Nursing Quality Improvement Proposal Project

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 Nursing Quality Improvement Proposal ProjectClinical Application Project (CAP) Instructions and Rubric Description: The Clinical Application Project (CAP) is an opportunity for the BSN student to identify an issue, topic, or challenge that is relevant to their Role Transition clinical placement. The student will examine the research related to their topic and investigate the literature regarding a potential solution for, or intervention to improve, the issue. The student then creates a final project, intervention, or solution to their identified topic. They will present their work in a professional paper and electronic poster presentation. Directions: Identify a problem, issue of concern, or area for improvement relevant to your clinical setting. Describe the importance of the area of concern (include facts, statistics etc.). Consult with your RN preceptor and ResU clinical faculty regarding your topic. Your clinical instructor must approve the topic before work is initiated. Critically analyze the literature related to the area of concern. Appendix E (cont’d) Professional Role Transition Grading criteria for PAPER Points Introduction • Introduces topic and provides overview of the issue (2 pts.) hospital acquired pressure injury • Discusses why this issue is pertinent to the particular /7 unit/organization and what led student to choose the topic (2 pts.) on medical surgical unit observed multiple patients with limited mobility who were not repositioned throughout whole night shift despite being at high risk for skin injuries, charged nurse identified increasd incidences of pressure injuries throughout the hospital units • Identifies unit, manager, etc. support for the project (1 pt.) nurse preceptor supported the idea. He identified stuff shortage and workload as a cause of the neglect • Identifies how the project will specifically benefit the unit/organization (2 pts.) nursing morale will improve, patients’ quality of life will be improved, shorter hospital stay, cost of patient hospital stay will decreased Literature review: topic/issue ONLY FOCUS ON THE PROBLEM NOT THE IMPROVEMENT • Includes two recent articles (less than 5-7 years) from /10 professional nursing or health sciences journals (2 pts.) • For each article: provides brief summary and discusses how the article is pertinent and relevant to the topic/issue (4 pts./each article=8 total) Comments SAMPLE OF THE WORK Family-Centered Communication in Day Surgery Three Quality of Care key drivers for Our Lady of the Resurrection (OLR) Medical Center’s Surgical Services department are measured quarterly. The Surgical Services Department has met or exceeded targets for two of the three key drivers. However, for the past six months, the department has not met the goal for a third key driver: explanations provided about progress following surgery. Meeting the goal for the third key driver is dependent on effective communication processes from staff and surgeons to patients and their families. A communication process exists, but by looking at areas in which the process is broken, relatively easy and effective fixes can be put into place. (Topic introduction, overview of issue, choice of topic) The charge nurse for preoperative and recovery care has identified difficulty in adhering to the current process due to difficulty in locating family members if they leave the waiting room and due to the volume and acuity of patients that enter the recovery area. The nurse manager has also identified meeting the third key driver as a priority for the institution and supports the project. (Pertinence of issue to the unit and preceptor and unit manager buy-in) Increasing patient satisfaction—and thereby increasing the likelihood of returning to the facility for healthcare needs—can benefit the unit and the organization by increasing revenues. The profession of nursing can also benefit by increasing staff and improving technologies for patient care with additional revenues. (Benefit to the unit/organization) Literature Review of Problem Much research on factors influencing patient satisfaction in perioperative care has been conducted. A driving factor identified is communication to patients and families during care. Yellen (2003) surveyed ambulatory surgery patients to determine the influence of the nurse-sensitive variables of age, gender, culture, previous hospital admissions, nurse communication, pain, and satisfaction with pain management on overall patient satisfaction. Results showed that nurse communication was the most significant indicator of patient satisfaction, and satisfaction with pain management was the second most significant indicator. Furthermore, patients who were satisfied with nurse communication also reported satisfaction with pain management. Fry and Warren (2005) conducted a qualitative study to determine the needs of family members in the waiting room of a critical care unit. Results showed that all participants sought some information about the patient’s outcomes during the stay. In addition, an element of trust was essential to a family member’s sense of well-being, especially with nurses. The study concluded that an environment that supports a nurse’s interaction with patients and families enhances trust. Conversely, a lack of information or trust of nurses can reduce a sense of wellbeing and, ultimately, patient satisfaction. Etafa et al. BMC Nursing (2018) 17:14 RESEARCH ARTICLE Open Access Nurses’ attitude and perceived barriers to pressure ulcer prevention Werku Etafa1*, Zeleke Argaw2, Endalew Gemechu2 and Belachew Melese3 Abstract Background: The presence or absence of pressure ulcers has been generally regarded as a performance measure of quality nursing care and overall patient health. The aim of this study- wasto explorenurses’ attitude about pressure ulcer prevention’and to identify staff nurses’ perceived barriers to pressure ulcer prevention public hospitals in Addis Ababa, Ethiopia. Methods: A self-reported multi-center institutional based cross sectional study design was employed to collect data from staff nurses (N = 222) working in six (6) selected public hospitals in Addis Ababa, from April 01–28/2015. Results: Majority of the nurses had (n = 116, 52.2%) negative attitude towards pressure ulcer prevention. The mean scores of the test for all participants was 3.09out of 11(SD =0.92, range = 1–5). Similarly, the study revealed several barriers need to be resolved to put in to practice the strategies of pressure ulcer prevention; Heavy workload and inadequate staff (lack of tie) (83.1%), shortage of resources/equipment (67.7%) and inadequate training (63.2%) were among the major barriers identified in the study. Conclusions: The study finding suggests that Addis Ababa nurses have negative attitude to pressure ulcer prevention. Also several barriers exist for implementing pressure ulcer prevention protocols in public hospitals in Addis Ababa, Ethiopia. Suggestion for improving this situation is attractive. Keywords: Wound, Pressure ulcer prevention, Nurses attitude, Perceived barrier Background Pressure ulcers are defined as localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear [1]. PUs significantly limits many aspects of an individual’s well-being, including general health and physical, social, financial, and psychological quality of life [2]. In United States nearly 1 million people develop pressure ulcers annually, while approximately 60,000 acute care patients die from related complications [3]. The estimated cost of managing stage III/IV pressure injury per patient is $70–150 thousand, and the total cost for treatment of pressure ulcers in the United States is estimated at $9–11 billion per year [4]. Research evidences displayed that Pressure ulcer prevalence is varying from country to country For example, prevalence of pressure ulcer in Jordan (12%), * Correspondence: 1 Department of Nursing, College of Health Science, Wollega Unversity, Samara, Ethiopia Full list of author information is available at the end of the article Nigeria (3.22%), (Norway, 17%, Irish, 16%, Denmark, 15%, Sweden, 25%), Irish (9%), (Norwegian, 54% & Irish, 12%), Wales (8.9%) [5–10]. One study [11] identified risks for the development of pressure ulcers/injuries included advanced age, immobility, incontinence, inadequate nutrition and hydration, neurosensory deficiency, device-related skin pressure, multiple comorbidities and circulatory abnormalities. A systematic review reported that pressure ulcer incidence rates vary considerably by clinical setting; ranging from 0.4 to 38% in acute care, from 2.2 to 23.9% in long term care, and from 0 to 17% in home care [12]. A retrospective secondary analysis of database studies have shown that an estimated 3.5–4.5% of all hospitalized patients are developing potentially preventable, hospital-acquired pressure ulcers, despite heightened awareness [3]. Hospital-acquired pressure ulcers/injuries (HAPU/I) result in significant patient harm, including pain, expensive treatments, increased length of institutional stay and, in some patients, premature mortality [13]. © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated. Etafa et al. BMC Nursing (2018) 17:14 A single published study by Haileyesus & Mignote [14] conducted in Ethiopia in Felegehiwot referral hospital, among 422 found the overall prevalence rate of 16.8%. Of this, 62%, 26.8% and 2.8% developed stage I, II and stage IV pressure ulcer, respectively, based on European Pressure Ulcer Advisory Panel (EPUAP). This research also reported that the significant variables with the presence of PU such as stay in hospital for a long, slight limit of sensory perception, and friction and shearing forces. Fishbein & Ajzen [15] explicated that attitude is learned and is affected by knowledge, behavioral intent and the amount of affection for or against an object. Aperson who holds a positive attitude toward an issue will have a greater possibility of performing a supportive behavior related to that issue [15]. For example, the more positive attitude of nurses to PU prevention, the better practice of PU prevention care demonstrated [16]. Evidence-based clinical guideline has a significant correlation with positive feeling to pressure ulcer prevention [17]. Grimshaw et al. [18] stated that lack of knowledge, negative attitudes, or underdeveloped skills are the principal barriers to evidence-based practice at the level of the individual health care professional. Ayello & Meaney [19] also explicated negative attitude of nurses to PU prevention increase the prevalence rate of pressure ulcers. Similarly, Hill [20] expressed that nurses’ negative attitude could be affected by shortage of staff, lack of time, lack of knowledge and insufficient equipment. Among the researched and published documents on the same topic, six studies concluded that most nurses hold a positive attitude to PU prevention (Moore & Price 2004, Kallman & Suserud 2009, Islam 2010, Demarré et al. 2011, Tubaishat et al. 2013, and Uba et al. 2014) [21–26]. In addition to attitude of nurses explored, three papers identified the major barriers for nurses’ to demonstrate PU prevention practice such as lack of time, staff and uncooperative patient [21, 22, 25]. However, a study conducted among 145 Belgian nursing homes by Beeckman et al. [17] using convenience sampling found that poor attitude to PU prevention. Similarly, another data collected from 105 health care professionals (nurses, physical therapist, occupational therapist and physician medicine) in the rehabilitation at Fahad Medical College city, Riyadh found unsatisfactory attitude of health care professionals to PU prevention [27]. A cross sectional study among Jordanian nurses also found a positive relationship between positive attitude of nurses and longer year of experience [25]. Pressure ulcer prevention is a priority for nurses, healthcare professionals and healthcare organizations throughout the world, and a key factor in pressure ulcer prevention and management is individual nurse decision making [28]. Nurses hold the most responsibility for Page 2 of 8 prevention and management of pressure ulcers though it is a multidisciplinary team approach [29]. Padula et al. [3] described that hospitals adhering to PU updates had significant pressure injury reductions by average hospital 7.5 pressure injury case reductions and $500,000 + savings per year. Moore & Price [21] suggested that pressure ulcer prevention and management involves both emphasizing on educational strategies and promoting a positive attitude of nurses towards PU care. To date, no similar studies have been conducted in Ethiopia to examine nurses’ attitude and perceived barriers to PU prevention. Therefore, this study was undertaken to assess attitude of nurses in Public Hospitals in Addis Ababa to PU prevention. Objectives The objective of this study was to explore nurses’ attitudes toward the prevention of pressure ulcers, and to identify staff nurses’ perceived barriers to pressure ulcers prevention in Public hospitals in Addis Ababa, Ethiopia. Methods Study design Institutional based cross sectional multi-center study using quantitative method was employed from April 01–28, 2015. Study setting and sample The study was in Addis Ababa, the capital city of Ethiopia which contains 13 public referral hospitals (each contains from 120 to 400 beds for admission). There are 34 private hospitals, 86 health centers and various NGOs and health institutions. The data in this study included nurses working from patient admission units in six randomly selected public referral hospitals (46%). The units included were medical, surgical, orthopedics, intensive care unit, gynecology, pediatrics, dermatology, burn and oncology. Sample size and sampling procedure The sample size was determined using a formula of estimating a single population proportion for cross sectional study. Since the population size is less than 10, 000 (N = 534), the final sample size was estimated using correction formula. The final sample size obtained including 10% non-response rate was 252. Then, the number of participants in each selected hospitals to obtain similar proportion of participants were determined using the population proportionate sampling (PPS). It is estimated using the formula: n = (nf * N in a health facilities)/N total, where, n = Proportion of nurses participate in the study in a given public hospital, nf = Final sample Etafa et al. BMC Nursing (2018) 17:14 size obtained using correction formula (252), N = is the total number of nurses in the selected public hospitals (534). Study instrument A questionnaire used for gathering data contained three parts. For the purpose of the current study, demographic information which may or may not have an impact on the nurses’ attitude towards pressure ulcer prevention (age, sex, clinical working experience, educational level, and the nurses received training on PU prevention and read research articles about it) were added. Part two of the data collection tool was Pressure Ulcer Attitude Test tool contained 11 statements developed and validated by Moore & Price [21]. In this section, the response option utilized a 5 point Likert scale from strongly disagree to strongly agree. It was chosen since it allows scaling of an individual’s attitude and is more sensitive to the full range of attitude than a simple dichotomous agree/disagree option. The validity of instrument were assessed by nursing instructors holding MSc (Assistant professors) and had research experience (n = 3) before and after pilot study. Piloted test was conducted at St. Peters hospital Research after Review Ethical Committee granted us a letter of permission. After pilot test, marginal corrections such as order and wording of questions were assessed. Similarly, the questionnaire was pilot tested (n = 25). The internal consistency reliability (Cronbach’s α) was 0.76. Part three of the data collection tool in the questionnaire was comprised a closed-ended questions (‘Yes’ or ‘No’ response) to identify nurses’ barriers to implement pressure ulcer prevention protocol adapted by reviewing different literatures [21, 22, 25]. The hospital which agreed for participation was asked to give the list of their participants through matron. The head nurses at study site were asked for their assistance to distribute questionnaires and were cooperative. The participants were selected using random sampling table (Fig. 1). Data analysis The data cleaning was done, entered in to computer using EPI data version 3.1 statistical packages, and 10% of the response was randomly selected and checked for the consistency of data entry. SPSS version 20 was used for data analysis. Frequencies and percentages were calculated to all variables which were related to the objectives of the study. The mean score attained from the scale was used to measure nurses’ attitude. A numeric value was assigned for each attitude test items: 5 = strongly agree, 4 = Agree, 3 = neither agree nor Page 3 of 8 disagree, 2 = disagree, and 1 = strongly disagree. The questions include both positive and negative statements. But for negatively stated questions the score is reversed. The attitude mean was obtained by collapsing the Likert scales strongly disagree, disagree and neither agree nor disagree to the negative attitude, and strongly agree and agree to the positive attitude. Appropriate inferential test like ANOVA (analyses of variance) were used to test the effect of demographics on attitude. Results for p- value < 0.05 were considered significant. Results Demographic characteristics of the nurses A total of 252 professional nurses were invited to participate in the study, 222 fully participated in the study, for a response rate of 78.7%. Among 369 nurses 128 (36%) were males. The mean ages of participants were 29 with minimum 20 and 61 years maximum. Most participants had a bachelor’s degree in (n = 140, 63%), while 11% (n = 24) were enrolled in masters of Science degree in nursing. Nurses who are counted for their experiences in more than 10 years were 20.2% while majority of them 54% have 1–4 years of experience in nursing profession. Sixteen nurses (n = 16, 7.2%) reported that they had received and the largest proportion of them (n = 148, 66.7%) never received any training in PU prevention, while majority of them (n = 191, 86%) had not previously read research articles about PU compared to 31 (14%) who had read it. A limited number of nurses had attended PU training on conference. The majority of the participants were from medical ward (30.0%) as shown in Table 1. Nurses’ attitude towards pressure ulcer prevention The study result indicated that more than half (n = 116, 52.2%) of nurses’ attitude towards pressure ulcer prevention were negative (mean = 3.09, SD = 0.92, range = 1–5). The lowest possible score (negative attitude) was 11 whilst the highest possible score (positive attitude) was 55. Data analysis of the nurses’ attitudes showed some interesting points in relation to certain statements (Table 2). More than half of staff nurses (n = 126, 56.6%) felt that all patients are at risk of developing PUs, and around three quarter of the participants (n = 162, 72.9%) thought PU treatment was seen as lesser priority than its prevention. Nurses also believed that PU could be voided (n = 153, 68.8%), PU prevention care was not time consuming (n = 129, 58%), and 69% was considered continuous assessment of patient would give an accurate process of identifying patient at risk for PU. The only statistically significant association in this study was gender of staff nurses (P = 0.032). It found that Etafa et al. BMC Nursing (2018) 17:14 Page 4 of 8 Fig. 1 Schematic Presentation of Sampling Procedure male staff nurses showed that more positive attitude to PU prevention than female staff nurses. Other variables like age group, educational level, whether PU training received and reading research articles about PU had no effect on the nurses’ attitude to pressure ulcer prevention. Nurses’ perceived barriers for practicing PU prevention care Among thestaff nurses participated in the study (n = 222), only 2% of them had not reported any challenge for preventing pressure ulcer while majority (98%) of them had reported different challenges. The most frequently cited barriers were heavy work load and inadequate staff (n = 185, 83.1%), shortage of pressure relieving devices (inadequate equipment and devices), (n = 150, 67.7%), inadequate training about PUprevention (n = 140, 63.22%), lack of job satisfaction (n = 125, 56.2%), presence of other priorities than PU (n = 130, 58.7%) and lack of universal guide lines (n = 133, 59.3%) as illustrated in (Table 3). Discussion The results of this cross-sectional study explored that Addis Ababa nurses’ hold a negative attitude to PU prevention. Similarly, major staff nurses’ barriers to practice PU prevention such as heavy workload/inadequate staff, shortage of resources and inadequate training about PU prevention were identified. The present research result contradicted with several other previous study results [21–26]. This may be due to this study participants’ included were from inpatient units. However, the present study result is in agreement with study conducted by Beeckman et al. [17] and Kaddourah et al. [27]. According to Moore and Price [21], the presence of barriers and obstacles (lack of time and staff, training, resources, and guideline) could prevent positive attitudes of nurses’ from being reflected in practice. So, for the current study, it can be interpreted that the major barriers identified by staff nurses to practice PU prevention such as heavy workload and inadequate staff, and shortage of resources and inadequate training about PU prevention could be the possible reasons for most nurses’ negative attitude. Etafa et al. BMC Nursing (2018) 17:14 Page 5 of 8 Table 1 Frequency distribution of nurses’ socio-demographic variables (N = 222) Variables N (%) Sex • Male 77 (34.7) • Female 145 (65.3) Age (M = 29, SD = 6.65,max = 61,min = 20) • 20–29 years 148 (66.7) • 30–39 years 49 (22) • > = 40 years 25 (11.3) Level of education • Diploma in nursing 58 (26) • Degree in nursing 140 (63) • Masters in nursing 24 (11) Working experience (max = 41, min = 1) • 1–4 years 115 (51.8) • 5–10 years 55 (24.8) • Above 10 years 52 (23.4) Where you received training on PU prevention? • In-service 16 (7.2) • Course 37 (16.7) • Conference 2 (0.9) • Workshop 19 (8.5) • Never 148 (66.7) Have you read researchs about pressure ulcers? • Yes 31 (14) • No 191 (86) The Knowledge, Attitude and Practice (KAP) model [29] explained that individual’s ability to perform actions can be influenced by certain knowledge, and attitude affects individual towards practice. Beeckman, et al. [17] suggested the more positive attitude towards prevention of PU, the more adequate preventive care patients will receive. This is supported by two other studies [18, 20]. In addition to identified barriers, for this study poor knowledge of nurses could be another possible reason for staff nurses’ negative attitude towards PU prevention. This paper showed that male nurses hold more positive attitude than female nurses (p = 0.032) to PU prevention though no similar researched topic agree with this point. The current study is in line with Moore and Price (2004) [22], who found that nurses’ level of education and year of clinical working experience had no significant effect on nurses’ attitude. Although Tubaishat et al. [25] found that nurses who had more year of experience, showed more positive attitude, our study did not support it. In addition, the respondents who had received PU care training and read research articles about PU did not scored higher attitudes than their counter parts. This supported by other research results [21, 22]. However, Kallman and Suserud [22] identified perceived barriers such as lack of time and un-cooperative patients, and lack of pressure relieving devices as the possible barriers, whereas as, Tubaishat et al. [25] identified as lack of policies and guidelines about PU prevention (50%), lack of cooperation with other health professionals (51%) and lack of job satisfaction (57%) as the major barriers to prevent PU cited by most of the nurses. Similarly, this study displayed heavy workload and inadequate staff (lack of time) as the major barrier Table 2 Nurses’ attitude towards pressure ulcer prevention, 2015 (N = 222) Variables Nurses’ attitude rate Strongly agree N (%) Agree N (%) Neither agree nor disagree N (%) Disagree N (%) Strongly disagree N (%) All patients are at risk of developing PUs 64 (28.8) 62 (28) 46 (20.7) 28 (12.6) 22 (9.9) PU prevention is time consuming for me 34 (15.3) 59 (26.6) 39 (17.6) 34 (15.3) 56 (25.2) In my opinion, patients tend not to get as many PUs now days. 24 (10.8) 56 (25.2) 56 (25.2) 49 (22.1) 37 (16.7) I do not need to concern myself with PU prevention in my job. 25 (11.3) 32 (14.4) 36 (16.2) 47 (21.2) 82 (36.9) PU treatment is greater priority than its prevention. 37 (16.7) 23 (10.4) 17 (7.7) 27 (12.1) 118 (53.1) Most pressure ulcers can be avoided 107 (48.1) 46 (20.7) 36 (16.2) 14 (6.3) 19 (8.7) Continuous assessment of patient will give an accurate account of their PU risk 90 (40.6) 63 (28.4) 27 (12.1) 23 (10.3) 19 (8.6) I am less interested in PU prevention than other aspects of care 22 (9.9) 34 (15.3) 2 6 (11.8) 46 (20.7) 94 (42.3) My clinical judgment is better than any PU risk assessment tool available to me 34 (15.3) 31 (14) 32 (14.5) 36 (16.2) 89 (40) In comparison with other areas of care, PU prevention is a low priority for me. 48 (21.5) 51 (22.9) 70 (31.4) 33 (14.8) 21 (9.4) PU risk assessment should be regularly carried out on all patients during their stay in hospital 94 (42.3) 46 (20.7) 34 (15.3) 26 (11.7) 22 (10) Etafa et al. BMC Nursing (2018) 17:14 Page 6 of 8 Table 3 Nurses’ perceived barriers practice to prevent pressure ulcer prevention (N = 222) Nurses’ perceived barriers for preventing PU Frequency (%) Poor access to literature and reading facilities 110 (49.7) Heavy workload and inadequate staff 185 (83.1) Lack of universal guide line on prevention of pressure ulcer 133 (59.8) Inadequate training coverage of pressure ulcer prevention 140 (63.2) Uncooperative patients 87 (39.3) Lack of job satisfaction in nursing profession 125 (56.2) Presence of other priorities than pressure ulcer 130 (58.7) Shortage of resources (equipment/resource) 150 (67.7) Inadequate knowledge about pressure ulcer among nurses 60 (27) Lack of multidisciplinary among staff nurses 64 (28.9) I don’t have any challenge 4 (2) for being practicing PUP care, whilst, uncooperative patients as not cited as a major barrier to PU prevention. But, majority (58%) of them believed that PU is not consuming. This could be they had not sufficient time and adequate man powerto provide PU prevention. This study described that 70.7% of nurses believed that their clinical judgment is better than risk assessment tool. This indicated they can assess PU clinically better than using risk assessment tool. Bergstrom et al. [30] found that risk assessment tool is more accurate and reliable than clinical judgment to who are at risk for PU development. However, Samuriwo, & Dowding [28] indicated that assessment tools were not routinely used to identify pressure ulcer risk, and that nurses rely on their own knowledge and experience rather than research evidence to decide what skin care to deliver. Almost three quarter (74.8%) of the respondents also more interested in PU prevention than other aspects of nursing care. This is in line with Moore and Price study result [21] and Kaddourah et al. [27]. This suggested nurses had high interest in PU care; but, priority was given to other illnesses. This is why most of the staff nurses (n = 130, 58.7%) complained priority for other illnesses rather than PU as a barrier. A significant number of the staff nurses (66.7%) surveyed had received no training to PU prevention, 191 (86%) have not ever read research about PU while 133 (59.8%) identified lack of universal guide line among the major barriers to practice prevent PU care. This idea is strengthened by the participants’ response for which majority of them had disagreed that patients are tends not to get as many PUs now days. Further, poor access to literatures and journals due to lack of electronic libraries near the nurse’ working units/wardswas another cited barrier to practice PU prevention. Hunt [31] stated that if nurses did not read scientific journals, they will not be able to integrate research into their practice. From researchers’ experience in developing countries it is obvious that nursing care provided for patients are not adequate. This is highly due to shortage of resources. According to this study, one of the most commonly cited barriers was shortage of equipment/resource or facilities (67.7%) which is in agreement with the study finding among (Irish, Belgian and Jordanian nurses [21, 24, 25]. The shortage of resources in developed countries (among Belgian [24] and Irish [21] nurses) may be due to the participants were nurses who give caring at home. Lack of job satisfaction (56.2%) may be another reason behind for not practicing PU prevention care. According to Tubaishat et al. [25] lack of job dissatisfaction (25%) was also among the most commonly cited barrier. In Ethiopia,there is scarcity of pressure ulcer relieving devices which help nurses lifting patient or changing the patient position paying off the minimum energy particularly for severely ill patients in addition to time it saves. Majority (66.7%) of the nurses that participated in this study reported that they never attended any training concerning pressure ulcersand about 133 (59.8) of participants reported lack of universal guideline for PUP. This indicates how much attention is paid to prevent PU in Addis Ababa. Padula et al. [4] stated hospitals adhering to PU updates had significant pressure injury reductions and $500,000+ savings per year. Currently evidences exhibited that prevalence of pressure ulcer is vary from country to country. This is supported by study results [5–10]. As observed from the participants’ characters only 26 (11%) were second degree holders and 58 58 (26%) were diploma holders in nursing. It is reported that educational program will improve the knowledge of PU prevention. Similarly, updating nurses’ education is the cardinal to increase nurses’ competency to help them better clinical decision maker [32]. Generally, authors noted that lack of knowledge, negative attitudes, or underdeveloped skills are the principal barriers to PU prevention [18, 19]. Limitations The data are from self-report questionnaires and qualitative method was not employed. But, since there is similar educational setting and resources fairly distributed to all hospitals, the result of the study can be generalizableto all nurses working from Addis Ababa region. Conclusions In the current study, the attitude of most nurses towards PUP was negative. The study also identified the major barriers to carry out PUP practice: Heavy work load/ Etafa et al. BMC Nursing (2018) 17:14 inadequate staff or lack of time 185 (83.3%), Shortage of resources (equipment/resources) 150 (67.6%), Inadequate training coverage of pressure ulcer prevention140 (63%) and lack of universal guide line on prevention of pressure ulcer 133 (59.9%) are the most commonly cited barriers. Further research into nurses’ attitude to pressure ulcer is needed using structured interview questionnaire. Abbreviation NGO: Non-Governmental organization; SD: Standard Deviation; SPSS: Statistical Package for Social Sciences Acknowledgements We would like to extend our sincere gratitude to thedata collectors, participants, hospitals directors, matrons and head nurses for their great assistance and cooperation. Funding The cost of data collection for this research was funded by Addis Ababa University. Availability of data and materials All data generated or analyzed during this study are included in this published article and its supplementary information files. Authors’ contributions WE contributed to the drafting of proposal, design, analysis and interpretation of the data, and manuscript preparation. ZA and BM were also involved in data analysis as well as drafting and revising this research paper. EG and BM were involved in the interpretation of the data and contributed to manuscript preparation. All authors were informed and gave the go ahead to publish the work. WE agrees to be held accountable for all aspects of the work hence any questions related to the accuracy or integrity of the work should be directed to WE. The authors declare that this manuscript has not been presented to any other journal for publication. All authors read and approved the final manuscript. Ethics approval and consent to participate Initially ethical clearance was obtained from Addis Ababa University, College of Health Sciences, Department of Nursing and Midwifery Research Review Ethical Committee(Protocol number was 18/Nurse and approved on 27/03/ 150), and Addis Ababa Regional Health Bureau Ethical Clearance Committee for four hospitals includedin the study (Yekatit 12 Medical College, ZewdituMemoriall Hospital, Tirunesh Beijing Hospital, Menilik II Hospital and RasDesta Memorial Hospital)(reference number: A.A.H/5973/227 and approved on 24/04/2015) to obtain participants in each hospitals. The sixth hospital is teaching hospital (Black Lion Hospital) administered by Addis Ababa University. These findings were part of a research titled “An assessment Nurses’ knowledge, attitude and practice towards pressure ulcer prevention in admitted patients in Public referral hospitals in Addis Ababa. Permissions to obtain participants secured from each hospital medical directors, matrons and head nurses for the research to be undertaken at each hospital. The anonymity of the participants was respected. The names of the participants were not mentioned to keep the confidentiality. A signed written consent was obtained from participants before participation. Consent for publication Not applicable. Competing interests This manuscript maintains no competing financial interest declaration from any person or organization, or non-financial competing interests such as political, personal, religious, ideological, academic, intellectual, commercial or any other. Page 7 of 8 Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details 1 Department of Nursing, College of Health Science, Wollega Unversity, Samara, Ethiopia. 2School of Nursing, College of Health Science, Addis Ababa University, Addis Ababa, Ethiopia. 3Department of Statistics, College of Natural and Computational Sciences, Arsi University, Asella, Ethiopia. Received: 21 September 2017 Accepted: 14 March 2018 References 1. NPUAP, EPUAP and PPPIA. In: Haesler E, editor. Prevention and treatment of pressure ulcers: quick reference guide. Osborne Park: Western Australia, Cambridge Media; 2014. p. 2014. 2. Baranoski S, & Ayello, EA. Wound care essentials: practice principles. (3rd edition) Springhouse PA: Lippincott Williams & Wilkins. 2012, (4). 3. LyderCH WY, MeterskyM CM, KlimanR VNR, Hunt DR. Hospital-acquired pressure ulcers: results from the national Medicare patient safety monitoring system study. J Am GeriatrSoc. 2012;60(9):1603–8. 4. Padula WV, Mishra MK, Makic MB, Sullivan PW. Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis. Med Care. 2011;49(4):385–92. 5. Tubaishat A, Anthony D, Saleh M. Pressure ulcers in Jordan: a point prevalence study. J Tissue Viability. 2011;20(1):14–9. 6. Adegoke BOA, Odole AC, Akindele LO, Akinpelu AO. Pressure ulcer prevalence among hospitalised adults in university hospitals in South-west Nigeria. Wound Practice & Research. 2013;21(3):128–34. 7. Moore Z, Johanssen E, van Etten M. A review of PU prevalence and incidence across Scandinavia, Iceland and Ireland (part I). J Wound Care. 2013;22(7):361–8. 8. Moore Z, Cowman S. Pressure ulcer prevalence and prevention practices in care of the older person in the Republic of Ireland. J Clin Nurs. 2012;21:362–71. 9. Moore Z, Johansen E, van Etten M, Strapp H, Solbakken T, Smith BE, Faulstich J. Pressure ulcer prevalence and prevention practices: a crosssectional comparative survey in Norway and Ireland. J Wound Care. 2015;24(8):333–9. 10. Clark M, Semple MJ, Ivins N, Mahoney K, Harding K. National audit of pressure ulcers and incontinence-associated dermatitis in hospitals across Wales: a cross-sectional study. BMJ Open. 2017;7(8) 11. VanDenKerkhof EG, Friedlberg E, Harrison MB. Prevalence and risk of pressure ulcers in acute care following implementation of practice guidelines: annual pressure ulcer prevalence census 1994-2008. J Healthcare Quality. 2012;33(5):58–67. 12. Reddy M, Gill, Rochon PA. Preventing pressure ulcers: a systematic review. JAMA 2006;296:974–984. 13. Health Research & Educational Trust. Hospital acquired pressure ulcers/ injuries (HAPU/I). Chicago, IL: Health Research & Educational Trust; 2017. Accessed at 14. Haileyesus Gedamu, Mignote Hailu A. A. Prevalence and Associated Factors of Pressure Ulcer among Hospitalized Patients. Journal of Advanced in nursing. December 2014(8). 15. Fishbein M, Ajzen I. The influence of attitudes on behavior. In: Albarracín D, Johnson BT, Zanna MP, editors. The Handbook of Attitudes: Psychology Press. p. 2005. 16. Maylor M, Torrance C. Pressure sore survey part 3: locus of control. J Wound Care. 1999;8:101–5. 17. Beeckman D, Defloor T, Schoonhoven L, Vanderwee K. Knowledge and attitudes of nurses on pressure ulcer prevention: a cross-sectional multicenter study in Belgian hospitals. Worldviews Evid-Based Nurs. 2011;8:166–76. 18. Grimshaw J, Eccles M, Tetroe J. Implementing clinical guidelines: current evidence and future implications. J Contin Educ Heal Prof. 2004;24(Suppl. 1):S31–7. 19. Ayello EA, Meaney G. Replicating a survey of pressure ulcer content in nursing textbooks. J Wound Ostomy Continence Nurs. 2003;30:266–71. 20. Hill L. Wound care nursing: the question of pressure. Nurs Times. 1992;88(12):76. Etafa et al. BMC Nursing (2018) 17:14 Page 8 of 8 21. Moore Z, Price P. Nurses’ attitudes, behaviours and perceived barriers towards pressure ulcer prevention. J Clin Nurs. 2004;13:942–51. 22. Kallman U, Suserud B. Knowledge, attitudes and practice among nursing staff concerning pressure ulcer prevention and treatment – a survey in a Swedish healthcare setting. Scand J Caring Sci. 2009;23:334–41. 23. Islam S, Sae-Sia APDW, Khupantavee APDN. Knowledge attitude and practice on pressure ulcer prevention among nurses in Bangladesh. Poster presentation in the 2nd international conference on humanities and. Soc Sci. 2010; 24. Demarré L, Vanderwee K, Defloor T, et al. Pressure ulcers: knowledge and attitude of nurses and nursing assistants in Belgian nursing homes. J ClinNurs. 2012;21:1425–34. 25. Tubaishat A, Aljezawi M, Al Qadire M, Mohammad. Nurses’ attitudes and perceived barriers to pressure ulcer prevention in Jordan. Journal of wound care. 2013;22:490–7. 26. Uba A, Kever L. Knowledge, attitude and practice of nurses towards pressure ulcer prevention. Int J Nurs and midwifery. 2015;7(4):54–60. 27. Kaddourah B, Abu-Shaheen AK, AL Tannir M. Knowledge and attitudes of health professionals towards pressure ulcers at a rehabilitation hospital. BMC Nurs. 2016;15:17. 28. Samuriwo R, Dowding D. Nurses’ pressure ulcer related judgments and decisions in clinical practice: a systematic review. International Journal of Nursing Studies. 2014;51(12):1667–85. 29. Carol Tweed & Mike Tweed. Intensive care nurses’ knowledge of pressure ulcers. American J Crit Care, July 2008, Volume 17, No. 4 (online www. and click). 30. Launiala A. How much can KAP survey tell us about people’s knowledge, attitude, and practice? Some observations from medical anthropology research on malaria in pregnancy in Malawi. Anthropology matters Journal. 2009;11:1–13. 31. Bergstrom N, Bennet MA, Carlos CE. Treatment of pressure ulcers in adults: clinical practice guide line. Agency for health care policy and Research Publications. 1994;15:181–8. 32. Lamond D, Farnell S. The treatment of pressure sores: a comparison of novice and expert nurses’ knowledge, information use and decision accuracy. J Advnurs. 2001;27:280–6. Submit your next manuscript to BioMed Central and we will help you at every step: • We accept pre-submission inquiries • Our selector tool helps you to find the most relevant journal • We provide round the clock customer support • Convenient online submission • Thorough peer review • Inclusion in PubMed and all major indexing services • Maximum visibility for your research Submit your manuscript at HAPI The Impact of Education and Feedback on the Accuracy of Pressure Injury Staging and Documentation by Bedside Nurses Kathleen Sankovich, DNP, RN , Laura Ann Fennimore, DNP, RN, Rose L. Hoffmann, PhD, RN & Dianxu Ren, PhD DOI: 10.33940/HAPI/2019.9.2 Abstract Background: Pressure Injuries (PIs) are largely preventable. Accurate documentation of PI stage or progression is a key quality measure. Local Problem: Nurses frequently fail to accurately assess and document their findings in the electronic medical record. This project sought to increase nurses’ knowledge and accuracy of staging and documentation of PIs. Method: Educational interventions; direct observation of PI status; review of nurse documentation; feedback; and referrals to wound, ostomy, and continence nurses (WOCNs). Corresponding author Forbes Hospital University of Pittsburgh Medical Center  University of Pittsburgh Disclosure: The authors declare that they have no relevant or material financial interests.    10 I I September 2019 Interventions: Nurses completed a pre- and posttest and online training modules, and participated in training sessions. Clinical experts completed direct skin observations and provided feedback about PI staging. Results: There was a statistically significant improvement in nurses’ knowledge about PIs (p = 0.004). Skin assessments were conducted on 108 patients (13 PIs identified). The bedside nurse accurately assessed a PI stage in only 31% of these observations. Referrals to WOCNs increased by 18% compared to the baseline period. Conclusions: Educational interventions enhanced nurses’ knowledge; however, appropriate PI staging may require skills development and validation to build competency. Keywords: pressure injury, pressure ulcer, wound care, prevention, evidence-based practice, prevalence, assessment, documentation, education Problem Description Pressure injuries (PIs) are painful, costly, and largely preventable, and they represent key opportunities for nurses to improve the quality of patient care. The National Pressure Ulcer Advisory Panel defines a PI as the “localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device.”1 Patients at higher risk for PI development include those with poor nutritional status, impaired tissue perfusion, immobility, and comorbidities such as diabetes.1,2 In 2014, the Agency for Healthcare Research and Quality reported that PIs affected over 2.5 million patients annually at a cost of $20,900 to $151,700 per pressure injury. Each year, approximately 60,000 deaths are a direct result of a PI.3 The Patient Safety Authority (PSA) described hospital-acquired pressure injuries (HAPI) as the fifth-most common event reported through the electronic interface by patient safety officers.4 Documentation of PI risk poses many challenges, including variability in assessment skills, knowledge deficit, type of skin risk assessment scale utilized, and electronic medical record inefficiencies. The Medical Care Availability and Reduction of Error (MCARE) Act was enacted in Pennsylvania in 2002 and defined patient safety events and required reporting structures for patient injuries.5 In 2008, the Centers for Medicare and Medicaid Services (CMS) included PIs in the Hospital-Acquired Condition Reduction Program and no longer reimburses hospitals for care expenses that result from the development of a Stage 3 or Stage 4 PI.6 The PSA issued guidelines effective January 1, 2018, that require Pennsylvania hospitals to report HAPIs that develop and/or progress or worsen as patient safety events, regardless of the patients’ illness, contributing factors, and/or care refusal.7,8 In anticipation of these new reporting requirements, the patient safety officer reviewed documentation congruence between the hospital occurrence reporting system and nurse documentation in the medical record compared to observations noted by wound, ostomy, and continence nurses (WOCNs). Significant variation in staging of PIs was noted between staff nurses and WOCNs. For example, some PIs identified by bedside nurses as Stage 2 were assessed by WOCNs to be either Stage 3 or incontinenceassociated dermatitis. Improving accurate nursing assessment and documentation of PIs is essential to enhance patient safety and reduce patient discomfort and risk for increased morbidity and mortality.1 Inaccurate documentation of publicly reported quality metrics “including PIs” can negatively impact hospital reimbursement and financial viability.3 The purpose of this quality improvement project was to enhance the accuracy of bedside nurse assessment and documentation of PIs following completion of an online training module and direct feedback about the nurses’ assessment and documentation. Rationale The literature describes limited evidence of the accuracy of nurses’ assessment skills and knowledge related to PI staging and documentation. Only 55% of 647 nurses responding to a wound care study conducted in 2012 were able to identify the stages of PIs in their patients. The authors also noted that only 32% of the respondents to this survey acknowledged that they had received sufficient education on chronic wounds in their basic nursing education program.9 Dahlstrom et al. conducted a quality improvement campaign to improve identification, documentation, and treatment of PIs. The authors noted complete documentation (including stage, size, and location) of the PIs improved from 29% to 46% following the implementation of a wound assessment form and point-of-care reminders. While this campaign demonstrated a significant increase in complete documentation, more than 50% of the reported injuries were inappropriately documented.10 Clearly, problems have been identified with nurses’ knowledge of how to accurately stage and document pressure injuries. Problems With Nursing Staging Beal and Smith conducted a retrospective study of initiatives to reduce inpatient PI prevalence in a large community hospital over a 10-year period. The PI prevalence rate in this institution was consistently above the national average. The organization created a wound committee charged with oversight of PI activities. Over six years, they implemented several initiatives to reduce the incidence, including standardized PI prevention training with a self-learning staging module, implementation of evidence-based practices, and care plan prompts in the electronic medical record. Their relentless efforts resulted in a 6.4% reduction in HAPIs.11 Patient Safety I September 2019 I 11 HAPI Critical care nurse knowledge related to PI prevention and staging was described in a postintervention descriptive study by Miller et al. Over a two-year period, nurses in the medical and surgical intensive care units were provided with various educational programs (e.g., lectures, selflearning modules, wound care nurse shadowing). The authors utilized the Pieper-Zulkowski PI knowledge test to evaluate nursing knowledge of prevention, risk identification, and staging. The overall score for knowledge of PI staging was 81%, compared to an overall score of 70% for knowledge of prevention strategies.12 The Veterans Health Administration (VHA) embarked on a journey to reduce PIs in all settings (i.e., hospital, long-term care, outpatient) utilizing a virtual breakthrough series model. This approach used a rapid cycle of change coupled with evidence-based practices, clinical expert and quality improvement coaching on each multidisciplinary team, and a prevention bundle. A total of 38 teams throughout the VHA network participated in this study. The most common interventions were implemented with the following frequencies: staff education 68% (26 out of 38), documentation templates implemented 61% (23 out of38), and utilization of equipment (e.g., protective dressings, chair cushions) 55% (21 out of 38). These interventions led to a 44% reduction in PI development, decreasing the PI incidence from 1.6/1000 to 0.9/1000 bed days. This was statistically significant (p = 0.017).¹³ Problems with Documentation Accurate documentation of patient’s condition, plan of care, and treatments is an essential component of quality nursing care. Thoroddsen and colleagues conducted a cross-sectional descriptive study to review the completeness of PI documentation. Accuracy and completeness of documentation was defined as the correlation between the data, the patient’s presentation, and the care delivered. Their findings indicated that only 60% of the documentation in the medical record reflected a PI and only 42% of the patients’ records included documentation of PI prevention interventions. Risk factors for PIs were rarely identified. The authors concluded that the lack of documentation can impact patient safety and lead to adverse outcomes.14 No studies were identified that evaluated the impact of 12 I I September 2019 educational interventions in combination with direct feedback to nurses following expert skin assessment and documentation review. Project Aims The specific aims of this quality improvement project were to: 1. Increase bedside nurse knowledge of PI assessment, staging, documentation, and occurrence reporting 2. Improve the accuracy of bedside nurse assessment and staging of PIs 3. Improve bedside nurse documentation of PIs in the medical record and occurrence reporting system 4. Increase the number of wound, ostomy, and continence nurse (WOCN) referrals Methods Donabedian’s theoretical model for assessing health quality in terms of structure, process, and outcomes guided the development of this project. The project occurred within the structure of a medical/surgical inpatient unit. Improvement in nurse knowledge regarding assessment and staging of PIs served as the processes examined in this project. Outcomes were evaluated comparing pre- and post-intervention scores demonstrating changes in nurse knowledge and accuracy of pressure injury staging and the number of WOCN referrals.15 The Standards for QUality Improvement Reporting Excellence (SQUIRE) 2.0 Guidelines provided a framework for this project.16 Setting This quality improvement project took place in a 315bed, community-based, acute-care hospital and Level II trauma center affiliated with a large integrated delivery network in Western Pennsylvania. A 43-bed medicalsurgical unit served as the intervention pilot unit. This unit was identified in 2017 as having one of the highest rates of PIs in this hospital (4.17%). Patients on this unit were thought to be at higher risk for PIs due to long length of stay and complex care needs. Sample The patient sample included all patients admitted to the 43-bed medical-surgical pilot unit from August– November 2018. The patient population on this unit included patients with varied medical diagnoses (e.g., stroke, diabetes) and post-operative surgical patients (e.g., colorectal, vascular, or other surgical procedures). The staff sample included all 41 registered nurses (RNs) and two licensed practical nurses (LPNs) on this medicalsurgical unit. of PIs, and participants were asked to identify the appropriate PI stage. Five additional questions addressed reporting and appropriate documentation requirements. The test content was reviewed by a random sample of WOCNs in the health system to assure clinical accuracy. Ethical Considerations This project was approved by the health system’s institutional review board and the hospital’s evidence-based practice and research councils. An abstract of the project was submitted to the university’s human research protection office, which agreed that this is a quality improvement project and did not require full review by the institutional review board. All data collected was identified, documented in an Excel spreadsheet, and stored in a cloud-based data storage secured through the health system’s information technology network with restricted access, and, if applicable, was transmitted utilizing encryption to safeguard the information. PI Staging Discrepancy Assessment A baseline assessment to identify possible PI staging discrepancies was completed using occurrence reports submitted from August through November 2017 and was repeated during the intervention period from August through November 2018. The project coordinator compared the description of the PI in the occurrence report with nurse documentation in the medical record. Education Program A two-part education program targeted toward improving nurses’ knowledge related to PI staging was delivered to nurses on the pilot unit. Before and after the education interventions, nurses completed a 15-question test developed by the project coordinator. This pre- and post-test included 10 case descriptions Part 1: All nurses on the pilot unit were asked to complete a pre-test to assess their knowledge related to PIs and were assigned the online National Database of Nursing Quality Indicators (NDNQI) pressure injury training modules 1 and 2 (v. 5.0). Module 1 addressed PIs and staging; module 2 covered other wound types and skin injuries (e .g., diabetic ulcer, venous stasis ulcers). Nurses were asked to complete these modules as a part of their scheduled work within a 30-day period. Each nurse that completed the training modules provided an electronic certificate to the project coordinator. Part 2: The project coordinator provided four faceto-face educational sessions regarding assessment, staging, and appropriate documentation of PIs, as well as the required MCARE reporting. Nurses then completed a post-test within 28 days of completing the online and face-to-face training sessions. The project coordinator provided direct feedback to the bedside nurses on the results of their pre- and post-test results. For each incorrect answer selected, the project coordinator reviewed the appropriate stage and the rationale with the nurse. Patient Safety I September 2019 I 13 HAPI Skin Observations Skin observations were conducted once a month for four consecutive months. The project coordinator conducted a full assessment of all patients on the pilot unit along with unit-based skin care champions.These bedside nurses are required to complete the four NDNQI PI training modules (PIs and staging, other wound types and skin injuries, PI survey guide, and community vs. hospital/unit acquired PIs); accompany the WOCN on their unit to assess PIs; and attend monthly educational meetings. This assessment included a head-to-toe inspection of the patients’ skin, noting the color, turgor, temperature, presence of wounds or lesions, and any areas of moisture. Medical Record Audits The project coordinator reviewed the skin assessment documented in the medical record to determine congruence between the observation and the last documented skin assessment. Patients with Stage 2 or greater PIs were referred to a WOCN. The project coordinator discussed any discrepancies between the nurse’s documentation of PI stage and the findings noted by the skin care champion or WOCN with the nurse caring for the patient, reinforcing information from the online training modules and documentation in service training. The project coordinator shared a summary of assessment and documentation findings during the monthly staff meetings to give feedback for all nurses on this unit. Nurses absent from the staff meetings received the information in a secure email. PI Skin Discrepancies Twenty-three PIs were reported through the occurrence reporting system in the baseline period of August– November 2017 on the pilot unit. The WOCNs noted PI staging discrepancies in 22% (n = 5) of the cases reporting in the baseline period. Thirty-eight PIs were reported in the occurrence reporting system in the postintervention period of August–November 2018. The WOCNs noted PI staging discrepancies in 24% (n = 9) of the cases reported in the post-intervention period. Education Program Outcomes Thirty-two RNs (74%) and two LPNs (100%) completed the two online NDNQI pressure injury training modules. Staff also attended a face-to-face training offered by the project coordinator addressing skin assessment, staging, prevention strategies, and documentation. The pre- and post-test results and follow-up staff discussions were entered in an Excel spreadsheet. Individual questions were evaluated by absolute frequency and the percent correct for the pre- and Table 1. Pre/Post-test Results Question Pre N = 32 Post N = 32 Q1 31 (93.9%) 31 (96.9%) Q2 29 (87.9%) 21 (65.6%) Q3 32 (97.0%) 29 (90.6%) Q4 33 (100%) 32 (100%) Q5 28 (84.8%) 31 (96.9%) WOCN Referrals Q6 30 (90.9%) 32 (100%) The average number of WOCN consults per month for the four-month intervention period was compared with the same period in 2017 to ascertain if there was an increase following the educational intervention and direct observations. Q7 24 (72.7%) 28 (87.5%) Q8 15 (45.5%) 25 (78.1%) Q9 33 (100%) 32 (100%) Q10 17 (51.5%) 31 (96.9%) Q11 31 (93.9%) 31 (96.9%) Q12 33 (100%) 32 (100%) Sample Description Q13 17 (51.5%) 26 (81.3%) The sample of nursing staff completing the education program included 41 RNs and two LPNs on a medical or surgical unit in a community hospital. Q14 33 (100%) 32 (100%) Q15 30 (90.9%) 27 (84.4%) Total 84.1 + 9.08% 91.4% + 8.33% Results Overall Knowledge Improvement p = 0.004 14 I I September 2019 Table 2. Comparison of Pressure Injuries Bedside Nurse Skin Care Champion/ Project Coordinator WOCN Stage 2 Stage 2 Stage 2/Early Stage 3 Stage 1 Stage 2 Stage 2 Abrasion Abrasion Stage 2 Incontinent-Associated Dermatitis Stage 2 Stage 2 Abrasion Abrasion Deep Tissue Injury Unstageable Stage 3 Stage 2 Stage 2 Suspected Deep Tissue Injury Yeast Infection Stage 3/Possible Deep Tissue Injury* Stage 4 Stage 3 Missed Assessment* Missed Assessment Stage 2 * PI coccyx/ischium, same patient post-test respectively, noting the direction of change per question. Thirty RNs and two LPNs completed the pre- and post-test. Nurses demonstrated improved knowledge in eight of the 15 questions on the post-test. The total score for the pre- and post-test questions was calculated by using a paired sample t-test. Utilizing the Statistical Package for the Social Sciences (SPSS) software version 25.0.0 for Windows, a p value of .05 was considered statistically significant. The average pretest score mean was 84.1% + SD 9.08% and the average post-test mean score was 91.4% + SD 8.33%. There was a statistically significant improvement (p = 0.004) in nurse knowledge about PIs following the completion of the online educational modules and face-to-face training sessions offered by the project coordinator (Table 1). Skin Observation and Medical Record Audit A “snapshot” observation was conducted on one day each month for four consecutive months between August–November 2018 on the pilot unit. The project coordinator, a unit-based bedside nurse identified as a skin care champion, and a WOCN conducted the observations. On the days of the direct observations, 143 patients were admitted to the pilot unit. A skin assessment was conducted on 108 (76%) of these patients. (Note: A few patients refused a skin assessment or were off the pilot unit for tests at the time of the skin assessment.) A full skin assessment included a head-to-toe inspection of the patient’s skin, noting its color, turgor, and temperature, as well as any presence of wounds, lesions, or areas of moisture. Thirteen PIs were identified. The project coordinator noted nine staging discrepancies between the documented stage of the PI by the bedside nurses and the stage identified by the skin care champion and project coordinator. For example, a nurse assessed a patient as having incontinence-associated dermatitis; however, the skin care champion and project coordinator assessed the wound as a Stage 2 PI. The bedside nurse documented accurate PI staging in only 31% of PI observations. The staging discrepancies noted between the bedside nurse, skin care champion/project coordinator, and WOCN are noted in Table 2. WOCN Referral Results The monthly WOCN referrals increased by 18% compared to the baseline period. Twenty-eight WOCN referrals were submitted from August through November 2017. Patient Safety I September 2019 I 15 HAPI Thirty-two referrals were submitted from August through November 2018. Discussion This quality improvement project was designed to improve the accuracy of nurse assessment, staging, and documentation of PIs by the bedside nurses following completion of an online educational module, reinforced by a face-to-face session highlighting appropriate documentation of PIs. The project incorporated a review of documented PI assessment and staging by the bedside nurse and direct observations with immediate feedback for any discrepancies noted. A statistically significant improvement in knowledge regarding PIs following these interventions was identified through administration of a pre- and post-test. The direct observation feedback served to reinforce accurate PI assessment and staging. For example, during one of the direct observations, the bedside nurse assessed a PI as unstageable (wound covered in eschar and slough), but based on the characteristics (partial thickness loss of the dermis layer, red or pink wound bed) and WOCN evaluation, it was determined to be a Stage 2 PI. These results were consistent with findings noted by Miller et al. that described improved staging of PIs following educational programs including selflearning modules and lectures.12 There was a negligible increase in PI staging discrepancies from the baseline data in the occurrence reporting system (22% to 24%). Notably, 44% of the PIs reported in this system in the post-intervention phase were entered by nurses who had not completed the online or face-to-face training. Nurses in this study failed to document an accurate assessment of the PI stage in 69% of the observed cases. Appropriate PI assessment and staging are skills that may develop over time and may require validation by clinical experts to build competency. Thoroddsen et al. noted that incomplete or inaccurate documentation could lead to missed hand-off communication opportunities affecting patient safety and outcomes. In this project, 9% (n = 10) of the skin assessments and 30% (n = 108) of the preventive interventions were noted to be inconsistently documented or absent in the electronic medical record. Although a review of documented interventions was not a defined objective of this quality improvement project, the project coordinator noted the lack of documentation 16 I I September 2019 of interventions used to treat or prevent PIs. This project heightened awareness of accurately assessing and staging PIs as well as drew attention to the need to document preventive strategies. Results of the project findings were shared through the monthly staff meetings and daily care huddles.14 The Wound, Ostomy and Continence Nurses Society’s scope of practice outlines the contribution of the WOCN to improve “the quality of care, life, and health of healthcare consumers with wound, ostomy, and/or continence care needs.”17 This project demonstrated the enhanced value of the expertise of the WOCN to support accurate assessment of PIs and enhance bedside nurse competency. WOCN referrals may be an underutilized resource in the care of patients with PIs. There may be an opportunity to use telemedicine to enhance a WOCN’s ability to assess, diagnose, and manage PIs and other chronic wounds; the successful use of telemedicine in dermatology suggests the promising potential of bringing clinical expertise to the management of PIs and capitalize on limited WOCN resources.18 Limitations This project was piloted on one nursing unit and included a small convenience sample. The project coordinator was not able to require or mandate training for this quality improvement project; however, nurses were strongly encouraged to participate in the education strategies. Nurse scheduling complicated the conduct of this quality improvement project. It was not possible to assess improvement in individual nurse assessment skills, as different nurses frequently were assigned on each of the observation days. This project did not include an assessment of prevention or treatment interventions that were incorporated into the plan of care. Implications for Practice Pressure injuries represent a serious patient safety concern that may be prevented or minimized with accurate assessment by the bedside nurse and referral to a WOCN. As PIs develop or worsen, they can prolong hospitalization, lead to infection, impair mobility, and increase morbidity and mortality. This project demonstrated increased nurse knowledge following an online and face-to-face educational program about PIs. The project confirmed that nurses frequently fail to correctly assess, stage, and document their findings. It is imperative that nurses accurately assess and stage PIs in order to implement appropriate interventions for prevention and treatment. The education program and assessment strategies described in this paper would be enhanced with mandatory participation in the education strategies and ongoing feedback provided to the bedside nurses regarding the accuracy of their assessment, staging, and documentation of PIs, with support from a WOCN. Ongoing education about PI assessment, staging, and documentation requirements should be incorporated into the annual nursing competencies to ensure appropriate actions are implemented. The NDNQI pressure injury training modules may serve as an effective educational strategy to increase nurse knowledge about appropriate assessment and care of pressure injuries; however, this online training may be insufficient by itself and should be supported with regular skin surveillance rounds with direct feedback from clinical experts to enhance nurses’ assessment and staging skills. Hospitals will need to determine available resources to accomplish an improvement in accurate assessment, staging, and documentation of PIs. Future projects are warranted to evaluate interventions to prevent PI development or progression, and to study the impact of utilizing TeleWOCN18 in rural areas as well as hospitals that do not possess a WOCN. References 1. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014. 2. Delmor BA, Ayello EA. Pressure injuries caused by medical devices and other objects: A clinical update. Am J Nurs. 2017; 117(12):36-45 3. Agency for Healthcare Research Quality. Preventing pressure ulcers in hospitals: Are we ready for this change? Content last reviewed October 2014. 4. Patient Safety Authority. Hospital-acquired pressure ulcers remain a top concern for hospitals. Pennsylvania Patient Safety Advisory, 2015; 12(1): 28-36. 5. Pennsylvania Department of Health. Medical Care Availability and Reduction of Error (MCARE) Act. 2002; 6. Centers for Medicare & Medicaid Services. Final changes to hospital inpatient prospective payment systems and fiscal year 2009 rates. August 19, 2008. html?DLPage=1&DLSort=3&DLSortDir=ascending 7. Pennsylvania Bulletin. Final Guidance for Acute Health Care Facility Determinations of Reporting Requirements for Pressure Injuries under the Medical Care Availability and Reduction of Error (MCARE) Act. [47 Pa. B. 2163]. 2017. 8. Seid AG, Bishop K, Arnold TV, Motts MA, Feil M. Pressure injury reporting: Preparing to implement the new reporting requirements under MCARE. 2017. 9. Ayello EA, Baranoski S. Wound care and prevention. Nursing. 2014; 44(4): 32-40. 10. Dahlstrom M, Best T, Baker C, et al. Improving identification and documentation of pressure ulcers at an urban academic hospital. Jt Comm J Qual Patient Saf. 2011; 37(3):123-130 11. Beal ME, Smith K. Inpatient pressure injury prevalence in an acute care hospital using evidence-based practice. Worldview Evid Based Nurs. 2016;13(2):112-117. doi: 10.1111/wvn.12145 12. Miller DM, Neelon L, Kish-Smith K, Whitney L, Burant CJ. Pressure injury knowledge in critical care nurse. J Wound Ostomy Continence Nurs. 2017; 44(5):455-457. doi: 10.1097/WON.0000000000000350 13. Zubkoff L, Neily J, King B, et al. Preventing pressure ulcers in the Veterans Administration using a virtual breakthrough series collaborative. J Nurs Care Qual. 2017;32(4):301-308. doi: 10.1097/ NCQ.000000000000242 14. Thoroddsen A, Sigurjónsdóttir G, Ehnfors M, Ehrenberg A. Accuracy, completeness and comprehensiveness of information pressure injuries recorded in the patient record. Scand J Caring Sci. 2013;27(1):84–91. doi. org/10.1111/j.1471-6712.2012.01004.x 15. Donabedian A. Evaluating the quality of medical care. 1966. Milbank Q. 2005; 83(4):691-729. articles/PMC2690293/pdf/milq0083-0397.pdf. doi:10.1111/j.14680009.2005.00397.x. 16. Ogrinc G, Davies L, Goodman D, Batalden PB, Davidoff F, Stevens D. SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Quality and Safety. 2016, 25: 986-92. 17. Wound, Ostomy and Continence Nursing Society. WOCN Society Position statement: Role and scope of practice for wound care providers. 2017. 18.Chanussot-Deprez, C., Contreras-Ruiz, J. Telemedicine in wound care. Adv in Skin and Wound Care, 2013: 26(2): 78-82. This article is published under the Creative Commons Attribution-NonCommercial license. Patient Safety I September 2019 I 17

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