journal critique

critique_journal.pdf

Home >English homework help >journal critique

O R I G I N A L A R T I C L E

Pediatric skin care: What do nurses really know? Jennifer Drake, Wendi S. Redfern, Eileen Sherburne, Melodee L. Nugent, and Pippa Simpson

Jennifer Drake, RN, MS, CPN, is a Nurse and Clinical Nursing Instructor, Neuroscience Unit; Wendi S. Redfern, MSN, RN, CCRN, is an Advanced Practice

Nurse, Department of Advanced Practice Nursing, Children’s Hospital of Wisconsin; Eileen Sherburne, MS, ACNS-BC, FNP-BC, CRRN, WCC, is an Advanced

Practice Nurse, Department of Advanced Practice Nursing, Children’s Hospital of Wisconsin; Melodee L. Nugent, MA, is a Pediatric Biostatistician; and

Pippa Simpson, PhD, is a Section Chief Director, Professor—Pediatrics, Quantitative Health Sciences, Children’s Research Institute, Medical College of

Wisconsin, Milwaukee, Wisconsin, USA

Search terms Attitude, barrier, behavior, belief,

evidence-based practice, facilitator, knowledge,

nursing, pediatrics, perception, practice,

pressure sore, pressure ulcer, prevention,

research utilization, skin care, skin integrity.

Author contact [email protected], with a copy to the Editor:

[email protected]

Acknowledgements This project was supported by the Sophie

Schroeder Endowment Fund. The authors wish

to thank Shelly Malin PhD, RN, NEA-BC, Karen

Gralton, RN, MS, PCNS-BC, Children’s Research

Institute, and Children’s Hospital of Wisconsin

Nursing Research Council for their advice and

encouragement.

Disclosure: The authors report no actual or

potential conflicts of interest. This research was

funded in part by Sophie Schroeder Endowment

Fund.

First Received October 12, 2011; Revision

received March 8, 2012; Accepted for

publication June 23, 2012.

doi: 10.1111/j.1744-6155.2012.00342.x

Abstract

Purpose. The purpose of this study was to explore pediatric nurses’ knowl- edge of pressure ulcer prevention, investigate their beliefs and practices, and identify the barriers and facilitators to providing evidence-based pres- sure ulcer preventive practices. Design and Methods. An exploratory, descriptive, and cross-sectional survey was taken of registered nurses in a freestanding children’s hospital. Results. Nurses have adequate knowledge of general pressure ulcer pre- vention; however, they struggle with individualization. Further, analysis revealed that nursing knowledge did not always correlate with nursing practice. Practice Implications. Nurses require education on individualized inter- ventions and access to user-friendly, interactive, and comprehensive resources, including unit-based champions and order sets.

From local to national organizations, private and public, pressure ulcer prevention is a priority for insti- tutional goals. Despite these efforts, pressure ulcers remain a significant threat for hospitalized and immobilized populations. While often seen as an issue of the elderly and in the nursing home setting, pressure ulcers also adversely affect infants and children and remain a major concern in pediatric inpatient facilities with prevalence in pediatric patients ranging from 1.6% to 27.7% (McLane, Bookout, McCord, McCain, & Jefferson, 2004; Noonan, Quigley, & Curley, 2006; Schindler et al.,

2007; Schluer, Cignacco, Muller, & Halfens, 2009), resulting in pain, infection, disfigurement, altered body image, and mortality, as well as increased costs, length of stay, and litigation (Baharestani & Ratliff, 2007). In the past, pressure ulcers in children were not recognized as an issue; as the industry has become more knowledgeable through research, national patient safety goals, and certifying bodies (i.e., Med- icaid reimbursement, Magnet recognition, and Joint Commission), it has become apparent in the last decade that the issue of pressure ulcer prevention needs to be addressed in the pediatric setting.

bs_bs_banner

Journal for Specialists in Pediatric Nursing

Identifying barriers to the implementation of pres- sure ulcer prevention is pivotal to improve the quality of care provided. Further, initiatives involv- ing staff may create an environment in which prac- tice changes are better accepted (Beitz, 2001; Buss, Halfens, Abu-Saad, & Kok, 2004; Cheater et al., 2005; Flynn & Fink, 2001; van Gaal et al., 2009; Maylor, 2001; McElhinny & Hooper, 2008; Moore & Price, 2004). Focusing on barriers and facilitators to evidence-based pressure ulcer prevention is impera- tive. An exhaustive review (Medline, CINAHL, PubMed, Cochrane, and Ovid 1995–2011) revealed a gap in the literature addressing nursing knowl- edge, barriers, and facilitators to providing preven- tive skin care in the pediatric setting. Keywords included pediatrics, pressure ulcers, pressure sores, prevention, perception, nursing, barriers, facilita- tors, skin care, evidence-based practice (EBP), practice, knowledge, research utilization, attitudes, behaviors, beliefs, and skin integrity. As differently aged populations vary greatly, it would be difficult, presumptuous, and potentially incorrect to assume that the barriers identified by nurses and aides in intensive care units (ICUs), orthopedics, rehab facili- ties, home care, and general adult inpatient facilities would be identical to those of nurses in a pediatric inpatient facility. The aim of the study described in this article was to look at pediatric nurses’ self- reported practices, beliefs, and knowledge of pres- sure ulcer prevention and to identify the barriers and facilitators in their work setting. Thereby, a strategy can be developed targeting support staff, providing education, and lowering barriers to improve pressure ulcer prevention.

BACKGROUND AND SIGNIFICANCE

Ensuring that nursing staff regard preventive skin care as a priority is critical to the success of any inter- vention. The relationship between attitudes toward, knowledge of, and practices in pressure ulcer pre- vention is complex and not necessarily linear (Källman & Suserud, 2009). Nurses often have an inaccurate image of the prevalence of pressure ulcers, and preventive skin care is neither a highly ranked concern for nurses nor a priority in the way nurses plan their care (Beitz, Fey, & O’Brien, 1999; Buss et al., 2004; Maylor, 2001; Moore & Price, 2004). Despite efforts to enhance nurses’ knowledge base, disseminate guidelines, and generally improve the practices of nurses working with patients at risk for skin breakdown, there continue to be barriers

that impede the implementation of practice guide- lines, the effectiveness of educational interventions, and the adoption of evidence-based recommenda- tions (McElhinny & Hooper, 2008; Pancorbo- Hidalgo, García-Fernández, López-Medina, & López-Ortega, 2007). Clinical practice strategies and guidelines are often inadequately and unsuccess- fully implemented (Ozdemir & Karadag, 2008). Furthermore, “the existing work has not accounted for the compromises that nurses are asked to make when combining limited resources (e.g., nursing time, equipment) with the service users’ unlimited healthcare needs in order to provide clinically effec- tive nursing care” (Papanikolaou, Lyne, & Ratcliffe, 2007, p. 589).

Nursing barriers that have been identified in a variety of settings are vast and not limited to an inad- equate caregiver knowledge base; a failure to form meaningful partnerships; a lack of a continuous quality improvement framework; a lack of well- disseminated, research-based care guidelines, algo- rithms, and pathways; time; the patient condition; a lack of resources or equipment; an inadequate focus on population outcomes with a lack of long-term prevention strategies; staff and faculty nursing shortages; a lack of national benchmarks that are well researched and enforced; and severe federal fiscal constraints (Beitz, 2001; Buss et al., 2004; Chau, Lopez, & Thompson, 2008; Källman & Suserud, 2009; Moore & Price, 2004). In a Cochrane systematic review of randomized controlled trials of interventions tailored to address explicitly specified barriers to change, the results were nebulous (Cheater et al., 2005). The authors were unable to determine if the barriers were valid, if all barriers had been identified and addressed, or which were the most important barriers to address. Ultimately, the effectiveness of tailored interventions remains uncertain. In spite of this confusion about what the barriers are and what their role is in affecting prac- tice, it is clear that further attention to these impedi- ments to best practice is essential when creating interventions to enhance the quality of care. Addi- tionally, attention to the qualities that facilitate prac- tice change and the implementation of EBP may contribute to the success of any intervention.

Aims

The purposes of this study were to (a) explore pedi- atric nurses’ knowledge of pressure ulcer preven- tion, (b) investigate their beliefs and practices through self-report, and (c) identify any barriers and

Pediatric Skin Care: What Do Nurses Really Know? J. Drake et al.

facilitators to providing evidence-based pressure ulcer prevention.

Research methods

The study was exploratory and descriptive, utilizing a cross-sectional survey approach. The convenience sample was nurses practicing in the inpatient setting at a freestanding academic Midwestern children’s hospital (N = 348). This research focused on acute care nurses to avoid duplication of data and again to allow for further comparisons, as other research in the institution was in process studying the skin care practices of nurses in the pediatric ICU (PICU). The nurses in our study cared for all pediatric specialty patients outside of the ICU.

The hospital institutional review board approved the study. Participants consented for participation at the onset of the survey, and no identifying data were obtained. The electronic survey used Survey Monkey and consisted of demographics and a series of questions about the nurse’s knowledge, beliefs, practices, and barriers and facilitators within their work setting to the implementation of evidence- based pressure ulcer prevention.

Survey instrument

The questionnaire was developed, with permission, utilizing portions of two previously validated instru- ments used throughout the literature on barriers to pressure ulcer prevention in the adult healthcare setting (Halfens & Eggink, 1995; Moore & Price, 2004). The questionnaire used in this section was adapted with permission by Halfens and Eggink and is used throughout the literature on nurses’ beliefs, attitudes, knowledge, and barriers to providing pressure ulcer prevention. However, some of the guidelines were modified or eliminated for different standards in the pediatric setting. The hospital policy and procedure was used as a standard upon which to adapt the guidelines (Children’s Hospital of Wisconsin, 2010). This skin integrity maintenance policy includes pediatric-focused skin assessment parameters, bathing, and incontinence manage- ment guidelines. Standard nursing education within the hospital includes description of the proper use of the Braden Q tool (Noonan et al., 2006) and admis- sion assessment guidelines. There were several pre- ventive methods that were excluded from this section of the questions because they were not in current practice at the study site (such as certain spe- cialty mattresses, creams, or use of ice or warm com-

pressors). Further, as the original study in which the questionnaire was developed was an adult setting and in the Netherlands, questions had to be modi- fied for language because they were not applicable to the pediatric setting in the United States (such as paramedical treatment [e.g., physiotherapy for mobility and reactivity]). As each question should be reliable on its own, eliminating certain methods that were not in practice should not have affected the validity of the modified tool used.

Previous studies used a calculation system for knowledge score. The questions were broken into three categories: interventions that are always recommended, those that are recommended in certain situations, and those that are contraindi- cated. Knowledge scores were calculated similarly to the study by Panagiotopoulou and Kerr (2002) and Halfens and Eggink (1995) in which a numerical value of 1 was assigned if they answered correct and a value of 0 was assigned if incorrect for a total possible score of 14. Additionally, one section was added that was currently used at the same facility in a similar study in the PICU (Schindler et al., 2011).

Face and content validity were determined by a group of staff nurses (n = 6), advanced practice nurses, and an expert biostatistician and researcher in quantitative health science. The reliability of the survey was assessed using Cronbach’s alpha on the overall survey and subsets of questions.

Data analysis

As expected when using a self-report questionnaire, the data set was not 100% complete. The data were summarized for those completing each section, and the level of response was indicated. The data were coded, and the frequencies were obtained using the statistical software package SPSS (version 20; SPSS Inc., Chicago, IL, USA). Chi-square tests or Fisher– Halton Exact tests were used to compare two groups of data, and the McNemar test/Kendall tau-b test was performed for paired analyses. The level of significance was set to be p = .05. No adjustment for multiple testing was done. To aid interpretation of tables, a “heat-map” approach was used where a darker color represented a higher percentage.

RESULTS

The total number of responses was 161, for a response rate of 52%; however, completed surveys were 113, for a total response rate of 32%. The overall Cronbach’s alpha was .728. The subsets

J. Drake et al. Pediatric Skin Care: What Do Nurses Really Know?

(number of questions) included beliefs (a = .372, n = 11), practices (a = .582, n = 9), barriers (a = .811, n = 14), facilitators (a = .794, n = 7), pressure ulcer prevention: advice (a = .824, n = 14), and pressure ulcer prevention: knowledge: (a = .812, n = 14).

Sample demographics

As shown in Table 1, the majority of participants had been nurses for less than 5 years (66%), with most

having 2–5 years experience since licensing (39%). Sixteen percent had been registered nurses between 6 and 10 years, with almost 20% with greater than 10 years since receiving their license. The majority of nurses (70%) had worked at the facility as a nurse for less than 5 years. The vast majority was female (98%), and most were employed full time (63%). While degree type was not a requirement for employment at this hospital, nearly 78% had a bac- calaureate degree. No statistically significant differ- ences were found between any of the other findings and demographics.

Beliefs

Respondents were asked to answer a series of ques- tions on their beliefs about pressure ulcer preventive practice. Results are summarized in Table 2. The majority of nurses agreed that all patients are at risk of pressure ulcer development (84%), and few believed that prevention is time consuming (5%). There was some lack of consensus on interest in pressure ulcer prevention, the effectiveness of risk assessment tools, whether pressure ulcer prevention is a low priority, and especially the prevalence of pediatric pressure ulcers. Additionally, nearly all nurses believed that they do need to be concerned with pressure ulcer pre- vention in their practice (98%) and disagreed that treatment ought to be a greater priority than preven- tion (85%). Finally, 93% believed that a continuous

Table 1. Demographics

N evaluation N (%)

Length of time as a registered nurse (years)

161

< 2 46 (29) 2–5 59 (37)

6–10 26 (16)

10+ 30 (18) Length of employment at this

hospital (years) 161

< 2 49 (31) 2–5 63 (39)

6–10 26 (16)

10 + 23 (14) Gender 160

Male 4 (2)

Female 156 (98)

Employment status 161 As needed 30 (19)

Part time 29 (18)

Full time 102 (63)

Table 2. Pressure Ulcer Prevention Percentages—Beliefs for 161 Nurses

Strongly agree Agree

Neither agree nor disagree Disagree

Strongly disagree

1. All inpatients are at potential risk of developing pressure sores 25 59 7 8 1

2. Pressure sore prevention is time consuming for me to carry out 1 4 25 57 13

3. In my opinion, patients tend not to get as many pressure sores

nowadays

1 24 33 36 6

4. I do not need to concern myself with pressure sore prevention in my

practice

1 0 1 53 45

5. Pressure sore treatment is a greater priority than pressure sore

prevention

1 4 10 48 37

6. Continuous nursing assessment of patients will give an accurate

picture of their pressure sore risk

32 61 6 1 0

7. Most pressure sores can be avoided 30 64 4 1 1

8. I am less interested in pressure sore prevention than other aspects of

nursing care

1 18 31 41 9

9. My clinical judgment is better than any pressure sore risk assessment

tool available to me

3 6 47 37 7

10. In comparison to other areas of nursing care, pressure sore

prevention is a low priority for me

1 7 23 58 11

11. Pressure sore risk assessment should be regularly carried out on all

patients during their stay in hospital

26 61 10 3 0

Legend: 0–4% 5–9% 10–24% 25–49% �50%.

Pediatric Skin Care: What Do Nurses Really Know? J. Drake et al.

nursing assessment will give an accurate picture of risk, 94% believed that most pressure ulcers can be avoided, and 87% believed that pressure ulcer risk assessment should be regularly carried out on all patients during their hospital stay.

Practice

The study setting utilizes a pressure ulcer risk assess- ment tool within the admission assessment and screening for every patient admitted as an inpatient to identify those at risk. Only 38% of respondents stated that they performed pressure ulcer assess- ment on all patients; 58% stated that they per- formed risk assessment only on some patients at risk; while only 4% stated that they never performed a pressure ulcer risk assessment. When asked when they performed pressure ulcer risk assessment, 59% stated that they did so on admission only, 69% daily, 20% when they remembered to, and 12% when they had time. A small percentage stated that they only perform pressure ulcer risk assessment when the patient develops a pressure ulcer (4%) or that they do not perform it at all (4%). Seventy-four percent stated that they were aware of a pressure ulcer risk assessment tool in use, and 56% stated that they were aware of a pressure ulcer grading tool in use within their practice. Eighty-four percent stated that they had not received any formal training (such as a seminar or conference) outside of the

hospital on pressure ulcer prevention and manage- ment since becoming a registered nurse.

In the hospital where the study was performed, a standardized pressure ulcer order set existed to assist staff in risk assessment and pressure ulcer preventive interventions. When asked about the order set, 28% of participants indicated that they order it on all patients at risk, while 48% order it only on some patients at risk. Forty-three percent acknowledged that they review the pressure ulcer order set every time they care for the patient. When asked why they review the order set, 59% of respondents indicated that they do it to re-familiarize themselves with the plan of care. Additionally, 49% stated that they review it because there is a change in the patient’s condition, 27% stated that they do it because the patient develops a pressure ulcer, and 18% stated that they never review the care plan.

Cross tabulations were run with the McNemar– Bowker paired test on the belief by practice ques- tions. Practice 1 (Do you carry out pressure ulcer risk assessment?) and practice 3 (Do you order the pres- sure ulcer prevention set?) were almost always significant with the belief questions (p � .002). The results are summarized in Table 3. Nurses believ- ing that pressure ulcer prevention was a priority were more likely to practice risk assessment and implement the prevention order set. However, there was still a substantial number who did not practice what they believed.

Table 3. Paired Analyses of Beliefs by Practices

For all patients at risk*

Do you carry out pressure ulcer risk assessment? (%)

Do you order the pressure ulcer prevention order set? (%)

1. Agree that all inpatients are at potential risk of developing pressure sores 41 27

2. Agree that pressure sore prevention is time consuming for me to carry out 43 32

3. Disagree that patients tend not to get as many pressure sores nowadays 48 34

4. Disagree that they do not need to concern myself with pressure sore prevention in

my practice

38 29

5. Disagree that pressure sore treatment is a greater priority than pressure sore

prevention

36 29

6. Agree that continuous nursing assessment of patients will give an accurate picture

of their pressure sore risk

39 29

8. Disagree that they are less interested in pressure sore prevention than other aspects

of nursing care

NS 30

9. Disagree that their clinical judgment is better than any pressure sore risk

assessment tool available to me

42 36

10. Disagree that in comparison to other areas of nursing care, pressure sore

prevention is a low priority for me

44 32

11. Agree that pressure sore risk assessment should be regularly carried out on all

patients during their stay in hospital

43 30

NS, not significant; *p value � .002.

J. Drake et al. Pediatric Skin Care: What Do Nurses Really Know?

Barriers and facilitators

The results of the identification of barriers and facili- tators to pressure ulcer preventive practice are sum- marized in Table 4. Only one barrier was highlighted by the majority to impede practice: competing demands on time (68%). Other barriers were identi- fied with a relative majority (such as low priority given to pressure ulcer prevention by medical staff [36%], current documentation format [45%], and insufficient resources to provide guidance and exper- tise [43%]). Barriers that did not impede pressure ulcer prevention included limitations in assessment ability (55%), limitations in knowledge (59%), low priority by me (64%), insufficient help (68%), patient refusal (52%), and family refusal (55%). Seventy-five percent of nurses responded that they were able to overcome barriers to provide pressure ulcer prevention to their patients.

Seventy-one percent of respondents agreed that education about the Braden Q contributed to their ability to perform pressure ulcer prevention. Par- ticipants identified current documentation format (51%), pressure ulcer prevention nursing order set (56%), ease of obtaining pressure reduction surfaces (56%), collaboration with interdisciplinary team (53%), and appropriate skin care products readily available (69%) as facilitating practice. Participants (45%) stated that education received about pressure

ulcer grading contributed positively to their practice.

Beliefs and knowledge of preventive strategies

Belief score (preventive strategies). Eighty-five percent of nurses believed that the universal recommendations are always helpful to pressure ulcer prevention. Those interventions included clean drawsheet, good hygiene, daily skin assessment, maceration prevention, patient/family involvement, frequent repositioning, and use of a risk assessment tool. The recommended individualizable interven- tions included daily use of a risk assessment tool, use of synthetic sheepskin for infants younger than 2 months, use of pressure redistribution surface, and physical therapy consultation. The interventions assessed that are never recommended included the use of a foley catheter and massage. Sixty-eight percent of nurses believed that they should always assess pressure ulcer risk using a risk assessment tool, and 44% believe in always using a synthetic sheep- skin for infants younger than 2 months old. Thirty- seven percent of nurses believed that the use of an air mattress and physical therapy for mobility were sometimes useful. Eight percent of the nurses correctly believed that interventions that are con- traindicated by EBP were never useful (e.g., massage and foley catheter placement).

Table 4. Barriers and Facilitators Percentages to Pressure Ulcer Prevention Practices

N evaluation Strongly agree Agree

Neither agree/disagree Disagree

Strongly disagree

Competing demand on time 122 10 58 19 11 2

Limitations in ability to assess pressure ulcer risk 123 0 25 20 48 7

Limitations in knowledge about pressure ulcer prevention 123 1 18 23 52 6

Low priority given to pressure ulcer prevention by medical staff 123 0 37 28 34 1

Low priority given to pressure ulcer prevention by nursing staff 123 0 26 33 37 4

Low priority given to pressure ulcer prevention by me 123 0 13 24 55 8

Current documentation format 122 5 40 31 22 2

Insufficient resource to provide expertise 123 5 38 25 30 2

Insufficient supplies/equipment to provide optimal care 123 4 26 30 36 4

Insufficient staff to assist 122 3 28 30 36 3

Patient refusal 123 3 20 25 46 6

Family refusal 123 4 16 24 50 6

Lack of care guidelines, algorithms, and/or clinical pathways 123 2 31 37 28 2

Education received about Braden Q risk assessment 119 7 65 21 6 1

Education I have received about pressure ulcer grading 119 3 41 34 20 2

Current documentation format for pressure ulcer risk/nursing

interventions

119 3 48 30 17 2

Sunrise pressure ulcer prevention nursing order set 119 2 54 35 7 2

Ease of obtaining pressure reduction surfaces 118 8 48 28 15 1

Collaboration with interdisciplinary team 119 4 49 36 10 1

Appropriate skin care products readily available 118 5 64 19 10 2

Legend: 0–4% 5–9% 10–24% 25–49% �50%.

Pediatric Skin Care: What Do Nurses Really Know? J. Drake et al.

Knowledge score (preventive strategies). Staff indicated that universally recommended interven- tions that are recognized by EBP are useful 85% of the time. One intervention, using a synthetic sheep- skin for infants younger than 2 months old, was less recognized as useful; only 48% of respondents rec- ognized it as a beneficial intervention. For the indi- vidualized interventions, knowledge accuracy of the usefulness of interventions ranged from 32% to 40%. Fifty-eight percent to 66% of staff indicated that these interventions were always useful. Four percent to 9% of staff correctly indicated that the interventions that are contraindicated in EBP are never useful. When the knowledge questions were scored, the mean of knowledge was 60%.

DISCUSSION

Nurses’ knowledge

One aim of the study was to explore pediatric nurse’s knowledge of evidence-based preventive pressure ulcer practices. In previous studies, a score of greater than 70% was considered an adequate level of knowledge (Halfens & Eggink, 1995; Panagiotopou- lou & Kerr, 2002). Overall, pediatric nurses possess adequate knowledge of universally recommended interventions. Our findings are comparable with those found in the adult literature (Beitz et al., 1999; Halfens & Eggink, 1995; Panagiotopoulou & Kerr, 2002; Pancorbo-Hidalgo et al., 2007). However, similar to adult findings, when pediatric nurses were asked to identify interventions applicable in only certain cases, they struggled to correctly individualize the intervention to the patient care plan. This may be attributed to the fact that the majority of literature regarding pressure ulcers focuses on the adult popu- lation, and pediatric literature is limited to preva- lence, incidence, and general information about prevention, with only recent research addressing pediatric preventive pressure ulcer nursing practices in the PICU (Schindler et al., 2011). There is virtually no information about pediatric nursing behaviors and perception regarding pressure ulcer prevention practice and knowledge. Education alone is unlikely to change the prevalence of pressure ulcers in the pediatric setting (McElhinny & Hooper, 2008).

Nurses’ beliefs and practices

Another aim of the study was to explore what nurses believe and report as their practice in relationship to preventive pressure ulcer care. There is inconsistency

between what is recognized as useful and what nurses do in practice. Interestingly, 100% of patients at this institution received a pressure ulcer risk screening upon admission based on components of the Braden Q; however, only 59% of nurses reported performing a risk assessment upon admission. Hospi- tal policy dictated that all patients are screened for pressure ulcer risk, and if identified at risk, the Braden Q must be completed on a daily basis as a part of a greater order set of interventions to be implemented. Admission data audits revealed that all patients were being screened, so it remained unclear why nurses did not believe they performed a risk assessment. Nurses were unaware of both what their practice should be and what might help facilitate practice. It is likely that nurses were unaware of the usefulness or purpose of the standardized tools already in place and required further education regarding risk assess- ment. Further, whether they were assessing pati- ents for pressure ulcer risk and utilizing the order set available seems to be directly linked to their beliefs. Targeting nurses’ belief systems and helping them understand the importance of pressure ulcer preven- tion practices may be one means of improving practices.

Factors that may have influenced knowledge and practice

No statistically significant differences were found between the demographic groups and knowledge scores. Nurses with more years of experience or those with higher degrees did not demonstrate a higher level of knowledge or individualization of preventive care measures. The majority (84%) of nurses reported not having had any formal training on pressure ulcer prevention and management, which may have been why there was no difference noted between the groups. In addition, information from formal pressure ulcer educational programs, risk factors, and interventions tend to be based on knowl- edge gleaned from the adult population and must be adapted for pediatric practice (Schindler et al., 2011). This may discourage some pediatric nurses from seeking further formal education regarding pressure ulcer care.

Barriers and facilitators to good practice

The final purpose of the study was to identify the barriers nurses reported as impeding their ability to provide preventive skin care and the factors that facilitate good practice. In fact, nurses identified few

J. Drake et al. Pediatric Skin Care: What Do Nurses Really Know?

significant barriers. Competing demands on nurses’ time, current documentation format, and available resources were cited as the top three barriers to pro- viding preventive skin care. Time is frequently cited as a barrier to providing optimal patient care regardless of the context. Given the complex process nurses utilize to prioritize care, it is essential that technology, documentation, and resources aid in the delivery of care and not become burdensome. Docu- mentation formats and resources are barriers that, when targeted, are modifiable, and, when combined with other strategies, could positively affect patient care. However, it is important to note that the ques- tionnaire did not collect information on the indi- vidual nurse’s practice and the outcomes of the patients cared for by this nurse. While nurses stated that they were able to overcome barriers to provide optimal care, it remains evident that the nurses were unaware both what their practice is and what it should be. So the question remains are they even aware of what optimal care is and, if not, how can they know that they overcame all barriers?

The evidence suggests that the most effective means of increasing pressure ulcer preventive prac- tices is not to focus on increasing knowledge; instead, there is a need for coordinated programs that focus on developing interventions that can be applied in an environment of limited resources and that take into account those patient-related risk factors that cannot be modified by the nurse (Bostrom & Kenneth, 1992; Wound Ostomy Continence Nurses Society, 2009). Positive attitude, education, and equipment are not enough to change practice, though these variables must be acknowledged or ritualistic traditional prac- tices will prevail (Maylor, 2001; Maylor & Torrance, 1999; Moore & Price, 2004). Singularly-focused interventions will likely have limited effects; multi- faceted interventions, on the other hand, will have a synergistic effect and their success is increasingly likely (Rashotte, Thomas, Grégoire, & Ledoux, 2008). Additionally, the issue of patients impeding preven- tion by refusing care and the relationship between staff knowledge and attitude needs further explora- tion (Moore & Price, 2004).

Research utilization must be a shared responsibil- ity among researchers, managers, and clinicians (Chau et al., 2008). Successful change is more likely to occur in contexts with a supportive organizational culture and existing change agents (Marchionni & Ritchie, 2008). Additionally, system-wide barriers and not individual issues pose the greatest impedi- ments to achieving significant improvements in pressure ulcer prevention practices (Gruneir & Mor,

2008). Multilevel systemic solutions must include a sense of collective worry and concern; a recognition of resource limitations; a newer perspective on health for Americans; litigation about chronic wound care; innovative electronic communication in all its forms; partnerships between businesses, healthcare, and academia; the use of alternative healthcare providers; innovative wound care treat- ments; alternative sites of care; and a renaissance in healthcare education (Beitz, 2001).

Finally, social influences may be a key in the pro- motion of behavior change; furthermore, identify- ing and targeting social leaders may help promote longer lasting changes (Flynn & Fink, 2001; Maylor, 2001; Maylor & Torrance, 1999). Teaching strategies are often ineffective in isolation, and acquiring nurse buy-in for projects that improve patient outcomes is critical to their success (McElhinny & Hooper, 2008). Approaches that incorporate performance feedback, the involvement of learners in setting priorities, and face-to-face encounters between practitioners and educators may be more effective in promoting long- lasting results (Haines & Jones, 1994). Additionally, research suggests that focusing on the senior nurses or those with the most social capital will help to create an environment that will accept, support, and sustain lasting change. Until social leaders make pressure ulcer prevention a priority, the mass of nursing personnel will undoubtedly fail to enhance the quality of their practice (Maylor, 2001; Maylor & Torrance, 1999; Moore & Price, 2004).

STUDY LIMITATIONS

The main limitation of the study is that it is a self- report survey. Nurses could consult references during the completion of the questionnaire, thereby altering the results. Also, nurses had the option not to com- plete all of the questions; therefore, some of the data were missing. Given the design of the study, practice was self-reported, and actual practice was not observed. Additionally, because the population cap- tured was only at a single facility, generalizability outside of this location may be limited. Finally, the study was limited by the tools used; as they were not specific to pediatrics and had to be modified to be applicable to the setting, reliability and validity may have been affected.

CONCLUSIONS AND RECOMMENDATIONS FOR PRACTICE

The results of our study are consistent with what has been previously identified in the adult literature and

Pediatric Skin Care: What Do Nurses Really Know? J. Drake et al.

provide a foundation for targeting interventions that will aid in sustaining change and in improving patient care in the pediatric setting. Given the current state and changing atmosphere of health care, nurses need to advocate for adequate staffing ratios, and diligence to current EBP is essential for optimal patient outcomes. Nurses must avoid the tendency to rely on tradition and ritualistic practices.

To address the persistent issue of pressure ulcers, leaders need to combine multiple influences into an overwhelming strategy that is multifaceted and interdisciplinary, with input from nurses through- out the process. Employing unit-based champions to assist with assessments, interventions, and products may help support nurses and give them more resources. Furthermore, order sets and risk assess- ment tools need to be user friendly, interactive, and comprehensive to include assessments and indi- vidualized interventions. Any national guidelines or standards need to be population focused and indi- vidualized as appropriate; specifically for children’s hospitals, interventions need to be based on EBP for pediatrics, which may at times differ from the national standards designed for adult care settings. Nurses need to consider EBP in their pressure ulcer prevention practice and seek new knowledge as it becomes available. Meanwhile, leaders need to support staff around the application of EBP findings and provide the resources, program development, education, and time allocation necessary. Finally, nurses and leaders alike must work together to ensure that pressure ulcer prevention remains a pri- ority in their clinical setting and that a defined pre- vention plan is in place.

There is a clear imperative to expand on the ability of nurses to access, understand, and apply research in their clinical settings. The chasm between knowledge, beliefs, and practice is disturb- ing. The role of research within the nursing profes- sion needs to be addressed, and organizations must consider how to best support their nursing staff around the exploration and application of research in their clinical settings. Nurses must stay current on research that pertains to their clinical settings. However, if organizations want to increase the number of nurses who are conducting research and applying EBP, they must support staff from entry- level to advanced practice, through education, time allocation, and funding within their institutions to continue to grow their knowledge and to develop their skills around the ever-changing healthcare environment.

How might this information affect nursing practice?

Healthcare systems looking to increase the use of pressure ulcer prevention practices within their settings should look toward the champion model, in which informal leaders are identified and uti- lized to teach and encourage staff to employ EBP in the clinical setting, as one intervention to increase pressure ulcer prevention. The objective would be to designate a staff nurse to act as a mentor to increase communication methods with prevention and identification of pressure ulcers as well as to assist with the review and application of interven- tions. The use of champions can also increase awareness of pressure ulcers in the environmental context of the individual patient, thereby increas- ing the use of individualized interventions and supporting those with less knowledge and experi- ence. The knowledge about proper evidence-based pressure ulcer prevention, even when well under- stood, is not disseminated throughout the unit. Leaders need to be chosen wisely and need to be knowledgeable, well respected, and open to new, innovative ideas and technologies. The use of the champion model is one of a set of interventions to target pressure ulcer management and the lack of prevention practices in the nursing environment.

References

Baharestani, M. M., & Ratliff, C. R. (2007). Pressure ulcers in neonates and children: An NPUAP white paper. Advances in Skin and Wound Care, 20(4), 208–220. doi:10.1097/01.ASW.0000266646.43159.99

Beitz, J. M. (2001). Overcoming barriers to quality wound care: A systems perspective. Ostomy/Wound Management, 47(3), 56–64.

Beitz, J. M., Fey, J., & O’Brien, D. (1999). Perceived need for education versus actual knowledge of pressure ulcer care in a hospital nursing staff. Dermatology Nursing, 11(2), 125–134.

Bostrom, J., & Kenneth, H. (1992). Staff nurse knowledge and perceptions about prevention of pressure sores. Dermatology Nursing, 4(5), 365–368.

Buss, I. C., Halfens, R., Abu-Saad, H., & Kok, G. (2004). Pressure ulcer prevention in nursing homes: Views and beliefs of enrolled nurses and other health care workers. Journal of Clinical Nursing, 13(6), 668–676. doi:10.1111/j.1365-2702.2004.00953.x

Chau, J., Lopez, V., & Thompson, D. R. (2008). A survey of Hong Kong nurses’ perceptions of barriers to and facilitators of research utilization. Research in Nursing &

J. Drake et al. Pediatric Skin Care: What Do Nurses Really Know?

Health, 31(6), 640–649. doi:10.1111/j.1365-2702.2010. 03349.x

Cheater, F., Baker, R., Gillies, C., Hearnshaw, H., Flottorp, S., Robertson, N., . . . Oxman, A. D. (2005). Tailored interventions to overcome identified barriers to change: Effects on professional practice and health care outcomes. Chichester: John Wiley & Sons. doi:10.1002/14651858.CD005470; 10.1002/14651858.CD005470

Children’s Hospital of Wisconsin. (2010). Skin integrity maintenance policy and procedure. Milwaukee, WI.

Flynn, M. B., & Fink, R. (2001). Committing to evidence-based skin care practice. Critical Care Nursing Clinics of North America, 13(4), 555–568.

van Gaal, B. G., Schoonhoven, L., Hulscher, M. E., Mintjes, J. A., Borm, G. F., Koopmans, R. T., & van Achterberg, T. (2009). The design of the SAFE or SORRY? study: A cluster randomised trial on the development and testing of an evidence based inpatient safety program for the prevention of adverse events. BMC Health Services Research, 9, special section, 1–8.

Gruneir, A., & Mor, V. (2008). Nursing home safety: Current issues and barriers to improvement. Annual Review of Public Health, 29, 369–382. doi:10.1146/ annurev.publhealth.29.020907.090912

Haines, A., & Jones, R. (1994). Implementing findings of research. British Medical Journal, 308(6942), 1488–1492. doi:10.1136/bmj.308.6942.1488

Halfens, R., & Eggink, M. (1995). Knowledge, beliefs and use of nursing methods in preventing pressure sores in Dutch hospitals. International Journal of Nursing Studies, 32(1), 16–26. doi:10.1016/0020-7489(94)00032-F

Källman, U., & Suserud, B. (2009). Knowledge, attitudes and practice among nursing staff concerning pressure ulcer prevention and treatment—A survey in a Swedish healthcare setting. Scandinavian Journal of Caring Sciences, 23(2), 334–341. doi:10.1111/ j.1471-6712.2008.00627.x

Marchionni, C., & Ritchie, J. (2008). Organizational factors that support the implementation of a nursing best practice guideline. Journal of Nursing Management, 16(3), 266–274. doi:10.1111/j.1365-2834.2007. 00775.x

Maylor, M. (2001). Control beliefs of orthopaedic nurses in relation to knowledge and prevalence of pressure ulcers. Journal of Orthopaedic Nursing, 5(4), 180–185. doi:10.1054/joon.2001.0181

Maylor, M., & Torrance, C. (1999). Pressure sore survey: Part 3: Locus of control. Journal of Wound Care, 8(3), 101–105.

McElhinny, M. L., & Hooper, C. (2008). Reducing hospital-acquired heel ulcer rates in an acute care facility: An evaluation of a nurse-driven performance improvement project. Journal of Wound, Ostomy, and Continence Nursing, 35(1), 79–83.

McLane, K. M., Bookout, K., McCord, S., McCain, J., & Jefferson, L. S. (2004). The 2003 national pediatric pressure ulcer and skin breakdown prevalence survey: A multisite study. Journal of Wound, Ostomy, and Continence Nursing, 31(4), 168–178.

Moore, Z., & Price, P. (2004). Nurses’ attitudes, behaviours and perceived barriers towards pressure ulcer prevention. Journal of Clinical Nursing, 13(8), 942–951.

Noonan, C., Quigley, S., & Curley, M. A. (2006). Skin integrity in hospitalized infants and children. Journal of Pediatric Nursing, 21(6), 445–453. doi:10.1016/j.pedn.2006.07.002

Ozdemir, H., & Karadag, A. (2008). Prevention of pressure ulcers: A descriptive study in 3 intensive care units in Turkey. Journal of Wound, Ostomy, and Continence Nursing, 35(3), 293–300.

Panagiotopoulou, K., & Kerr, S. M. (2002). Pressure area care: An exploration of Greek nurses’ knowledge and practice. Journal of Advanced Nursing, 40(3), 285–296. doi:10.1046/j.1365-2648.2002.02370.x

Pancorbo-Hidalgo, P., García-Fernández, F., López-Medina, I., & López-Ortega, J. (2007). Pressure ulcer care in Spain: Nurses’ knowledge and clinical practice. Journal of Advanced Nursing, 58(4), 327–338. doi:10.1111/j.1365-2648.2007.04236.x

Papanikolaou, P., Lyne, P., & Ratcliffe, J. (2007). Using the discrete choice experimental design to investigate decision-making about pressure ulcer prevention by community nurses. Health and Social Care in the Community, 15(6), 588–598. doi:10.1111/j.1365-2524. 2007.00728.x

Rashotte, J., Thomas, M., Grégoire, D., & Ledoux, S. (2008). Implementation of a two-part unit-based multiple intervention: Moving evidence-based practice into action. Canadian Journal of Nursing Research, 40(2), 94–114.

Schindler, C. A., Mikhailov, T. A., Fischer, K., Lukasiewicz, G., Kuhn, E. M., & Duncan, L. (2007). Skin integrity in critically ill and injured children. American Journal of Critical Care, 6(16), 568–574.

Schindler, C. A., Mikhailov, T. A., Kuhn, E. M., Christopher, J., Conway, P., Ridling, D., . . . Simpson, V. S. (2011). Protecting fragile skin: Nursing interventions to decrease development of pressure ulcers in pediatric intensive care. American Journal of Critical Care, 20(1), 26–35. doi:10.4037/ajcc2011754

Schluer, A., Cignacco, E., Muller, M., & Halfens, R. (2009). The prevalence of pressure ulcers in four paediatric institutions. Journal of Clinical Nursing, 18, 3244–3252. doi:10.1111/j.1365-2702.2009.02951.x

Wound Ostomy Continence Nurses Society. (2009). Position paper: Avoidable versus unavoidable pressure ulcers. Retrieved from http://www.wocn.org/resource/ resmgr/docs/wocn-avoidable-unavoidable_p.pdf

Pediatric Skin Care: What Do Nurses Really Know? J. Drake et al.

not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written

permission. However, users may print, download, or email articles for individual use.