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International Journal of Orthopaedic and Trauma Nursing

journal homepage: www.elsevier.com/locate/ijotn

Prevention of heel pressure ulcers among adult patients in orthopaedic wards: an evidence-based implementation project Siew Yi Koha, Hui Ling Yeoa, Mien Li Gohb,∗

aUniversity of Orthopaedic Cluster, National University Hospital, Singapore b Evidence Based Nursing Unit, National University Hospital, Singapore

A B S T R A C T

Background: Immobility and prolonged bed rest often lead to heel pressure ulcers in patients. A point prevalence audit undertaken in the orthopaedic wards of a Singapore tertiary hospital reported that 6 out of 30 patients who were audited had mild to blanching redness on their heels. Aims: The evidence-based project sought to achieve 80% compliance from nurses to perform heel off-loading practice and a 50% reduction in the occurrence of heel pressure ulcers. Methods: The project, lasting two years, was undertaken in two orthopaedic wards and utilized a pre- and post-implementation audit strategy using the Joanna Briggs Institute on-line 'Practical Application of Clinical Evidence System' and 'Getting Research into Practice' programs. Implementation occurred in four phases and involved a sample consisting of 30 adult patients. Results: Nurses’ compliance with performing heel off-loading techniques increased. The post-implementation audit showed 93.3% compliance of nurses undertaking heel off-loading techniques in the subsequent four follow-up audits. Meanwhile, the compliance with documentation increased from 63.3% to 86.7%. The project resulted in more than 50% reduction in stage one heel pressure ulcers. Conclusion: The implementation of heel off-loading techniques significantly reduced the incidences of heel pressure ulcers in orthopaedic wards.

Background

Pressure ulcers are a common and perpetual problem in healthcare settings worldwide (Corbett et al., 2017). Pressure ulcers (PUs), also known as pressure injury or bed sores, are areas of necrotic soft tissue, that usually occur over bony prominences (Ministry of Health [MOH] Nursing Clinical Practice Guidelines, 2001; Sussman and Bates-Jensen, 2007; Smeltzer et al., 2010). They usually develop when skin is sub- jected to shear, friction and prolonged unrelieved pressure. Many areas in the human anatomy are susceptible to PUs, for instance occiput, sacrum, elbow and heel (Smeltzer et al., 2010).

There are six classifications of PUs (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, & Pan Pacific Pressure Injury Alliance, 2014). Stage one PU presents as non-blanching discoloration of intact skin, often in red, blue or purplish hues. Stage two PUs involve partial thickness loss of dermis with a shallow wound or intact blister. An ulcer progresses to stage three when there is full thickness tissue loss, accompanied by undermining or tunneling. Full thickness tissue loss with ex- posed bone, tendon or muscle indicates a stage four PU. Un-stage- able ulcers are classified when the base of an ulcer is covered with slough or eschar, concealing the real depth of the wound. Lastly,

suspected deep tissue injury (DTI) involves damage to the under- lying soft tissue and presents with discolored, but intact skin or blood-filled blister indicating deep tissue damage that has not yet become an open ulcer.

Predictive risk factors that result in patients developing PU are: old age, decreased mobility and ability to engage in daily activities (Bredesen et al., 2015). Evidence shows a prevalence of 10–20% PUs in the acute hospital settings (MOH Nursing Clinical Practice Guidelines, 2001; Bååth et al., 2014; Bredesen et al., 2015). One study conducted in a tertiary hospital in 2014 reported that 15% of patients in the geriatric unit suffered from PUs (Khalid, 2015). The hospitals in Singapore have identified cost effective resources and measures to prevent hospital acquired PUs. These include: edu- cating nurses on the necessary knowledge; accurate Braden Scale (BS) risk assessment; initiating interventions such as specialty beds, repositioning of a patient every 2 – 4 hours to re-distribute body weight, and ensuring patients’ adequate nutritional status (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, & Pan Pacific Pressure Injury Alliance, 2014; Palfreyman and Stone, 2015; Soban et al., 2017). Clearly, PUs still persist in acute hospital settings despite the existence of standard interventions and advanced medical technology. This results in adverse impacts on

https://doi.org/10.1016/j.ijotn.2018.08.003 Received 22 October 2017; Received in revised form 14 April 2018; Accepted 22 August 2018

∗ Corresponding author. Singapore National University Hospital (NUH) Centre for Evidence-Based Nursing: A Joanna Briggs Institute Centre of Excellence, 5Lower Kent Ridge Road, Main Building, Level 6, 119074, Singapore. E-mail address: [email protected] (M.L. Goh).

International Journal of Orthopaedic and Trauma Nursing 31 (2018) 40–47

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patients, leading to increased healthcare costs, hospital stay and nursing workload (Palfreyman and Stone, 2015).

Heel pressure injury

The heel is the second most common area for PU occurrence after the sacrum and accounts for 30% of pressure injuries (Lyman, 2009; Thomas and Compton, 2014; Delmore et al., 2015). The most common cause of heel PU is hyperemia (Lyman, 2009; Wong, 2014). Damjanov (2016) defined hyperemia as “an accumulation of blood in the per- ipheral circulation” (p. 121). Pressure exerted from external surfaces results in hyperemia. A reduction in oxygenation and venous perfu- sion over the heel will consequently lead to PU development. Tissue perfusion differs from person to person and declines with ageing. Ef- fects of ageing include: thinning of the epidermis, diminished blood supply to the dermis and reduced sensitivity of the immune system cells residing in the skin (Martini and Bartholomew (2010). These factors encourage skin damage and infection and, subsequently, pa- tients older than 65y are at a higher risk of developing heel PUs (Wong and Stotts, 2003).

Another host factor for heel PU development is impaired mo- bility (Smeltzer et al., 2010; Wong, 2014). Prolonged duration of pressure is exerted on the skin when a person is less mobile or ac- tive. Patients with orthopaedic conditions have an increased risk for heel PU due to transient impaired mobility. Studies have shown that patients with hip fracture are more vulnerable to developing heel PU (Campbell et al., 2010; Wong, 2014). Aside from hip fracture, patients who have had a knee replacement or a lower limb fracture are particularly susceptible to developing heel PU (Campbell et al., 2010).

Heel PUs can impact on overall health status and quality of life (QoL). The complications of PU include: localized infections, os- teomyelitis, altered body image, extended hospital stays and cost (Lyman, 2009; Thomas and Compton, 2014). Patients with pre-ex- isting comorbidities may further impede the healing process of the PU; for instance, diabetes mellitus and neuropathy (Smeltzer et al., 2010; Australian Wound Management Association (AWMA), 2012). These conditions affect the venous and arterial supply to existing PUs and, consequently, the wound healing process is delayed (Khalil et al., 2015). Patients stated that the development of a PU had resulted in loss of independence in self-care regarding their day-to-day activities of living, wound care treatment, as well as increased burden costs, poor coping mechanisms and social func- tioning. In addition, pain correlates positively with PU (AWMA, 2012). Patients are unable to bear weight or ambulate normally without experiencing pain from an existing heel PU. Evidently, heel PU has a detrimental effect and impacts on a patient's QoL (Gorecki et al., 2012).

Heel PUs are avoidable with appropriate preventive measures during patients' hospitalization. Regular skin assessment and off- loading of patients’ heels with a pressure relieving device are ef- fective in preventing heel PU occurrence (Campbell et al., 2010; Lawrence et al., 2015; Miller et al., 2015; National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, & Pan Pacific Pressure Injury Alliance, 2014; Wound, Ostomy and Continence Nurses Society-Wound Guidelines Task Force, 2017). The Braden Score (BS) for Predicting Pressure Sore Risk is a tool that assesses the risk of developing PU in adults (Brown, 2004). With an interrater reliability of 0.99, p < 0.001 (Bergstrom et al., 1987), several studies adopted the BS as the assessment instrument

(McElhinny and Hooper, 2008; Lyman, 2009; Miller et al., 2016). Subsequently, the BS is widely utilized in local hospitals as a tool for identifying patients at risk of developing PU.

Application of heel foam protectors is a fundamental preventive measure for preventing heel PUs in the local context. Studies un- dertaken by Lyman (2009) and Hanna-Bull (2016) confirmed that heel foam protectors were able to reduce the incidence of heel PUs. However, approximately 1–4% of participants still developed a heel PU. Evidence was found that heels are subjected to pressure even when heel foam protectors are applied (Griffin et al., 2015). The calcaneum of the heel is a large and heavy bone encircled by a small area of dermis which explains why higher pressure on the heel occurs when resting on a bed.

According to Nguyen (2016), the Joanna Briggs Institute's (JBI) Evidence Summary suggested utilizing heel foam protectors in conjunction with individualized PU prevention interventions. Griffin et al. (2015) conducted a study comparing the effectiveness of various heel off-loading methodologies. Their results revealed that using a pillow to off-load heels with the feet extending beyond the pillow end significantly reduces pressure at the heels and con- tact with the bed's surface. This project adopted the practice of off- loading heels using a pillow or a towel with the legs extending beyond the pillow or towel end, coupled with applying heel foam protectors for at-risk patients.

Nursing documentation is one of the main tools to communicate care in a healthcare institution (Lawrence et al., 2015; Törnvall and Wilhelmsson, 2008). It records patients' condition, care plans, and most importantly, the quality of care rendered (Lawrence et al., 2015). According to the Singapore Nursing Board's (SNB, 2011) Standards of Practice, Standard 1; nurses are accountable for their practice and should document their decisions accurately. In the local context, a turning chart was incorporated into the care for patients at risk of developing PU. The turning chart records the frequency of repositioning, position to be adopted, and the patients' skin condition. This is effective in monitoring patients' skin in- tegrity and serves as evidence that nursing intervention has oc- curred and is working. However, Inan and Dinc (2013) stated there are evident gaps in the consistency of care delivered to patients and nurses' documentation. There is consensus that documentation of nursing interventions is vital in preventing heel PU development (AWMA, 2012; National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, & Pan Pacific Pressure Injury Alliance, 2014). Therefore, one critical audit criterion was to ensure that nurses had documented that patients' heels had been off- loaded.

Identifying a clinical problem

The current hospital heel PU prevention practice is to off-load heels with the use of heel foam protectors. In comparison, the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, & Pan Pacific Pressure Injury Alliance (2014) recommended that patients' heels should not rest on the bed's surface but, instead, be suspended in the air.

A point prevalence audit was conducted in two orthopaedic wards of a Singapore tertiary hospital to: 1) obtain a baseline result on heel PU; and 2) identify knowledge gaps in current practice. The audit results showed that 6 out of 30 patients had between mild redness to blanchable redness on their heels. Five patients had blanchable redness over the heel, while one patient had mild non-

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blanchable redness over the heel. It emerged that there were in- consistent heel PU prevention techniques; while some patients had heel foam protectors applied, none of them had their heels off- loaded from the bed. Furthermore, there was no documentation on the nursing intervention used to prevent heel PUs.

Objectives

This evidence-based project aimed to attain 80% compliance by nurses to practice standardized heel off-loading techniques. The project also aimed to achieve a 50% reduction in heel PU occurrence in the orthopaedic units.

Methods

Establishing a project team

The project was led by a nurse clinician with experience in evidence-based nursing research whose role is to improve clinical practice. The team included four registered nurses (RNs) with two RNs from the PU Nursing Standard Team (NST) from each ortho- paedic ward of the study institution. The team members were identified to assist in facilitating feedback and conduct post-im- plementation audits. A nurse educator from the evidence-based nursing unit of the institution assisted by supervising the project's progress. The project team RNs collected all data during the audits. Strong support and expert opinions are integral when introducing change within an organization, especially a health care institution. Thus, this project identified the Assistant Director of Nursing and a senior nurse manager from the orthopaedic department as key stakeholders. The project's success was enhanced by convincing the senior management to be engaged in it (Albert, 2016).

Setting and sample size

This project was undertaken in two orthopaedic wards of a tertiary hospital in Singapore over a period of 17 months. Both wards com- prised 63 beds and admitted orthopaedic trauma patients and elective orthopaedic surgery patients.

The Joint Commission International (JCI) recommended a sample size of 30 patients based on the sample population (Larrabee, 2009). Consecutive sampling was employed during each audit phase whereby participants were readily available (Polit and Beck, 2014).

The inclusion criteria were that participants should be adult patients who are over 21 years old and patients with impairments in mobility or

activity identified by the BS. Patients with existing heel PUs were ex- cluded.

Data analysis

Analysis of the data was conducted using the Statistical Package for the Social Sciences (SPSS) version 21.0 (IBM Corp., New York, USA). Fisher's exact test was utilized to test the association between the data collected from baseline and follow-up audits as this test provides more accurate results with small sample sizes (Connelly, 2016).

Ethical considerations

Ethical approval was not required because this project was im- plemented in agreement with the hospital's clinical quality im- provement policy. The audit process consisted purely of observa- tions, and the patients' particulars were not recorded. This evidence-based project incurred zero cost since the pillows or to- wels are readily available in the clinical setting, while the heel foam protectors were acquired by the institution for the existing heel PU prevention practice.

Identifying audit criterion

An audit tool was formulated using the JBI Practical Application of Clinical Evidence System (PACES). Several criteria were gener- ated with the use of JBI PACES (JBI, 2017). One main criterion was identified in line with the standards of the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, & Pan Pacific Pressure Injury Alliance's Guide to prevention and treatment of PU (2014). Sub-components of this criterion were established based on the gaps that were observed from the baseline audit (Table 1).

Data collection

Prior to the baseline audit, the project team members were trained to perform the audits in a reliable manner. The project team identified those patients who met the inclusion criteria and checked the patients' nursing records to determine if there was documented information about patients’ heels being nursed by off-loading. The project team also examined the patients at bedside to ensure their heels were off-loaded with the appropriate device. Each audit was conducted over a period of two weeks. The findings were then

Table 1 Audit tool (Adopted and modified from JBI PACES).

Date: __/__/__ Ward: _______

Evidence-Based Practice Project AUDIT TOOL: Heel Pressure Ulcers Prevention in Acute Care Staff: _______ Pt Bed: ______

JBI Criterion Observation Validate Documentation Met Not Met NA Remarks

1. It is documented that at-risk patients have a heel protector, pressure relieving device, or other form of heel offloading

Patient has: o heel protector o lower limbs offloaded o a pillow under the calves to

offload heels o a pillow in between bony

prominences

o Check information list o Check turning chart

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recorded on the audit forms before being transcribed into the JBI PACES and SPSS programs.

Implementation (March 2015–April 2015)

A pre- and post-implementation audit strategy was employed. The Getting Research into Practice (GRIP) strategy was used to analyze barriers encountered in the clinical context and to formulate strategies addressing the barriers (JBI, 2017). The ward nurses identified two issues: 1) knowledge deficit in nurses; and 2) lack of standardization of care delivered to patients.

PU prevention is an essential aspect of nursing care, yet nurses failed to acknowledge its importance. A study in Turkey reported that about 50% of the nurses had insufficient knowledge regarding optimal PU care, and about 65% of nurses indicate discrepancies concerning preventive practices (Lawrence et al., 2015). This sug- gests the need to educate nurses on the basis of heel PU prevention. Prior to the commencement of this project, the current clinical issue and results of the point prevalence baseline audit were dis- seminated to the ward nurses during roll-call sessions. The im- portance of heel off-loading and its implications were reinforced at the same time. In this tertiary hospital, it has been a standardized practice to assess the Braden Score (BS) of all patients during every afternoon shift. Nurses were to initiate heel off-loading practice once a patient was assessed to have a reduced score on either the mobility or activity items in the BS.

A pictorial guide was developed to aid nurses in performing consistent heel off-loading practice. It included an image on how to off-load patients' heels (Fig. 1). Patients' heels should be off-loaded with heel foam protectors along with either a pillow or a towel. The knee must be slightly flexed while off-loading the heels to prevent foot drop caused by impingement of the common peroneal nerve (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, & Pan Pacific Pressure Injury Alliance, 2014). At the same time it is vital to avoid pressure on the Achilles tendon. The pictorial guide was placed on the nurses’ work desks and case file trolleys to facilitate the heel off-loading practice (Fig. 2).

Nurses were reminded to perform heel off-loading through

routine roll-call sessions and the 'MeeC' system. Messages and handovers were passed on during roll-call sessions before each afternoon shift commenced. MeeC is an on-line platform for the organization to convey notices or messages to all the nurses in the workplace.

Results

Baseline audit

There was inconsistency in the heel off-loading practice prior to the implementation of this project. The baseline audit results showed that 20% of the at-risk patients had heel foam protectors. Of these 20% none of them had their interventions documented in the nursing notes, which reflected poorly on nurses’ awareness of the importance of heel off- loading.

Post-implementation audit

The initial post-implementation audit was done two months after the launch of this project. Data were collected using the same methodology as the baseline audit. There was an increase in nurses performing the heel off-loading practice (76.7%) and documenta- tion in the nursing notes (66.7%). Criterion 1 showed 63.3% com- pliance (p < 0.05), which indicates that the patients’ heels were off-

Fig. 1. Heel offloaded with towel.

Fig. 2. Visual aid placed on the nurses' work desk.

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loaded, but it was not documented in the nursing notes, or vice versa.

Sustenance audits

A second round of audit was undertaken six months after the initial post-implementation audit. It is necessary to conduct regular audits to evaluate the consistency and adherence of heel off-loading practice within clinical settings (Cullum et al., 2008). Regular sustenance audits were subsequently conducted every six months.

The nurses demonstrated consistency in performing the heel off- loading practice in the follow-up audits (Table 2). In follow-up audit 2, there was a slight decrease in nurses’ documentation as compared to the follow-up audit 1 (66.7% vs 63.3%). The follow-up audit 4, in March 2017, achieved 86.7% compliance (p < 0.05), meaning there was more heel PU prevention whereby at-risk pa- tients had heel protectors, pressure relieving devices or other form of heel off-loading in place. Improved documentation of nursing care was also evident. However, not all at-risk patients had their heels off-loaded. Table 2 reveals that 93.3% of at-risk patients had their heels off-loaded while 86.7% had the intervention docu- mented in the nursing notes. Overall, the follow-up audit 4 reported good results of heel PU prevention practice.

Discussion

There were statistically significant results in nurses performing the heel off-loading practice pre- and post-implementation (p < 0.05). This evidence-based project has reduced the incidence of heel PU in at- risk patients (Fig. 3), improved nurses’ awareness and compliance in performing the heel off-loading practice.

The results of this project confirmed the relationship between heel off-loading practice and reduced incidences of stage one heel PU (Fig. 3). There was more than 50% reduction in stage one heel PU occurrence in the orthopaedic wards following the initiation of this project. There were 7 heel PU incidences across all orthopaedic wards in the tertiary hospital from 2013 to 2014 prior to the im- plementation of this project. While a total of four patients devel- oped heel PU from March 2015 to March 2017 when the project began. These were due to the delayed initiation of the heel off-

loading practice. Seemingly, there are still deficiencies that need to be addressed regarding nurses’ engagement in this practice (Fig. 3).

Heel off-loading technique

The heel off-loading technique remains the best practice for patients with chronic conditions, such as diabetic and ischemic foot conditions, lower-extremity wound management, bedridden pa- tients and during surgeries that require anaesthetized patients to lie supine over a long period of time (Malkoun et al., 2012; Miller and Armstrong, 2014; Sopher et al., 2011). The patients' heel-bed in- terface pressure has been shown to be very high while lying supine (Bosanquet et al., 2016; Tong et al., 2016). Since the heel has thin

Table 2 Audit results.

Table 2: Audit results

Audit Criteria Pre-implementation (n=30)

Post- Implementation (n=30)

0 months 3rd months 9th months 16th months 24th months

March 2015 June 2015 Dec 2015 July 2016 March 2017

Pre-Implementation Follow-up audit 1

P-value Follow-up audit 2

P-value Follow-up audit 3

P-value Follow-up audit 4

P-value

1 It is documented that at risk patients have a heel protector, pressure relieving device or other form of heel offloading

0 63.3% .000 63.3% .000 70.0% .000 86.7% .000

1.1 Lower limb offload 20 76.7 83.3% 83.3% 93.3% .000 1.3 Documentation information list 3.3 66.7 63.3% 66.7% 86.7% .000

Statistical significance was set at P < 0.05.

Fig. 3. HPU Incidences in the Orthopaedic wards.

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skin and minimal fat and muscle, it is highly susceptible to PU de- velopment (Bosanquet et al., 2016). In addition, the heels of elderly patients aged 70 and above are usually dry and lack sebum, re- sulting in a greater risk of developing PUs (Tong et al., 2016). During the implementation phase, some patients had some form of mobility impairments which required assistance to be mobilized in the bed, so the nurses ensured these patients had their heels off- loaded.

Education and early intervention of off-loading

Studies have reported that nurses are more likely to off-load pa- tients' heels after receiving education and training (Hanna-Bull, 2016; Sving et al., 2016). The strategy of initiating PU preventive interven- tions as early as pre-hospitalization stay can reduce the development of PUs (Athlin et al., 2016). PU risk assessments are performed daily upon admission to the ward and whenever necessary. The nurses commenced heel off-loading immediately when patients were identified to be at- risk. All of the above factors have contributed to the reduction of stage one heel PU occurrence.

Nursing documentation

Nursing documentation is a significant nursing practice, sig- naling continuity of care and a means of communication to inform care (Broderick and Coffey, 2013). The purpose of documentation is to ensure that the appropriate interventions are implemented by the nurses for patients' care (Jacobson et al., 2016). The follow-up audits reflected the fact that, although the nurses had off-loaded patients’ heels, they had not satisfactorily documented this proce- dure. Underreported nursing activities are generally interpreted as missed care, resulting in adverse patient outcomes such as PUs and falls. The reasons for missed care are often related to high work- load, inadequate workforce, poor staffing and patient satisfaction (Jones et al., 2015; Kalisch and Xie, 2014). In collaboration with the nursing leaders, the team members were empowered to embed the documentation of nursing care, specifically 'off-loading of heels' as a routine care documentation in the nursing notes. The involvement of good leadership, getting support from various stakeholders and embedding practices into daily routine are strategies that will sus- tain quality improvement initiatives (Chambers, 2015; Cranley et al., 2018).

Challenges

A session was organized with the stakeholders and members to discuss the outcomes and barriers concerning this project. The ward nurses were also updated on the audit results and feedback was gathered. A main challenge identified was nurses' readiness. Nurses were resistant to the project because they saw this practice as ad- ditional workload. The results on nursing documentation com- pliance in the post-implementation audits were around 65%. Nurses stated that they did not document heel off-loading practice reg- ularly. According to Lewin's change theory, the first step in en- couraging nurses to change is to increase the driving forces that compel them to accept that such changes are necessary (Marquis and Huston, 2009). In this instance, the driving force was to create awareness for the need to change. Polit and Beck (2014) noted that it is essential to communicate findings with the nurses. The purpose of the heel off-loading project and the changes after the im- plementation of this project were disseminated to the ward nurses.

Furthermore, this project engaged the senior nurse manager as a role model in performing the heel off-loading practice. Nurses were also reminded to perform heel off-loading techniques through roll- call sessions and MeeC routinely.

Another factor affecting the results of this project was patients’ non-adherence to the heel off-loading practice. It was observed that patients tended to kick the pillow to the side or ask a family member to remove it. Some patients gave feedback that it was un- comfortable to have a pillow or towel placed under their calves. Despite explaining the purpose of heel off-loading, some patients still did not comply with the practice. This continued to be a major factor hindering the project. The ward nurses were encouraged to educate and reinforce the purpose of heel off-loading to the patients and their significant others to promote compliance with heel off- loading (AWMA, 2012).

There is a need to sustain this project to evaluate the effectiveness of the heel off-loading practice in the long run. Nurses' improved knowl- edge on heel PU prevention may not necessarily translate into practice. Therefore, constant reminders are vital in increasing nurses’ compliance with heel off-loading practice.

Strengths

The heel off-loading practice is a basic but important aspect of nursing care. In this project, the nurses understood that off-loading patients' heels helped to prevent heel PU. This is important because it prevents missed nursing care, improves patient safety, reduces hospital acquired complications, reduces healthcare cost and en- hances nurses’ satisfaction. Teamwork and increased participation among the nurses led to fewer incidents of heel PU development. To date, nursing leaders have worked to involve nurses in sustaining the practice by embedding it in the daily nursing care activities.

Limitations

The project was limited to two orthopaedic wards. Furthermore, the small sample size restricted the effectiveness of the results. The initial phase of the project was challenging because nurses' atti- tudes towards the practice were negative. Hence, efforts were made, including effective communication and role modeling, to change nurses’ resistance.

Conclusion

There was a notable reduction of stage one heel PU occurrence post-implementation. Heel PUs are often difficult to heal as they are located at the most distal anatomy of the body and at the end ar- terial blood supply of the peroneal and tibial vessels (Thomas and Compton, 2014). Accurate assessment is crucial in identifying at- risk patients. The combined usage of heel foam protectors and a pillow or a towel is effective in preventing heel PU development. Proper documentation and providing timely intervention help to reduce the risk of heel PU occurrence in patients.

Finally, it is essential to equip nurses and patients with knowl- edge about heel off-loading and its importance to enhance support for this project. Despite various barriers and constraints, this pro- ject did attain positive clinical outcomes. The positive results are attributed to the work of supportive stakeholders and nurses.

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Funding

No funding has been received to complete this study.

Potential conflict of interest

We declared there are no conflict of interest.

Ethical statement

Ethical approval was not required as this project was conducted in agreement with the hospital's clinical quality improvement policy.

Funding

No funding has been received to complete this study.

Potential conflict of interest

We declared there are no conflict of interest.

Acknowledgement

The authors would like to thank the following staff who have con- tributed to the success of this project: Assistant Nursing Director of Nursing Ms Usha Menon and all nurses at the National University Hospital inpatient wards. The authors would also like to thank the Publications Support Unit of the National University Health System, Singapore, for reviewing this manuscript.

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