Pressure ulcers are a major patient safety concern for hospitals: they are common, costly, and generally preventable. Guidelines and best practices describing specific nursing care processes for pressure ulcer prevention (e.g., use of a risk assessment tool to screen patients at high risk for skin breakdown) are well established. Unfortunately, our understanding of how to incorporate these processes into clinical care routines is very limited. Implementation efforts are sensitive to the organizational context-the local conditions within the setting in which care is delivered. Two resources that provide guidance on implementation are: the VHA Handbook1180.02 Prevention of Pressure Ulcers and the Agency for Healthcare Research and Quality (AHRQ) Toolkit for Preventing Pressure Ulcers in Hospitals. Both resources include details about organizational structures and processes for pressure ulcer program implementation. However, the extent to which hospitals have translated this guidance into their care delivery systems is unknown. Findings from our prior qualitative study of pressure ulcer prevention within six VA acute care facilities indicate variations in organizational structures and processes across facilities including: the staffing of wound care specialists; the provision of ongoing staff education specific to pressure ulcer prevention; and the use of performance data to guide improvement. Given the variations seen in our small sample-and the importance of organizational context on implementation-a comprehensive assessment of organizational variations in pressure ulcer prevention activities across the VA system is needed to inform implementation and future policy decisions.
The goal of this project was to collect data to inform operational and policy decisions related to pressure ulcer prevention activities across the entire population of VA acute care hospitals. We accomplished this goal through the following aims:
1. Develop and field an organizational survey to assess how VA acute care hospitals are organized to delivery pressure ulcer preventive care, including implementation of the VHA Handbook1180.02 Pressure Ulcer Prevention;
2. Work with VA Office of Nursing Services to disseminate findings to key stakeholder groups.
We developed and fielded a key informant survey to assess how VA acute care hospitals are organized to delivery pressure ulcer preventive care, including implementation of the VHA Handbook1180.02 Pressure Ulcer Prevention. Survey content (domains, measures and items) were based on our logic model which was informed by: the VHA Handbook1180.02, findings from our six-site qualitative research study (NRI 10-124), the AHRQ toolkit, systematic reviews specific to pressure ulcer prevention (Soban 2011; Sullivan et al 2013), and constructs from the Framework for Organizational Transformation (VanDeusen Lukas, 2010). We used cognitive interview techniques to refine the survey and produce the final survey instrument. The final survey was fielded by email to the Chief Nurse Executive (ADPCS) at each facility for distribution and completion by staff who are most knowledgeable about pressure ulcer prevention activities in the acute care setting. We used descriptive statistics to examine variations in program elements. To examine the role of organizational factors (e.g., complexity) in explaining variations, we linked the survey data to data on facility complexity (high=1, medium=2, low=3) and tested for associations using chi square, bivariate linear and logistic regression models.
The survey achieved a 97% response rate (N=121). Overall, 91% of hospitals reported implementing all five major program elements (i.e., policy, oversight committee, wound care specialists (WCS), performance monitoring, staff education). However, there were considerable variations in the operationalization of program elements. Oversight committees for pressure ulcer prevention varied in terms of: membership (e.g., nursing, physicians, quality improvement) and senior leadership engagement/support for the committee. The use of single vs. multiple sources of data for performance monitoring varied across hospitals as did the perceived value of different data sources. Despite high rates of pressure ulcer prevention training offered to nursing staff (RN/LVN/LPN), fewer than one-third of the respondents (29%) reported nurses' time to complete training as "completely or mostly sufficient". Wound care specialist staffing varied across hospitals (mean 2.7; range 0-9) and was the only program element associated with facility complexity levels (p<.001). Most hospitals (91%) reported conducting at least one improvement project specific to pressure ulcer prevention within the last 3 years. Responses to open-ended questions about improvement activities showed strong convergence with responses to closed-ended questions. The factors most commonly reported as supportive of improvement activities included leadership support, availability of wound care specialists, and skin champions. The most commonly reported challenges to improvement efforts included lack of available time for staff education and training, staff competence and accountability structures, and lack of involvement by other disciplines (e.g., medicine, nutrition, pharmacy).
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 a comprehensive look at variations in pressure ulcer prevention activities across all VA acute care facilities, nationwide. Findings from this study are currently being disseminated and discussed with relevant groups within the VA such as the VA Office of Nursing Services and the National VA Pressure Ulcer Prevention (PUP) Workgroup. These findings are expected to inform both policy development and decision making assist VA facilities to build stronger pressure ulcer prevention programs.
- Soban LM, Miltner RS. Translating Policy into Practice: Insights about Variations in Implementation of Pressure Ulcer Prevention Programs. Paper presented at: AcademyHealth Interdisciplinary Research Group on Nursing Issues Annual Meeting; 2015 Jun 13; Minneapolis, MN.
- Soban LM, Miltner RS. Variations in Hospital Staff Education Programs for Pressure Ulcer Prevention. Paper presented at: Quality and Safety Education for Nurses Institute National Forum; 2015 May 26; San Diego, CA.