Literature Evaluation Table In nursing practice, accurate identification and application of research is essential to achieving successful outcomes. The ability to articulate research data and summari

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Literature Evaluation Table

In nursing practice, accurate identification and application of research is essential to achieving successful outcomes. The ability to articulate research data and summarize relevant content supports the student’s ability to further develop and synthesize the assignments that constitute the components of the capstone project.

The assignment will be used to develop a written implementation plan.

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For this assignment, provide a synopsis of the review of the research literature. Using the “Literature Evaluation Table,” determine the level and strength of the evidence for each of the eight research articles you have selected. The articles should be current (within the last 5 years) and closely relate to the PICOT question developed earlier in this course. The articles may include quantitative research, descriptive analyses, longitudinal studies, or meta-analysis articles. A systematic review may be used to provide background information for the purpose or problem identified in the proposed capstone project.

While APA style is not required for the body of this assignment, solid academic writing is expected, and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.


THE ASSIGNMENT IS TO FILL OUT THE ATTACHED TABLE USING EIGHT ARTICLES ATTACHED

Literature Evaluation Table In nursing practice, accurate identification and application of research is essential to achieving successful outcomes. The ability to articulate research data and summari
British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT SPB S6 British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT Pressure ulcer prevention in hospitals: a successful nurse-led clinical quality improvement intervention S usceptibility to wounds, including pressure damage, becomes more common after the age of 65, owing to thinning of the epidermis and diminishing immunity. As the UK has an ageing population, wound care is a public health concern. Posnett and Franks (2008) reported that one in five hospital inpatients in the UK has a pressure ulcer. Pressure ulcers are an area of concern in Denmark, which also has an ageing population. Odense University Hospital (OUH) is one of the four university hospitals in Denmark. All medical specialties are represented. OUH is one of the largest education and training centres in the Region of Southern Denmark, and has a close collaboration with the University of Southern Denmark. The hospital has two units: one in the city of Odense and one in Svendborg. In 2010, OUH conducted a prevalence study on pressure ulcers, which showed it to be 32.3% among inpatients. If category 0 pressure ulcers were excluded, the prevalence was 17.3% (Dorsche and Fremmelevholm, 2010). This result prompted action and in 2012 a quality improvement intervention was planned at OUH with the aim of reducing pressure ulcers at the hospital by implementing the recommendations from the Danish Safer Hospital Programme in clinical practice (Dansk Selskab for Patientsikkerhed, 2015a). Background Between 2010 and 2014 there was a focus on prevention of adverse events and patient safety at hospitals in Denmark. The Region of Southern Denmark—one of 5 regional health authorities—and OUH had patient safety strategies, and one of the aims was the elimination of pressure ulcers (> category 0) during hospitalisation in the region by the year 2014 (Odense University Hospital, 2011). The Danish Safer Hospital Programme was introduced in 2010 with bundles of recommendations to improve patient safety in hospitals in various clinical areas. Five hospitals participated in the programme and one of the aims was to prevent pressure ulcers developing in hospitalised patients (Dansk Selskab for Patientsikkerhed, 2015b). The pressure ulcer bundle was incorporated in guidelines for the region but each hospital decided on its own quality improvement method. OUH was not one of the hospitals in the Danish Safer Hospital Programme. The hospital planned a quality improvement intervention by using the recommendations in the pressure ulcer bundle, and used its own quality improvement method. Aim The aim of the quality improvement intervention was to reduce pressure ulcers by 50% at the hospital and have no pressure ulcers at category 3 (full thickness skin loss) or higher. Pressure ulcers were graded according to the European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Ulcer Advisory Panel (NPUAP) and Pan Pacific Pressure Injury Alliance system (EPUAP et al, 2014). Method Inspired by different quality improvement methods, a quality improvement intervention for pressure ulcer prevention was planned at the hospital. A steering committee was established with leading nurses (executive director and three head nurses), a clinical nurse specialist in pressure ulcers and an experienced quality consultant. The elements of this quality improvement intervention are discussed below. Establishment of a pressure ulcer specialist nurse A specialist nurse dedicated to pressure ulcer prevention was established at the hospital for a period of 2 years with funds from TrygFonden, a Danish foundation to promote safety. Together with the steering committee, the specialist nurse had overall responsibility for implementation of the ABSTRACT A pressure ulcer prevalence of 17.3% at Odense University Hospital in Denmark in 2010 prompted action and a quality improvement project was planned. This had two aims: to reduce pressure ulcers at the hospital by 50% and to have no pressure ulcers at or above category 3. An project was established with a steering committee, a pressure ulcer specialist nurse, local dedicated nurses and nurse assistants to implement a pressure ulcer bundle in clinical practice at all departments at the hospital. Six years later the pressure ulcer prevalence was down to approximately 2% and in 2018 only one stage 3 pressure ulcer occurred in the hospital. Pressure ulcer prevention is now incorporated into clinical practice in all departments at the hospital. Key words : Pressure ulcer ■ Prevention ■ Prevalence study ■ Quality improvement ■ Pressure ulcer specialist nurse Aase Fremmelevholm, Wound Specialist Nurse, Department of Plastic Surgery, Odense University Hospital, Odense, Denmark Knaerke Soegaard , Quality Consultant, Department of Plastic Surgery, Odense University Hospital, Odense, Denmark, [email protected] Accepted for publication: December 2018 2019 MA Healthcare Ltd British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT SPB S8 British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT guidelines in clinical practice in all 50 departments at the hospital and for the establishment of an internal organisation to support implementation. The specialist nurse also became a consultant that every nurse or nurse assistant at the hospital could contact for supervision and specialist advice in the prevention and treatment of pressure ulcers and other skin damage, such as incontinence-associated dermatitis. The pressure ulcer nurse was very visible in the departments at OUH and arranged training and bedside instruction in the treatment of pressure ulcers. In 2016, the role of pressure ulcer specialist nurse was made permanent. Steering committee and dedicated local clinicians The steering committee supported the pressure ulcer specialist nurse and encouraged a focus on pressure ulcer prevention among leading nurses at the hospital, for example by initiating audits on documentation of pressure ulcer risk assessment. The committee also supported a theme day on pressure ulcer prevention once a year, as well as establishing an internal structure with a nurse or nurse assistant dedicated to pressure ulcer prevention in all 50 departments at the hospital. These nurses and nurse assistants received one day of training in risk assessment, categorisation of pressure ulcers, and training in the pressure ulcer prevention guidelines from April to July 2012. Along with the leading nurse in their departments, their job was to secure implementation of the guidelines and pressure ulcer prevention by training their colleagues. The pressure ulcer specialist nurse planned meetings every third month for this group of dedicated nurses and nurse assistants to make time for networking, mutual inspiration and discussions of difficulties in implementation. Guidelines for pressure ulcer prevention The pressure ulcer guidelines for the southern Denmark region are based on the Braden scale (1988), the pressure ulcer bundle from the safer hospital programme and the EPUAP guidelines (EPUAP, 2014). The guidelines prescribe early risk assessment of pressure damage and describes prevention methods and how to document observations and preventive actions (Region of Southern Denmark, 2016). The pressure ulcer bundle from the Danish Safer Hospital Programme (Dansk Selskab for Patientsikkerhed, 2015a) states: ■■ All patients must be risk assessed on admission ■■ Patients at risk must be risk assessed every day ■■ Patients at risk must be evaluated for nutritional risk and patients at nutritional risk must have a nutrition plan ■■ Patients at risk must be mobilised as much as possible by repositioning and the use of pressure-distributive aids must be considered. By the end of the Safer Hospital Programme an analysis concluded that the use of the pressure ulcer bundle can reduce pressure ulcers in hospitals by 50% (COWI consulting group, 2014). Adhering to the programme is time- consuming, but time is saved if the patients develop fewer pressure ulcers. Pressure ulcer prevention theme days Every year since 2014 the hospital has arranged a theme day with a focus on pressure ulcer prevention. The programme consists of presentations from different departments at OUH and presentations about clinical topics from the pressure ulcer specialist nurse. Since 2016 colleagues from primary care have been invited to attend, and during the past 3 years there have been presentations from primary care staff. In 2016 a theme day for clinicians from the other five hospitals and primary healthcare areas in the southern Denmark region was held. In 2018, OUH hosted a presentation by Professor Dimitri Beeckman, President-Elect of EPUAP. Monitoring Between 2012 and 2015 the number of patients with documented risk assessments at admission and documented daily skin checks was counted in all departments at OUH. The pressure ulcer incidence was difficult to measure due to a lack of consequent documentation of pressure ulcers. In Denmark there is a system to register adverse events but it is well known that not all adverse events are registered. OUH therefore monitors pressure ulcers in two ways; pressure ulcer prevalence and counting days with no pressure ulcers. Pressure ulcer prevalence The overall pressure ulcer prevalence was examined once a year by the pressure ulcer specialist nurse to see if the prevalence would decrease year on year. Due to difficulties with documentation we decided to measure by prevalence knowing that the measurement method was not ideal. Patients who already had pressure ulcers at admission were counted as well as those whose pressure ulcers developed during hospitalisation. The prevalence study was initially inspired by a method prepared by the Videncenteret for Sårheling—a wound healing knowledge centre at Bispebjerg Hospital in the Capital Region of Denmark (Bermark, 2009). Inpatients were examined using the following inclusion and exclusion criteria: Inclusion criteria ■■ All inpatients of more than 15 years of age in all hospital departments, including intensive care units ■■ All patients who were self-sufficient in their personal care and all patients who were able to mobilise. Exclusion criteria ■■ Patients with dementia, who were unable to co-operate in the examination (this patient group may have an increased risk of pressure ulcers and so undergoes routine risk assessment) ■■ Patients who did not understand the Danish language ■■ Patients who did not wish to participate or where their inclusion was unethical for some reason. The examination was performed by two professionals: the pressure ulcer specialist nurse and the dedicated nurse or nurse assistant from the department. All the patients’ pressure- exposed areas were examined and pressure ulcers was categorised according to the EPUAP classification system (EPUAP, 2014; EPUAP et al, 2014). The data were recorded in a standard form and the patient record was checked to see if there was any documentation of risk assessment in 2019 MA Healthcare Ltd British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT S11 S10 British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT In 2012 and 2013 five category 3 pressure ulcers and one category 4 pressure ulcer were found during prevalence inspections in OUH. In 2016 and 2017 no pressure ulcers of category 3 or above were found during prevalence studies, but in 2018 there was one category 3 pressure ulcer. The departments at OUH have been counting days without pressure ulcers to keep a focus on prevention. On a few occasions during the project a total count of days without pressure ulcers was made for all departments (Figure 2 ) . Discussion The pressure ulcer quality improvement intervention at OUH has involved nurses and nurse assistants (and their leaders) in all departments at the hospital. Activities such as an annual pressure ulcer theme day, audits and prevalence studies, along with celebrations of milestones, have secured a focus on pressure ulcer prevention. The pressure ulcer nurse specialist has supported all the local dedicated nurses and nurse assistants as well as their leaders to secure a focus on pressure ulcer prevention in clinical practice every day. Networking between dedicated clinicians has inspired them and they have learned from each other. This quality improvement intervention showed that some departments were more successful than others. In departments with very ill and dependent patients, the job of pressure ulcer prevention was more difficult. However, staff had specialist knowledge of their own patient categories and their risk factors, which helped in pressure ulcer prevention. The pressure ulcer specialist nurse has been available for all nurses and nurse assistants to contact to secure specialist supervision when needed. This has continued after the intervention ended in 2015 and was made a permanent feature. Conclusion The pressure ulcer project, the introduction of the pressure ulcer specialist nurse role and the various activities have led to a focus on pressure ulcer prevention at OUH. The aim was a 50% reduction in pressure ulcers at the hospital, and the results from the prevalence studies and from counting days without pressure ulcers, suggest that this goal has been surpassed. The managerial support was a major reason for this good result, but the increased focus on the pressure ulcer issue nationally, regionally and locally was also significant. Keeping the prevention of pressure ulcers on the hospital’s agenda in the future would benefit both patient wellbeing and the hospital’s economy. Impact on clinical practice The introduction of a pressure ulcer specialist nurse role has, as a side effect, led to several smaller projects at the hospital such as the following: ■■ A focus on prevention of pressure ulcers in operating rooms at the OUH ■■ A pressure ulcer reduction among patients with a hip fracture from 15% to 4% by using a parking disc (a sign to remind staff when the patient is due to be turned) and an the patient’s file. All occurrences of pressure ulcers were investigated by the pressure ulcer specialist nurse. The departments were notified in advance of the date of examination in order to keep the staff and patients informed. Counting days with no pressure ulcers Manual registration of days without pressure ulcers was established in each department. This method was dependent on the nurses and nurse assistants registering patients with pressure ulcers every day. Every time a department achieved 200, 300, 400 or 500 days without pressure ulcers, they celebrated the achievement (with a large cake). The celebration was shared on the hospital’s internet site with photographs to inspire staff in other departments. The aim of this method was not to compare the individual departments, because they had different patient populations with different risks. Results Prevalence studies have been conducted since 2012 at OUH in Odense and the unit in Svendborg. Figure 1 presents the improvements that have achieved over the subsequent 6 years. KEY POINTS ■ Establishment of a nurse-led project involving a pressure ulcer specialist nurse and dedicated nurses and nurse assistants led to quality improvement in pressure ulcer-related clinical practice in one hospital ■ Ongoing focus on prevention is a way to reduce pressure ulcers in clinical practice ■ Prevalence studies and daily monitoring of pressure ulcers helped clinicians to focus on a topic in a quality improvement project ■ The number of pressure ulcers occurring in a hospital can be reduced by systematic effort and leadership Figure 1. Prevalence of pressure ulcers at Odense University Hospital and Svendborg Hospital, Denmark, 2012 to 2018 2012 2014 2015 2016 2017 2018 15 12 9 6 3 0 OdenseSvendborg Percentage 2019 MA Healthcare Ltd British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT S11 ordinary pillow placed under the patient’s legs to ensure that the heels are not in contact with the surface ■■ Testing dressings for pressure ulcer prevention in cardiac intensive care, resulting in a reduction of 24% ■■ A hospital-based health technology assessment (HTA) carried out within a clinical pilot test area in care of the elderly and orthopaedic units at OUH, where two types of static overlays were tested for 6 months. Incidence of pressure ulcers was investigated before and after the implementation ■■ Presentations by the specialist nurse at several national and international conferences. The pressure ulcer quality improvement project was terminated at the end of 2015, but the work of the pressure ulcer specialist nurse, the local dedicated nurses and nurse assistants continues, as do the annual theme days, prevalence studies and audits. It is important to maintain the results achieved so far and to continue to focus on pressure ulcer prevention. BJN Declaration of interest: none Acknowledgement: the Danish safety foundation ‘TrygFonden’ has contributed to the quality improvement project by providing funds to establish the pressure ulcer specialist nurse role Braden B, Bergstrom N. The Braden scale for predicting pressure sore risk. 1988. http://tinyurl.com/yxdh3pbc (accessed 14 March 2019) Bermark SE. Seks prævalensundersøge lser for tryksår på danske hospitaler. [Six prevalence studies for pressure ulcers in Danish hospitals.] Sår. [Wounds.] 2009; 4:203–210. COWI consulting group. Evaluering af Patientsikkert Sygehus. [Evaluation of the Danish Safer Hospital Program.] Lyndby, Denmark: COWI; 2014 Dansk Selskab for Patientsikkerhed. [Danish Society for Patient Safety]. Patientsikkert Sygehus [Danish Safer Hospital Programme.] 2015a. https://tinyurl.com/y2ancmyb (accessed 14 March 2019) Dansk Selskab for Patientsikkerhed. [Danish Society for Patient Safety.] Tryksårspakken. [The pressure ulcer bundle.] 2015b. https://tinyurl.com/ y25gs3cf (accessed 14 March 2019) Dorsche KM, Fremmelevholm A. Forekomst af decubitus på hospital. Occurrence of pressure ulcers in a hospital. Ugeskrift for læger [Weekly note for Doctors]; 15 March 2010; 601-606 European Pressure Ulcer Advisory Panel. 2014 prevention and treatment of pressure ulcers: clinical practice guidelines. 2014. https://tinyurl.com/yyuxd4wy (accessed 14 March 2019) European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers: quick reference guide. 2nd edn. 2014. http://tinyurl.com/y5uu43ct (accessed 14 March 2019) Odense University Hospital Department of Quality, Research, Innovation and Development. Strategi for patientsikkerhed 2012-2014. [Strategy for patients safety 2012-2014]. Odense: Odense University Hospital; 2011 Posnett J, Franks PJ. The burden of chronic wounds in the UK. Nursing Times 2008; 104(3):44-45 Region of Southern Denmark. Tryksår – forebyggelse [Guideline: pressure ulcer prevention.] Vejle: Region of Southern Denmark; 2016 CPD reflective questions ■ Reflect on whether the method implemented in this project could be used as an inspiration for other quality improvement projects in your area ■ Think about how the establishment of local dedicated nurses and nurse assistants can support quality improvement in clinical practice ■ Think about how quality improvements in clinical practice in your area can be maintained over time Figure 2. Odense University Hospital departments with days without pressure ulcers: March 2015 and December 2017 Number of departments at OUH with days without pressure ulcers: ≥50 to ≥1500 days ≥50 ≥100 ≥200 ≥300 ≥400 ≥500 ≥600 ≥700 ≥800 ≥900 ≤1000 ≤1100 ≤1500 March 2015 December 2017 50 40 30 20 10 0 PRESSURE ULCERS 2019 MA Healthcare Ltd Copyright ofBritish Journal ofNursing isthe property ofMark Allen Publishing Ltdand its content maynotbecopied oremailed tomultiple sitesorposted toalistserv without the copyright holder’sexpresswrittenpermission. However,usersmayprint, download, oremail articles forindividual use.
Literature Evaluation Table In nursing practice, accurate identification and application of research is essential to achieving successful outcomes. The ability to articulate research data and summari
PRESSURE ULCERS British Journal of Nursing 2020, Vol 29, No 12: TISSUE VIABILITY SUPPLEMENT S25 S24 British Journal of Nursing 2020, Vol 29, No 12: TISSUE VIABILITY SUPPLEMENT Static overlays for pressure ulcer prevention: a hospital-based health technology assessment P ressure ulcers (PUs) are a frequently occurring adverse event in hospitals, especially among immobilised patients (Fremmelevholm and Soegaard, 2019). In Denmark, there are no national data for PU prevalence, but studies at four hospitals between 2002 and 2018 showed a PU prevalence of between 14% and 43% (Bermark et al, 2009). A 2007 European study (5947 patients) across 25 hospitals in Belgium, Italy, Portugal, Sweden and the UK showed a PU prevalence of 18.1% among admitted patients (Vanderwee et al, 2007). At Odense University Hospital (OUH), the prevalence is assessed yearly and a successful quality improvement intervention has reduced the PU prevalence from 10% in 2012 to 2% in 2018 (Fremmelevholm and Soegaard, 2019). PUs are painful and have severe consequences for patients as well as the economy. In the UK, PUs have been estimated to cost up to 4% of the annual healthcare budget (Bennett et al, 2004). The annual treatment cost of pressure ulcers in the Danish Healthcare System is estimated to be €174.5 million (£154 million) (Mathiesen et al, 2013) Support surfaces, such as mattresses and overlays, play an important role in PU prevention (European Pressure Ulcer Advisory Panel et al, 2014; Nixon et al, 2019). At OUH, alternating-air mattresses (AAM) are used for patients with a medium to high risk of developing PUs. According to a review of randomised controlled trials (RCTs) there are no differences in PU incidence between static mattresses or overlays and AAM (Chou et al, 2013). Qaseem et al (2015) recommended static mattresses or overlays due to their lower costs. Furthermore, AAM are not preferred by patients owing to the reduced ability to move and noise nuisance (Nixon et al, 2019). The use of AAM was increasing at OUH and, in 2016, the cost of renting AAM was €40 000-48 000 a month. In order to investigate the properties and consequences of implementing static overlays at OUH, a hospital-based health technology assessment (HTA) was conducted. The aim was to investigate the effects of overlays on clinical effectiveness, patient perspectives, and organisational and economic considerations. Owing to confidential information concerning costs of AAM, an economic analysis is not included in this paper. Methods Study design, setting and participants The HTA was based on a literature review and original data from an observational study testing two types of overlays. This article focuses on the observational study. Two types of overlay were tested from August 2017 to January 2018. We used a high-density viscoelastic foam overlay (Tempur – Topper7, TEMPUR-MED, Denmark) and a thermoplastic polyurethane overlay (Stimulite, Zibo Care, Denmark) as alternatives to AAM (Sentry, Hospitech, Denmark). Box 1 g ives examples of comparable overlays. For patients with a medium ABSTRACT Introduction: At Odense University Hospital (OUH) alternating-air mattresses (AAM) are used in the prevention of pressure ulcers (PU); however, static overlays might be more effective and have lower costs. To investigate the properties and consequences of using static overlays for prevention of PU at OUH, a hospital-based health technology assessment (HTA) was conducted. Methods: Two types of static overlays were tested in an observational study and compared with AAM for patients with a medium–high risk of PU in geriatric and orthopaedic wards at OUH. Incidence of PU was investigated 7 months before ( n=720) and 6 months after implementation ( n=837). Staff attitudes were examined in a questionnaire survey ( n=55) and focus group interviews ( n=13). Patients who had tried one of the overlays and the AAM were interviewed ( n=12). Results: No statistical difference in PU incidence was found before and after the implementation of overlays (2.5% before, 2.7% after, P=0.874, n=1557) and no patients lying on overlays developed PU (n=123). Staff had mixed attitudes, but the majority preferred having overlays as an option for their patients. Interviewed patients preferred overlays due to less noise and improved mobility. Conclusion: Both types of overlay are effective in PU prevention. However, overlays introduce challenges for staff and clear guidelines for the selection of support surfaces are needed. Overall, it is recommended that static overlays are considered as an alternative to AAM for PU prevention. Key words : Pressure ulcer ■ Prevention ■ Health technology assessment ■ Static overlay ■ Alternating-air mattresses Mette Boeg Horup , Project Manager, Centre for Innovative Medical Technology, Odense University Hospital, Denmark Knaerke Soegaard , PhD candidate, Nurse, Department of Plastic Surgery, Odense University Hospital, Denmark, [email protected] Tue Kjølhede , Project Manager, Centre for Innovative Medical Technology, Odense University Hospital, Denmark Aase Fremmelevholm , Pressure Ulcer Specialist Nurse, Department of Plastic Surgery, Odense University Hospital, Denmark Kristian Kidholm , Professor, Centre for Innovative Medical Technology, Odense University Hospital, Denmark Accepted for publication: June 2020 2020 MA Healthcare Ltd PRESSURE ULCERS British Journal of Nursing 2020, Vol 29, No 12: TISSUE VIABILITY SUPPLEMENT S25 to high risk of developing PUs, the overlays were placed on a standard viscoelastic foam mattress and tested as a supplement to standard care, which was the use of AAM for patients at medium-high risk for PU and standard mattresses for patients not at risk. Thus, there were three types of mattress available during the test period. The overlays were used in a geriatric ward (46 beds) and an orthopaedic ward (23 beds). Each ward had overlay types available for two periods of 3 months as described in Figure 1 . PU incidence was investigated in both wards for 7 months (January-July 2017) before the test periods. The HTA study had four aspects: clinical effect (PU incidence); organisational aspects (staff attitudes); patient perspectives; and economic consequences. However, only the first three parts are included in this paper owing to confidential information in the economic analysis. Inclusion criteria All patients admitted to the two wards in the 7 months prior to implementation of the static overlays and for 6 months after the implementation were included in the study. During the test period, patients lying on AAM on arrival at the ward were moved to a bed with an overlay. The optimal support surface for each patient was chosen at admission by ward nurses and/or a specialist wound care nurse based on risk score (Braden scale; Halfens et al, 2000) and clinical assessment. Some high-risk patients and patients with a category 4 PU remained on AAM for clinical reasons. Patients with PUs at admission were excluded in both periods. Patients lying on a standard mattress on arrival who were moved to a bed with an overlay in the test period were excluded from the study because overlays were meant to replace AAM rather than standard mattresses. Data sources, variables and analyses Clinical effectiveness A specialist wound care nurse examined all admitted patients on the wards for PUs three times a week during the study period and recorded the type of support surface and whether the patient had developed a PU. The average number of hospital days for patients in the two departments was 6 days, and, with examination three times per week, it was possible to examine all patients at the beginning of their hospitalisation and before discharge. Fisher’s exact test was calculated using the statistical software package SPSSv24 to investigate statistical difference in PU incidence before and after implementation of overlays. Organisational perspectives Staff attitudes were investigated using both a questionnaire survey and semi-structured focus group interviews. ■ Questionnaire : nurses and nurse assistants from the two wards, who had experience with patients lying on an overlay, were invited to participate in the questionnaire survey. The questionnaire was set up using the SurveyXact survey tool and distributed by an email with unique links to the online questionnaire. In order to increase the response rate, three reminders were sent in the first period and two in the second period. We sent 147 questionnaires and Figure 1. Set-up and data collection. The two types of overlays were tested in two different wards in a period of 3 months each. Pressure ulcer incidence was monitored before (7 months) and during the two 3-month test periods. Staff attitude s and patient perspectives were investigated at the end of each test period Set -up Orthopaedic ward Geriatric ward Alternating- air mattress ‘Stimulite’ overlay Tempur overlay ‘Tempur’ overlay ‘Stimulite’ overlay Data collection Clinical effects Incidence of pressure ulcers: all admitted patients were examined by a specialist wound care nurse Organisational aspects: staff attitudes Questionnaire survey: round 1 Questionnaire survey: round 2 Focus group interviews Patient perspectives Interviews: round 2 Interviews: round 2 1 Jan 2017 1 Aug 2017 30 Oct 2017 31 Jan 2018 Implementat ion Before Af ter 7 months 3 months 3 months Box 1. Examples of comparable static viscoelastic foam overlays including those used in the health technology assessment Basic Top: ZiboCare Stimulite: ZiboCare TEMPUR – Topper7: TEMPUR-MED Pentaflex: ArjoHuntleigh 2020 MA Healthcare Ltd PRESSURE ULCERS British Journal of Nursing 2020, Vol 29, No 12: TISSUE VIABILITY SUPPLEMENT S27 S26 British Journal of Nursing 2020, Vol 29, No 12: TISSUE VIABILITY SUPPLEMENT received 55 responses. Using a five-point Likert scale, the respondents were asked to assess: (a) the level of difficulty of different tasks when taking care of patients lying on overlays compared with AAM (ie personal care); (b) their agreement with statements regarding the procedure of selection of support surface and patient comfort; and (c) which of the support surfaces they preferred. Data from the questionnaire survey were analysed using descriptive statistics ■ Focus group interviews: 13 informants (nurses, nurse assistants, physiotherapists, occupational therapists and clinical assistants) were questioned about the same topics, as described above, in four multidisciplinary focus group interviews. The interviews were audio recorded, transcribed (non-verbatim), and synthesised into summaries with themes, including the main points and selected citations. Summaries were sent to all informants for approval. Patient perspectives Patients’ attitudes were investigated in structured in-person interviews by the specialist wound care nurse or an HTA consultant. All patients who had tried both AAM and one overlay, and who were physically and cognitively able were invited to participate. All included patients were aware that they had been lying on both mattresses. Patients were introduced to the investigation and their rights. They were asked which type of support surface they would prefer, followed by questions with defined response categories regarding comfort in relation to softness, noise nuisance, mobility and temperature. Patients also had the opportunity to elaborate on their answers and give further comments. Ethical approval Verbal informed consent was obtained from all individual patients included in interviews. No personally identifiable information was recorded. According to our regional ethics committee, this type of study did not require ethical approval. Results Clinical effectiveness In total, 1557 patients were included in the study: 720 patients in the period before implementation (7 months) and 873 patients during the test period (6 months). Some 123 patients used overlays during the study and no statistical difference in PU incidence was found between the periods before and after the implementation of overlays ( n=1557, P=0.874) and no patients lying on overlays developed PU (n=123) ( Table 1 ). Organisational aspects The total response rate for the staff questionnaire survey was 46% (68/147). Of the 68 respondents, 13 had no experience with the overlays, 15 answered both questionnaires (one for each test period) and 40 answered one questionnaire. Thirteen informants participated in focus group interviews: three nurses, four nurse assistants, two physiotherapists, one occupational therapist and three clinical assistants. Table 2 summarises the main results from the two study parts within the different themes. Patient perspectives In total, 12 patients who had tried both an overlay and AAM were interviewed (5 men, 7 women, aged 51–99 years). All interviewed patients, except one, found the overlays comfortable and none was bothered by the noise. In contrast, some informants mentioned that noise could be bothersome with AAM. Patients answered that it was ‘easy to change position on overlays’ or ‘neither difficult nor easy’, whereas most found it difficult on AAM. With regard to temperature, both AAM and overlays seemed suitable. One patient said: ‘It is easier to move around and it fits me well in regards to softness.’ When asked which type of support surface patients would prefer, all except one preferred overlays. One patient replied: ‘The new mattress is perfect.’ Discussion Our aim was to investigate the properties and consequences of implementing static overlays based on an observational study comparing AAM with two different types of static overlay. The results showed no statistical difference in PU incidence and none of the patients on overlays developed PUs during the study period. Overall, the patients were satisfied with the overlays, whereas staff had mixed attitudes because there was a change in working procedures. During care and repositioning, sliding material must be used under the patients because they lie more heavily on overlays. After use, the rented AAM are simply rolled up and returned for cleaning and preparation by the company, but the purchased overlays must be cleaned and prepared by the hospital staff. The staff said that cleaning of overlays was more time consuming, and the majority found personal care more difficult for patients who were lying on overlays compared with those on AAM. However, they still preferred overlays as an option and thought that they were beneficial for patients. This could possibly be related to the challenges in repositioning experienced with immobile patients. There are many studies on the effect of support surfaces for PU prevention, including several reviews (McInnes et al, 2015; Qaseem et al, 2015; Shi et al, 2018). However, in our literature review, we identified only two studies that compared static overlays with AAM on their effect on PU incidence in hospitals (Andersen et al, 1983; Jiang et Table 1. Incidence of pressure ulcers in the periods before and after implementation of static overlays Support surface Pressure ulcer incidence Standard mattress (n) Alternating- air mattresses (n) Overlay Tempur (n) OverlayStimulite (n) Total * (n) Before implementation (n=729) 1.8% (9) 4.2% (9) — — 2.5% (18) After implementation (n=837) 2.8% (14) 4.2% (9) 0% (0) 0% (0) 2.7% (23) *Fisher’s exact test was calculated in order to investigate statistical difference in pressure ulcer incidence before and after implementation. P=0.874 2020 MA Healthcare Ltd PRESSURE ULCERS British Journal of Nursing 2020, Vol 29, No 12: TISSUE VIABILITY SUPPLEMENT S27 al, 2014). Both studies were RCTs and our results are in alignment with their findings, that is, there was no significant difference in PU incidence between overlays and AAM. However, Andersen et al was published in 1983 and the support surfaces used then may not be comparable with those used in our study. Both RCTs are of low quality based on the Cochrane risk of bias tool (Higgins et al, 2011) due to ‘unclear risk’ for selection bias (randomisation) in Andersen et al (1983) and unclear risk of ‘performance bias’ (blinding) for both studies. McInnes et al (2015) and Qaseem et al (2015) had similar results as described above, but they did not distinguish between mattresses and overlays in the comparison with AAM. McInnes et al (2015) found that the majority of included studies comparing AAM with ‘constant low pressure mattresses’ showed no difference in PU prevention and concluded that it was unclear which type of support surface was most beneficial. Similarly, Qaseem et al (2015) concluded that there is no difference between AAM and ‘advanced static’ support surfaces, but recommended static support surfaces due to lower costs. Shi et al (2018) also concluded that it was uncertain which type of support surface was most effective in preventing PUs and that there was a need for RCTs investigating the effect of static foam surfaces with powered active air surfaces, including AAM. Nixon et al (2019) compared AAM with high-specification foam mattresses in an RCT and reported no significant difference in PU prevention. Based on our results and those from the literature review, there are no clear indications as to which type of support surfaces are most beneficial with respect to PU prevention. Thus, there are no clinical arguments for using AAM rather than overlays in PU prevention, but AAM has been the only option and standard of care for patients at risk of developing PUs at our hospital. Limitations This study was an observational comparative study without randomisation and blinding, which affects the internal validity Table 2. Main results from interviews with staff and the questionnaire survey Theme Staff attitude Training in using the support surfaces Not enough information prior to implementation, more information requested about guidelines for selection of support surface Selection of support surface 25% of respondents disagreed with the statement: ‘I never have doubts about what type of support surface the patient should lie on.’ However, only 13% thought that the guidelines/criteria were unclear Working procedures and application ■ Mixed attitudes towards general application and handling of overlays and for making/preparing beds with overlay ■ Clinical assistants thought that cleaning overlays was more time consuming ■ 67% of respondents thought personal care was more difficult for patients lying on overlays ( n=55) ■ For suitable patients (ie patients who could assist with their own repos itioning), overlays were considered an advantage for mobilisation. For these patients, repositioning and getting in and out of bed was easier. The overlays were also considered to be safer due to their lower height and less slippery surface ■ For immobile patients who could not help with repositioning, it was more difficult to move them on overlays, due to their surfaces. Alternating-air mattresses (AAM) have smooth surfaces and some informants said they could sometimes reposition patients without the use of a transfer slid e sheet Time spent on tasks affected by support surface Informants thought nursing was more time consuming for immobile patients lying on overlays, but unchanged for patients who could assist with their own repositioning Work environment Informants thought immobile patients lying on overlays seemed heavier and more difficult to handle, which could cause long-term physical injuries/discomfort Organisation ■ Overlays should not be used for immobile patients who cannot assist in reposit ioning ■ Results were ambiguous when asking whether the overlays were used as intended. Based on interviews, staff thought that overlays were used for the patients for whom they were intended ■ There may have been patients who were not candidates for AAM, but who would have benefited from an overlay ■ There were challenges with logistics and storage of overlays during the test period that should be solved if overlays were to be implemented after the test period Staff assessment of patient experience ■ 47% of respondents believed that overlays were more comfortable for patients compared with AAM ■ Informants found patients to be pleased with the overlays Satisfaction 71% of respondents preferred to have overlays as an option for their patients; however, they are not suitable for all patients and AAM are still needed KEY POINTS ■ There is a general lack of evidence for choice of mattress for pressure ulcer prevention ■ Overlays are a suitable alternative to alternating air mattresses ■ Overlays were preferred by the patients 2020 MA Healthcare Ltd PRESSURE ULCERS S28 British Journal of Nursing 2020, Vol 29, No 12: TISSUE VIABILITY SUPPLEMENT of the study. For example, there may have been an increased focus on PU prevention for patients on overlays and these patients may have been at less risk of developing PU compared with patients on AAM. It was not possible to investigate this further and adjust for any differences in patient groups because we recorded data for PU incidence only. The small number of participants is a limitation of the study. The staff found overlays more time-consuming to clean and the personal care of patients more difficult compared with the use of AAM. This could have affected their responses. The results are uncertain, but in alignment with the results of other studies. We focused on the use of two types of overlay, but there may be other, more beneficial, alternatives to AAM. Conclusion Despite limitations, the results of the HTA show that overlays are a suitable alternative to AAM for patients with a medium to high risk of developing PUs, since no difference in PU incidence was found and no patients on overlays developed PUs. Furthermore, patients, as well as staff, preferred having overlays as an option. However, the overlays are not suitable for all patients and clear guidelines on the selection of support surfaces are necessary. Organisational challenges, such as more time spent on cleaning, should be taken into consideration before implementation. Further investigation of the economic aspects of using overlays is needed because there could be possible financial benefits.  BJN Declaration of interest: none The interview guide and questionnaire used in the study are available from the corresponding author Andersen KE, Jensen O, Kvorning SA, Bach E. Decubitus prophylaxis: a prospective trial on the efficiency of alternating-pressure air-mattresses and water-mattresses. Acta Derm Venereol. 1983; 63(3):227–230 Bennett G, Dealey C, Posnett J. The cost of pressure ulcers in the UK. Age Ageing. 2004; 33(3):230–235. https://doi.org/10.1093/ageing/afh086 Bermark S, Jensen LB, Krejberg E et al. Seks prævalensundersøgelser for tryksår: øjebliksbilleder fra danske hospitaler. Sår. 2009; 17:203–210 Chou R, Dana T, Bougatsos C et al. Pressure ulcer risk assessment and prevention: a systematic comparative effectiveness review. Ann Intern Med. 2013; 159(1):28–38. https://doi.org/10.7326/0003-4819-159-1-201307020-00006 European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers: quick refe rence guide. 2nd edn. 2014. https://tinyurl.com/v3h44b8 (accessed 10 June 2020) Fremmelevholm A, Soegaard K. Pressure ulcer prevention in hospitals: a successful nurse-led clinical quality improvement intervention. Br J Nurs. 2019; 28(6):S6–S11. https://doi.org/10.12968/bjon.2019.28.6.S6 Halfens RJ, Van Achterberg T, Bal RM. Validity and reliability of the Braden scale and the influence of other risk factors: a multi-centre prospective study. Int J Nurs Stud. 2000; 37(4):313–319. https://doi.org/10.1016/s0020-7489(00)00010-9 Higgins JPT, Altman DG, Gøtzsche PC et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials BMJ 2011; 343:d5928. https://doi.org/10.1136/bmj.d5928 Jiang Q, Li X, Zhang A et al. Multicenter comparison of the efficacy on prevention of pressure ulcer in postoperative patients between two types of pressure-relieving mattresses in China. Int J Clin Exp Med. 2014; 7(9):2820–2827 Mathiesen AS, Norgaard K, Andersen MF, Moller KM, Ehlers LH. Are labour- intensive efforts to prevent pressure ulcers cost-effective? J Med Econ. 2013; 16:1238–1245. https://doi.org/ 10.3111/13696998.2013.832256. McInnes E, Jammali-Blasi A, Bell-Syer SE et al. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev. 2015; (9):CD001735. https://doi.org/ 10.1002/14651858.CD001735.pub5 Nixon J, Brown S, Smith IL et al. Comparing alternating pressure mattresses and high-specification foam mattresses to prevent pressure ulcers in high-risk patients: the PRESSURE 2 RCT. Health Technol Assess. 2019; 23(52):1–176. https://doi.org/10.3310/hta23520 Qaseem A, Mir TP, Starkey M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015; 162(5):359–369. https://doi.org/10.7326/M14-1567 Shi C, Dumville JC, Cullum N. Support surfaces for pressure ulcer prevention: a network meta-analysis. PLoS One. 2018; 13(2):e0192707. https://doi.org/10.1371/journal.pone.0192707 Vanderwee K, Clark M, Dealey C, Gunningberg L, Defloor T. Pressure ulcer prevalence in Europe: a pilot study. J Eval Clin Pract. 2007; 13(2):227–235. https://doi.org/10.1111/j.1365-2753.2006.00684.x CPD reflective questions ■ Does your hospital have clear guidelines on which overlay to choose for your patients? ■ Is your choice of mattress supported by the scientific literature? ■ Could patient and/or staff satisfaction be improved by using an alternative to the current standard of care? 2020 MA Healthcare Ltd Copyright ofBritish Journal ofNursing isthe property ofMark Allen Publishing Ltdand its content maynotbecopied oremailed tomultiple sitesorposted toalistserv without the copyright holder’sexpresswrittenpermission. However,usersmayprint, download, oremail articles forindividual use.
Literature Evaluation Table In nursing practice, accurate identification and application of research is essential to achieving successful outcomes. The ability to articulate research data and summari
Contents lists available atScienceDirect Journal of Tissue Viability journal homepage:www.elsevier.com/locate/jtv Nurses’ knowledge and practice of pressure ulcer prevention and treatment: An observational study Mohammad Y.N. Saleh a,∗ , Panos Papanikolaou b, Omayyah S. Nassar c, Abeer Shahin d, Denis Anthony e aClinical Nursing Department, School of Nursing, The University of Jordan, Amman, JordanbIndependent Investigator of Nursing Issues, 3 Thrush Close Cardi ff, CF3 0PE, UKcMaternal Child Health Department, School of Nursing, The University of Jordan, JordandCommunity Health Nursing Department, School of Nursing, The University of Jordan, JordaneApplied Health Research, School of Healthcare, G20 Baines Wing, University of Leeds, Leeds, LS2 9UT, UK ARTICLE INFO Keywords: Pressure ulcer Knowledge Pressure ulcer prevention Pressure ulcer treatment Jordan ABSTRACT Aims and objectives: To assess nurses’ knowledge on pressure ulcer (PU) prevention and treatment in Jordan, and the frequency of and factors infl uencing nurses’implementation of PU prevention and treatment interventions. Background: Highly educated and experienced nurses can provide eff ective PU care; however, previous studies highlighted poor knowledge and implementation of PU care. Design: A correlational study examining nurses ’knowledge of PU prevention and frequency of PU preventive actions in Jordanian hospitals. Methods: Participants were 377 nurses and 318 patients from 11 hospitals. Data were collected to quantify the frequency of nurses ’implementation of pressure ulcer prevention and treatment interventions for patients suf- fering from PUs and/or at risk of PU development using a self-reported cross-sectional survey and prospective 8- h observation. Results: For observed PU prevention while type of hospital and number of beds in units were signi ficant it is not known without further work if this is replicable. For observed PU treatment, linear regression analysis revealed signi ficant negative beta values for more than 50 beds in clinical unit ( β= −2.49). Conclusion: The study addressed new factors, facilitating the provision of prevention and treatment strategies to PU development, including type of clinical institution and number of beds in clinical unit. Relevance to clinical practice: There is a need to develop training programmes to improve insufficient nurses ’ knowledge and, thus, clinical practices on PU prevention and treatment. These programmes would assist both junior and senior nurses and other key stakeholders (e.g. hospital managers, policy-makers, and educators) to improve the performance of PU services, thus, minimising patient suff ering. 1. Introduction Pressure ulcers (PUs) are a major health problem, resulting in re- duced quality of life [ 1]and demanding resources from healthcare systems worldwide [ 2]. PUs are seen as an outcome of poor-quality nursing care [ 3]; they are largely preventable [ 4] and clinical guide- lines are available to assist clinicians. In 2017, Anthony et al. reported that there were 854 grade 2 –4 PUs in a single year (2015) in Greater Glasgow and Clyde (an area of Scotland with a population of 1.2 mil- lion), of which 48.4% were assessed as avoidable [ 5]. PU rates continue to increase signi ficantly [ 6]in some regions, but not in all. For example, in Germany, total prevalence fell from 12.5% in 2002to 5.0%in2008, probably due to more e ffective PU prevention strategies [ 7]. Differences in PU prevalence among countries may be attributed to di fferences in the risk levels and/or use of di fferent prevention strategies. Halfens et al. [ 8] compared PU prevalence among Austrian, Swiss, and Dutch hospitals. The PU rate was highest among Dutch hospitals which was probably not due to di fferent risk scores as when only at risk patients were considered the rate remained higher. Preventive measures di ffered among the countries and this may be the explanation for di ffering rates. https://doi.org/10.1016/j.jtv.2019.10.005 Received 10 October 2018; Received in revised form 31 July 2019; Accepted 21 October 2019 ∗Corresponding author. E-mail addresses: [email protected] (M.Y.N. Saleh),[email protected] (P. Papanikolaou),[email protected] ,[email protected] (O.S. Nassar), [email protected] ,[email protected] (A. Shahin),[email protected] (D. Anthony). Journal of Tissue Viability 28 (2019) 210–217 0965-206X/ © 2019 Published by Elsevier Ltd on behalf of Tissue Viability Society. T 1.1. Nurses‘knowledge about PU prevention and treatment Nurses ’knowledge about PU prevention and treatment is a pre- requisite to undertake e ffective prevention and therapeutic interven- tions of PU and its complications, which can lead to mortality if not treated e ffectively. Numerous studies on nurses’ knowledge about PU management re- vealed contradictory findings. Nurses ’knowledge about PU prevention is a signi ficant predictor of implementing PU prevention in practice (9). In 2006, Pancorbo-Hidalgo et al. identi fied that about 65% of nurses implemented PU prevention interventions [ 10]. Aslan and Giersbergen [ 11] con firmed that almost 59% of Turkish nurses implemented PU knowledge in clinical practice. Several studies have shown inadequate knowledge about PU pre- vention and treatment, though Demarré et al. [ 12] revealed that knowledge was not a signi ficant independent predictor for applyingPU prevention toat-risk nursing-home residents. Further, a Jordanian study revealed that 73% of nurses had inadequate PU knowledge and skills, leading to ineff ective prevention and implementation plans [ 13]. Saleh et al. [ 14] showed that, although nurses had adequate PU knowledge, their prevention measures were insu fficient. Thus, there is a gap be- tween theory and practice. Several factors in fluencing knowledge about PU prevention and treatment indicated con flicting findings. For example, despite nurses with bachelor degrees having better knowledge on PU prevention, this was not associated with providing PU prevention [ 15]. One study re- vealed that highly educated nurses demonstrated less knowledge than those with baccalaureate degrees [ 16]. Additionally, nurses working in orthopaedic, trauma, and emergency departments lacked knowledge about PU prevention, classi fication, and management [ 17,18]. 1.2. Factors in fluencing nurses ’implementation of PU management Moore and Price [ 19] con firmed that well-educated nurses, having received additional formal training on skin and PU risk assessment, were aware that early actions would reduce the likelihood of PU oc- currence. Insu fficient documentation and training may have impeded their ability to provide e ffective preventive care-plans. Both factors have been repeatedly recognised as important for e ffective nursing [ 20]. Number of unit beds also a ffects PU prevention and practices. For instance, crowding is a common problem in Greek hospitals [ 21]. In Jordan, however, the number of unit beds was not associated with implementing PU prevention and treatment interventions [ 9]. Nurses’ characteristics such as gender, age, and experience may in fluence implementing PU prevention and treatment. There are find- ings such as that male nurses showed better knowledge on PU pre- vention [ 13] that remain to be replicated or substantiated. The litera- ture con firmed no associations with nurses’ knowledge and implementation of PU care [ 9,11]. Although having more than 10 years ’experience was signi ficantly associated with PU prevention knowledge, work experience was not in fluential in practising better PU prevention [ 15]. International PU prevention guidelines recommend using an estab- lished risk assessment scale (RAS) [ 6]. The purpose of a RAS (e.g. the Braden scale) is to guide nurses’ clinical judgement [ 10] to expand the clinical e ffectiveness of PU prevention (e.g. incidence reduction). The predictive capability of nurses’ clinical judgement can be augmented by access to structured PU risk assessment activities [ 22]. This might be expected to improve nurses ’clinical e ffectiveness of PU prevention. RASs, along with advanced PU prevention measures, have been em- ployed recently in Jordan hospitals, which may explain nurses’ lack of PU prevention [ 9]. What is most needed is to explore factors in fluencing PU care, to determine the level of knowledge and observe its implementation in clinical practice [ 19]. Thus, the present study was developed to assess nurses ’knowledge and practice of PU prevention and treatment in Jordan and to observe factors associated with PU care in clinical practice. 2. Materials and methods 2.1. Aims This study aimed to assess: Nurses’ knowledge of pressure ulcer prevention and treatment. Frequency of observed implementation of pressure ulcer prevention and treatment in clinical practice. Factors in fluencing nurses’ implementation of pressure ulcer pre- vention and treatment interventions. 2.2. Study design This is a correlational study examining nurses ’knowledge of PU prevention and frequency of PU preventive actions in Jordanian hos- pitals. First, a self-reported cross-sectional survey was undertaken to assess nurses’ knowledge of PU prevention and treatment. Next, a prospective 8-h observation quanti fied the frequency of nurses ’PU prevention and treatment interventions for patients su ffering from, or at risk of PUs. 2.3. Sample and setting Inclusion criteria were hospitals in Jordan with 200 or more beds and medical-surgical, and critical care units. Eleven hospitals (6 gov- ernment, 2 university, 1 military, and 2 private) met the inclusion criteria [ 23]. From these, a list of all units with potential PU patients, including medical-surgical, and critical care units was obtained from the nursing directors. Three clinical units per hospital were randomly selected (33 in total). All selected units implemented the Braden RAS as a require- ment for hospital accreditation [ 24]. Nurses working in the selected units were surveyed. The sample consisted of registered nurses with baccalaureate and/or 3-year di- ploma, and associate degree nurses (2-year diploma). All participants were involved in direct patient assessment and PU prevention and treatment. Senior nurses were excluded. Observed patients were adults (18 years and older), and having at least a mild risk of developing a pressure ulcer- Braden score ≤17. We also included any patient suf- fering from PU grade 1– 4according to EPUAP-NPUAP guidelines [ 25], who had been admitted to critical care or medical-surgical unit for at least 24 h, regardless of their Braden score. 2.4. Power calculation A power analysis using G*power [ 26] gave a required sample size of128 for an independent groups t-test. This figure used power = 0.80, α = 0.05 (2-tailed) and e ffect size = 0.5 (medium e ffect). A sample of 377 nurses and 318 patients was achieved. 2.5. Measures 2.5.1. Nurse demographics and professional characteristics Nurses ‘ characteristics included gender, age, education, having postgraduate education, experience, hospital type, type of clinical unit number of unit beds, knowledge about PU, having PU training, using PU RAS and PU classi fication system involvement in PU research, and whether they agree with EPUAP-NPUAP’s [ 25]definition of PU. 2.5.2. Patients ’demographics Observed patients ’characteristics included gender, age, hospital M.Y.N. Saleh, et al. Journal of Tissue Viability 28 (2019) 210–217 211 type, length of stay, previous hospitalisation, medical diagnosis, and level of PU risk using the Braden scale. 2.5.3. Nurses‘knowledge and implementation of PU prevention and treatment In the first part of the study a questionnaire collected data about Jordanian nurses ’knowledge and practice of PU prevention and treat- ment, based on previous works [ 9,21, 27] and EPUAP-NPUAP’s PU prevention and treatment recommendations (6, 25). An initial 60-item questionnaire was subjected to validation by researchers and expert nurses (n = 10), assessing comprehensiveness, clarity, avoidance of ambiguity, and content validity. This involved circulating the draft items until there was consensus on content, order, and wording. The questionnaire contained the following subscales: PU prevention: 16 interventions considered e ffective/ine ffective according to EPUAP-NPUAP [ 6,25] guidelines and expert panel. PU treatment: 29 interventions considered e ffective/ine ffective ac- cording to EPUAP-NPUAP [ 6,25] guidelines and expert panel. For each intervention, participants were asked to indicate its degree of appropriateness according to their knowledge (yes = 1/no = 0). Eleven items were reverse-coded ( Appendix 1). The total knowledge index scores were reached by adding positive responses in both sub- scales. Cronbach’s alpha reliability was as follows: total instru- ment = 0.61, prevention knowledge subscale = 0.47, treatment knowledge subscale = 0.62, observed prevention subscale = 0.61, and observed treatment subscale = 0.71. The questionnaire was piloted using a sample of 40 nurses after gaining ethical approval. Thirty-two questionnaires were received. Afterwards, some items were reworded for clarity and the questionnaire was revised to combine similar items and remove misleading or re- peated items. The pilot sample was excluded from the main study. 2.5.4. Observed PU prevention and treatment In the second part of the study, the items assessing nurses’ knowl- edge in the first part were used to formulate an observational checklist to measure nurses’ implementation of prevention and treatment inter- ventions in clinical practice. For each item, the observer assessed nurses ’performance assisting patients with and/or at risk of PU as follows: always = 2, sometimes = 1, never = 0. The Braden scale was used to determine the risk of PU occurrence (cut-o ffscore ≤17). EPUAP-NPUAP’s classi fication system [ 6,25 ] was applied to distinguish those patients with PU. These checklists were assessed through an inter-rater reliability index. Two trained nurses assessed the performance of one nurse caring for a patient with grade 3PU. These nurses showed an almost 0.90 intra-class correlation coef- fi cient in scoring checklist items and were in agreement with the re- searchers’ (Tissue Viability Nurse Specialist) assessment. 2.6. Ethical considerations Ethical approval was sought and granted by the Research and Ethics Committee at the School of Nursing, The University of Jordan, and the Research and Ethics Committee of each participating hospital. Participation was voluntary. The anonymity and con fidentiality of both nurse and patient participants were ensured by assigning identi fication numbers to participants, restricted to the research team. The ques- tionnaire contained detailed information about the study’s objectives, and returned questionnaires implied consent. Written consent was obtained from patients involved in the ob- servation. Patient participants could choose to leave the study at any time, or they could refuse participation and/or inspection for PU de- velopment. 2.7. Data collection 2.7.1. Survey of knowledge A detailed explanation of the study was presented to senior nurses at participating hospitals. A list of available nurses was prepared by se- lected hospitals one day before data collection. Questionnaires were distributed to nurses by the researchers via departmental managers and charge nurses. Each questionnaire had a covering letter explaining the study, its aims, and how to complete and return the form. Self-com- pleted questionnaires were returned in a sealed envelope to the re- searchers. 2.7.2. Observation When the self-reported questionnaires were collected from partici- pants, observational checklists were used to measure nurses’ im- plementation of PU prevention and treatment interventions. The ob- servation procedure was implemented in nursing units that had completed the survey. The 8-h prospective observation of nurses’ per- formance with patients showed that flexibility, consistency, and ade- quacy of PU prevention and treatment interventions were applied in clinical settings. Each nurse participant was observed separately. Observation followed an arranged plan with unannounced visits to participating units. To reduce observational bias, 10 nurses were trained for two weeks on the EPUAP-NPUAP [ 6,25] grading system, Braden scale for PU risk assessment, EPUAP guidelines for PU preven- tion and treatment, and using the observational checklists. Trained nurses reviewed patients’ medical records to document patients ’de- mographic data and identify eligibility. Observed nurses who performed care with patients were aware of the observers ’presence but not their speci fic tasks [ 28]. 2.8. Data analysis Items that were not practice-recommended were reverse-coded ( Appendix 1). Total scores were computed for prevention knowledge, treatment knowledge, observed PU prevention, and observed PU treatment. Dependent variables were observed PU prevention and ob- served PU treatment (both normalised 0 –100). Independent variables were type of clinical unit (medical-surgical or critical care), institution, number of beds in ward/unit, years of experience, basic education, higher education (yes/no), length of time since last attended PU training session, involvement in PU research (yes/no), knowledge sources about PU, using RAS (yes/no), agreement with de finition of PU, PU grading (yes/no), and demographics (gender, age). Also, knowledge of prevention/treatment was calculated (normalised 0 –100). Univariate inferential tests were used to determine variables that may in fluence observed PU prevention/treatment (dependent vari- ables). Both were roughly normally distributed by visual inspection using histograms. Finally, linear regression analysis was employed to show associations of independent variables found to be signi ficant under univariate analysis, on observed implementation of PU preven- tion and PU treatment. Additionally, knowledge of prevention was added as a covariate for observed PU prevention, and knowledge of treatment was added as a covariate for observed PU treatment. Signi ficant results were examined at α= 0.05 (2-tailed) probability, and the beta showed the strength of the relationship between the de- pendent and independent variables. 3. Results 3.1. Descriptive statistics Of 460 questionnaires distributed, 377 were returned (Response rate = 81.9%). In addition, of 360 eligible patients, 318 were observed for PU prevention and treatment intervention (Response rate = 88.3%). Demographic data of nurse participants are presented in Table 1and M.Y.N. Saleh, et al. Journal of Tissue Viability 28 (2019) 210–217 212 observed patients’ characteristics are presented inTable 2. Knowledge sources about PU were largely from formal education or in-service education. Most nurses (89.9%, n = 339) were not involved in research activities on pressure ulcers. Only 34.2% stated using RAS. About 90% of participants (n = 335) agreed on the defi nition of PU and 49.6% acknowledged using the EPUAP-NPUAP classi fication system. Re- garding observed patients, about 168 (52.8%) were aged ≥60 years and most (89.9%, n = 286)had previous hospitalisation. Half had a short length of stay, for 1– 3 days (52.5%, n = 167), and 218 (68.6%) had mild to moderate risk of PU development. Sixty-six percent and 79% of nurse participants disagreed with using ‘doughnuts ’and ‘mas- sage ’, respectively, yet 32% said they always use’doughnuts’to prevent pressure ulcers. The knowledge and observed implementation scores are shown in Tables 3 and 4. Table 5showsknowledge and implementation indices of PU prevention and treatment. Results showed less than satisfactory knowledge on PU prevention and treatment (74.5% and 72.6%respec- tively, where we would hope to have at least 80%) and very inadequate implementation of PU prevention and treatment (49.2% and 44.9%, respectively). 3.2. Univariate analysis Institution was signi ficantly associated with observed prevention and treatment interventions (p = 0.001), with the military hospital having higher implementation than governmental, university, or pri- vate hospitals in both cases. Type of clinical unit, namely critical care, was signi ficant for observed prevention (p = 0.007), but not signi ficant for observed treatment. Gender was not signi ficant for either im- plementations, nor were experience, age, basic education, knowledge sources, last attended PU training, involvement in PU research, agree- ment with PU defi nition or PU classification. Higher education was signi ficant for implementing treatment (p = 0.005), but was not sig- ni ficant for prevention. Using RAS was signi ficant for treatment (p = 0.031), with higher implementation for those employing a RAS. Number of beds was signi ficant for both prevention and treatment (p = 0.001 and p = 0.018), with units having fewer beds experiencing higher implementation than larger units in both cases. 3.3. Regression analysis Linear regression used observed prevention as the dependent vari- able. Independent variables included institution, type of clinical unit, number of beds in unit, and knowledge about PU prevention, all were signi ficant under univariate analysis. All categorical independent vari- ables were dummy coded, except for knowledge of prevention. This gave signi ficant negative beta values for the type of institution (uni- versity and private hospitals) and signi ficant positive association for the number of beds in unit (10 –20 beds) ( Table 6). For observed treatment ( Table 7), linear regression used observed treatment as dependent and independent variables were those sig- ni fi cant under univariate analysis-institution, higher education, using RAS, number of beds in unit, and knowledge about PU treatment. All independent variables were dummy coded, except for treatment knowledge. This gave signi ficant negative beta values for institution (governmental and private hospitals) and also for number of beds in unit (> 50 beds). Table 1 Nurse Participant’s characteristics (N = 377). N% Institution Governmental 133 35.3 University 86 22.8 Private 66 17.5 Military 92 24.4 Unit Medical-surgical 175 46.4 Critical care 202 53.6 Unit Beds M=22 SD = 14 R = 5-64 Less than 10 101 26.8 10 –20 102 27.1 21 –30 53 14.1 31 –40 94 24.9 41 –50 3 0.8 More than 50 16 4.2 Experience in Years Less than 1 year 78 20.7 1–4 140 37.1 5 –10 103 27.3 11 –15 32 8.5 16 –20 14 3.7 More than 20 years 10 2.7 Gender Male 189 50.1 Female 188 49.9 Age (years) M = 27.4 SD = 4.5 R = 21-50 21 –26 207 54.9 27 –32 125 33.2 33 –38 31 8.2 39 –44 12 3.2 45 –50 2 0.5 Basic Education BsC 329 87.3 Diploma 3 years 32 8.5 Associate Degree 2 years 15 4.0 Higher education Yes 63 16.7 No 314 83.3 Source of knowledge University Degree 178 47.2 In service education 43 11.4 Conference attendance 4 1.1 Product Promotion 24 6.4 Degree plus in service education128 34.0 Last attended PU training Less than one year ago 113 30.0 1–2 years 57 15.1 More than 2 years 70 18.6 Never attended 136 36.1 Using RAS Yes 129 34.2 No 248 65.8 Involved in PU research Yes 38 10.1 No 339 89.9 Agreement with PU de finition Disagree 42 11.1 Agree 335 88.9 Availability PU classi fication (Grading) Yes 187 49.6 No 190 50.4 M = Mean, SD=Std. Deviation, R (Range) = Min-Max. Table 2 Observed patient’s characteristics (N = 318). Patient’s Characteristics n (%) Institution Governmental126 (39.6%) University 80 (25.1%) Private 31 (9.7%) Military 81 (25.5%) Gender Male204 (64.1%) Female 114 (35.8%) Age (in years) 18–39 69 (21.7%) 40 –59 81 (25.5%) 60 –69 82 (25.7%) 70 –79 64 (20.1%) 80 –89 18 (5.7%) ≥ 90 4 (1.2%) Length of stay 1 day-3 Days167 (52.5%) 4 days –6 days 83 (26.1%) 1 week –29 days 49 (15.4%) 1 month-6 months 19 (5.9%) > 6 Months 0 (0.0%) Previous hospitalisation Yes286 (89.9%) No 32 (10.1%) Diagnosis Medical-surgical197 (61.9%) Critically ill 121 (38.01%) Level of PU risk using Braden scale ≤9 (Severe risk) 57 (17.9%) 10-12 (High risk) 43 (13.5%) 13-14 (Moderate risk) 61 (19.2%) 15-17 (Mild risk) 157 (49.3%) M.Y.N. Saleh, et al. Journal of Tissue Viability 28 (2019) 210–217 213 Table 3 Assessed level of prevention knowledge and the actual preventive care provided. PU prevention knowledge and implementationPrevention knowledge Prevention Implementation Yes (%) No (%) Never (%) Sometimes (%) Always (%) 1. Assess pressure ulcer using risk assessment scale suchas The Braden scale 71.1 28.9 24.9 54.420.7 2. Inspect and document skin condition on daily basis (basically areas at risk and bony prominences such as the Sacrum) for dryness, cracking, erythema (redness), maceration, Fragility, heat and induration. 90.2 9.8 3.7 92.8 3.5 3. Avoid excessive friction (rubbing) and/or friction over bony prominences in patient’s movements 88.1 11.9 5.0 94.2 0.8 4. Avoid excessive moisture due to incontinence, perspiration, wound drainage and maintain skin clean and dry. 90.5 9.5 0.8 97.9 1.3 5. Assess, support and maintain nutritionally compromised patients.For example, the need for NGT feeding and serum Albumin level. 85.9 14.1 22.3 77.2 0.5 6. Maintain patient’s activity (outside the bed) and mobility (within the bed)according to patient’s health condition 92.3 7.7 21.2 76.4 2.4 7. Reposition those patients at risk frequently and on regular basis (if it is safe to do so) 92.8 7.2 0.0 87.013.0 8. Use pillows, foam wedges to relief pressure over bony prominences such as knees, or heels 91.5 8.5 1.9 95.82.3 9. Use principles of safe manual handling during transfer and/or positioning of the patient 90.5 9.5 0.0 97.82.2 10. For those patients seated on chair, they should not exceed 2 h out of the bed 80.1 19.9 5.9 72.321.8 11. Encourage patients to reposition themselves and redistribute weight every 15 min (if this possible) 81.2 16.2 13.0 49.9 37.1 12. Educate nurses and/or care givers the principles of pressure ulcer prevention 88.1 11.9 10.1 88.51.4 13. aUse skin barrier creams to protect reddened skin 13.3 86.7 2.4 91.06.6 14.aUse alcohol solution on the skin 55.4 44.6 37.6 62.40.0 15.aUse donuts-type devices to relieve pressure on areas at risk 34.0 66.0 15.6 52.531.9 16.aMassage reddened areas and/or bony prominences is helpful in pressureulcer prevention 21.0 79.0 10.1 86.23.7 aReverse-coded items. Table 4 Assessed level of knowledge of implementation and the actual treatment implemented. PU treatment knowledge and implementation Treatment knowledge PU Treatment Implementation Yes (%) No (%) Never (%) Sometimes (%) Always (%) 1. Existence of appropriate pressure ulcer de finition 82.5 17.5 6.1 81.412.5 2. Using valid classi fication system that de fine pressureulcer into four stages (grades) 70.0 30.0 7.5 85.76.8 3. Full assessment and documentation of a pressure ulcer included (location, size, grade, wound bed, exudates, pain, surrounding skin, and undermining) on daily or weekly basis 84.9 15.1 1.6 92.8 5.6 4. Re evaluate a pressureulcer as the patient’s condition deteriorates 85.9 14.1 4.2 93.42.4 5. Performing complete physical examination for those patients who are newly developed pressureulcer 82.8 17.2 11.7 84.1 4.2 6. Assess and manage nutritional needs of patients who developed or at risk of pressure ulcer development suchas food ingestion 84.1 15.9 3.7 94.4 1.9 7. Assess for and manage pain related to pressureulcer development 89.7 10.3 1.9 98.10.0 8. Educate nurses and caregivers on pressure ulcer management 85.9 14.1 1.9 95.82.3 9. Manual repositioning ofthe patient of at least 3 h 83.3 16.7 8.8 91.20.0 10. Using special devices inpatient’s repositioning suchas sliding sheet, sliding board and/or hoist 68.2 31.8 10.1 58.431.5 11. Assess patient’s bed or chair for safety, mobility, and comfortability 88.3 11.7 1.6 96.02.4 12. Avoid positioning of the patient on a developed pressure ulcer 63.7 36.3 22.8 77.20.0 13. Apply pressure ulcer relief, reduction, or redistribution devices such alternating air mattress (bed), low air loss system, foam overlays, gel pads,and/or air fluidized beds 81.4 18.6 2.1 91.2 6.7 14. Debridement (removal of dead tissues) of necrotic tissues using surgical (scalpel), enzymatic agents, and/or hydrocolloid hydrogel dressings 84.1 15.9 1.9 93.9 4.2 15. Clean a pressure ulcer using normal saline 0.9%solution 89.9 10.1 2.1 97.30.6 16. Cover a pressure ulcer with moist primary dressings such as hydrocolloids 76.4 23.6 20.7 77.41.9 17. Wound dressing proto colplanned and supervised by Tissue Viability Nurse Specialist (TVNS) 67.4 32.6 39.6 33.227.2 18. Assess for signs and symptoms of pressure ulcer wound infection such as purulent discharge, odor, pathology findings, and/or osteomyelitis 89.1 10.9 3.2 96.8 0.0 19. Apply aseptic technique (hand washing, sterile dressing) in caring those patients who are having infected pressure ulcer or with signs and symptoms of osteomyelitis 91.8 8.2 1.6 98.4 0.0 20. Collaborate with healthcare professionals to provide adjunctive therapies relevant to pressure ulcer care such as electrotherapy, hyperbaricoxygenation, or laser therapy 60.5 39.5 30.9 43.4 25.7 21. Obtain Tissue culture for infected pressure ulcer 83.2 16.8 26.6 57.815.6 22. aUsing antiseptics frequently to clean pressure ulcer wound suchas iodine povidine, H2O2,chlorohexidine 27.6 72.4 38.0 62 0.0 23. aDry dressing used ona pressure ulcer such as drygauze or iodine soakedgauze 22.5 77.5 30.9 69.10.0 24.aChange dressing on daily basis regardless the condition of the wound bedand findings of wound assessment 24.4 75.6 7.8 92.2 0.0 25. aUse topical antibiotics on pressure ulcer with signs of infection 10.1 89.9 18.6 81.40.0 26. Antibiotics are prescribed according to the results of swab culture in an infected pressure ulcer 88.1 11.9 2.2 96.8 1.0 27. aUse alternative methods in pressure ulcer treatment such as (honey, heat, or other preparations) 57.5 42.5 55.3 22.3 22.4 28.aLeave the necrotic (dead) tissues with nodebridement on ulcers without signs of infection 43.2 56.8 62.8 37.20.0 29.aUse the same type of dressing for all ulcers 36.9 63.1 38.8 61.20.0 aReverse-coded items. M.Y.N. Saleh, et al. Journal of Tissue Viability 28 (2019) 210–217 214 4. DiscussionThe present study assessed nurses ’knowledge and practice of PU prevention and treatment in Jordan and explored factors associated with PU care in clinical practice. Pressure ulcer care was better in the military hospitals, but with only one military hospital included it is di fficult to interpret this result – it may just be that the particular military hospital has high standards not generalizable to other military hospitals. The number of beds in clinical units was only signi ficant for pre- vention interventions for units with 10– 20 beds, neither more nor fewer were signi ficant (though 31– 40 beds approaches signi ficance) and it is possible this result is not replicable. For treatment interventions only beds > 50 was signi ficant. A previous study found no such relation with bed size [ 9]. This may be attributable to limited nursing resources in clinical units with more beds (and far more beds than would be typical in most countries). . Nurses have less than adequate knowledge of PU prevention and very inadequate implementation of PU care. There is a need to increase pressure ulcer training both in nurse education and continuing educa- tion after graduation. Our study revealed that more educated nurses did not provide better PU treatment. However, highly educated nurses were aware that un- dertaking early actions would reduce the likelihood of PU [ 19]. Training and documentation are recognised as being essential for pro- viding PU care [ 20]. A consideration is the mismatch between supply and demand for highly educated nursing services (19). Additionally, anecdotal evidence suggests that more educated nurses undertake less hands-on care. Poor knowledge of managing PU complications by highly educated nurses was evident compared with those holding a baccalaureate degree [ 16]. Additionally, highly educated nurses may have insu fficient clinical experience; in Jordan, many degree-level nurses continue with postgraduate education at the expense of clinical experience. We suggest that the recent use of RASs (the Braden scale) and clinical employability of PU defi nition and PU staging in Jordan may orient nurses to organise clinically e ffective PU prevention plans. Most nurses agreed with the latest defi nition of PU and that using structured RAS was signi ficant for PU treatment. But no predictive value was evident regarding their impact on undertaking e ffective PU prevention and treatment. A higher Braden score may increase use of PU preven- tion and treatment activities, though there is no evidence that using such scales reduces pressure ulcer incidence. In addition, the validity and reliability of frequently used RASs for PU are questionable due to limited evidence regarding their usefulness [ 22]. However, the pre- dictive capability of nurses ’clinical judgement can be augmented through access to structured PU risk assessment activities. Besides, the usefulness of a structured RAS has no clinical signi ficance once the PU has developed [ 29]. Our study found no in fluence of nurses ’demographics (e.g. age, gender) on their likelihood of undertaking PU care activities. The lit- erature suggests that neither demographics nor experience infl uence PU care [ 30]. 4.1. Limitations to the study The observed data on nurses’ knowledge were self-reported. The observation approach was applied to at-risk patients and the PU in- terventions were examined. Yet, the unplanned observations were ex- clusive of the prevention and treatment care provided —not all PU in- terventions provided to at-risk patients could be observed. Further, the 8-hourobservation interval may have missed observing changes on patients ’skin and PU interventions. The questionnaire and its content validity have not been tested other than by its piloting and the team of experts, respectively. Also, familiarity of ward nurses with the investigator may have biased their use of PU management interventions. 5. Conclusions PU treatment is less good in units with > 50 beds which leads one to consider that work load, occupancy rate, availability of resources, and nurse –patient ratios essential to plan e ffective PU care may be di fferent in these units. Additional investigation is required to shed light on the theory –practice gap, perhaps through an experimental approach, to Table 5 Nurses’ knowledge index and implementation index of PU prevention and treatment. Index M SD Min – Max Percentiles 25th 50th 75th Knowledge of PU Prevention 74.5 11.1 31–100 68.7 75.0 81.2 Knowledge of PU treatment 72.6 11.0 38–93 65.5 75.8 79.3 Observed implementation of PU prevention 49.2 8.1 34 –78 43.7 50.0 56.2 Observed implementation of PU treatment 44.9 6.9 29 –64 41.3 43.1 48.2 M = Mean, SD=Std. Deviation. Table 6 Regression analysis of observed PU prevention interventions (obtained from linear regression using enter method). B Std. Error Standardized Beta t P Value a (Constant) 54.3 3.30 16.4 < 0.001 a Knowledge of PU prevention − 0.01 0.04 −0.02 −0.36 0.711 University Hospital − 4.37 1.32 −0.23 −3.31 0.001 a Private Hospital −3.67 1.48 −0.17 −2.57 0.011 a Military Hospital 0.34 1.44 0.01 0.23 0.812 Critical Care unit −1.21 1.33 −0.07 −0.91 0.362 Number of unit beds < 10 1.8 1.55 0.10 1.17 0.240 10 –20 3.7 1.33 0.21 2.77 0.006 a 21–30 2.9 1.59 0.12 1.83 0.06 41 –50 0.93 4.60 0.13 0.202 0.84 > 50 2.0 2.29 0.05 0.874 0.38 aRegression analysis of PU observed prevention intervention final model produced at a = 0.05, F = 3.65, P < 0.001, R 2= 0.32. Table 7 Regression analysis of observed PU treatment interventions (obtained from linear regression using enter method). B Std. Error Standardized Beta t P Value a (Constant) 44.12 2.66 16.57 < 0.001 Knowledge of PU treatment 0.029 0.034 0.045 0.84 0.39 Governmental Hospital - 7.24 1.009 - 0.493 −7.19 < 0.001 a University Hospital − 2.28 1.25 −0.190 −1.899 0.059 Private Hospital −8.51 1.399 −0.422 −6.08 < 0.001 a Having higher education 0.34 1.006 0.018 0.339 0.735 Using RAS 0.41 0.88 0.027 0.46 0.645 Number of unit beds < 10 1.33 1.01 0.084 1.31 0.19 21 –30 0.38 1.26 0.019 0.30 0.76 31 –40 −1.63 1.09 −0.103 −1.49 0.13 41 –50 −0.30 3.78 −0.004 −0.07 0.93 >50 −5.00 2.04 −0.147 −2.49 0.013 a aRegression analysis of observed PU treatment intervention final model produced at a = 0.05, F = 8.801, P < 0.001, R 2= 0.508. M.Y.N. Saleh, et al. Journal of Tissue Viability 28 (2019) 210–217 215 improve the transformation of knowledge into practice. 5.1. Relevance to clinical practiceSigni ficant gaps of knowledge were identi fied on skin assessments, risk assessment procedures, and management strategies regarding nurses' views towards PU care policies. Therefore, there is a clear need to develop training programmes to improve the clinical utility of nurses' knowledge regarding PU prevention and treatment. These training programmes would assist both junior and senior nurses (e.g. nurse managers) and other key stakeholders (e.g. hospital managers, policy- makers, and educators) to improve PU prevention and treatment ser- vices, thus minimising patients ’su ffering. One form of training would be to arrange courses regarding the e ffective management of PU and its complications. At ward level, senior nurses would update junior sta ff, while promoting best practice. Another form would be to introduce a simulation-based training system for di fferent stages of PU manage- ment, such as debridement of a deep ulcer. Regular updates on best practice should be shared among ward sta ff and newcomers to ensure excellent standards are maintained, reducing the theory –practice gap and the time-lag between research findings and implementation. Consequently, the well-being of patients and their families would improve, and there would be long-term cost-savings for healthcare organisations due to reduced patients ’stays. This study's practice implications move beyond the speci fic nursing specialty (i.e. PU management) and are applicable to other specialties. In palliative care, it is imperative to provide lifelong training to nurses to bridge the theory –practice gap and well-recognised strategies ad- dress this issue (e.g. use of a nurse-link) [ 31]. Similar activities help to improve the translation of knowledge into practice in other specialties (e.g. paediatric nursing) and geographical areas (e.g. Pakistan) [ 32]. Funding This research has been funded by Deanship of Scienti fic Research at the University of Jordan. Declaration of competing interest No con flict of interest for any of the authors. Appendix 1. Description of the reverse-coded items used in the analysis Prevention interventions Item no. 13: Use skin barrier creams to protect reddened skin Item no.14: Use alcohol solution on the skin. Item no.15: Use donuts-type devices to relieve pressure on areas at risk. Item no. 16: Massage reddened areas and/or bony prominences is helpful in pressure ulcer prevention. Treatment interventions Item no. 22: Using antiseptics frequently to clean PrU wounds (e.g. iodine providing, H2O2, chlorohexidine). Item no. 23: Dry dressing used on a PrU such as dry gauze or iodine soaked gauze. Item no. 24: Change dressing on daily basis regardless of the condition of the wound-bed and findings of wound assessment. Item no. 25: Use topical antibiotics on PrU with signs of infection Item no. 27: Use alternative methods in PrU treatment such as (honey, heat, or other preparations) Item no. 28: Leave the necrotic (dead) tissues with no debridement on ulcers without signs of infection Item no. 29: Use the same type of dressing for all ulcers. Source: Original items as adapted from the tool (Saleh et al., 2013). References [1] Gorecki C, Brown JM, Nelson EA, et al. Impact of pressure ulcers on quality of life in older people: a systematic review. J Am Geriatr Soc 2009;57:1175 –83 . [2] Posnett J, Gottrup F, Lundgren H, et al. The resource impact of wounds on health- care providers in Europe. J Wound Care 2009;18:154 –61 . [3] Chamanga E, Ward R. Documentation and record-keeping in pressure ulcer man- agement. Nurs Stand 2015;29(36):56 –63. 2015 . [4] Elliott R, McKinley S, Fox V. Quality improvement program to reduce the pre- valence of pressure ulcers in intensive care units. Am J Crit Care 2008;4(17):328 –34 . [5] Anthony D, Hodgson H, Horner J. Reducing avoidable pressure ulcers. Wounds UK, May. 2017. p. 14 –8 . [6] EPUAP and NPUAP. Prevention and treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009 . [7] Lahmann NA, Dassen T, Poehler A, Kottner J. Pressure ulcer prevalence rates from 2002 to 2008 in German long-term care facilities. Aging Clin Exp Res 2010;22:152 –6 . [8] Halfens RJG, Meesterberends E, Nie-visser NC, Lohrmann C, Schönherr S, Meijers JMM, Hahn S, Vangelooven C, Schols JMGA. International prevalence measurement of care problems: results. J Adv Nurs 2013;69:e5 –17 . [9] Saleh M, Al-Hussami M, D Anthony D. Pressure ulcer prevention and treatment knowledge of Jordanian nurses. J Tissue Viability 2013;22(1):1 –11 . [10] Pancorbo-Hidalgo P, García-Fernández FP, López-Medina IM, Alvarez-Nieto C. Risk assessment scales for pressure ulcer prevention: a systematic review. J Adv Nurs 2006;54(1):94 –110 . [11] Aslan A, Giersbergen M. Nurses' attitudes towards pressure ulcer prevention in Turkey. J Tissue Viability 2016;25:66 –73 . [12] Demarré L, Vanderwee K, De floor T, Verhaeghe S, Schoonhoven L, Beeckman D. Pressure ulcers: knowledge and attitude of nurses and nursing assistants in Belgian nursing homes. J Clin Nurs 2012;21:1425 –34. https://doi.org/10.1111/j.1365- 2702.2011.03878.x Accessed February 2016. [13] Qaddumi J, Khawaldeh A. Pressure ulcer prevention knowledge among Jordanian nurses: a cross-sectional study. BMC Nurs 2014;13(1) http://www.biomedcenral.com/1472-6955/13/6 Accessed November, 2015. [14] Saleh M, Anthony D, Parboteeah S. The impact of pressure ulcer risk assessment on patient outcomes among hospitalised patients. J Clin Nurs 2009;18(13):1923 –9 . [15] Nuru N, Zewdu F, Amsalu S, Mehretie Y. Knowledge and practice of nurses towards prevention of pressure ulcer and associated factors in Gondar University Hospital, Northwest Ethiopia. BMC Nurs 2015;14(34):2 –8 . [16] Beeckman D, De floor T, Schoonhoven L, Vanderwee K. Knowledge and attitudes of nurses on pressure ulcer prevention: a cross-sectional multicenter study in Belgian hospitals. Worldviews Evidence-Based Nurs 2011. https://doi.org/10.1111/j.1741- 6787.2011.00217.x Accessed January, 2017. [17] Iranmanesh S, Tafti AA, Rafi ei H, Dehghan M, Razban F. Orthopaedic nurses' knowledge about pressure ulcers in Iran: a cross-sectional study. J Wound Care 2013;22(3):138 –40 . [18] Rafiei H, Esmaeli M, Iranmanesh S, Lalegani H, Safdari H, Hassanpoor A. Knowledge about pressure ulcer prevention, classi fication and management: a survey of registered nurses working with trauma patients in the emergency de- partment. Int. J. Orthop. Trauma. Nurs 2014;18(3):135 –42 . [19] Moore Z, Price P. Nurses' attitudes, behaviors and perceived barriers towards pressure ulcer prevention. J Clin Nurs 2004;13:942 –52 . [20] McDonagh V. Sustaining pressure ulcer prevention in practice. Nurs. Times 2013;109(15):12 –6 . [21] Panagiotopoulou K, Kerr MS. Pressure area care: an exploration of Greek nurses' knowledge and practice. J. Adv. Nurs 2002;40(3):285 –96 . [22] Garcia-Fernandez FP, Pancorbo-Hidalgo PL, Soldevilla AJJ. Predictive capacity of risk assessment scales and clinical judgment for pressure ulcers: a meta-analysis. J Wound, Ostomy Cont Nurs 2014;41(1):24 –34 . [23] Jordan Ministry of Health. Retrieved from http://www.moh.gov.jo/Pages/ viewpage.aspx Accessed April 2015. [24] Health Care Accreditation Council (HCAC). Retrieved from http://hcac.jo/ar-jo/. NQSG Accessed November 2015. [25] EPUAP and NPUAP. Treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009 . [26] Faul F, Erdfelder E, Buchner A, Lang A. Statistical power analysis using G*Power 3.1: test for correlation and regression analysis. Behav Res Methods 2009;41(4):1149 –60 . M.Y.N. Saleh, et al. Journal of Tissue Viability 28 (2019) 210–217 216 [27]Bostrom J, Kenneth H. Sta ffnurse knowledge and perceptions about prevention of pressure sores. Dermatol Nurs 1992;4:365 –78 . [28] Polit Denise F, Tatano Beck Cheryl. Nursing research: generating and assessing evidence for nursing practice. Philadelphia: Wolters Kluwer Health; 2017 . [29] Anthony D, Parboteeah S, Saleh M, Papanikolaou P. Norton, Waterlow and Braden scores: a review of the literature and a comparison between the scores and clinical judgement. J Clin Nurs 2008;17(5):646 –53 . [30] Hulsenboom MA, Bours GJWW, Halfens RJG. Knowledge of pressure ulcer prevention: a cross-sectional and comparative study among nurses. BMC Nurs 2007;6(2). https://doi.org/10.1186/472-6955-6-2 Accessed November, 2015. [31] Ward C, Wright M. Fast-track palliative care training to bridge the theory-practice gap. Nurs. Times 2004;100(12):38 –40 . [32] Essani RR, Ali TS. Knowledge and practice gaps among pediatric nurses at a tertiary care hospital Karachi Pakistan. ISRN. Pediatr 2011. https://doi.org/10.5402/2011/ 460818 Accessed July, 2016. M.Y.N. Saleh, et al. Journal of Tissue Viability 28 (2019) 210–217 217 Literature Evaluation Table In nursing practice, accurate identification and application of research is essential to achieving successful outcomes. The ability to articulate research data and summari 1 Open access Effects of implementing Pressure Ulcer Prevention Practice Guidelines (PUPPG) in the prevention of pressure ulcers among hospitalised elderly patients: a systematic review protocol Amos Wung Buh, 1 Hassan Mahmoud, 2 Wenjun Chen ,3,4 Matthew D F McInnes, 2,5,6 Dean A Fergusson 6 To cite: Wung Buh A, Mahmoud H, Chen W, et al. Effects of implementing Pressure Ulcer Prevention Practice Guidelines (PUPPG) in the prevention of pressure ulcers among hospitalised elderly patients: a systematic review protocol. BMJ Open 2021;11:e043042. doi:10.1136/ bmjopen-2020-043042 ►Prepublication history and additional material for this paper is available online. To view these files, please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjopen- 2020- 043042). AWB and HM contributed equally. AWB and HM are joint first authors. Received 23 November 2020 Revised 08 February 2021 Accepted 17 February 2021 For numbered affiliations see end of article. Correspondence to Wenjun Chen; [email protected] uottawa. ca Protocol © Author(s) (or their employer(s)) 2021. Re- use permitted under CC BY- NC. No commercial re- use. See rights and permissions. Published by BMJ. ABSTRACT Introduction Pressure ulcers are serious and potentially life- threatening problems across all age groups and across all medical specialties and care settings. The hospitalised elderly population is the most common group to develop pressure ulcers. This study aims to systematically review studies implementing pressure ulcer prevention strategies recommended in the Pressure Ulcer Prevention Practice Guidelines for the prevention of pressure ulcers among hospitalised elderly patients globally. Methods and analysis A systematic review of all studies that have assessed the use of pressure ulcer prevention strategies in hospital settings among hospitalised elderly patients shall be conducted. A comprehensive search of all published articles in Medline Ovid, Cumulative Index to Nursing and Allied Health Literature, PubMed, Embase, Cochrane library, Scopus and Web of Science will be done using terms such as pressure ulcers, prevention strategies, elderly patients and hospital. Studies will be screened for eligibility through title, abstract and full text by two independent reviewers. Study quality and risk of bias will be assessed using the Joanna Briggs Institute for Meta- Analysis of Statistics Assessment and Review Instrument. If sufficient data are available, a meta- analysis will be conducted to synthesise the effect size reported as OR with 95% CIs using both fixed and random effect models. I 2 statistics and visual inspection of the forest plots will be used to assess heterogeneity and identify the potential sources of heterogeneity. Publication bias will be assessed by visual inspections of funnel plots and Egger’s test. Ethics and dissemination No formal ethical approval or consent is required as no primary data will be collected. We aim to publish the research findings in a peer- reviewed scientific journal to promote knowledge transfer, as well as in conferences, seminars, congresses or symposia in a traditional manner. PROSPERO registration number CRD42019129088. BACKGROUND Pressure ulcers (PU) also known as pressure injuries are areas of localised damage to the skin and/or underlying structures due to pressure and/or friction and shear. 1 They are serious and potentially life- threatening problems across all age groups from the very young to the very old and across all medical specialties and care settings. 2 It has been documented that hospital admissions due to PU are 75% higher than admissions for any other medical conditions and that, the conse- quences of PU development in hospitalised patients are particularly serious. 2 Patients with hospital admission PU are three times more likely to be discharged to long- term care facilities and mortality of these patients is twice that of patients without hospital admis- sion PU. 3 The cost of treatment of PU is 2.5 times than its prevention, and PU increases the length of stay in the hospital from 4 to Strengths and limitations of this study ►This is a systematic review and meta- analysis of randomised controlled trials. ►This review will be the first to synthesise the ev- idence regarding the effectiveness of guidelines used in pressure ulcer prevention for elderly pa- tients in hospitals and offer the highest level of evidence for informed decisions on use of Pressure Ulcer Prevention Practice Guidelines (PUPPG) in prevention pressure ulcers in the elderly patients in hospital. ►There may be heterogeneity of interventions used on eligible studies and incomplete information reported about the interventions in the literature which could limit our ability to statistically compare the effective- ness of interventions. ►The main limitation of this review might be scarcity of randomised controlled trials on the use of PUPPG for preventing pressure ulcers in elderly patients, publication bias and methodological quality of grey literature that shall be found. Wung BuhfiA, etal. BMJ Open 2021;11:e043042. doi:10.1136/bmjopen-2020-043042 2 Open access 30 days, decreases quality of life, and increases pain, morbidity and mortality. 4 On international level, hospital- acquired PUs (some- times called decubitus ulcers) are very common. 5 Although many of these cases are preventable, their point prevalence in Canadian hospitals for example is measured to be 25.1%. 6 Unfortunately, the high rates of such condi- tion are associated with subsequent high burden on the healthcare system and the national economy considering the high cost of their management, and the frequent occurrence of associated significant morbidity and mortality. 5 According to the Ontario Case Costing Initia- tive database in 2013 using the European Pressure Ulcer Advisory Panel (EPUAP) staging system, it was estimated that the cost of management of stage II ulcer is up to US$40 000 and can reach more than double this price for managing a single case of stage IV ulcer. 7 A good example of the burden that PU add to the national economy was measured in USA; it was estimated that hospital acquired PUs increase the financial expenses on healthcare systems between US$6 and US$15 billion annually. 8 The National Pressure Ulcer Advisory Panel (NPUAP), the EPUAP and the Pan Pacific Pressure Injury Alliance (PPPIA) 9 have defined PU as a ‘lesion or a trauma to the skin and/or underlying tissue usually over a bony promi- nence and is the result of undiminished pressure, or pres- sure combination with shear, friction and moisture’. It is a degenerative progress attributable to biological tissues (skin and underlying tissues) being exposed to pressure and shearing forces. The pressure constrains the proper blood circulation and causes cell death, tissue necrosis and the development of ulcers. 9 While the quality of PU prevention and treatment has increased considerably over the past years, PUs remains a global concern because of its frequency of occurrence and negative consequences for patients and families as well as for the healthcare system. 10 Incidence of PUs for hospitalised patients ranges from 9% to 18%, among which the elderly popu- lation appears to be the most common group to develop the ulcers. 11 At the same time, many elderly patients are more vulnerable to be ‘stuck’ at a certain stage of PU for a long period of time and sometimes for the remainder of their lives. 12 This may result in longer length of hospital stay, heavier burdens for the healthcare system and family members, worst quality of life for elderly patients, which may also influence their mental health such as emotional stability. 13 14 NPUAP, EPUAP and PPPIA 9 developed the Pressure Ulcer Prevention Practice Guideline (PUPPG), which involves a range of evidence- based recommendations for PUs prevention that could be applied by healthcare profes- sionals globally. Frequently used PU prevention strategies recommended in this guideline includes PU risk assess- ment, regular repositioning, prevention management plan, appropriate use of support surfaces and protection, continence management, patient education, skin protec- tion, nutritional assessment and adequate nutrition. 15 It also includes some recommendations specifically for elderly people—‘protect aged skin from skin injury asso- ciated with pressure and shear forces’, taking into consid- eration that an aged person’s skin is vulnerable. 15 A number of studies have been conducted on the implementation of PU prevention strategies among hospitalised patients. One cluster randomised trial conducted in Canada revealed that multidisciplinary PU prevention groups are more cost effective than usual care and yields no significant improvement in the treatment of PUs. 16 Despite the existence of the guidelines on the prevention of PU, their effective utilisation in preventing PUs among hospitalised elderly patients varies in settings and countries. Also, although a number of studies have assessed strategies used in preventing PUs, there appears to be little or no information on systematic reviews that have assessed the effectiveness of guidelines used in PU prevention for elderly patients in hospitals. This study, therefore, aims to systematically review studies imple- menting PU prevention strategies recommended in the PUPPG for the prevention of PUs among hospitalised elderly patients globally. OBJECTIVE The objective of this review is to assess the effectiveness of each of the strategies included in the PUPPG guide- line in reducing the incidence and prevalence of hospital acquired PUs in hospitalised elderly patients in compar - ison to no strategy (usual practice), or other strategies. The review question is: what is the effectiveness of imple- menting each of the PU prevention strategies included in the PUPPG in decreasing the incidence and prevalence of PUs among hospitalised elderly patients compared with no strategies (basic usual care) or different preven- tion strategies? METHODS Study design This will be a systematic review and meta- analysis of published and unpublished studies that have assessed the use of PU prevention strategies in hospital settings among hospitalised elderly patients. The systematic review protocol has been developed and reported following the Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) criteria (see online supple- mental appendix 1). 17 Inclusion criteria Population included This systematic review will focus on studies that involved all vitally stable (not admitted in the intensive care unit) bed ridden hospitalised patients aged 60 or above. Interventions All studies that assessed the effect of PU preventive strat- egies found in the PUPPG, that were implemented on vitally stable bed ridden hospitalised patients aged 60 and Wung BuhfiA, etal. BMJ Open 2021;11:e043042. doi:10.1136/bmjopen-2020-043042 3 Open access above with an aim to decrease the occurrence of PUs, will be included in this review. Interventions will be limited to use of risk assessment, skin assessment, skin care, nutri- tion, position and repositioning, education and training, and medical devices care. Comparator Interventions will be compared with other strategies to identify the most effective among them and/or will also be compared with no interventions (regular basic management). Outcomes In this study, the primary outcome will be directly related to the incidence of the disease among elderly hospitalised patients (incidence shall be considered as the propor - tion of hospitalised patients who developed PUs while in hospital). Included studies must measure study duration related incidence of the disease and/or its point preva- lence and /or stage of PU (severity) as a measure of the effectiveness of the preventive strategies. Types of studies We will focus only on Quantitative studies—experimental and quasi- experimental studies. These might include randomised and non- randomised controlled trials in addition to comparative and before- and- after studies. Language Only studies written in English will be included in this systematic review. SEARCH STRATEGY We will use a three- step strategy to find published and unpublished studies on PUs and their management. First, we will conduct an initial search through the Medline Ovid database using an analysis of text words found in the title and abstract, and the index terms used to describe the article. Second, we will use identified keywords and index terms to search for studies in identified databases. Finally, we will use the reference list of selected studies from the first and second searches to look for additional studies not found in the databases. For this study, we will consider only studies either published or unpublished in English. The databases that shall be searched for this review will include Medline Ovid, Cumulative Index to Nursing and Allied Health Literature, PubMed, Embase, Cochrane library, Scopus and Web of Science. See online supple- mental appendix 2 for the example searching strategy and results in Medline (Ovid). All these databases will provide published studies. To find unpublished studies on our topic, we will use Google, Grey Literature reports and the Centers for Disease Control and Prevention. The keywords we will use for our initial searches in Medline Ovid will include ‘pressure ulcers’, ‘pressure sore’, ‘bed sore’, ‘pressure injuries’, ‘prevention st rate- gies’, ‘elderly patients’ and ‘hospital’. Study screening and selection The titles, abstracts and full text of studies selected for this study will be reviewed by two independent researchers to identify studies that potentially meet the inclusion criteria outlined above. The Covidence software will be used for title, abstract and full- text screening. After importing references and inclusion/exclusion criteria into the Covi- dence software, two independent reviewers will screen titles of included studies according to the eligible criteria. Conflicts between those two reviewers will be resolved through discussion with a third reviewer. The same proce- dures shall be used for abstract screening. Following the abstract screening, full texts of these potentially eligible studies will be retrieved and independently assessed for eligibility by two reviewers. Any disagreement between the two reviewers over the eligibility of a particular study will also be resolved through discussion with the third reviewer. The process of study selection will be reported using the PRISMA flow diagram. 17 Assessment of methodological quality Two independent reviewers will be used to assess the methodological validity of the quantitative papers that will be selected for retrieval prior to their inclusion in the review using standard critical appraisal tools from the Joanna Briggs Institute for Meta- Analysis of Statistics Assessment and Review Instrument (see online supple- mental appendix 3). All disagreement between the two reviewers shall be settled through discussions. Data extraction After screening and selecting studies, key information from those studies will be extracted into an excel sheet for further analysis. We shall use a data extraction tool adapted from the standardised data extraction tool from the Joanna Briggs Institute Meta- Analysis of Statistics Assessment and Review Instrument (JBI- MAStARI). Considering the infor - mation, we will need for the data synthesis of our study, we shall use the JBI- MAStARI to develop a data extraction tool specifically for quantitative research data extraction (see online supplemental appendix 4). The tool will be used to extract: (1) Study characteristics of reviewed papers, such as authors, year of publication, journal; (2) Methods of the study, including study design (randomised control trial (RCT), quasi- RCT, longitudinal, retrospective), research purpose and/or questions; (3) participant characteristics, country where the study took place, setting, population, sample size, age, sex, ethnicity, socioeconomic status and/ or education level; (4) PU prevention strategies used in experimental group and control group (if applicable), (5) outcome measures and results and (6) conclusions of reviewed papers and any comments from reviewers. Two reviewers will independently perform data extraction. Authors of reviewed papers will be contacted in case of any missing details about their studies. Data synthesis A meta‐analysis of outcomes combining various studies included in the review shall be done. We will assess Wung BuhfiA, etal. BMJ Open 2021;11:e043042. doi:10.1136/bmjopen-2020-043042 4 Open access statistical heterogeneity with I 2, which will indicate the percentage of the total variation across studies: 0%–40% low heterogeneity, 30%–60% moderate heterogeneity, 50%–90% may represent substantial heterogeneity and 75%–100% is considerable heterogeneity. If there is a substantial amount of heterogeneity (75%), then sources of heterogeneity will be examined through subgroup and sensitivity analyses. We will also use χ 2 test to test the heterogeneity and consider p<0.05 as statistically signifi- cant. A fixed‐effects model will be selected for significant homogeneous studies; otherwise we will apply a random‐ effects model. All outcomes will be summarised using ORs and 95% CI. An OR <1 will represent a lower rate of outcome among the group of patients who were treated following the guidelines. Publication bias will be assessed by visual inspections of funnel plots and Egger’s test. We will also provide a narrative synthesis of the find- ings from the included studies. The narrative synthesis shall be structured by describing the studies according to the type of intervention used. This will include the three categories of interventions recommend in the PUPPG guideline 9: 1. Prevention of PUs, including risk factors and risk as- sessment, skin and tissue assessment, preventive skin care and emerging therapies for prevention of PUs. 2. Interventions for prevention and treatment of PUs, such as nutrition in PU prevention and treatment, re- positioning and early mobilisation, repositioning to prevent and treat PUs, support surface and medical device- related PUs. 3. Treatment of PUs, for example, assessment of PUs and monitoring of healing, pain assessment and treatment, wound care, assessment and treatment of infection and biofilms, wound dressings for treatment of PUs and surgery for PUs. Results will be presented in tables, figures and graphs, followed by discussion. Publication bias will be assessed in all analyses synthe- sising 10 or more studies to ensure adequate power in the analysis. 18 For investigation of the effect of small studies and publication bias, data from included stud- ies will be entered into a funnel plot asymmetry test if we have at least 10 studies in the meta- analysis. Egger’s statistical test will be implemented using STATA/SE V.13 (StataCorp). The quality of supporting evidence will be assessed by the Grades of Recommendation, Assessment, Development and Evaluation. 19 Patient and public involvement No patient involved. Ethics and dissemination This review will only use published literature and will not recruit participants. Therefore, no formal ethical approval or consent is necessary. It is anticipated that this systematic review will provide a detailed summary of the evidence of the effectiveness of the PUPPG in preventing the occurrence of PUs among elderly patients in hospital. It is also expected that the study will provide recommendations on the best PU preventive strategies applicable in healthcare settings. We aim to publish the research findings in a peer- reviewed scientific journal to promote knowledge transfer, as well as in various media, such as: conferences, seminars, congresses or symposia in a traditional manner. Author affiliations1Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada 2School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada 3School of Nursing, University of Ottawa, Ottawa, Ontario, Canada4Xiangya School of Nursing, Central South University, Changsha, Hunan, China5Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada6Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada Acknowledgements The authors would like to thank Lindsey Sikora (librarian) for counselling in developing the searching strategies. Contributors AWB, HM and WC contributed to the conception of the research question and writing of the protocol. HM, AWB, WC, MDFM and DAF contributed to the development of search strategies, eligibility criteria and methodology for data synthesis. HM, AWB, WC, MDFM and DAF contributed to drafting of the protocol and provided approval for the final version of this protocol. HM, AWB and WC will work in duplicate to screen the titles and abstracts of all the materials obtained using the search strategy to exclude the articles that do not meet the eligibility criteria. HM, AWB and WC will evaluate the potentially eligible studies with the full text and further exclude studies with documentation of the reason for exclusion. All authors will contribute to the bias assessment strategy and data extraction criteria. HM, AWB and WC will independently extract data from the included studies. HM, AWB and WC will analyse the data and draft the manuscript. All authors will read, provide feedback and approve the final manuscript. Funding This work was supported by Hunan Provincial Key Laboratory of Nursing, grant number (2017TP1004), Hunan Provincial Science and Technology Department, China. Competing interests None declared. Patient consent for publication Not required. Provenance and peer review Not commissioned; externally peer reviewed. Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer- reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise. Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non- commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non- commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/. ORCID iDs Wenjun Chen http:// orcid. org/ 0000- 0001- 5398- 8508 Dean A Fergusson http:// orcid. org/ 0000- 0002- 3389- 2485 REFERENCES 1 Stadnyk B, Mordoch E, Martin D. Factors in facilitating an organisational culture to prevent pressure ulcers among older adults in health- care facilities. J Wound Care 2018;27:S4–10. 2 Nursing in Practice. Management of pressure ulcers | nursing in practice. Available: https://www. nursinginpractice. com/ article/ management- pressure- ulcers [Accessed 30 Jan 2019]. 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Cochrane Handbook for systematic reviews of interventions. Available: /handbook/current [Accessed 20 Jul 2020]. 19 Guyatt GH, Oxman AD, Vist GE, et al. Grade: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924–6. Wung BuhfiA, etal. BMJ Open 2021;11:e043042. doi:10.1136/bmjopen-2020-043042 © 2021 Author(s) (or their employer(s)) 2021. Re-use permitted under CCBY-NC. No commercial re-use. See rights and permissions. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is give n, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/. Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License. Literature Evaluation Table In nursing practice, accurate identification and application of research is essential to achieving successful outcomes. The ability to articulate research data and summari Contents lists available atScienceDirect Journal of Tissue Viability journal homepage:www.elsevier.com/locate/jtv Nurses' knowledge and practice of pressure ulcer prevention and treatment: An observational study Mohammad Y.N. Saleh a,∗ , Panos Papanikolaou b, Omayyah S. Nassar c, Abeer Shahin d, Denis Anthony e aClinical Nursing Department, School of Nursing, The University of Jordan, Amman, JordanbIndependent Investigator of Nursing Issues, 3 Thrush Close Cardi ff, CF3 0PE, UKcMaternal Child Health Department, School of Nursing, The University of Jordan, JordandCommunity Health Nursing Department, School of Nursing, The University of Jordan, JordaneApplied Health Research, School of Healthcare, G20 Baines Wing, University of Leeds, Leeds, LS2 9UT, UK ARTICLE INFO Keywords: Pressure ulcer Knowledge Pressure ulcer prevention Pressure ulcer treatment Jordan ABSTRACT Aims and objectives: To assess nurses' knowledge on pressure ulcer (PU) prevention and treatment in Jordan, and the frequency of and factors infl uencing nurses’implementation of PU prevention and treatment interventions. Background: Highly educated and experienced nurses can provide eff ective PU care; however, previous studies highlighted poor knowledge and implementation of PU care. Design: A correlational study examining nurses ’knowledge of PU prevention and frequency of PU preventive actions in Jordanian hospitals. Methods: Participants were 377 nurses and 318 patients from 11 hospitals. Data were collected to quantify the frequency of nurses ’implementation of pressure ulcer prevention and treatment interventions for patients suf- fering from PUs and/or at risk of PU development using a self-reported cross-sectional survey and prospective 8- h observation. Results: For observed PU prevention while type of hospital and number of beds in units were signi ficant it is not known without further work if this is replicable. For observed PU treatment, linear regression analysis revealed signi ficant negative beta values for more than 50 beds in clinical unit ( β= −2.49). Conclusion: The study addressed new factors, facilitating the provision of prevention and treatment strategies to PU development, including type of clinical institution and number of beds in clinical unit. Relevance to clinical practice: There is a need to develop training programmes to improve insufficient nurses ’ knowledge and, thus, clinical practices on PU prevention and treatment. These programmes would assist both junior and senior nurses and other key stakeholders (e.g. hospital managers, policy-makers, and educators) to improve the performance of PU services, thus, minimising patient suff ering. 1. Introduction Pressure ulcers (PUs) are a major health problem, resulting in re- duced quality of life [ 1]and demanding resources from healthcare systems worldwide [ 2]. PUs are seen as an outcome of poor-quality nursing care [ 3]; they are largely preventable [ 4] and clinical guide- lines are available to assist clinicians. In 2017, Anthony et al. reported that there were 854 grade 2 –4 PUs in a single year (2015) in Greater Glasgow and Clyde (an area of Scotland with a population of 1.2 mil- lion), of which 48.4% were assessed as avoidable [ 5]. PU rates continue to increase signi ficantly [ 6]in some regions, but not in all. For example, in Germany, total prevalence fell from 12.5% in 2002to 5.0%in2008, probably due to more e ffective PU prevention strategies [ 7]. Differences in PU prevalence among countries may be attributed to di fferences in the risk levels and/or use of di fferent prevention strategies. Halfens et al. [ 8] compared PU prevalence among Austrian, Swiss, and Dutch hospitals. The PU rate was highest among Dutch hospitals which was probably not due to di fferent risk scores as when only at risk patients were considered the rate remained higher. Preventive measures di ffered among the countries and this may be the explanation for di ffering rates. https://doi.org/10.1016/j.jtv.2019.10.005 Received 10 October 2018; Received in revised form 31 July 2019; Accepted 21 October 2019 ∗Corresponding author. E-mail addresses: [email protected] (M.Y.N. Saleh),[email protected] (P. Papanikolaou),[email protected] ,[email protected] (O.S. Nassar), [email protected] ,[email protected] (A. Shahin),[email protected] (D. Anthony). Journal of Tissue Viability 28 (2019) 210–217 0965-206X/ © 2019 Published by Elsevier Ltd on behalf of Tissue Viability Society. T 1.1. Nurses‘knowledge about PU prevention and treatment Nurses ’knowledge about PU prevention and treatment is a pre- requisite to undertake e ffective prevention and therapeutic interven- tions of PU and its complications, which can lead to mortality if not treated e ffectively. Numerous studies on nurses' knowledge about PU management re- vealed contradictory findings. Nurses ’knowledge about PU prevention is a signi ficant predictor of implementing PU prevention in practice (9). In 2006, Pancorbo-Hidalgo et al. identi fied that about 65% of nurses implemented PU prevention interventions [ 10]. Aslan and Giersbergen [ 11] con firmed that almost 59% of Turkish nurses implemented PU knowledge in clinical practice. Several studies have shown inadequate knowledge about PU pre- vention and treatment, though Demarré et al. [ 12] revealed that knowledge was not a signi ficant independent predictor for applyingPU prevention toat-risk nursing-home residents. Further, a Jordanian study revealed that 73% of nurses had inadequate PU knowledge and skills, leading to ineff ective prevention and implementation plans [ 13]. Saleh et al. [ 14] showed that, although nurses had adequate PU knowledge, their prevention measures were insu fficient. Thus, there is a gap be- tween theory and practice. Several factors in fluencing knowledge about PU prevention and treatment indicated con flicting findings. For example, despite nurses with bachelor degrees having better knowledge on PU prevention, this was not associated with providing PU prevention [ 15]. One study re- vealed that highly educated nurses demonstrated less knowledge than those with baccalaureate degrees [ 16]. Additionally, nurses working in orthopaedic, trauma, and emergency departments lacked knowledge about PU prevention, classi fication, and management [ 17,18]. 1.2. Factors in fluencing nurses ’implementation of PU management Moore and Price [ 19] con firmed that well-educated nurses, having received additional formal training on skin and PU risk assessment, were aware that early actions would reduce the likelihood of PU oc- currence. Insu fficient documentation and training may have impeded their ability to provide e ffective preventive care-plans. Both factors have been repeatedly recognised as important for e ffective nursing [ 20]. Number of unit beds also a ffects PU prevention and practices. For instance, crowding is a common problem in Greek hospitals [ 21]. In Jordan, however, the number of unit beds was not associated with implementing PU prevention and treatment interventions [ 9]. Nurses' characteristics such as gender, age, and experience may in fluence implementing PU prevention and treatment. There are find- ings such as that male nurses showed better knowledge on PU pre- vention [ 13] that remain to be replicated or substantiated. The litera- ture con firmed no associations with nurses' knowledge and implementation of PU care [ 9,11]. Although having more than 10 years ’experience was signi ficantly associated with PU prevention knowledge, work experience was not in fluential in practising better PU prevention [ 15]. International PU prevention guidelines recommend using an estab- lished risk assessment scale (RAS) [ 6]. The purpose of a RAS (e.g. the Braden scale) is to guide nurses' clinical judgement [ 10] to expand the clinical e ffectiveness of PU prevention (e.g. incidence reduction). The predictive capability of nurses' clinical judgement can be augmented by access to structured PU risk assessment activities [ 22]. This might be expected to improve nurses ’clinical e ffectiveness of PU prevention. RASs, along with advanced PU prevention measures, have been em- ployed recently in Jordan hospitals, which may explain nurses' lack of PU prevention [ 9]. What is most needed is to explore factors in fluencing PU care, to determine the level of knowledge and observe its implementation in clinical practice [ 19]. Thus, the present study was developed to assess nurses ’knowledge and practice of PU prevention and treatment in Jordan and to observe factors associated with PU care in clinical practice. 2. Materials and methods 2.1. Aims This study aimed to assess: Nurses' knowledge of pressure ulcer prevention and treatment. Frequency of observed implementation of pressure ulcer prevention and treatment in clinical practice. Factors in fluencing nurses' implementation of pressure ulcer pre- vention and treatment interventions. 2.2. Study design This is a correlational study examining nurses ’knowledge of PU prevention and frequency of PU preventive actions in Jordanian hos- pitals. First, a self-reported cross-sectional survey was undertaken to assess nurses' knowledge of PU prevention and treatment. Next, a prospective 8-h observation quanti fied the frequency of nurses ’PU prevention and treatment interventions for patients su ffering from, or at risk of PUs. 2.3. Sample and setting Inclusion criteria were hospitals in Jordan with 200 or more beds and medical-surgical, and critical care units. Eleven hospitals (6 gov- ernment, 2 university, 1 military, and 2 private) met the inclusion criteria [ 23]. From these, a list of all units with potential PU patients, including medical-surgical, and critical care units was obtained from the nursing directors. Three clinical units per hospital were randomly selected (33 in total). All selected units implemented the Braden RAS as a require- ment for hospital accreditation [ 24]. Nurses working in the selected units were surveyed. The sample consisted of registered nurses with baccalaureate and/or 3-year di- ploma, and associate degree nurses (2-year diploma). All participants were involved in direct patient assessment and PU prevention and treatment. Senior nurses were excluded. Observed patients were adults (18 years and older), and having at least a mild risk of developing a pressure ulcer- Braden score ≤17. We also included any patient suf- fering from PU grade 1– 4according to EPUAP-NPUAP guidelines [ 25], who had been admitted to critical care or medical-surgical unit for at least 24 h, regardless of their Braden score. 2.4. Power calculation A power analysis using G*power [ 26] gave a required sample size of128 for an independent groups t-test. This figure used power = 0.80, α = 0.05 (2-tailed) and e ffect size = 0.5 (medium e ffect). A sample of 377 nurses and 318 patients was achieved. 2.5. Measures 2.5.1. Nurse demographics and professional characteristics Nurses ' characteristics included gender, age, education, having postgraduate education, experience, hospital type, type of clinical unit number of unit beds, knowledge about PU, having PU training, using PU RAS and PU classi fication system involvement in PU research, and whether they agree with EPUAP-NPUAP's [ 25]definition of PU. 2.5.2. Patients ’demographics Observed patients ’characteristics included gender, age, hospital M.Y.N. Saleh, et al. Journal of Tissue Viability 28 (2019) 210–217 211 type, length of stay, previous hospitalisation, medical diagnosis, and level of PU risk using the Braden scale. 2.5.3. Nurses‘knowledge and implementation of PU prevention and treatment In the first part of the study a questionnaire collected data about Jordanian nurses ’knowledge and practice of PU prevention and treat- ment, based on previous works [ 9,21, 27] and EPUAP-NPUAP's PU prevention and treatment recommendations (6, 25). An initial 60-item questionnaire was subjected to validation by researchers and expert nurses (n = 10), assessing comprehensiveness, clarity, avoidance of ambiguity, and content validity. This involved circulating the draft items until there was consensus on content, order, and wording. The questionnaire contained the following subscales: PU prevention: 16 interventions considered e ffective/ine ffective according to EPUAP-NPUAP [ 6,25] guidelines and expert panel. PU treatment: 29 interventions considered e ffective/ine ffective ac- cording to EPUAP-NPUAP [ 6,25] guidelines and expert panel. For each intervention, participants were asked to indicate its degree of appropriateness according to their knowledge (yes = 1/no = 0). Eleven items were reverse-coded ( Appendix 1). The total knowledge index scores were reached by adding positive responses in both sub- scales. Cronbach's alpha reliability was as follows: total instru- ment = 0.61, prevention knowledge subscale = 0.47, treatment knowledge subscale = 0.62, observed prevention subscale = 0.61, and observed treatment subscale = 0.71. The questionnaire was piloted using a sample of 40 nurses after gaining ethical approval. Thirty-two questionnaires were received. Afterwards, some items were reworded for clarity and the questionnaire was revised to combine similar items and remove misleading or re- peated items. The pilot sample was excluded from the main study. 2.5.4. Observed PU prevention and treatment In the second part of the study, the items assessing nurses' knowl- edge in the first part were used to formulate an observational checklist to measure nurses' implementation of prevention and treatment inter- ventions in clinical practice. For each item, the observer assessed nurses ’performance assisting patients with and/or at risk of PU as follows: always = 2, sometimes = 1, never = 0. The Braden scale was used to determine the risk of PU occurrence (cut-o ffscore ≤17). EPUAP-NPUAP's classi fication system [ 6,25 ] was applied to distinguish those patients with PU. These checklists were assessed through an inter-rater reliability index. Two trained nurses assessed the performance of one nurse caring for a patient with grade 3PU. These nurses showed an almost 0.90 intra-class correlation coef- fi cient in scoring checklist items and were in agreement with the re- searchers' (Tissue Viability Nurse Specialist) assessment. 2.6. Ethical considerations Ethical approval was sought and granted by the Research and Ethics Committee at the School of Nursing, The University of Jordan, and the Research and Ethics Committee of each participating hospital. Participation was voluntary. The anonymity and con fidentiality of both nurse and patient participants were ensured by assigning identi fication numbers to participants, restricted to the research team. The ques- tionnaire contained detailed information about the study's objectives, and returned questionnaires implied consent. Written consent was obtained from patients involved in the ob- servation. Patient participants could choose to leave the study at any time, or they could refuse participation and/or inspection for PU de- velopment. 2.7. Data collection 2.7.1. Survey of knowledge A detailed explanation of the study was presented to senior nurses at participating hospitals. A list of available nurses was prepared by se- lected hospitals one day before data collection. Questionnaires were distributed to nurses by the researchers via departmental managers and charge nurses. Each questionnaire had a covering letter explaining the study, its aims, and how to complete and return the form. Self-com- pleted questionnaires were returned in a sealed envelope to the re- searchers. 2.7.2. Observation When the self-reported questionnaires were collected from partici- pants, observational checklists were used to measure nurses' im- plementation of PU prevention and treatment interventions. The ob- servation procedure was implemented in nursing units that had completed the survey. The 8-h prospective observation of nurses' per- formance with patients showed that flexibility, consistency, and ade- quacy of PU prevention and treatment interventions were applied in clinical settings. Each nurse participant was observed separately. Observation followed an arranged plan with unannounced visits to participating units. To reduce observational bias, 10 nurses were trained for two weeks on the EPUAP-NPUAP [ 6,25] grading system, Braden scale for PU risk assessment, EPUAP guidelines for PU preven- tion and treatment, and using the observational checklists. Trained nurses reviewed patients' medical records to document patients ’de- mographic data and identify eligibility. Observed nurses who performed care with patients were aware of the observers ’presence but not their speci fic tasks [ 28]. 2.8. Data analysis Items that were not practice-recommended were reverse-coded ( Appendix 1). Total scores were computed for prevention knowledge, treatment knowledge, observed PU prevention, and observed PU treatment. Dependent variables were observed PU prevention and ob- served PU treatment (both normalised 0 –100). Independent variables were type of clinical unit (medical-surgical or critical care), institution, number of beds in ward/unit, years of experience, basic education, higher education (yes/no), length of time since last attended PU training session, involvement in PU research (yes/no), knowledge sources about PU, using RAS (yes/no), agreement with de finition of PU, PU grading (yes/no), and demographics (gender, age). Also, knowledge of prevention/treatment was calculated (normalised 0 –100). Univariate inferential tests were used to determine variables that may in fluence observed PU prevention/treatment (dependent vari- ables). Both were roughly normally distributed by visual inspection using histograms. Finally, linear regression analysis was employed to show associations of independent variables found to be signi ficant under univariate analysis, on observed implementation of PU preven- tion and PU treatment. Additionally, knowledge of prevention was added as a covariate for observed PU prevention, and knowledge of treatment was added as a covariate for observed PU treatment. Signi ficant results were examined at α= 0.05 (2-tailed) probability, and the beta showed the strength of the relationship between the de- pendent and independent variables. 3. Results 3.1. Descriptive statistics Of 460 questionnaires distributed, 377 were returned (Response rate = 81.9%). In addition, of 360 eligible patients, 318 were observed for PU prevention and treatment intervention (Response rate = 88.3%). Demographic data of nurse participants are presented in Table 1and M.Y.N. Saleh, et al. Journal of Tissue Viability 28 (2019) 210–217 212 observed patients' characteristics are presented inTable 2. Knowledge sources about PU were largely from formal education or in-service education. Most nurses (89.9%, n = 339) were not involved in research activities on pressure ulcers. Only 34.2% stated using RAS. About 90% of participants (n = 335) agreed on the defi nition of PU and 49.6% acknowledged using the EPUAP-NPUAP classi fication system. Re- garding observed patients, about 168 (52.8%) were aged ≥60 years and most (89.9%, n = 286)had previous hospitalisation. Half had a short length of stay, for 1– 3 days (52.5%, n = 167), and 218 (68.6%) had mild to moderate risk of PU development. Sixty-six percent and 79% of nurse participants disagreed with using ‘doughnuts ’and ‘mas- sage ’, respectively, yet 32% said they always use'doughnuts'to prevent pressure ulcers. The knowledge and observed implementation scores are shown in Tables 3 and 4. Table 5showsknowledge and implementation indices of PU prevention and treatment. Results showed less than satisfactory knowledge on PU prevention and treatment (74.5% and 72.6%respec- tively, where we would hope to have at least 80%) and very inadequate implementation of PU prevention and treatment (49.2% and 44.9%, respectively). 3.2. Univariate analysis Institution was signi ficantly associated with observed prevention and treatment interventions (p = 0.001), with the military hospital having higher implementation than governmental, university, or pri- vate hospitals in both cases. Type of clinical unit, namely critical care, was signi ficant for observed prevention (p = 0.007), but not signi ficant for observed treatment. Gender was not signi ficant for either im- plementations, nor were experience, age, basic education, knowledge sources, last attended PU training, involvement in PU research, agree- ment with PU defi nition or PU classification. Higher education was signi ficant for implementing treatment (p = 0.005), but was not sig- ni ficant for prevention. Using RAS was signi ficant for treatment (p = 0.031), with higher implementation for those employing a RAS. Number of beds was signi ficant for both prevention and treatment (p = 0.001 and p = 0.018), with units having fewer beds experiencing higher implementation than larger units in both cases. 3.3. Regression analysis Linear regression used observed prevention as the dependent vari- able. Independent variables included institution, type of clinical unit, number of beds in unit, and knowledge about PU prevention, all were signi ficant under univariate analysis. All categorical independent vari- ables were dummy coded, except for knowledge of prevention. This gave signi ficant negative beta values for the type of institution (uni- versity and private hospitals) and signi ficant positive association for the number of beds in unit (10 –20 beds) ( Table 6). For observed treatment ( Table 7), linear regression used observed treatment as dependent and independent variables were those sig- ni fi cant under univariate analysis-institution, higher education, using RAS, number of beds in unit, and knowledge about PU treatment. All independent variables were dummy coded, except for treatment knowledge. This gave signi ficant negative beta values for institution (governmental and private hospitals) and also for number of beds in unit (> 50 beds). Table 1 Nurse Participant’s characteristics (N = 377). N% Institution Governmental 133 35.3 University 86 22.8 Private 66 17.5 Military 92 24.4 Unit Medical-surgical 175 46.4 Critical care 202 53.6 Unit Beds M=22 SD = 14 R = 5-64 Less than 10 101 26.8 10 –20 102 27.1 21 –30 53 14.1 31 –40 94 24.9 41 –50 3 0.8 More than 50 16 4.2 Experience in Years Less than 1 year 78 20.7 1–4 140 37.1 5 –10 103 27.3 11 –15 32 8.5 16 –20 14 3.7 More than 20 years 10 2.7 Gender Male 189 50.1 Female 188 49.9 Age (years) M = 27.4 SD = 4.5 R = 21-50 21 –26 207 54.9 27 –32 125 33.2 33 –38 31 8.2 39 –44 12 3.2 45 –50 2 0.5 Basic Education BsC 329 87.3 Diploma 3 years 32 8.5 Associate Degree 2 years 15 4.0 Higher education Yes 63 16.7 No 314 83.3 Source of knowledge University Degree 178 47.2 In service education 43 11.4 Conference attendance 4 1.1 Product Promotion 24 6.4 Degree plus in service education128 34.0 Last attended PU training Less than one year ago 113 30.0 1–2 years 57 15.1 More than 2 years 70 18.6 Never attended 136 36.1 Using RAS Yes 129 34.2 No 248 65.8 Involved in PU research Yes 38 10.1 No 339 89.9 Agreement with PU de finition Disagree 42 11.1 Agree 335 88.9 Availability PU classi fication (Grading) Yes 187 49.6 No 190 50.4 M = Mean, SD=Std. Deviation, R (Range) = Min-Max. Table 2 Observed patient’s characteristics (N = 318). Patient’s Characteristics n (%) Institution Governmental126 (39.6%) University 80 (25.1%) Private 31 (9.7%) Military 81 (25.5%) Gender Male204 (64.1%) Female 114 (35.8%) Age (in years) 18–39 69 (21.7%) 40 –59 81 (25.5%) 60 –69 82 (25.7%) 70 –79 64 (20.1%) 80 –89 18 (5.7%) ≥ 90 4 (1.2%) Length of stay 1 day-3 Days167 (52.5%) 4 days –6 days 83 (26.1%) 1 week –29 days 49 (15.4%) 1 month-6 months 19 (5.9%) > 6 Months 0 (0.0%) Previous hospitalisation Yes286 (89.9%) No 32 (10.1%) Diagnosis Medical-surgical197 (61.9%) Critically ill 121 (38.01%) Level of PU risk using Braden scale ≤9 (Severe risk) 57 (17.9%) 10-12 (High risk) 43 (13.5%) 13-14 (Moderate risk) 61 (19.2%) 15-17 (Mild risk) 157 (49.3%) M.Y.N. Saleh, et al. Journal of Tissue Viability 28 (2019) 210–217 213 Table 3 Assessed level of prevention knowledge and the actual preventive care provided. PU prevention knowledge and implementationPrevention knowledge Prevention Implementation Yes (%) No (%) Never (%) Sometimes (%) Always (%) 1. Assess pressure ulcer using risk assessment scale suchas The Braden scale 71.1 28.9 24.9 54.420.7 2. Inspect and document skin condition on daily basis (basically areas at risk and bony prominences such as the Sacrum) for dryness, cracking, erythema (redness), maceration, Fragility, heat and induration. 90.2 9.8 3.7 92.8 3.5 3. Avoid excessive friction (rubbing) and/or friction over bony prominences in patient’s movements 88.1 11.9 5.0 94.2 0.8 4. Avoid excessive moisture due to incontinence, perspiration, wound drainage and maintain skin clean and dry. 90.5 9.5 0.8 97.9 1.3 5. Assess, support and maintain nutritionally compromised patients.For example, the need for NGT feeding and serum Albumin level. 85.9 14.1 22.3 77.2 0.5 6. Maintain patient’s activity (outside the bed) and mobility (within the bed)according to patient’s health condition 92.3 7.7 21.2 76.4 2.4 7. Reposition those patients at risk frequently and on regular basis (if it is safe to do so) 92.8 7.2 0.0 87.013.0 8. Use pillows, foam wedges to relief pressure over bony prominences such as knees, or heels 91.5 8.5 1.9 95.82.3 9. Use principles of safe manual handling during transfer and/or positioning of the patient 90.5 9.5 0.0 97.82.2 10. For those patients seated on chair, they should not exceed 2 h out of the bed 80.1 19.9 5.9 72.321.8 11. Encourage patients to reposition themselves and redistribute weight every 15 min (if this possible) 81.2 16.2 13.0 49.9 37.1 12. Educate nurses and/or care givers the principles of pressure ulcer prevention 88.1 11.9 10.1 88.51.4 13. aUse skin barrier creams to protect reddened skin 13.3 86.7 2.4 91.06.6 14.aUse alcohol solution on the skin 55.4 44.6 37.6 62.40.0 15.aUse donuts-type devices to relieve pressure on areas at risk 34.0 66.0 15.6 52.531.9 16.aMassage reddened areas and/or bony prominences is helpful in pressureulcer prevention 21.0 79.0 10.1 86.23.7 aReverse-coded items. Table 4 Assessed level of knowledge of implementation and the actual treatment implemented. PU treatment knowledge and implementation Treatment knowledge PU Treatment Implementation Yes (%) No (%) Never (%) Sometimes (%) Always (%) 1. Existence of appropriate pressure ulcer de finition 82.5 17.5 6.1 81.412.5 2. Using valid classi fication system that de fine pressureulcer into four stages (grades) 70.0 30.0 7.5 85.76.8 3. Full assessment and documentation of a pressure ulcer included (location, size, grade, wound bed, exudates, pain, surrounding skin, and undermining) on daily or weekly basis 84.9 15.1 1.6 92.8 5.6 4. Re evaluate a pressureulcer as the patient’s condition deteriorates 85.9 14.1 4.2 93.42.4 5. Performing complete physical examination for those patients who are newly developed pressureulcer 82.8 17.2 11.7 84.1 4.2 6. Assess and manage nutritional needs of patients who developed or at risk of pressure ulcer development suchas food ingestion 84.1 15.9 3.7 94.4 1.9 7. Assess for and manage pain related to pressureulcer development 89.7 10.3 1.9 98.10.0 8. Educate nurses and caregivers on pressure ulcer management 85.9 14.1 1.9 95.82.3 9. Manual repositioning ofthe patient of at least 3 h 83.3 16.7 8.8 91.20.0 10. Using special devices inpatient’s repositioning suchas sliding sheet, sliding board and/or hoist 68.2 31.8 10.1 58.431.5 11. Assess patient’s bed or chair for safety, mobility, and comfortability 88.3 11.7 1.6 96.02.4 12. Avoid positioning of the patient on a developed pressure ulcer 63.7 36.3 22.8 77.20.0 13. Apply pressure ulcer relief, reduction, or redistribution devices such alternating air mattress (bed), low air loss system, foam overlays, gel pads,and/or air fluidized beds 81.4 18.6 2.1 91.2 6.7 14. Debridement (removal of dead tissues) of necrotic tissues using surgical (scalpel), enzymatic agents, and/or hydrocolloid hydrogel dressings 84.1 15.9 1.9 93.9 4.2 15. Clean a pressure ulcer using normal saline 0.9%solution 89.9 10.1 2.1 97.30.6 16. Cover a pressure ulcer with moist primary dressings such as hydrocolloids 76.4 23.6 20.7 77.41.9 17. Wound dressing proto colplanned and supervised by Tissue Viability Nurse Specialist (TVNS) 67.4 32.6 39.6 33.227.2 18. Assess for signs and symptoms of pressure ulcer wound infection such as purulent discharge, odor, pathology findings, and/or osteomyelitis 89.1 10.9 3.2 96.8 0.0 19. Apply aseptic technique (hand washing, sterile dressing) in caring those patients who are having infected pressure ulcer or with signs and symptoms of osteomyelitis 91.8 8.2 1.6 98.4 0.0 20. Collaborate with healthcare professionals to provide adjunctive therapies relevant to pressure ulcer care such as electrotherapy, hyperbaricoxygenation, or laser therapy 60.5 39.5 30.9 43.4 25.7 21. Obtain Tissue culture for infected pressure ulcer 83.2 16.8 26.6 57.815.6 22. aUsing antiseptics frequently to clean pressure ulcer wound suchas iodine povidine, H2O2,chlorohexidine 27.6 72.4 38.0 62 0.0 23. aDry dressing used ona pressure ulcer such as drygauze or iodine soakedgauze 22.5 77.5 30.9 69.10.0 24.aChange dressing on daily basis regardless the condition of the wound bedand findings of wound assessment 24.4 75.6 7.8 92.2 0.0 25. aUse topical antibiotics on pressure ulcer with signs of infection 10.1 89.9 18.6 81.40.0 26. Antibiotics are prescribed according to the results of swab culture in an infected pressure ulcer 88.1 11.9 2.2 96.8 1.0 27. aUse alternative methods in pressure ulcer treatment such as (honey, heat, or other preparations) 57.5 42.5 55.3 22.3 22.4 28.aLeave the necrotic (dead) tissues with nodebridement on ulcers without signs of infection 43.2 56.8 62.8 37.20.0 29.aUse the same type of dressing for all ulcers 36.9 63.1 38.8 61.20.0 aReverse-coded items. M.Y.N. Saleh, et al. Journal of Tissue Viability 28 (2019) 210–217 214 4. DiscussionThe present study assessed nurses ’knowledge and practice of PU prevention and treatment in Jordan and explored factors associated with PU care in clinical practice. Pressure ulcer care was better in the military hospitals, but with only one military hospital included it is di fficult to interpret this result – it may just be that the particular military hospital has high standards not generalizable to other military hospitals. The number of beds in clinical units was only signi ficant for pre- vention interventions for units with 10– 20 beds, neither more nor fewer were signi ficant (though 31– 40 beds approaches signi ficance) and it is possible this result is not replicable. For treatment interventions only beds > 50 was signi ficant. A previous study found no such relation with bed size [ 9]. This may be attributable to limited nursing resources in clinical units with more beds (and far more beds than would be typical in most countries). . Nurses have less than adequate knowledge of PU prevention and very inadequate implementation of PU care. There is a need to increase pressure ulcer training both in nurse education and continuing educa- tion after graduation. Our study revealed that more educated nurses did not provide better PU treatment. However, highly educated nurses were aware that un- dertaking early actions would reduce the likelihood of PU [ 19]. Training and documentation are recognised as being essential for pro- viding PU care [ 20]. A consideration is the mismatch between supply and demand for highly educated nursing services (19). Additionally, anecdotal evidence suggests that more educated nurses undertake less hands-on care. Poor knowledge of managing PU complications by highly educated nurses was evident compared with those holding a baccalaureate degree [ 16]. Additionally, highly educated nurses may have insu fficient clinical experience; in Jordan, many degree-level nurses continue with postgraduate education at the expense of clinical experience. We suggest that the recent use of RASs (the Braden scale) and clinical employability of PU defi nition and PU staging in Jordan may orient nurses to organise clinically e ffective PU prevention plans. Most nurses agreed with the latest defi nition of PU and that using structured RAS was signi ficant for PU treatment. But no predictive value was evident regarding their impact on undertaking e ffective PU prevention and treatment. A higher Braden score may increase use of PU preven- tion and treatment activities, though there is no evidence that using such scales reduces pressure ulcer incidence. In addition, the validity and reliability of frequently used RASs for PU are questionable due to limited evidence regarding their usefulness [ 22]. However, the pre- dictive capability of nurses ’clinical judgement can be augmented through access to structured PU risk assessment activities. Besides, the usefulness of a structured RAS has no clinical signi ficance once the PU has developed [ 29]. Our study found no in fluence of nurses ’demographics (e.g. age, gender) on their likelihood of undertaking PU care activities. The lit- erature suggests that neither demographics nor experience infl uence PU care [ 30]. 4.1. Limitations to the study The observed data on nurses’ knowledge were self-reported. The observation approach was applied to at-risk patients and the PU in- terventions were examined. Yet, the unplanned observations were ex- clusive of the prevention and treatment care provided —not all PU in- terventions provided to at-risk patients could be observed. Further, the 8-hourobservation interval may have missed observing changes on patients ’skin and PU interventions. The questionnaire and its content validity have not been tested other than by its piloting and the team of experts, respectively. Also, familiarity of ward nurses with the investigator may have biased their use of PU management interventions. 5. Conclusions PU treatment is less good in units with > 50 beds which leads one to consider that work load, occupancy rate, availability of resources, and nurse –patient ratios essential to plan e ffective PU care may be di fferent in these units. Additional investigation is required to shed light on the theory –practice gap, perhaps through an experimental approach, to Table 5 Nurses’ knowledge index and implementation index of PU prevention and treatment. Index M SD Min – Max Percentiles 25th 50th 75th Knowledge of PU Prevention 74.5 11.1 31–100 68.7 75.0 81.2 Knowledge of PU treatment 72.6 11.0 38–93 65.5 75.8 79.3 Observed implementation of PU prevention 49.2 8.1 34 –78 43.7 50.0 56.2 Observed implementation of PU treatment 44.9 6.9 29 –64 41.3 43.1 48.2 M = Mean, SD=Std. Deviation. Table 6 Regression analysis of observed PU prevention interventions (obtained from linear regression using enter method). B Std. Error Standardized Beta t P Value a (Constant) 54.3 3.30 16.4 < 0.001 a Knowledge of PU prevention − 0.01 0.04 −0.02 −0.36 0.711 University Hospital − 4.37 1.32 −0.23 −3.31 0.001 a Private Hospital −3.67 1.48 −0.17 −2.57 0.011 a Military Hospital 0.34 1.44 0.01 0.23 0.812 Critical Care unit −1.21 1.33 −0.07 −0.91 0.362 Number of unit beds < 10 1.8 1.55 0.10 1.17 0.240 10 –20 3.7 1.33 0.21 2.77 0.006 a 21–30 2.9 1.59 0.12 1.83 0.06 41 –50 0.93 4.60 0.13 0.202 0.84 > 50 2.0 2.29 0.05 0.874 0.38 aRegression analysis of PU observed prevention intervention final model produced at a = 0.05, F = 3.65, P < 0.001, R 2= 0.32. Table 7 Regression analysis of observed PU treatment interventions (obtained from linear regression using enter method). B Std. Error Standardized Beta t P Value a (Constant) 44.12 2.66 16.57 < 0.001 Knowledge of PU treatment 0.029 0.034 0.045 0.84 0.39 Governmental Hospital - 7.24 1.009 - 0.493 −7.19 < 0.001 a University Hospital − 2.28 1.25 −0.190 −1.899 0.059 Private Hospital −8.51 1.399 −0.422 −6.08 < 0.001 a Having higher education 0.34 1.006 0.018 0.339 0.735 Using RAS 0.41 0.88 0.027 0.46 0.645 Number of unit beds < 10 1.33 1.01 0.084 1.31 0.19 21 –30 0.38 1.26 0.019 0.30 0.76 31 –40 −1.63 1.09 −0.103 −1.49 0.13 41 –50 −0.30 3.78 −0.004 −0.07 0.93 >50 −5.00 2.04 −0.147 −2.49 0.013 a aRegression analysis of observed PU treatment intervention final model produced at a = 0.05, F = 8.801, P < 0.001, R 2= 0.508. M.Y.N. Saleh, et al. Journal of Tissue Viability 28 (2019) 210–217 215 improve the transformation of knowledge into practice. 5.1. Relevance to clinical practiceSigni ficant gaps of knowledge were identi fied on skin assessments, risk assessment procedures, and management strategies regarding nurses' views towards PU care policies. Therefore, there is a clear need to develop training programmes to improve the clinical utility of nurses' knowledge regarding PU prevention and treatment. These training programmes would assist both junior and senior nurses (e.g. nurse managers) and other key stakeholders (e.g. hospital managers, policy- makers, and educators) to improve PU prevention and treatment ser- vices, thus minimising patients ’su ffering. One form of training would be to arrange courses regarding the e ffective management of PU and its complications. At ward level, senior nurses would update junior sta ff, while promoting best practice. Another form would be to introduce a simulation-based training system for di fferent stages of PU manage- ment, such as debridement of a deep ulcer. Regular updates on best practice should be shared among ward sta ff and newcomers to ensure excellent standards are maintained, reducing the theory –practice gap and the time-lag between research findings and implementation. Consequently, the well-being of patients and their families would improve, and there would be long-term cost-savings for healthcare organisations due to reduced patients ’stays. This study's practice implications move beyond the speci fic nursing specialty (i.e. PU management) and are applicable to other specialties. In palliative care, it is imperative to provide lifelong training to nurses to bridge the theory –practice gap and well-recognised strategies ad- dress this issue (e.g. use of a nurse-link) [ 31]. Similar activities help to improve the translation of knowledge into practice in other specialties (e.g. paediatric nursing) and geographical areas (e.g. Pakistan) [ 32]. Funding This research has been funded by Deanship of Scienti fic Research at the University of Jordan. Declaration of competing interest No con flict of interest for any of the authors. Appendix 1. Description of the reverse-coded items used in the analysis Prevention interventions Item no. 13: Use skin barrier creams to protect reddened skin Item no.14: Use alcohol solution on the skin. Item no.15: Use donuts-type devices to relieve pressure on areas at risk. Item no. 16: Massage reddened areas and/or bony prominences is helpful in pressure ulcer prevention. Treatment interventions Item no. 22: Using antiseptics frequently to clean PrU wounds (e.g. iodine providing, H2O2, chlorohexidine). Item no. 23: Dry dressing used on a PrU such as dry gauze or iodine soaked gauze. Item no. 24: Change dressing on daily basis regardless of the condition of the wound-bed and findings of wound assessment. Item no. 25: Use topical antibiotics on PrU with signs of infection Item no. 27: Use alternative methods in PrU treatment such as (honey, heat, or other preparations) Item no. 28: Leave the necrotic (dead) tissues with no debridement on ulcers without signs of infection Item no. 29: Use the same type of dressing for all ulcers. Source: Original items as adapted from the tool (Saleh et al., 2013). References [1] Gorecki C, Brown JM, Nelson EA, et al. Impact of pressure ulcers on quality of life in older people: a systematic review. J Am Geriatr Soc 2009;57:1175 –83 . [2] Posnett J, Gottrup F, Lundgren H, et al. The resource impact of wounds on health- care providers in Europe. J Wound Care 2009;18:154 –61 . [3] Chamanga E, Ward R. Documentation and record-keeping in pressure ulcer man- agement. Nurs Stand 2015;29(36):56 –63. 2015 . [4] Elliott R, McKinley S, Fox V. Quality improvement program to reduce the pre- valence of pressure ulcers in intensive care units. 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Statistical power analysis using G*Power 3.1: test for correlation and regression analysis. Behav Res Methods 2009;41(4):1149 –60 . M.Y.N. Saleh, et al. Journal of Tissue Viability 28 (2019) 210–217 216 [27]Bostrom J, Kenneth H. Sta ffnurse knowledge and perceptions about prevention of pressure sores. Dermatol Nurs 1992;4:365 –78 . [28] Polit Denise F, Tatano Beck Cheryl. Nursing research: generating and assessing evidence for nursing practice. Philadelphia: Wolters Kluwer Health; 2017 . [29] Anthony D, Parboteeah S, Saleh M, Papanikolaou P. Norton, Waterlow and Braden scores: a review of the literature and a comparison between the scores and clinical judgement. J Clin Nurs 2008;17(5):646 –53 . [30] Hulsenboom MA, Bours GJWW, Halfens RJG. Knowledge of pressure ulcer prevention: a cross-sectional and comparative study among nurses. BMC Nurs 2007;6(2). https://doi.org/10.1186/472-6955-6-2 Accessed November, 2015. [31] Ward C, Wright M. Fast-track palliative care training to bridge the theory-practice gap. Nurs. Times 2004;100(12):38 –40 . [32] Essani RR, Ali TS. Knowledge and practice gaps among pediatric nurses at a tertiary care hospital Karachi Pakistan. ISRN. Pediatr 2011. https://doi.org/10.5402/2011/ 460818 Accessed July, 2016. M.Y.N. Saleh, et al. Journal of Tissue Viability 28 (2019) 210–217 217 Literature Evaluation Table In nursing practice, accurate identification and application of research is essential to achieving successful outcomes. The ability to articulate research data and summari Literature Evaluation Table Student Name: Change Topic (2-3 sentences): Criteria Article 1 Article 2 Article 3 Article 4 Author, Journal (Peer-Reviewed), and Permalink or Working Link to Access Article Article Title and Year Published Research Questions (Qualitative)/Hypothesis (Quantitative) Purposes/Aim of Study Design (Type of Quantitative, or Type of Qualitative) Setting/Sample Methods: Intervention/Instruments Analysis Key Findings Recommendations Explanation of How the Article Supports EBP/Capstone Project Criteria Article 5 Article 6 Article 7 Article 8 Author, Journal (Peer-Reviewed), and Permalink or Working Link to Access Article Article Title and Year Published Research Questions (Qualitative)/Hypothesis (Quantitative) Purposes/Aim of Study Design (Type of Quantitative, or Type of Qualitative) Setting/Sample Methods: Intervention/Instruments Analysis Key Findings Recommendations Explanation of How the Article Supports EBP/Capstone

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