Pressure ulcers ("bedsores") are a major patient safety concern for hospitals, and little progress in decreasing pressure ulcer rates has been achieved. Guidelines and best practices describing nursing care processes for pressure ulcer prevention (e.g., use of a risk assessment tool to screen patients at high risk for pressure ulcers) are well established, yet evidence indicates low rates of nurse adherence to these guidelines. How hospitals support the implementation of these nursing care processes through organizational structures and processes is not known and is an important step to facilitating implementation.
This study aims to understand how pressure ulcer prevention programs are organized in VA acute care hospitals and how organizational environments (contexts) at the hospital and nursing unit levels influence implementation of this care. The study objectives are to: (1) understand the relationships between pressure ulcer programs, organizational context, and delivery of guideline-concordant pressure ulcer preventive care; and (2) to convene an advisory group designed to review study findings and discuss next steps including ideas for future interventions.
We used a multi-site case, comparative case study approach. Qualitative data were collected using semi-structured interviews of key informants from six diverse VA acute care hospitals. Hospitals were selected based on size and pressure ulcer prevalence rates. Key informants represented 3 different perspectives: (1) nursing executive leadership, (2) nurse unit managers, and (3) frontline nursing staff (RNs). Data were analyzed by top coding interviews for key themes, the creation of case narratives for each site, and conducting cross case comparisons.
Forty eight key informants participated in interviews. Wound care specialists were central to pressure ulcer preventive care activities and all hospitals had at least one wound care specialist on staff. Staffing levels for wound care specialists varied considerably across hospitals and were unrelated to facility size. Only half of the hospitals reported providing annual training specific to pressure ulcer prevention for nursing staff (RN/LVN/LPNs), yet most launched recent, one-time educational efforts to improve nurses' skills in identification of pressure ulcers. Unit-level systems for nurses to request wound care consultations were established in all facilities; however, systems to support communication specific to pressure ulcer prevention among staff on nursing units (e.g., use of hourly rounds; use of handoff tools) were generally not in place. Informants consistently reported wound care specialists as an important facilitator to pressure ulcer prevention programs. Insufficient staffing of wound care specialists was reported as a barrier in half the sites. Among unit-level barriers, variable staffing of nursing assistants was consistently reported across most sites as an impediment to delivery of pressure ulcer preventive care (i.e., patient repositioning and prompt incontinence care). Limited nurse staffing was also reported as a barrier to staff participation in educational offerings including the implementation of wound care rounds.
Improving the quality of pressure ulcer preventive care is a goal in VA, but quality improvement must begin with a clear understanding of how nursing care processes for pressure ulcer preventive care are supported or impeded by organizational context. This study contributes to improving veterans' healthcare by providing detailed descriptions of strategies used in VA hospitals to support pressure ulcer preventive care, and identifying contextual barriers and facilitators to implementation of these strategies. Findings from this study will inform policy decisions specific to pressure ulcer prevention in VA and will lead to the development of interventions to improve care delivery. In addition, study findings were used to inform development of a VA nationwide survey to assess implementation of pressure ulcer prevention programs in all VA acute care facilities, system wide.
- Soban LM, Mittman BS. Laying a Foundation for Implementation: 4 studies examining hospital quality of care for pressure ulcer prevention. 2013 Apr 4.
- Soban L, Finley E, Miltner R. Implementation of Pressure Ulcer Prevention Programs: An Opportunity to Improve Value in Healthcare. Paper presented at: International Nursing Administration Research Conference; 2014 Nov 13; Dallas, TX.
- Soban LM, Finley E. Are hospitals organized to support pressure ulcer prevention? Poster session presented at: Southern California Dissemination, Implementation, and Improvement Science Annual Symposium; 2014 Mar 4; Los Angeles, CA.