title: Pressure Injury Prevention in Hospitalised Adult Patients: A Case Study
Creators: name: Li, Zhaoyu
Publisher: name: Griffith University
Year: 2022
Subjects: subject: Injury Prevention
subject: Nursing
subject: FOS: Health sciences
subject: Pressure injuries
subject: patient safety

description: Background: Pressure injuries (PI) are common adverse events in hospitals, which can cause pain and distress and threaten patient safety in hospitals. Despite growing evidence and guidelines for pressure injury prevention (PIP) in Western countries, there is limited understanding about PIP practices in China, yet the reported prevalence of PI appears to be lower than that reported elsewhere. Aim: The first aim of this thesis was to examine the frequency of PIs to understand the extent of PI burden among hospitalised adults worldwide (Phase 1). The findings informed the second aim, to describe Chinese nurses’ PIP practices in its natural context (Phase 2). Methods: Phase 1 was a systematic review to identify the PI prevalence, incidence and hospital-acquired PI (HAPI) rate among hospitalised adults. Underpinned by the System Engineering Initiative for Patient Safety (SEIPS) model, Phase 2 was a multiple (embedded) case study to investigate the work system, processes and outcomes of registered nurses’ PIP practices in a Chinese tertiary hospital, where two medical and two surgical wards were used as embedded units of analysis. Triangulated methods including survey, observation and chart audit, interview and policy analysis were used. The survey described Chinese nurses’ PIP knowledge, one characteristic of the work system. The observation and chart audit described nurses implemented and documented PIP practices to reflect the detailed PIP work system and processes. Interview was used to explore nurses’ perceptions, how to prioritise patients for PIP and influencing barriers and facilitators in PIP delivery to depict the work system, processes and outcomes in PIP. Policy analysis was used to understand the external context influencing PIP. Finally, findings of multiple sources of data were triangulated and cross-case synthesis was conducted to generate an in-depth understanding of PIP in the Chinese context from a holistic system level. Results: The systematic review included forty-two studies from nineteen countries. The pooled prevalence was 12.8% (95%CI 11.8-13.9%) and the hospital-acquired PI rate was 8.4% (95% CI 7.6-9.3%). Asian studies showed the lowest PI prevalence and HAPI rate compared to other regions. That is, 98% of the Asian samples were from China where the reported PI prevalence and HAPI rate was only 1.5% and 0.5%. A total of 423 nurses from twenty-four medical surgical wards in one Chinese hospital were recruited and 404 (95.5%) completed the knowledge survey. Nurses’ mean score of PI knowledge was 11.6±3.0 (medical 10.7±2.8; surgical 12.2±3.0) out of a maximum score of 25; 335 (82.9%) nurses scored lower than the 60% acceptable level, indicating unsatisfactory knowledge. In the observation and chart audit, a total of 577 patients (medical n=294, 50.9%; surgical n=283, 49.1%) participated. Among the PIP strategies observed, risk assessment and repositioning were the most frequently used and nutrition was the least frequently used. Fewer than half of the patients received recommended skin care, nutrition care, support surfaces and patient education. Surgical patients generally received better preventive care than medical patients. Underpinned by the SEIPS model, four themes and one category were identified in interviews of 27 nurses: Work system: (i) Nurses lead and coordinate PIP; Work processes: (ii) Individualised PIP is founded on comprehensive patient assessment; (iii) Collaborating ensures patients receive appropriate PIP; and (iv) Competing factors influence the delivery of appropriate PIP. One category related to work outcome: Nurses strive to do their best in PIP but hold major concerns when PIs occur. Three government policies, three scholarly works and three hospital-level protocols were identified in the policy analysis and helped explain the external environment’s influence on the PIP work system. The findings of data triangulation and cross-case synthesis showed limitations of current nurses’ PIP practices and were synthesised into six themes: Work system: (i) Nurses are motivated to prevent PI despite limited knowledge; (ii) Organisational commitment underpins PIP; and (ii) External environment impacts on PIP; Work processes: (iv) Mismatch between PIP documentation and PIP implementation; and (v) Ritualistic PIP practices; and Work outcomes: (vi) Dilemmas in PI reporting. Conclusion: Overall, this body of work has contributed to a valuable understanding of nurses’ contemporary PIP practices in China. Nurses’ insufficient knowledge of PIP, limited accessibility of resources and organisational support hindered nurses’ practices and resulted in missed care. Recommendations to improve the quality of PIP practices focus on continuous education, seeking support from multidisciplinary healthcare professionals and the involvement of nurses and other stakeholders in policy review. System level designs that meet nurses’ requirements including manpower, education, resourcing and external policies should be considered in further research.