A qualitative analysis of pressure injury development among medically underserved adults with spinal cord injury.

Purpose: Medically underserved adults with spinal cord injury (SCI) remain at high risk of incurring medically serious pressure injuries even after receiving education in prevention techniques. The purpose of this research is to identify circumstances leading to medically serious pressure injury development in medically underserved adults with SCI during a lifestyle-based pressure injury prevention program, and provide recommendations for future rehabilitation approaches and intervention design.Methods: This study entailed a qualitative secondary case analysis of treatment notes from a randomized controlled trial. Participants were 25 community-dwelling, medically underserved adults with SCI who developed medically serious pressure injuries during the course of the intervention of the RCT.Results and conclusions: Among the 25 participants, 40 unique medically serious pressure injuries were detected. The six themes related to medically serious pressure injury development were: (1) lack of rudimentary knowledge pertaining to wound care; (2) equipment and supply issues; (3) comorbidities; (4) non-adherence to prescribed bed rest; (5) inactivity; and (6) circumstances beyond the intervention's reach. Together, these factors may have undermined the effectiveness of the intervention program. Modifications, such as assessing health literacy levels of patients prior to providing care, providing tailored wound care education, and focusing on equipment needs, have potential for altering future rehabilitation programs and improving health outcomes.Implications for rehabilitationTo provide patients with spinal cord injury with the necessary information to prevent medically serious pressure injury development, health care providers need to understand their patient's unique personal contexts, including socio-economic status, language skills, and mental/cognitive functioning.When providing wound care information to patients with spinal cord injury who have developed a medically serious pressure injury, practitioners should take into account the level of health literacy of their patient in order to provide education that is appropriate and understandable.Practitioners should be aware of how to help their patient advocate for outside services and care that address their equipment needs, such as finding funding or grants to pay for expensive medical equipment.

Factors Protecting Against Pressure Injuries in Medically Underserved Adults With Spinal Cord Injury: A Qualitative Study.

Background: Pressure injuries negatively impact quality of life and participation for individuals with spinal cord injury (SCI). Objective: To examine the factors that may protect against the development of medically serious pressure injuries in adults with SCI. Methods: A qualitative analysis was conducted using treatment notes regarding 50 socioeconomically disadvantaged individuals who did not develop medically serious pressure injuries during a 12-month pressure injury prevention intervention program. Results: Eight types of potentially protective factors were identified: meaningful activity, motivation to prevent negative health outcomes, stability/resources, equipment, communication and self-advocacy skills, personal traits, physical factors, and behaviors/activities. Conclusions: Some protective factors (eg, personal traits) may be inherent to certain individuals and nonmodifiable. However, future interventions for this population may benefit from a focus on acquisition of medical equipment and facilitation of sustainable, health-promoting habits and routines. Substantive policy changes may be necessary to facilitate access to adequate resources, particularly housing and equipment, for socioeconomically disadvantaged individuals with SCI. Further research is needed to understand the complex interplay of risk and protective factors for pressure injuries in adults with SCI, particularly in underserved groups.

Qualitative Experience of Sleep in Individuals With Spinal Cord Injury.

Poor sleep contributes to adverse health outcomes making it important to understand sleep in medically vulnerable populations, including those with spinal cord injury (SCI). However, little attention has been paid to circumstances specific to SCI that may negatively affect sleep, or to consequences of poor sleep in this population. The objective of this study was to examine the experience of sleep among individuals with SCI. Secondary analysis using thematic coding of qualitative data from an ethnographic study of community-dwelling adults with SCI was conducted. Sleep-related data were found in transcripts for 90% of the sample. Participants described diminished sleep duration and irregular sleep patterns. Several factors contributing to poor sleep were identified, including SCI-related circumstances and sleep environment. Participants also discussed how poor sleep affected occupational engagement. This study highlights the extent of sleep disturbance experienced after SCI and the subsequent impact on occupational performance, and provides direction for clinical practice.

Systematic review of behavioral and educational interventions to prevent pressure ulcers in adults with spinal cord injury.

OBJECTIVE: To investigate the efficacy of behavioral or educational interventions in preventing pressure ulcers in community-dwelling adults with spinal cord injury (SCI). DATA SOURCES: Cochrane, Clinical Trials, PubMed, and Web of Science were searched in June 2016. The search combined related terms for pressure ulcers, spinal cord injury, and behavioral intervention. Each database was searched from its inception with no restrictions on year of publication. REVIEW METHODS: Inclusion criteria required that articles were (a) published in a peer-reviewed journal in English, (b) evaluated a behavioral or educational intervention for pressure ulcer prevention, (c) included community-dwelling adult participants aged 18 years and older with SCI, (d) measured pressure ulcer occurrence, recurrence, or skin breakdown as an outcome, and (e) had a minimum of 10 participants. All study designs were considered. Two reviewers independently screened titles and abstracts. Extracted information included study design, sample size, description of the intervention and control condition, pressure ulcer outcome measures, and corresponding results. RESULTS: The search strategy yielded 444 unique articles of which five met inclusion criteria. Three were randomized trials and two were quasi-experimental designs. A total of 513 participants were represented. The method of pressure ulcer or skin breakdown measurement varied widely among studies. Results on pressure ulcer outcomes were null in all studies. Considerable methodological problems with recruitment, intervention fidelity, and participant adherence were reported. CONCLUSIONS: At present, there is no positive evidence to support the efficacy of behavioral or educational interventions in preventing pressure ulcer occurrence in adults with SCI.

The role of habit in recurrent pressure ulcers following spinal cord injury.

BACKGROUND: Despite the existence of numerous prevention strategies, pressure ulcers remain highly prevalent in those with spinal cord injury (SCI). The concept of habit, broadly defined, may help understand the persistence of this problem and offer strategies for its mitigation by occupational therapy. AIM: The aim of this paper is to describe the relationship between habits established prior to sustaining an SCI and post-injury habits that impacted on pressure ulcer risk. METHODS: Secondary analysis of qualitative data collected during an ethnographic study of community-dwelling adults with SCI. RESULTS: Participants' habits appeared to substantially affect their risk of developing pressure ulcers. Habits established before incurring the SCI either facilitated or hindered the acquisition of new habits intended to prevent pressure ulcers. CONCLUSIONS: An understanding of the individual's pre-existing habits may be important when designing a rehabilitation programme intended to minimize risk of pressure ulcer development following SCI. Habit-change strategies could be used to supplement education in pressure ulcer prevention techniques. SIGNIFICANCE: Occupational therapists have a longstanding interest in habit. A more comprehensive understanding of this concept may provide important insights into the persistence and management of pressure ulcers following SCI.

Building a framework for implementing new interventions.

Implementation into real-world practice of interventions previously studied in randomized controlled trials is an ongoing challenge. In this article, we describe the methodology we used for the first phase of a project for the implementation and outcomes assessment of an occupational therapy pressure ulcer prevention intervention for people with spinal cord injury in the Veterans Health Administration. This first phase of the project was guided by practice-based evidence research methodology and resulted in an intervention manual tailored to meet the needs of Veterans and the establishment of a system for documenting and monitoring care processes, patient characteristics, and intervention outcomes. This system, in turn, will provide the data-gathering template for the next phase in which the beneficial effects of the intervention will be assessed. We conclude by recommending that clinicians explore the utility of this approach for the implementation of other novel interventions.

Conducting intervention research among underserved populations: lessons learned and recommendations for researchers.

Randomized controlled trials (RCTs) are considered the criterion standard in research design for establishing treatment efficacy. However, the rigorous and highly controlled conditions of RCTs can be difficult to attain when conducting research among individuals living with a confluence of disability, low socioeconomic status, and being a member of a racial/ethnic minority group, who may be more likely to have unstable life circumstances. Research on effective interventions for these groups is urgently needed, because evidence regarding approaches to reduce health disparities and improve health outcomes is lacking. In this methodologic article, we discuss the challenges and lessons learned in implementing the Lifestyle Redesign for Pressure Ulcer Prevention in Spinal Cord Injury study among a highly disadvantaged population. These issues are discussed in terms of strategies to enhance recruitment, retention, and intervention relevance to the target population. Recommendations for researchers seeking to conduct RCTs among socioeconomically disadvantaged, ethnically diverse populations are provided.

The Meaningful Activity Participation Assessment: a measure of engagement in personally valued activities.

The Meaningful Activity Participation Assessment (MAPA), a recently developed 28-item tool designed to measure the meaningfulness of activity, was tested in a sample of 154 older adults. The MAPA evidenced a sufficient level of internal consistency and test-retest reliability and correlated as theoretically predicted with the Life Satisfaction Index-Z, the Satisfaction with Life Scale, the Engagement in Meaningful Activities Survey, the Purpose in Life Test, the Center for Epidemiologic Studies Depression Inventory and the Rand SF-36v2 Health Survey subscales. Zero-order correlations consistently demonstrated meaningful relationships between the MAPA and scales of psychosocial well-being and health-related quality of life. Results from multiple regression analyses further substantiated these findings, as greater meaningful activity participation was associated with better psychological well-being and health-related quality of life. The MAPA appears to be a reliable and valid measure of meaningful activity, incorporating both subjective and objective indicators of activity engagement.

Qualitative study of principles pertaining to lifestyle and pressure ulcer risk in adults with spinal cord injury.

PURPOSE: The aim of this article is to identify overarching principles that explain how daily lifestyle considerations affect pressure ulcer development as perceived by adults with spinal cord injury (SCI). METHOD: Qualitative in-depth interviews over an 18-month period with 20 adults with spinal injury and a history of pressure ulcers were conducted using narrative and thematic analyses. RESULTS: Eight complexly interrelated daily lifestyle principles that explain pressure ulcer development were identified: perpetual danger; change/disruption of routine; decay of prevention behaviors; lifestyle risk ratio; individualization; simultaneous presence of prevention awareness and motivation; lifestyle trade-off; and access to needed care, services and supports. CONCLUSIONS: Principles pertaining to the relationship between in-context lifestyle and pressure ulcer risk underscore previous quantitative findings, but also lead to new understandings of how risk unfolds in everyday life situations. Pressure ulcer prevention for community-dwelling adults with SCI can potentially be enhanced by incorporating principles, such as the decay of prevention behaviors or lifestyle trade-off, that highlight special patterns indicative of elevated risk. The identified principles can be used to theoretically drive future research or to guide innovative lifestyle-focused intervention approaches. Public policies that promote short-term preventive interventions at critical junctures throughout a person's life should be considered.

Power and confidence in professions: lessons for occupational therapy.

BACKGROUND: Powerful professions have the capacity to obtain leadership positions, advocate successfully in the policy arena, and secure the resources necessary to achieve their professional goals. Within the occupational therapy profession, cultivating power and confidence among our practitioners is essential to realize our full capacity for meeting society's occupational needs. PURPOSE AND KEY ISSUES: Drawing from a historical analysis of the medical and nursing professions, this paper discusses the implications of power and disempowerment among health professions for their practitioners, clients, and public image. Theoretical perspectives on power from social psychology, politics, organizational management, and post-structuralism are introduced and their relevance to the profession of occupational therapy is examined. IMPLICATIONS: The paper concludes with recommendations for occupational therapy practitioners to analyze their individual sources of power and evaluate opportunities to develop confidence and secure power for their professional work--in venues both in and outside the workplace.

Response factors surrounding progression of pressure ulcers in community-residing adults with spinal cord injury.

OBJECTIVE: This study examined how community-dwelling adults with spinal cord injury (SCI) respond in real-life circumstances after detecting a low-grade (Stage 1 or Stage 2) pressure ulcer. METHOD: We performed a secondary analysis of personal information profiles obtained in a previous qualitative research study. Profiles were examined to explore how individualized lifestyle considerations affected pressure ulcer risk in 19 adults with SCI who responded to an early ulcer that later progressed to a medically serious level. RESULTS: On the basis of a total of 46 pressure ulcer events, we identified a typological framework that described eight primary response categories and seven subcategories. CONCLUSION: The findings have significant practice implications for occupational therapists who provide services for adults with SCI living in the community. The importance of combining an initial individualized preventive intervention with structured follow-up within a person's unique everyday life setting is further explored.

Data-based models of how pressure ulcers develop in daily-living contexts of adults with spinal cord injury.

OBJECTIVE: To examine the daily-lifestyle influences on the development of pressure ulcers in adults with spinal cord injury (SCI). DESIGN: Qualitative investigation using in-depth interviewing and participant observation. SETTING: Participants were studied in their homes and other naturalistic contexts. PARTICIPANTS: Twenty men and women of diverse ethnicities with paraplegia or tetraplegia who were recruited at a pressure ulcer management clinic in a large rehabilitation facility. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Detailed descriptive information pertaining to the development of recurring pressure ulcers in relation to participants' daily routine and activity, personal choices, motivating influences, lifestyle challenges, and prevention techniques and strategies. RESULTS: The daily-lifestyle influences on pressure ulcer development in adults with SCI can be described through various models that vary in complexity, depending on whether they incorporate individualization, interrelations among modeled elements, situational specificity, and/or temporal comprehensiveness. Ulcers are most likely to develop when a person with a relatively high-risk background profile is exposed to an equilibrium-disrupting change event that culminates in a specific pressure ulcer risk episode. CONCLUSIONS: The results underscore the significant degree of complexity and individualization that characterize the emergence of pressure ulcers in daily-life contexts. Prevention efforts should therefore incorporate attention to the unique constellation of circumstances that comprise a person's everyday life.