NURSES' KNOW=
LEDGE
ABOUT THE PRESSURE INJURY PROTOCOL IN A PRIVATE AND ACCREDITED HOSPITAL
Vanessa Leal de Lima de Moura[1]
* Francisco José Koller[2]
* Aline Renata dos Santos[3] Josemar Batista[4]
* Vanes=
sa
de Fátima Burdzinski[5]
ABSTRACT
Objective: To investigate the knowledge=
of
nurses regarding the use of the pressure injury protocol instituted in a private a=
nd accredited hospital. Methodology: Research wit=
h quantitative and cross-sectional approach, carried ou=
t in a
private and internationall=
y
certified hospital, locate=
d
in the city of Curitiba, State of Paraná, Brazi=
l.
Data collection occurred
through the use of a questionnaire elaborated by the researchers themselves and applied to 27 nurses during November 2020. Results: There was a prevalence of participation of
nurses working in intensiv=
e
care units (n=3D8;29.63%), and in hospitalization
units (n=3D5; 18.52%). Regarding the use of the=
protocol for prevention and clas=
sification
of pressure injury established by the research
hospital, 16 nurses use it (59.26%) and 21 (77.78%) are able
to apply the Braden=
scale daily. Regarding the standardize=
d
dressings in the institution through the protocol, 14 (51.85%) of the nurses feel
secure for their indicatio=
n
and use and 13 (48.15%) do not feel secure. Nine nurses reported participating in the dressing committee (33.33%). Conclusion: The data revealed the use of the Braden
scale daily by nurses, low participation
of professionals in the committee of dressings and incipience =
regarding the knowledge of nurses in relation
to the protocol.
Keywords: Pressure Injury;
Quality of Health Care; Nursing Care; Nursing Evaluation; Patient
Safety.
Palavras
Chave: Lesão=
por
Pressão; Qualidade da Assistência à Saúde; Cuidados de Enfermagem; Avaliaçã=
o em
Enfermagem; Segurança do Paciente.
INTRODUCTION
Pressure Injury (PI) can be defined as damage caused to the skin and=
/or
underlying soft tissue resulting from an intense and/or prolonged pressure =
or a
force combined with shear, and can be classified as stage I, II, III, IV and
non-stateable and its classification will depend on characteristics such as
size and depth(1). The
incidence of this disease is a critical problem in hospital care, which aff=
ects
bedridden patients with impaired physical mobility, due to the clinical
picture, the therapeutic proposal, the use of devices, the use of health
technologies, the time of hospitalization of the patient and its clinical
evolution(2).
The occurrence of PI in hospitalized patients results in reduced qua=
lity
of life, increased length of hospital stay and c=
osts
for the health service and a higher incidence of infections related to heal=
th
care(3). A systematic literature review with analysis of 32 stud=
ies
and whose objective was to evaluate the direct cost of dressings in the
treatment of PI showed that the cost of treating these lesions was higher t=
han
with prevention. Among the most expensive forms of treatment are for PI sta=
ges
III and IV located in the sacral region(4). In this
sense, there is a proportional relationship between the costs for treatment=
and
the stages of PI, the more severe the injury, the greater the financial
expenditure(5).
To reduce the incidence of PI, it is necessary to adopt measures
prescribed by the multidisciplinary team, associated with the theory to
practice, such as nutritional assessment of the patient, planned reposition=
ing
with greater frequency of the patient (change of decubitus), reduction of s=
kin
exposure to moisture and pressure points, application of transparent film in
bony prominences and evaluation of the risk of PI development by the Braden
Scale(6). This scale assesses the risks in hospitalized patients,
using six criteria (sensory perception, skin moisture, activity, mobility,
nutrition, friction and shear). It is recommended that the health team be u=
sed
to patients hospitalized daily to assist nurses in clinical reasoning to
perform nursing care planning(7).
In the meantime, the importance of nurses in constantly seeking sour=
ces
of knowledge to update their practices in order to enhance the prevention a=
nd
treatment of PI is highlighted, and thus be able to effectively implement
measures that identify factors that contribute to the emergence of this
disease, in maintaining the integrity of the skin, and to increase the quality of care in the institu=
tion
that operates, since the incidence of PI reflects negatively for the
institution and generates an increase in the workload to be performed by the
nursing team(8).
The identification of the risks of PI performed by nurses and
implementation of prevention measures provides health gains regarding costs=
and
quality in the care provided(2). The nursing team's
support for the PI prevention protocol contributes positively to the low in=
jury
rate(9). It is emphasized that the PI protocol is one=
of
the strategies for implementing the National Patient Safety Program, which =
aims
to improve actions to qualify health care, aimed at patient safety, thus
reducing, to an acceptable minimum, the risk of unnecessary damage to the
individual during care(10).
For the nursing team to enjoy a good understanding of prevention practices and PI protocol and to perform the actions well, it is essential = to participate in the training of their team, in monitoring and continuous evaluation of the work performed; therefore, health education should be par= t of daily planning to standardize the conduct of professionals(11).<= o:p>
In view of the above, this study aimed to investigate the knowledge =
of
nurses regarding the use of the pressure injury protocol instituted in a
private and accredited hospital.
METHODS
This is a cross-sectional research with a quantitative approach, con=
ducted
from November 5 to 30, 2020, in a private hospital with 82 beds, providing
medium and high complexity care services, certified internationally with the
title Qmentum International Accreditation Program and that of surgical revi=
ew
corporation (certification focused on bariatric surgery), located in the ci=
ty of
Curitiba, State of Paraná, Brazil.
The research hospital applies the skin care protocol, which addresses
the prevention and treatment of PI, built based on national and internation=
al
literature. It was implemented by the nursing management and verified by the
skin committee, and its last update occurred in 2019. Its objective is to perform preventive and
systematized measures aimed at maintaining the integrity of the hospitalized
patient's skin. The protocol addresses injury prevention, eligibility, prev=
entive
measures, skin evaluation steps and treatment, being available for consulta=
tion
in a printed and digital form to all professionals.
The target population of the study consisted of 43 nurses. Inclusion
criteria were nurses with a time of work in the institution of more than 90
days, who have already fulfilled the period of experience on the date of da=
ta
collection, with availability and interest in participating in the research,
and the one with due signature in the Free and Informed Consent Form -FICF.
Nurses on vacation, medical leave or maternity were excluded.
After applying these crite=
ria,
the non-probabilistic and convenience sample consisted of 27 nurses.
The instrument used for data collection wa=
s a
questionnaire elaborated by the researchers themselves, composed in two par=
ts:
the first with the identification of the participant (age, gender, working =
time
in the nursing area, academic training, training in PI, participation in the
committee of hospital dressings and working time in the hospital) and the
second part composed of nine closed questions regarding the classification =
and
prevention of PI. The questionnaire was applied to nurses through =
the
digital platform Google Forms to be answered individually, after reading and
signing the Informed Consent. The data were transcribed by automatically
exporting Google Forms to Microsoft Office Excel 2016® Software for descriptive statistical analy=
sis
(absolute and relative frequency of questions). The research was approve=
d by
the Ethics and Research Committee of the Paraná Institute of Otorhinolaryng=
ology
under Opinion N 4,349,300.
RESULTS
Of the 27 (62.79%) nurses participating, 21
(77.78%) were female and 6 (22.22%) were male. Eight nurses were admitted to
the hospital in the last 12 months (29.63%). There was a prevalence of
professionals in the Intensive Care Unit (n=3D8;29.63%) followed by the
hospitalization ward (n=3D5;18.52%). The time of work in the nursing area w=
as
between six and eleven years old (n=3D10;37.04%) and from zero to five
(n=3D8;29.63%) according to Table 1.
Table 1=
-
Demographic and work profile of hospital nurses.
|
DESCRIPTION |
n |
% |
|
|
Gender |
|||
|
Female |
21 |
77.78 |
|
|
Male |
6 |
22.22 |
|
|
Age group (years) |
|||
|
20├ 25 |
1 |
3.7 |
|
|
26├ 31 |
10 |
37.04 |
|
|
32├ 37 |
7 |
25.93 |
|
|
38├ 43 |
7 |
25.93 |
|
|
44├ 49 |
1 |
3.7 |
|
|
50├ 55 |
1 |
3.7 |
|
|
Year of Admission |
|||
|
2007 |
2 |
7.41 |
|
|
2009 |
2 |
7.41 |
|
|
2011 |
1 |
3.7 |
|
|
2013 |
2 |
7.41 |
|
|
2014 |
2 |
7.41 |
|
|
2015 |
1 |
3.7 |
|
|
2016 |
2 |
7.41 |
|
|
2018 |
1 |
3.7 |
|
|
2019 |
6 |
22.22 |
|
|
2020 |
8 |
29.63 |
|
|
Sector of Operation |
|||
|
8 |
29.63 |
|
|
Inpatient Ward=
|
5 |
18.52 |
|
|
Ready RoSocor<=
span
lang=3DEN-US style=3D'font-size:12.0pt;font-family:"Times New Roman",seri=
f;
mso-fareast-font-family:"Times New Roman";mso-ansi-language:EN-US;mso-far=
east-language:
PT-BR'> |
5 |
18.52 |
|
|
*Rest taker/Vacation taker |
3 |
11.11 |
|
|
Surgical Center |
2 |
7.41 |
|
|
Administrative Sector=
|
2 |
7.41 |
|
|
Hospital Infection
Control |
1 |
3.7 |
|
|
Diagnosis and treatme=
nt |
1 |
3.7 |
|
|
Time Shift |
|||
|
19:00 h - 07:00 h |
7 |
25.94 |
|
|
13:00 h - 19:00 h |
4 |
14.81 |
|
|
07:00 h - 17:00 h |
4 |
14.81 |
|
|
*Rest taker/Vacation taker |
4 |
14.81 |
|
|
07:00 h - 13:00 h |
3 |
11.11 |
|
|
07:00 h - 15:12 h |
2 |
7.41 |
|
|
08:00 h - 16:12 h |
2 |
7.41 |
|
|
08:00 h - 18:00 h |
1 |
3.7 |
|
|
|||
|
00 - 05 |
8 |
29.63 |
|
|
06 - 11 |
10 |
37.04 |
|
|
12 - 17 |
5 |
18.52 |
|
|
18 - 23 |
4 |
14.81 |
|
|
TOTAL |
27 |
100 |
*Rest taker/Vacation taker these are nurses who work covering vacations, absences or absences of
other employees on a relay scale without schedule and fixed sector of work
defined.
Source: The authors
=
Due
to the institution presenting international quality certification of hospit=
al
level, there was a need to highlight the provision of knowledge to the care
team, since 20 nurses (74.07%) reported having training in the work environ=
ment
for the prevention and treatment of PI, as shown in Table 2.
Table 2=
-
Knowledge and training on injuries under pressure from nurses – 2020.
|
TRAINING/KNOWLEDGE |
n |
% |
|
Has participated in training course and
classification and prevention of pressure injury? |
|
|
|
Yes |
20 |
74.07 |
|
Offered<=
/span> by research
hospital |
11 |
55 |
|
In another
hospital that worked |
5 |
25 |
|
Own initiative |
4 |
20 |
|
No |
7 |
25.93 |
|
He is currently a member of the commission of
dressings of the institution? |
|
|
|
Yes |
9 |
33.33 |
|
> 6 months |
1 |
11.11 |
|
06 meses├ 11 months |
1 |
11.11 |
|
01├ 02 years |
3 |
33.34 |
|
02 anos├ 04 years |
2 |
22.22 |
|
Not mentione=
d
time |
2 |
22.22 |
|
No |
18 |
66.67 |
|
Did you conduct training regarding the protoc=
ol
for the prevention and treatment of pressure injury? In the hospital=
? |
|
|
|
Yes |
13 |
48.15 |
|
No |
9 |
33.33 |
|
I don't remember |
5 |
18.52 |
|
You request support from the multidisciplinary
team to assess the pressure injury? |
|
|
|
Yes |
14 |
51.85 |
|
No |
3 |
11.11 |
|
Sometimes |
10 |
37.04 |
|
Have you
suggested in the last six months standardization of any product or equipm=
ent
to assist in the prevention and treatment of pressure injury? |
|
|
|
Yes |
2 |
7.41 |
|
No |
25 |
92,59 |
|
TOTAL |
27 |
100 |
Source: The authors
=
Regarding
the use of the protocol of prevention and classification of PI, 16 nurses
(59.26%) reported using it and 7 (25.93%) sometimes use it, and 17 (62.97%)
reported that the protocol is easy to access for handling and consultation,=
and
5 (18.52%) stated that sometimes. Regarding the standardized dressings in t=
he
institution through the protocol, 14 participants (51.85%) felt safe for the
indication and use of coverage and 13 (48.15%) do not feel safe, as shown in
Table 3.
|
VARIABLE |
n |
% |
|
You feel safe to perform the classification o=
f a
pressure injury? |
||
|
Very Satisfactory |
3 |
11.11 |
|
Satisfactory |
17 |
62.96 |
|
Unsatisfactory<=
/span> |
7 |
25.93 |
|
In the institution where you work offers trai=
ning
and/or materials for updating related to the prevention and treatment of
pressure injury? |
||
|
Very Satisfactory |
3 |
11.12 |
|
Satisfactory |
17 |
62.96 |
|
Unsatisfactory<=
/span> |
6 |
22.22 |
|
Insufficient |
1 |
3.7 |
|
Do you use the protocol instituted in the hospital to assist in the prevention and treatment of pressure injuries?<= o:p> |
||
|
Yes |
16 |
59.25 |
|
No |
2 |
7.41 |
|
Sometimes |
7 |
25.93 |
|
I'm not in
the Protocol |
2 |
7.41 |
|
Can you apply the Braden scale daily? |
||
|
Yes |
21 |
77.78 |
|
No |
5 |
18.52 |
|
Rarely Apply |
1 |
3.7 |
|
Do you know and feel safe for the indication =
and
use of all dressing covers available in your work institution? |
||
|
Yes |
14 |
51.85 |
|
No |
13 |
48.15 |
|
Can you assess the continuity of prevention a=
nd
treatment in the unit that works? |
||
|
Yes |
13 |
48.15 |
|
No |
9 |
33.33 |
|
Sometimes |
5 |
18.52 |
|
Do you have easy access to the use of the cov=
ers
and dressings described in the protocol? |
||
|
Yes |
14 |
51.86 |
|
No |
4 |
14.81 |
|
Sometimes |
8 |
29.63 |
|
I'm not in
the Protocol |
1 |
3.7 |
|
Is the protocol for classification and preven=
tion
of pressure injury easily accessible for handling and consultation? |
||
|
Yes |
17 |
62.97 |
|
No |
4 |
14.81 |
|
Sometimes |
5 |
18.52 |
|
I'm not in
the Protocol |
1 |
3.7 |
|
TOTAL |
27 |
100 |
Source: The authors
DISCUSSION
The implementa=
tion
of the quality manual and strategic planning for certified institutions is =
of
paramount importance for the treatment of non-compliance and preventive act=
ions
to seek care with excellence and in prioritizing patient care(12).
Specifically, the PI prevention protocol provides the institution wit=
h a
quality service, with a view to patient safety, applicable to all patients =
at
risk, strictly providing care measures for the prevention and evaluation of
skin integrity(13).
The study hosp=
ital
has the PI protocol established, and just over half of the nurses claim to =
use
it for the prevention and treatment of injuries. A study conducted in the
Intensive Care Unit of the teaching hospital in northeastern Brazil, analyz=
ing
the actions of nursing professionals before and after the use of the PI
prevention protocol, it
showed that with the use of the protocol there was a higher frequency of
preventive actions by the nursing team, such as risk assessment for PI, care
for bone protein and skin hydration, this denotes the importance of this to=
ol(14),
and the importance of the PI protocol being accessible to all of the team f=
or
their knowledge and applicability.
The results
presented here revealed that among the nurses participating in the research,
not all of them affirm that the protocol established in the hospital is eas=
ily
accessible for handling and consultation. This is a vulnerability and an opportunity for
institutional improvement in order to facilitate access to information for
knowledge of PI prevention and treatment actions as well as to promote
familiarity of nursing professionals to the implemented protocol,
The intensive =
care
unit is a sector where patients with critical clinical conditions are inten=
ded,
who require constant monitoring and complex care, and require greater techn=
ical
and scientific knowledge of the nursing professional for the correct
decision-making(15). Patients in intensive care are m=
ore
vulnerable to developing PI due to clinical fragility. It is usually restri=
cted
to the bed, with physiological eliminations in diaper or bladder intake tub=
e,
with hemodynamic instabilities, some cases with sedation and other medical
devices, which hinders its mobility(16).
It is recogniz=
ed
that the incidence of PI may be related to intrinsic and extrinsic factors
specific to each patient, but it is necessary to identify potentially
preventable lesions(17). The integrative review condu=
cted
with articles published in the period between 2008 and 2019 showed that amo=
ng
the risk factors for the incidence of PI, the intrinsic relate to the clini=
cal
condition of the patient as his nutritional status, reduced or absent physi=
cal
mobility, cardiovascular diseases, urinary and fecal incontinence and advan=
ced
age and among the extrinsic factors have the actions of strength and shear =
on
the individual, skin moisture and lack of preventive measures(18).
In the search =
to
evaluate the nurses' knowledge about PI, it was evidenced that not all
participants feel safe about their classification, even if it is an accredi=
ted
hospital. This data corroborates the study conducted in a public hospital in
João Pessoa/Paraiba, with a sample of 17 nurses, in which it showed that mo=
st
nurses presented weaknesses to conceptualize, classify and cite the causes =
of PI(19).
In a near-experimental study conducted with 95 nurses from a teaching hospi=
tal
in the interior of Minas Gerais, it demonstrated that nurses have knowledge
about PI prevention, but presented weaknesses regarding the use of outdated
techniques, thus requiring updating and active participation of hospital
institutions in the provision of training(6).
Thus, the need=
to conduct
continuing education actions in health institutions is highlighted, to plac=
ate
the limitations identified(19), including for the participants of
this study, because, when nurses were asked about their safety for indicati=
on
and use of the coverage and dressings available in the institution, it was
possible to reveal that half of the professionals feel unsafe.
It is worth
mentioning that the dressings and covers aimed at the prevention and treatm=
ent
of PI are available in the hospital investigated and described in the
institution's protocol; however, the data indicate the need for managers to
invest in other strategies that can positively impact nurses' knowledge abo=
ut
the use of these technologies and raise the level of safety of these
professionals to use them to promote safety and quality of care.
This finding
corroborates another Brazilian study conducted in a teaching hospital in the
Midwest region that pointed out the main managerial needs of qualification =
of
the nursing team. Among them, we highlight the need to improve the nursing
process, implementation of procedure protocols and patient admission routin=
e.
The researchers of the stu=
dy
reaffirmed that continuing education contributes significantly to the quali=
ty
of care provided and guarantees valorization to workers(15).
The offer of
training/training to nurses in the institution presents a fragility, few
professionals claim to have already performed training regarding the
classification of PI in the hospital itself and specific training related to
the protocol, some claim not to remember, which makes us rethink about the
commitment on the subject by these professionals. For better effectiveness in the PI protocol in the
institution, it is necessary to support the administration in the provision=
of
human and material resources, being essential also, the engagement of health
team professionals in the execution of actions and in the constant search f=
or
knowledge(14).
It is notepoint
that health institutions have great responsibility in educational actions f=
or
their professionals and nurses play a fundamental role in improving the
knowledge of their team, so that there is an understanding about the service
itself(20). The elaboration of a standardized PI
prevention protocol should be applied to all sectors of hospital units and
approached by the nursing professional in an individualized manner for each
patient, whose purpose is to offer care according to their needs(18).
Often nurses h=
ave
limited care activities, due to insufficient materials to perform care, the
lack of specialization on the part of professionals also contributes to an
inefficiency, the
nurse has freedom to make decisions about the material to be used in the
dressing for skin rehabilitation, and this choice is efficient by evaluating
its therapeutic aspects according to the characteristics of each lesion and
skin integrity of the patient(19).
In this contex=
t,
scientific knowledge provides autonomy for nurses, being responsible for da=
ily
monitoring of the lesion and analysis of the efficacy of the product used f=
or
the dressing, if it is in accordance with the type and classification of the
lesion(21). It is important that this health professi=
onal
be engaged in this process and suggest improvements to the institution, in =
the
hospital it was evidenced that there is a great fragility in this regard, f=
ew
nurses have suggested in the last six months new products to assist in the
prevention and treatment of PI. Among
the suggestions some dressing coverages mentioned are already standardized =
and
available in the institution, and a point of attention, is the suggestion of
effective training, this reinforces the need to invest in the provision of
training for the team.
Nurses should
involve the role of the multidisciplinary team in the process of prevention=
and
treatment of PI, a fact that the protocol brings as a guideline, but only h=
alf
of the nurses claim to request support. It is important for the
multidisciplinary team to strengthen the commitment of collective work and
mature the culture of safer patient care. However, the challenge focuses on guiding and
re-educating the team for the implementation of actions aimed at patient
safety, and in this context, continuing education is fundamental for the
implementation of activities(22).
Another import=
ant
aspect is the involvement and participation of the skin committee in the
follow-up of patients in the prevention and treatment of existing lesions. =
The
role of the skin committee goes further, being fundamental in the promotion=
of
training programs for its members and care team addressing issues related t=
o debridement,
dressings, coverage, prevention, among other related issues(23).=
The committee of dressings in the institution is composed only of nur=
ses,
of the 27 professionals participating in the research 9 (33.33%) are member=
s.
Another valuable tool for the prevention of PI is the use of the Braden sca=
le
by nurses, which allows the assessment of the risks of developing these
lesions. The
daily application of the scale allows the health professional to know the
characteristics of the patient and to develop preventive actions, it is more
satisfactory to prevent an injury than to treat it afterwards(24).
The hospital
protocol determines the use of the Braden scale daily by nurses, which
justifies the high rate of use of the scale by participating nurses and a
strong point in the prevention of PI. In a study conducted at the university hospital lo=
cated
in southern Brazil, the application of the Braden scale daily was evaluated=
in
120 hospitalized patients, it was evidenced that with the applicability of =
the
scale the incidence of lesions was equal to zero. These data corroborate the
effectiveness of the Braden scale as a predictive instrument for assessing =
the
risk of PI(5).
CONCLUSION
Relevant points such as the
high rate of use of the Braden scale daily by nurses in the prevention of PI
are observed in this study. Some weaknesses were evidenced, such as the low
participation of professionals in the dressing committee. There is a lack
regarding the degree of knowledge of nurses in relation to the protocol, wh=
ich
generates a need for conducting and offering training on the part of the
institution.Training
is of paramount importance for the work to be performed with higher quality=
, to
obtain more effectiveness in health care.
This research has some
limitations. One of them results from the number of participating nurses and
the study in a single accredited health institution, which deserves caution=
in
the generalization of the data. In addition, the limitations are the fact t=
hat
it does not investigate the periodicity of training in the hospital.
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sponding author
Vanes=
sa
Leal de Lima de Moura, Rua Joval de Paula Souza=
, 676,
Thomaz Coelho, Araucária, Paraná, Brasil, CEP: 83707-190. Telefone +55 41 9=
9762-0432
E-mai=
l: vanessalealdelima@gmail.com=
Submi=
ssion: 2021-09-10
Appro=
val: 2021-10-26
[1] Acadêmica de
Enfermagem do Centro Universitário Santa Cruz de Curitiba. Curitiba, Paraná,
Brasil. ORCID –Open Researcher and Contributor ID – https://orcid.org/0000-0002-=
0478-491X
[2] Enfermeiro. Docen=
te
do Curso de Enfermagem do Centro Universitário Santa Cruz de Curitiba.
Curitiba, Paraná, Brasil. Mestre em Enfermagem pela Universidade Federal do
Paraná (UFPR). ORCID –Open Researcher and
[3] Acadêmica de
Enfermagem do Centro Universitário Santa Cruz de Curitiba. Curitiba, Paraná,
Brasil. ORCID – Open Researcher and Contributor ID – https://orcid.org/0000-0002-=
8420-3643
[4] Enfermeiro. Docen=
te
do Curso de Enfermagem do Centro Universitário Santa Cruz de Curitiba.
Curitiba, Paraná, Brasil. Mestre em Enfermagem pela Universidade Federal do
Paraná (UFPR). OR=
CID
– Open Researcher and C=
ontributor
ID – http://=
orcid.org/0000-0001-9838-1232
=
[5] Enfermeira. Graduada em Enfer=
magem.
Coordenadora da Rede Brasileira de Enfermagem e Segurança do Paciente Núcleo
Curitiba-PR. Enfermagem pela Pontifícia Universidade Católica do Paraná
(PUCPR). Curitiba, Paraná, Brasil. ORCID – O=
pen Researcher and Contributor ID – https://orcid.org/0000-0003-=
3145-1683
= =