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CDP 09-390 – HSR&D Study

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CDP 09-390
Nursing Work Required for Pressure Ulcer Prevention (CDA 06-015)
Mary Ellen Dellefield PhD BSN MS
VA San Diego Healthcare System, San Diego, CA
San Diego, CA
Funding Period: October 2010 - September 2011

BACKGROUND/RATIONALE:
Prevention of pressure ulcers (PUs) in all clinical settings in which Veterans receive healthcare services is a national priority. Such care is particularly important to provide in the Community Living Center (CLC) (i.e. nursing home) because Veterans receiving healthcare may be at risk of developing PUs. PU incidence and prevalence are used as indicators of quality and safety. Guidelines for best practices in prevention have been widely disseminated. Researchers have fond that implementation of PU prevention best practices is difficult to sustain. Prevention requires that basic nursing care processes are coordinated and consistently performed. Most recommended clinical structures and care processes associated with best practices are based on expert opinion rather than direct evidence. We need to better understand ways in which nursing staff attitudes, beliefs, knowledge, values, and work practices are related to effective preventive nursing care. Better identification of factors associated with barriers and facilitators to sustained implementation of PU prevention nursing care practices will enable researchers to tailor implementation of best practices for PU prevention to unique features of the practice context.

OBJECTIVE(S):
To describe CLC nursing assistant (NA), licensed vocational nurse (LVN), and registered nurse (RN) perceptions of factors associated with barriers and facilitators to PU prevention in 5 domains of interest - staff attitudes, beliefs, knowledge, values, and work practices.

METHODS:
A purposeful convenience sample of NAs, LVNs, RNs working full time on any shift was obtained at 2 VA Southern California CLCs. This mixed methods study employed 45-40 minute structured and audio-recorded individual interviews and 16 scaled questions (yes/no or 1-10) embedded in each interview. Transcripts were analyzed using content analysis and descriptive statistics.



FINDINGS/RESULTS:
The sample included 9 NAs, 4 LVNs, and 3 RNs. It was mostly female (88%); middle-age (average age 50 years); ethnically diverse (white/non-white); experienced (average 16 years/nursing); stably employed at VA (average 7 years). Aggregate analysis is noted. Little variation was found among subjects based on nursing skill mix except that NA understanding and articulation of components of best practices were seemingly less important than actual clinical performance. All nursing staff reported high levels of performing preventive practices. This may have contributed to the limited amount of variation in practice described.

Factors related to facilitation included a centralized wound care program (work practices/knowledge) that included CLC-level team members; intrinsic motivation (attitudes) by staff and beliefs that PUs were preventable (beliefs); surveillance and early detection of PUs during NA performance of activities of daily living (knowledge, work practices); belief that prevention enhanced Veteran quality of life (beliefs); strong sense of personal responsibility for PU prevention and pride in practice (attitudes/values); sustained provision of care despite positive or negative feedback received about performance (work practices); commitment to Veteran well-being (values, beliefs, attitudes); and teamwork and communication with wound team members (work practices, values).

Factors related to barriers included limited performance feedback by nurse managers (work practices/values); limitations in articulating specific policies and procedures that comprised best practices in prevention (knowledge, values); and inconsistent use of clinical documents (i.e. care plans and Braden Scale scores(work practices/knowledge).

On a scale of 1-10 (higher number indicated higher valuation), PU prevention was characterized as interesting (7.8), a priority (8.6), effective (9.2), and having an impact on Veteran quality of life (7.7). PUs were described as largely preventable (7.7). Resident (9.0) and family involvement (7.0) in PU prevention was recommended. Routine skin inspections were characterized as not at all difficult to perform. The Braden Scale score helped in identifying at-risk residents. Subjects described having enough quality equipment or supplies for PU prevention. Receipt of individual recognition/praise (5.9) and importance of wound care program (5.7) were rated more positively in the qualitative component of the study.











IMPACT:
Findings from this pilot study may be used to develop a larger study to describe and explain current variations in PU prevention practices within VISN 22 CLCs. Effective implementation of the VHA handbook 1180.02 Prevention of Pressure Ulcers and the VHA Hospital Acquired Pressure Ulcer Prevention Initiative will be enhanced by increased understanding of factors associated with barriers and facilitators to preventive practice in CLCs.

PUBLICATIONS:

Journal Articles

  1. Dellefield ME, Magnabosco JL. Pressure ulcer prevention in nursing homes: nurse descriptions of individual and organization level factors. Geriatric nursing (New York, N.Y.). 2014 Mar 1; 35(2):97-104.


DRA: Aging, Older Veterans' Health and Care, Health Systems, Brain and Spinal Cord Injuries and Disorders
DRE: Epidemiology
Keywords: none
MeSH Terms: none

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