure ulcers extensively explores different concepts. In selecting the appropriate articles to support the project, the search was limited to high-level evidence and primary research articles. Such articles include randomized controlled trials and quasi-experimental studies. Articles were sourced from the leading nursing databases, including CINAHL Plus with Full Text, PubMed, the Cochrane Library, Nursing Reference Center, and MEDLINE. All the selected articles were published in the last five years to meet the CRAAP Test, which requires nursing research to be current, relevant, authoritative, accurate, and purposeful (New Jersey Institute of Technology, 2022). Other considerations included being peer-reviewed, available in full text, and written in English. Any article that met these criteria and explored the effectiveness of a preventive care bundle for pressure ulcers or a component of the bundle was included.
Synthesis of Literature
Repositioning is among the critical components of a pressure ulcer preventive care bundle. Accordingly, Darvall et al. (2018) explored the effects of changing from 5-hourly turns to 3-hourly turns on reducing pressure injury incidence in critically ill patients. In this pre-post intervention evaluation study, subjects were patients admitted to the intensive care unit. The nursing staff conducted the patient turns and relevant data derived from the reporting database. Darvall et al. (2018) found that a change in turn frequencies reduced pressure injury incidence by 50%. The article supports the proposed intervention by underlining the importance of repositioning and increasing the frequency to optimize health outcomes.
In a different study, Pickham et al. (20180 explored the effects of optimizing turning compliance with wearable sensors. The research hypothesized that optimizing turns would give a better protective effect against pressure ulcers. In this randomized controlled trial, the study’s participants included 1312 patients in two intensive care units (ICUs) in a large medical center in California. In the intervention group (n = 659), patient turns were optimized through wearable sensors and data was relayed to a secure SQL database. The control group received care guided by traditional turn reminders. The primary finding was that patients in the intervention group had fewer pressure injuries than the control group. The study supports the DPI intervention by affirming the importance of optimized patient turns (repositioning) as a protective cover against pressure injuries.
Protective dressings are another crucial component of a preventive care bundle for pressure ulcers. To explore its effectiveness in pressure ulcer prevention, Hahnel et al. (2020) conducted a randomized controlled trial hypothesizing that appropriate dressing on the risk areas will significantly reduce pressure ulcers. The study’s subjects included 475 patients in a tertiary care facility in Berlin. The intervention group (n =212) received protective dressing on the sacrum and heels beside the standard care the control group received. The primary finding was a lower incidence of pressure ulcers in the intervention group (2.8%) than in the control group (10.5%). The study supports the DPI intervention by affirming the positive effects of preventive dressing as a care bundle component for pressure ulcers.
Yap et al. (2021) evaluated the effects of repositioning in reducing the incidence of pressure ulcers. The research hypothesized that outcomes vary with repositioning intervals. In this pragmatic cluster randomized controlled trial with three arms, 992 residents in 9 nursing homes participated. Each arm assessed the effects of one repositioning interval (2-hour, 3-hour, or 4-hour) on nurses’ compliance and the incidence of pressure ulcers. Yap et al. (2021) found that pressure ulcer incidence was 0.0% during the intervention (repositioning) and 5.245 in the baseline. A 4-hour repositioning produced better results (95% protection) than 3-hour and 2-hour repositioning, with 90% and 85% scores, respectively. The study supports the DPI intervention by demonstrating the positive effects of repositioning and how different turn intervals yield different results.
Santamaria et al. (2018) conducted a randomized controlled trial on the effectiveness of multi-layer silicone foam dressing in preventing pressure ulcers among elderly adults. The study subjects were 288 patients in residential aged care facilities in Australia. Nurses applied protective dressings on areas vulnerable to pressure injuries in the intervention group (n = 138) as the control group (n = 150) received standard care only. The primary finding was a higher pressure injury incidence in the control group than intervention group (p = 0.004). The study supports the DPI intervention by demonstrating the effectiveness of protective dressing as a preventive care bundle component for pressure ulcers.
Skin care also plays a significant role in pressure ulcers prevention. In response, Fallahi et al. (2022) conducted a randomized controlled trial to examine the impacts of aloe vera gel, olive oil, and their combinations in preventing pressure ulcers. Participants were 240 ICU patients in Iman Reza Hospital in Iran. Each treatment group had 60 patients and the control group had 60 patients too. The incidence of pressure ulcers was higher in the control group than treatment groups (p = 0.001). The study supports the DPI intervention by demonstrating the positive effects of skin care as a preventive care bundle component for pressure ulcers.
In another study on skin care, Parizi et al. (2022) conducted a randomized controlled trial to evaluate the effectiveness of rosemary extracts in enhancing healing in ICU patients with pressure ulcers. Seventy patients in selected ICUs in Iran participated. The intervention group had rosemary extracts applied on areas susceptible to pressure ulcers, while the control group received standard care only. The primary finding was a significant reduction in pressure ulcers in the intervention group. The study supports the DPI intervention by confirming the importance of skin care to reduce the incidence of pressure ulcers.
Zhang et al. (2021) evaluated the effectiveness of a pressure injury care bundle in reducing the incidence of pressure injuries in ICUs. In this quasi-experimental pre-and-post intervention, adults in ICUs in Chinese hospitals were included. Crucial data were recorded using a checklist that analyzed implementation and compliance. Zhang et al. (2021) found that implementing a pressure injury care bundle reduced the incidence of pressure injuries from 13.86% to 10.41%. The article supports the DPI intervention since it confirms the positive effects of a pressure injury care bundle among critically ill patients.
Oe et al. (2020) conducted a randomized controlled trial on the effectiveness of silicone foam dressing in preventing pressure ulcers in high-risk patients. The research randomized 600 patients into the intervention group (n = 300) and the control group (n = 300). Besides regular care, patients in the intervention group had silicone foam dressings applied to susceptible areas such as the coccyx and sacrum. The primary finding was a lower incidence of pressure ulcers in the intervention group than in the control group (p = 0.001). The article supports the DPI intervention by demonstrating the positive effects of preventive dressing as a pressure injury preventive care bundle component.
Forni et al. (2022) also evaluated the effectiveness of foam dressing in preventing pressure ulcers. In this multi-center randomized controlled trial, 709 patients admitted to ICUs participated. Besides standard preventive care, the intervention group had a multi-layer polyurethane dressing applied on the sacrum. The primary finding was a higher incidence of pressure ulcers (15 patients) in the control group than in the intervention group (n = 4). The article supports the DPI intervention by demonstrating the effectiveness of protective dressing as a component of a pressure injury preventive care bundle.
Pressure ulcers also stem from medical technologies and devices. In response, Tayyib et al. (2021) conducted a prospective, open-label clinical design to evaluate the effectiveness of the SKINCARE bundle in reducing the incidence of device-related pressure injuries in critical care units. All patients (223) in a tertiary hospital in Saudi Arabia received the care bundle, and relevant data were collected using a patient checklist. The primary finding was a significant reduction in pressure injury incidence after implementing the SKINCARE bundle (p = 0.001). The article supports the DPI intervention by confirming the effectiveness of a care bundle in pressure ulcers prevention.
Renganathan et al. (2019) evaluated the importance of improving turn compliance in patients with a high susceptibility to pressure ulcers. In this prospective, multiphase, multicenter trial, Renganathan et al. (2019) enrolled 47 patients receiving care in ICUs in Tamil Nadu, India. To optimize turn compliance, a monitoring system generated alerts in the intervention group and patient position and other crucial data collected. The primary finding was a higher incidence of pressure ulcers in the control group than in the intervention group (p < 0.001). The article supports the DPI project by confirming the protective benefits of patient turns, whose outcomes can be improved by improving turn compliance using a monitoring system.
In a related study, Hassan et al. (2020) conducted a quasi-experimental study to evaluate the effectiveness of body repositioning in reducing pressure ulcer incidence. All immobilized patients in a public hospital in Pakistan were subjected to 2-hourly repositioning, and the incidence of pressure injuries was recorded. The primary finding was a reduced incidence of pressure ulcers after implementing the 2-hour repositioning (p = 0.000). The article supports the DPI intervention by showing the positive effects of repositioning in reducing the incidence of pressure ulcers.
Hekmatpou et al. (2018) conducted a randomized, triple-blind clinical trial on the effectiveness of an evidence-based skin care routine in preventing pressure ulcers. The study subjects were patients (n =80) admitted to an orthopedic ward in Arak, Iran. The control group received standard cleaning through water and starch while aloe Vera gel was applied on susceptible areas such as the hips, sacrum, and heels in the intervention group. Twelve incidences were recorded in the control group versus three cases in the intervention group. The article supports the DPI intervention by confirming the protective benefits of a skin care routine as a component of a pressure injury preventive care bundle.
The last article was by Sharp et al. (2019), hypothesizing that repositioning cannot achieve the desired outcomes when used alone in pressure ulcer prevention. In this cross-sectional survey, Sharp et al. (2019) reviewed medical records of random elderly patients in aged care facilities in Australia. The key finding was that repositioning prevented pressure ulcer development in 76% of the patients hence the need to combine it with other interventions. The article supports the DPI intervention by suggesting the importance of a multi-component care bundle that includes repositioning.
Comparison of Articles
The articles share many features and differ in others. Regarding similarities, all articles confirm that the incidence of pressure ulcers can be reduced with a preventive care bundle. The bundle’s components can be used jointly or independently. However, their participants, study locations, samples, and methods differ. Common themes include the effectiveness of repositioning in reducing pressure ulcers (Sharp et al., 2019; Hassan et al., 2020; Yap et al., 2021; Darvall et al., 2018), protective covering through appropriate dressing (Hahnel et al., 2020; Santamaria et al., 2018; Forni et al., 2022, and Oe et al. 2020). The other theme is the skin care routine (Parizi et al., 2022; Fallahi et al., 2022). The other articles explore the effectiveness of a multi-component care bundle.
Methods also differ significantly. Most of the articles are randomized controlled trials, while others are experimental studies of high-level evidence. Regarding conclusions, the articles exploring the effectiveness of repositioning conclude that it is an effective method for pressure ulcer prevention but turns should be optimized to achieve better outcomes. Other conclusions include appropriate dressings being an effective protective cover and an evidence-based skin care routine should be a priority when taking care of critically ill patients (Parizi et al., 2022; Fallahi et al., 2022). Limitations include small samples affecting generalizability (Fallahi et al., 2022; Tayyib et al., 2021; Hassan et al., 2020), failure to blind the subjects (Santamaria et al., 2018) and selection bias (Pickham et al., 2018). No major controversies have been observed since the studies found the care bundle or its components to affect pressure injury prevention positively.
Recommendations for Future Research
The main research gap is the variance between repositioning, protective dressing, and skin care in preventing pressure ulcers. Although the studies confirm the effectiveness of each component and their combination, they do not analyze the best method in terms of outcomes. This is a significant gap since it implies that the priority area when implementing the DPI intervention is unknown. The other gap is whether research conducted in ICU can apply to other settings despite the severity of pressure ulcers. In agreement with Fallahi et al. (2022), more extensive research with subjects (patients) in other units is vital. Future research should also compare the outcomes of each component and rate them appropriately.
Pressure ulcers are a significant risk for patients in critical care settings. An evidence-based intervention is crucial to reduce the incidence among elderly and debilitated patients. Generally, the synthesized literature demonstrates the effectiveness of a pressure injury preventive bundle in reducing the incidence of pressure ulcers in health care settings. Similar results should be expected with the implementation of the DPI intervention.
Cox, J., Edsberg, L. E., Koloms, K., & VanGilder, C. A. (2022). Pressure injuries in critical care patients in US Hospitals: Results of the international pressure ulcer prevalence survey. Journal of Wound, Ostomy, and Continence Nursing: Official Publication of the Wound, Ostomy and Continence Nurses Society, 49(1), 21–28. https://doi.org/10.1097/WON.0000000000000834
Darvall, J. N., Mesfin, L., & Gorelik, A. (2018). Increasing frequency of critically ill patient turns is associated with a reduction in pressure injuries. Critical Care and Resuscitation, 20(3), 217-222. https://europepmc.org/article/med/30153784.
Fallahi, M., Soroush, A., Sadeghi, N., Mansouri, F., Mobaderi, T., & Mahdavikian, S. (2022). Comparative evaluation of the effect of aloe vera gel, olive oil, and compound aloe vera gel-olive oil on prevention of pressure ulcer: A randomized controlled trial. Advanced Biomedical Research, 11(6). doi: 10.4103/abr.abr_121_21
Forni, C., Gazineo, D., Allegrini, E., Bolgeo, T., Brugnolli, A., Canzan, F., … & Zanelli, S. (2022). Effectiveness of a multi-layer silicone-adhesive polyurethane foam dressing as prevention for sacral pressure ulcers in at-risk in-patients: Randomized controlled trial. International Journal of Nursing Studies, 127, 104172. https://doi.org/10.1016/j.ijnurstu.2022.104172
Gray, M., & Giuliano, K. K. (2018). Incontinence-associated dermatitis, characteristics and relationship to pressure injury: A multisite epidemiologic analysis. Journal of Wound, Ostomy, and Continence Nursing: Official Publication of the Wound, Ostomy and Continence Nurses Society, 45(1), 63–67. https://doi.org/10.1097/WON.0000000000000390
Hahnel, E., El Genedy, M., Tomova‐Simitchieva, T., Hauß, A., Stroux, A., Lechner, A., … & Kottner, J. (2020). The effectiveness of two silicone dressings for sacral and heel pressure ulcer prevention compared with no dressings in high‐risk intensive care unit patients: A randomized controlled parallel‐group trial. British Journal of Dermatology, 183(2), 256-264. https://doi.org/10.1111/bjd.18621
Hassan, N., & Afzal, M., Sehar, S., & Gilani, S. A. (2020). Effects of body repositioning in immobilized patients to prevent pressure ulcer in intensive care units at public hospital, Pakistan. Iris Journal of Nursing & Care- IJNC, 2(4), 2020. http://dx.doi.org/10.33552/IJNC.2020.02.000543
Hekmatpou, D., Mehrabi, F., Rahzani, K., & Aminiyan, A. (2018). The effect of Aloe Vera gel on prevention of pressure ulcers in patients hospitalized in the orthopedic wards: A randomized triple-blind clinical trial. BMC Complementary and Alternative Medicine, 18(1), 1-11. https://doi.org/10.1186/s12906-018-2326-2
Oe, M., Sasaki, S., Shimura, T., Takaki, Y., & Sanada, H. (2020). Effects of multilayer silicone foam dressings for the prevention of pressure ulcers in high-risk patients: A randomized clinical trial. Advances in Wound Care, 9(12), 649–656. https://doi.org/10.1089/wound.2019.1002
Parizi, F. K., Sadeghi, T., & Heidari, S. (2022). The effect of rosemary ointment on the pressure ulcer healing in patients admitted to the intensive care unit: A randomized clinical trial. Nursing Practice Today, 9(1), 15-23. doi: 10.18502/npt.v9i1.7321
Pickham, D., Berte, N., Pihulic, M., Valdez, A., Mayer, B., & Desai, M. (2018). Effect of a wearable patient sensor on care delivery for preventing pressure injuries in acutely ill adults: A pragmatic randomized clinical trial (LS-HAPI study). International Journal of Nursing Studies, 80, 12-19. https://doi.org/10.1016/j.ijnurstu.2017.12.012
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Oldland, E., Botti, M., Hutchinson, A. M., & Redley, B. (2020). A framework of nurses’ responsibilities for quality healthcare—Exploration of content validity. Collegian, 27(2), 150-163. https://doi.org/10.1016/j.colegn.2019.07.007
Renganathan, B. S., Nagaiyan, S., Preejith, S. P., Gopal, S., Mitra, S., & Sivaprakasam, M. (2019). Effectiveness of a continuous patient position monitoring system in improving hospital turn protocol compliance in an ICU: A multiphase multisite study in India. Journal of the Intensive Care Society, 20(4), 309-315. https://doi.org/10.1177/1751143718804682
Rutherford, C., Brown, J. M., Smith, I., McGinnis, E., Wilson, L., Gilberts, R., … & Nixon, J. (2018). A patient-reported pressure ulcer health-related quality of life instrument for use in prevention trials (PU-QOL-P): psychometric evaluation. Health and Quality of Life Outcomes, 16(1), 1-11. https://doi.org/10.1186/s12955-018-1049-x
Saeed, M., Swaroop, M., Ackerman, D., Tarone, D., Rowbotham, J., & Stawicki, S. P. (2018). Fact versus conjecture: Exploring levels of evidence in the context of patient safety and care quality. In Vignettes in Patient Safety-Volume 3. IntechOpen. doi: 10.5772/intechopen.76778
Santamaria, N., Gerdtz, M., Kapp, S., Wilson, L., & Gefen, A. (2018). A randomised controlled trial of the clinical effectiveness of multi-layer silicone foam dressings for the prevention of pressure injuries in high-risk aged care residents: The Border III Trial. International Wound Journal, 15(3), 482–490. https://doi.org/10.1111/iwj.12891
Sharp, C. A., Schulz Moore, J. 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. https://doi.org/10.1007/s11673-018-9892-3
Song, Y. P., Shen, H. W., Cai, J. Y., Zha, M. L., & Chen, H. L. (2019). The relationship between pressure injury complication and mortality risk of older patients in follow-up: A systematic review and meta-analysis. International Wound Journal, 16(6), 1533–1544. https://doi.org/10.1111/iwj.13243
Tayyib, N., Asiri, M. Y., Danic, S., Sahi, S. L., Lasafin, J., Generale, L. F., … & Reyes, M. (2021). The effectiveness of the SKINCARE bundle in preventing medical-device related pressure injuries in critical care units: A clinical trial. Advances in Skin & Wound Care, 34(2), 75-80. doi: 10.1097/01.ASW.0000725184.13678.80
Yap, T. L., Horn, S. D., Sharkey, P. D., Zheng, T., Bergstrom, N., Colon-Emeric, C., … & Kennerly, S. M. (2021). Effect of varying repositioning frequency on prevention of pressure injuries in nursing home residents: TEAM‐UP cluster‐randomized clinical trial results. Research Square, 1-21. https://doi.org/10.21203/rs.3.rs-717425/v1
Zhang, X., Wu, Z., Zhao, B., Zhang, Q., & Li, Z. (2021). Implementing a pressure injury care bundle in Chinese intensive care units. Risk Management and Healthcare Policy, 14, 2435–2442. https://doi.org/10.2147/RMHP.S292579
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