Is this to be another project that fizzles out? Using the i-PARIHS framework to evaluate implementation of a mentoring programme.

It is well-known that the implementation of evidence into clinical practice is complex and challenging. The integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework conceptualizes successful implementation of evidence into practice. As the implementation of the mentoring programme proved to be a challenge, it seemed valuable to retrospectively study the implementation process using a framework like the i-PARIHS. AIM: The aim of this study was to evaluate implementation of a multifaceted mentoring programme for bedside nurses using the i-PARIHS framework, to identify factors that influenced the implementation. DESIGN: A secondary analysis of qualitative data using the i-PARIHS framework as the theoretical lens. METHOD: A directed content analysis was performed, driven theoretically by the i-PARIHS framework. The analysis focused separately on (a) characteristics of the innovation and (b) successful and hindering factors in the implementation process. RESULTS: The results showed that successful factors influencing implementation of the mentoring programme included supportive and actively involved formal leaders and supervisors at the unit level. A major hindering factor was lack of resources in the form of personnel, time and money. A lack of facilitators, particularly experienced facilitators, throughout the organization hindered implementation. The i-PARIHS framework offered a structured how-to guide to identify factors that influenced the implementation process. CONCLUSION: Implementation of the mentoring programme was a challenge for the organization. Investment into implementation should continue, with a more structured facilitation process. A structured and prioritized management system, including supportive leadership at the unit level, should be established by the hospital board. IMPLICATIONS FOR THE PROFESSION: There is a need for experienced facilitators throughout the organization. This is crucial to achieve sustainability in the mentoring programme and ensure that the large investments of staff resources and money do not fizzle out. IMPACT: What problem did the study address? Implementing a mentoring programme for nurses in a large university hospital proved to be a challenge. Therefore, it seemed valuable to retrospectively study the implementation process using a framework like the i-PARIHS. What were the main findings? A lack of facilitators, particularly experienced facilitators, throughout the organization hindered the implementation. The i-PARIHS framework offered a structured how-to guide to identify factors that influenced the implementation process. Where and on whom will the research have an impact? Our findings are important for leaders on all levels in a hospital setting, including the hospital board, heads of departments and nurse managers. REPORTING METHOD: Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups is used. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Evaluation of patient participation in relation to the implementation of a person-centered nursing shift handover.

BACKGROUND: It has been suggested that nursing shift-to-shift handover should be a more team-based dialogue with and for the patient rather than about a patient. AIM: The aim of this study was to evaluate patient participation in relation to the implementation of the person-centered handover (PCH). METHOD: A pretest-posttest design was used without a comparison group, including patients from nine units in a university hospital at pretest (n = 228) and after implementing PCH (posttest, n = 253) per the framework integrated-Promoting Action on Research Implementation in Health Services. The PCH is inspired by an Australian bedside handover model. The Patient Preferences for the Patient Participation tool was used to rate the preference for and experience of participation on 12 items, combined into three levels of preference-based participation (insufficient-fair-sufficient). RESULTS: There were no differences regarding experience or preference-based participation between patients at pretest-posttest; however, posttest patients experienced participation in the item Reciprocal communication to a lesser extent than the pretest patients. Only 49% of the posttest group received PCH; of those not receiving PCH, some would have wanted PCH (27%), while some would have declined (24%). Patients receiving PCH had sufficient participation (82%), to a greater extent, regarding the item Sharing one's symptoms with staff than patients at pretest (72%). Patients receiving PCH also had sufficient participation, to a greater extent, than patients at posttest who did not receive, but would have wanted PCH, regarding four items: (1) sharing one's symptoms with staff, (2) reciprocal communication, (3) being told what was done, and (4) taking part in planning. LINKING EVIDENCE TO ACTION: Most patients want to be present at PCH. Therefore, nurses should ask for the patients' preferences regarding PCH and act accordingly. Not inviting patients who want PCH could contribute to insufficient patient participation. Further studies are needed to capture what assistance nurses would want in identifying and acting in alignment with patient preferences.

Bedside nurses' perspective on the Fundamentals of Care framework and its application in clinical practice: A multi-site focus group interview study.

BACKGROUND: A changing nursing workforce and an increase in demands for care together with more complex care, raise arguments that leading and guiding nursing practice is more challenging than ever. Therefore, nurses need to have a shared agenda and a common language to show the importance of nursing care and the consequences of not addressing this in an appropriate way. In response to this the Fundamentals of Care framework was developed to also contribute to the delivery of person-centred care in an integrated way. However, to gain acceptance and applicability we need to ensure the framework's relevance to clinical practice from bedside nurses' perspectives. OBJECTIVE: To describe bedside nurses' perspectives on the Fundamentals of Care framework and how it can be applied in clinical practice. DESIGN: A descriptive qualitative design informed by the Fundamentals of Care framework. SETTING(S): The study was undertaken at seven hospitals in Sweden, Denmark and the Netherlands during 2019. PARTICIPANTS: A total sample of 53 registered nurses working at the bedside participated. Participants had a wide variety of clinical experience and represented a range of different nursing practice areas. METHODS: Twelve focus group interviews were used to collect data and analysed with a deductive content analysis approach. RESULTS: Bedside nurses perceived that the Fundamentals of Care framework was adequate, easy to understand and recognised as representative for the core of nursing care. The definition for fundamental care covered many aspects of nursing care, but was also perceived as too general and too idealistic in relation to the registered nurses' work. The participants recognised the elements within the framework, but appeared not to be using this to articulate their practice. Three main categories emerged for implications for clinical practice; guiding reflection on one's work; ensuring person-centred fundamental care and reinforcing nursing leadership. CONCLUSIONS: The Fundamentals of Care framework is perceived by bedside nurses as a modern framework describing the core of nursing. The framework was recognised as having clinical relevance and provides bedside nurses with a common language to articulate the complexity of nursing practice. This knowledge is crucial for bedside nurses both in clinical practice and in leadership roles to be able to speak up for the need to integrate all dimensions of care to achieve person-centred fundamental care. Various activities for reflection, person-centred care and leadership to apply the framework in clinical practice were presented, together with minor suggestions for development of the framework. TWEETABLE ABSTRACT: Bedside nurses recognise their clinical practice within the Fundamentals of Care framework, showing the core of modern nursing.

Using pressure mapping intraoperatively to prevent pressure ulcers-A quasi-experimental study.

Background and Aim: Patients undergoing surgery are at high risk of developing pressure ulcers. However, pressure ulcer prevention in the operating room department is demanding and restricted. New techniques, such as continuous pressure mapping that visualizes interface pressure, are now available. The aim of the study was to determine whether pressure mapping information of interface pressure intraoperatively leads to (1) more frequent intraoperative micro repositioning and a reduced amount of pressure on the sacrum area and (2) a lower frequency of pressure ulcer development. Methods: A quasi-experimental ABA design was used. A total of 116 patients undergoing surgery were included. During the B phase, the need to consider repositioning the patient according to interface pressure readings was initiated. Results: The result showed that there was significantly higher interface pressure in the A2 phase than in the B phase. Micro repositioning of the patient during surgery was performed in the B phase, but not in the A phase. The regression model showed that a higher BMI was associated with higher interface pressure. None of the patients developed hospital-acquired pressure ulcers up to Day 1 postoperatively. Conclusion: Pressure mapping involves moving away from expert opinion and tradition towards objective assessment and flexibility and we see the benefits of using pressure-mapping equipment in operating room contexts. However, more research is needed in this area.

Feasibility of PURPOSE T in clinical practice and patient participation-A mixed-method study.

This study aimed to evaluate the feasibility of implementing an electronic version of PURPOSE T, a risk assessment instrument for pressure ulcers, in a Swedish hospital ward. A mixed-method was used. Nursing staff received training in PURPOSE T and a record review was performed (n = 30). PURPOSE T replaced the Modified Norton Scale, and after one month another record review was performed (n = 30). Individual interviews with patients (n = 15) and focus group interviews with nursing staff (n = 23) were performed after the implementation. The results of the record review and the focus group interviews showed good clinical feasibility of PURPOSE T. The record review showed that more patients were at risk of developing pressure ulcers and more nursing interventions were prescribed with PURPOSE T compared to the Modified Norton Scale. The focus group interviews showed that all nursing staff were satisfied with PURPOSE T. The instrument contributed to increased reflection and analysis as well as the opportunity for nursing staff to draw their own conclusions regarding patients´ risk status. The documentation encouraged the prescription of more preventive actions, and the nurses were more involved at bedside. However, almost all the patients expressed not receiving any information about pressure ulcers.

Swedish translation, cultural adaptation and psychometric evaluation of the pressure ulcer knowledge assessment tool for use in the operating room.

The aim of this study was to psychometrically evaluate the Swedish operating room version of PUKAT 2.0. In total, 284 Swedish operating room nurses completed the survey of whom 50 completed the retest. The item difficulty P-value of 14 items ranged between 0.38 and 0.96 (median 0.65). Three items were found to be too easy (0.90-0.96). The D-value of 14 items ranged between 0.00 and 0.42 (median 0.46). Three items had a D-value lower than 0.20 (0.11-0.16) and eight items scored higher than 0.40 (0.45-0.61). The quality of the response alternatives (a-value) ranged between 0.00 and 0.42. This showed that nurses with a master's degree had a higher knowledge than nurses with a professional degree (respectively 9.4/14 versus 8.6/14; t = -2.4, df = 199, P = 0.02). The ICC was 0.65 (95% CI 0.45-0.78). The ICCs for the domains varied from 0.12 (95% CI = -0.16-0.39) to 0.59 (95% CI = 0.38-0.75). Results indicated that 11 of the original items contributed to the overall validity. However, the low participation in the test-retest made the reliability of the instrument low. An extended evaluation with a larger sample should be considered in order to confirm aspects of the psychometric properties of this instrument.

Pressure ulcer prevalence and prevention interventions - A ten-year nationwide survey in Sweden.

The aim of this study was to describe pressure ulcer prevalence and prevention interventions in hospital care in Sweden based on nationwide surveys conducted over a 10-year period. All Swedish hospitals were invited to participate in annual pressure ulcer prevalence surveys during the period 2011-2020. The data collection protocols included gender, age, skin assessment, risk assessment, and preventive interventions. In total, more than 130,000 patients were included in the ten prevalence surveys. The prevalence of pressure ulcers in Swedish hospital patients decreased significantly from 17.0 %to 11.4% between 2011 and 2020 and hospital-acquired pressure ulcers decreased from 8.1% to 6.4% between 2018 and 2020. There was no significant decline in medicaldevice-related pressure ulcers during the same period. The proportion of patients who were risk and skin assessed increased, as did the use of pressure-reducing mattresses, sliding sheets, heel protection, and nrepositioning plans. This study shows that the implementation of a national patient safety program has had an impact on the nationwide prevalence of pressure ulcers in hospital care and the occurrence of prevention strategies. However, one in ten patients in Swedish hospitals still suffers from pressure ulcers. Further improvements can be made.

The Swedish version of the attitude towards pressure ulcer prevention instrument for use in an operating room context (APUP-OR): A nationwide psychometric evaluation.

INTRODUCTION: To assess operating room (OR) nurses' attitudes towards pressure ulcer prevention, the Attitude towards Pressure Ulcer Prevention (APuP) instrument was developed. AIM: The aim of this study was to psychometrically evaluate the Attitude towards Pressure Ulcer Prevention (APuP) instrument in a Swedish OR context. MATERIALS AND METHODS: A psychometric evaluation study was conducted, using a convenience sample, between February and August 2020. Validity (content, construct, discriminatory power) and reliability (stability and internal consistency) were evaluated. RESULTS: The first survey (test) was completed by 284 Swedish OR nurses, of whom n = 50 (17.6%) completed the second survey (retest). A Principal Component Analysis was conducted for the 13-item instrument. The KMO value for this model was 0.62. Bartlett's test for sphericity was statistically significant (p 0.001). Five factors were identified which accounted for 56% of the variance in responses related to attitudes toward pressure ulcer prevention. The Cronbach's α for the instrument "attitude towards Pressure Ulcer Prevention" was 0.66. The intraclass correlation coefficient was 0.49 (95% CI = 0.25-0.67). CONCLUSION: This Swedish version of the APuP- OR is the first step in the development of an instrument to measure OR nurses' attitudes towards PU prevention in a Swedish OR context. The reliability of the instrument was low and the validity moderate. A larger sample and the revision or addition of items related to the context of the operating room should be considered in order to confirm aspects of the psychometric properties.

Pressure ulcer risk assessment-registered nurses´ experiences of using PURPOSE T: A focus group study.

AIM: To evaluate the clinical usability of PURPOSE T among registered nurses in Sweden. BACKGROUND: Pressure ulcers are an adverse event and a problem worldwide. Risk assessment is a cornerstone, and a first step in pressure ulcer prevention is to identify possible risk patients and/or pressure ulcers. There are many pressure ulcer risk assessment instruments; however, they are not updated and/or evidence-based. PURPOSE T has been psychometrically evaluated in the UK and in Sweden with good inter-rater and test-retest reliability, and convergent validity was reported as moderate. DESIGN: A descriptive study design with a qualitative approach. METHODS: A total of six focus group interviews with 29 registered nurses were conducted. They were recruited from May 2018 to November 2018 from a university hospital and two nursing homes in Sweden. Data analysis was performed as described by Krueger. The study adheres to the COREQ guidelines. RESULTS: Four categories were identified: "An efficient risk assessment instrument performed at the bedside," "Deeper understanding and awareness of risk factors," "Benefits compared to the Modified Norton Scale" and "Necessity of integration of PURPOSE T in the electronic health record and team collaboration." CONCLUSION: The registered nurses acknowledged an overall positive perception of PURPOSE T´s clinical usability. Future research is needed to evaluate the feasibility of PURPOSE T. RELEVANCE TO CLINICAL PRACTICE: PURPOSE T has the potential to replace outdated pressure ulcers risk assessment instruments that are used today.

A mentoring programme to meet newly graduated nurses' needs and give senior nurses a new career opportunity: A multiple-case study.

AIM: To evaluate the implementation of a multifaceted mentoring programme in a large university hospital and describe its value from the perspectives of newly graduated nurses, experienced nurses and the hospital organisation. BACKGROUND: Healthcare organisations need long-term competence-planning strategies to retain nurses, prevent their premature departure from the profession and use their competencies. This paper reports a mentoring programme focused on supporting newly graduated nurse' transition to practice and senior nurses' professional development as supervisors. DESIGN: A multiple-case study. METHODS: We performed 35 interviews with nurses, supervisors and nurse managers in the five units that implemented the programme, mapped the programme at the hospital level and extracted the nurses' working hours. The interviews were analysed thematically using the theoretical lens of the head-heart-hand model to interpret the results. RESULTS: Of 46 units in the hospital, 14 had implemented one or several of the components in the mentoring programme. The programme corresponded to the newly graduated nurses' needs, gave senior nurses a new career opportunity and contributed to an attractive workplace. The main theme, Giving new nurses confidence, experienced nurses a positive challenge and the organisation an opportunity to learn, reflects the value of the programme's supervisory model to new and experienced nurses and to the organisation as a whole. CONCLUSION: The mentoring programme appeared to be a promising way to smooth the transition for newly graduated nurses. The experienced supervising nurses were key to the success of this complex programme, supporting the new nurses at the bedside and being available to respond to their questions and reflections. Embedding the supervisors in the units' daily practice was necessary to the success of the different parts of the programme. Despite the strategic and well-designed implementation of this mentoring programme aimed to solve the everyday challenge of nurse shortages in the hospital, it was a challenge to implement it fully in all the units studied.

PURPOSE T in Swedish hospital wards and nursing homes: A psychometric evaluation of a new pressure ulcer risk assessment instrument.

AIM: To evaluate the psychometric characteristics of the Pressure Ulcer Risk Primary or Secondary Evaluation Tool (PURPOSE T); reliability (inter-rater and test-retest) and validity (convergent validity) in a Swedish context. BACKGROUND: Pressure ulcers are considered as an adverse event and are a problem in healthcare worldwide. The first step in pressure ulcer prevention is to identify patients that are at risk. PURPOSE T is a new pressure ulcer risk assessment instrument that was developed in the UK using "golden standard" instrument method. DESIGN: Observational, descriptive and comparative. METHODS: A total of 235 patients and 28 registered nurses were recruited (May 2018-November 2018) from six hospital wards at a university hospital and two community nursing homes in Sweden. Blinded (ward/nursing home nurses and expert nurses) PURPOSE T assessments and follow-up retests were undertaken. Cross-tabulation and kappa statistics were used to examine the reliability, and phi correlation was used to test the convergent validity. The study followed the STROBE guideline. RESULTS: The clinical evaluation showed "very good" (kappa) inter-rater and test-retest reliability for PURPOSE T assessment decision overall. The agreement of "at risk"/"not at risk" for both inter-rater and test-retest was also high, at least 95.5%. The convergent validity between PURPOSE T and other traditional assessment instruments was moderate. CONCLUSION: The evaluation of PURPOSE T demonstrated good psychometric characteristics. Further research is needed to evaluate PURPOSE T's usability among registered nurses. RELEVANCE TO CLINICAL PRACTICE: There is a lack of evidence-based validated pressure ulcer risk assessment instruments for use in health care. According to our findings, the Swedish version of PURPOSE T could be used in hospitals and nursing homes to identify patients in risk or with pressure ulcers.

A multifaceted intervention for evidence-based pressure ulcer prevention: a 3 year follow-up.

AIM: To assess sustainability of an intervention used to implement pressure ulcer prevention. BACKGROUND: The Promoting Action on Research Implementation in Health Service, framework was used to develop an intervention aimed to implement evidence-based pressure ulcer prevention in a hospital setting. A short-term follow-up showed that significantly more patients received pressure ulcer prevention. A qualitative process evaluation gave support that the intervention and the implementation process changed the understanding and approach to working with pressure ulcer prevention from treating to preventing. METHOD: The study had a sequential mixed method approach, combining quantitative and qualitative data. For the quantitative data, baseline and short-term follow-up (6-8 months) data reported in an initial study were compared with long-term follow-up (36-42 months) data (n = 259 patients). For the qualitative data, interviews with registered nurses (n = 20), assistant nurses (n = 7) and first-line managers (n = 5) were performed. RESULTS: The performance of pressure ulcer prevention was sustained 3 years from its conception. The number of patients with pressure ulcers was reduced (P = 0.021). Systematic work with quality measurements, support from first-line managers, internal facilitation, collaboration and pressure ulcer prevention skills could explained the sustainability. Obstacles to achieve high-quality pressure ulcer prevention were inadequate communication, high workloads and high rates of new and substitute nurses. CONCLUSION: Three different components for sustainability on the micro-level are described; benefits for the patients, the need for routinization and development over time. Threats to sustainability are described as factors on the macro-level. There needs to be collaboration in the healthcare organization from the micro-to-macro levels, and committed experienced nurses are needed to obtain high-quality sustainable pressure ulcer prevention.

Information and Communication Technology Can Increase Patient Participation in Pressure Injury Prevention: A Qualitative Study in Older Orthopedic Patients.

PURPOSE: The aim of this study was to assess the participatory capabilities of hospitalized older adults in response to the Continuous Bedside Pressure Mapping system placed on the beds to prevent pressure injuries. DESIGN: Descriptive study. SUBJECTS AND SETTING: A convenience sample of 31 orthopedic patients were recruited from an orthopedic rehabilitation unit at a university hospital in Uppsala, Sweden, that served patients aged 65 years and older. METHODS: Semistructured interviews were conducted between November 2016 and February 2017, audio-recorded, and transcribed verbatim. Data were analyzed using qualitative content analysis. RESULT: The overall theme from 21 interviews was "A new way of understanding helped patients to recognize vulnerable pressure points and to take action in their own care" from which 2 categories, "awareness" and "action," emerged. The study showed that verbally adapted information combined with using information and communication technology increased most participants' knowledge and as they became aware of increased pressure, they started to take preventative action by changing position. CONCLUSIONS: It is possible for older participants in a rehabilitation unit who had recent orthopedic surgery to understand and use new information and communication technology and should be invited to participate in pressure injury prevention.

Registered nurses' perspectives of work satisfaction, patient safety and intention to stay - A double-edged sword.

AIM: To describe job satisfaction in registered nurses (RNs), their intention to stay at their current workplace and in the profession and to explore patient safety in relation to these. BACKGROUND: Nurse turnover presents a serious challenge to health care that may be predicted by factors related to the work environment. METHOD: Descriptive design with 25 qualitative interviews. RESULTS: Five categories were identified: RNs feel satisfied when providing person-centred care; RNs enjoy the variability of the nursing job, but want control; RNs feel frustrated when care is put on hold or left undone; RNs depend on team collaboration and the work environment to assure patient safety; intention to stay depends on the work environment and a chance for renewal. CONCLUSION: Registered nurses' job satisfaction could be described as a double-edged sword. Although the profession is described as a positive challenge, work overload threatens both job satisfaction and patient safety. IMPLICATIONS FOR NURSING MANAGEMENT: Our findings suggest that nursing leadership can increase RNs' intention to stay by meeting their needs for appreciation, a better work environment, competence development and professional career development.

Evidence-based nursing-How is it understood by bedside nurses? A phenomenographic study in surgical settings.

AIM: The aim was to identify and describe nurses' understanding of working with evidence-based nursing (EBN) in clinical practice. BACKGROUND: Evidence-based health care is recognized as fundamental to nursing practice, but it is challenging to implement. How nurses understand this part of their work can affect their practice. METHODS: Using a qualitative explorative design with a phenomenographic approach, we interviewed 21 nurses working in Swedish surgical wards. RESULTS: We identified three understandings of EBN among nurses in surgical care: A. a fragmentary and difficult concept that is not integrated or used in clinical practice; B. an important approach guided by knowledgeable colleagues and students; and C. a process that nurses are responsible for developing and leading. CONCLUSION: Nurses' understandings of working with EBN in surgical wards vary widely. Nurse managers have an important task to create a common outlook among nurses about integrating research, patient experience and clinical experience in decision-making. IMPLICATION FOR NURSING MANAGEMENT: These findings could inspire nurse managers to reflect on how to move nurses towards a more comprehensive understanding of EBN and how to identify nurses who could act as facilitators in quality improvement work.

Tracking pressure injuries as adverse events: National use of the Global Trigger Tool over a 4-year period.

AIM: To examine the frequency, preventability, and consequences of hospital acquired pressure injuries in acute care hospitals over a 4-year period. METHOD: A retrospective record review was performed using the Swedish version of the Global Trigger Tool (GTT). A total of 64 917 hospital admissions were reviewed. Data were collected between 2013 and 2016 from all 63 Swedish acute care hospitals. RESULTS: The prevalence of pressure injuries (category 2-4) was 1%. Older patients, "satellite patients", and patients with acute admissions had more pressure injuries. Most pressure injuries (91%) were determined to be preventable. The mean extended length of hospital stay was 15.8 days for patients who developed pressure injuries during hospitalization. CONCLUSION: The GTT provides a useful and complementary national perspective on hospital acquired pressure injuries across hospitals, informing health care providers on safety priorities to reduce patient harm. Clinical leaders can use information on the preventability and the consequences of pressure injuries, as well as evidence-based arguments for improving the health care organization.

Staff's perceptions of a pressure mapping system to prevent pressure injuries in a hospital ward: A qualitative study.

AIM: To describe staff's perceptions of a continuous pressure mapping system to prevent pressure injury in a hospital ward. BACKGROUND: Pressure injury development is still a problem in hospitals. It is important to understand how new information and communication technologies can facilitate pressure injury prevention. METHOD: A descriptive design with qualitative focus group interviews was used. RESULTS: Five categories were identified: "Need of information, training and coaching over a long period of time," "Pressure mapping - a useful tool in the prevention of pressure injury in high risk patients," "Easy to understand and use, but some practical issues were annoying," "New way of working and thinking," and "Future possibilities with the pressure mapping system." CONCLUSION: The pressure mapping system was an eye-opener for the importance of pressure injury prevention. Staff appreciated the real-time feedback on pressure points, which alerted them to the time for repositioning, facilitated repositioning and provided feedback on the repositioning performed. IMPLICATIONS FOR NURSING MANAGEMENT: A continuous pressure mapping system can be used as a catalyst, increasing staff's competence, focus and awareness of prevention. For successful implementation, the nurse managers should have a shared agenda with the clinical nurse leaders, supporting the sustaining and spread of the innovation.

Unavoidable pressure ulcers at the end of life and nurse understanding.

OBJECTIVES: prevention of pressure ulcers (PUs) in end-of-life care is often problematic because both PUs and interventions to prevent them can cause suffering. The primary aim of this study was to identify and describe the different ways in which nurses understood unavoidable PUs in late palliative care. A second aim was to explore the expediency of the different levels of understanding. METHODS: a qualitative interview study with a phenomenographic approach was carried out. The study participants were nurses and healthcare assistants who worked in nursing homes or in specialist palliative inpatient care units run by private providers, non-profit foundations, municipalities and county councils. A phenomenographic analysis of the interview data was undertaken. RESULTS: all participants shared a fundamental understanding that the prevention of PUs is highly worthwhile in end-of-life care. Within this common view, practitioners' understanding of whether PUs could be prevented differed in four main ways, and were divided into categories: A: unavoidable PUs do not exist. All can be prevented if all interventions are applied, and all patients are at the same risk for developing PUs in end-of-life care; B: unavoidable PUs do not exist, but some patients do not participate in prevention interventions, which makes prevention difficult. The risk of developing pressure ulcers in end-of-life care varies between patients; C: some PUs are unavoidable because some patients do not participate in prevention interventions; the risk of developing pressure ulcers in end-of-life care differs between patients. D: some PUs are unavoidable, depending on the pathophysiological processes in the dying body. The risk of developing pressure ulcers in end-of-life care differs between patients. CONCLUSION: it is paramount to communicate to nurses that not all PUs can be prevented in dying patients, to lessen the burden of ethical stress for the nurses.

Pressure mapping to prevent pressure ulcers in a hospital setting: A pragmatic randomised controlled trial.

BACKGROUND: Pressure ulcers cause suffering to patients and costs to society. Reducing pressure at the interface between the patient's body and the support surface is a valid clinical intervention for reducing the risk of pressure ulcers. However, studies have shown that knowledge of how to reduce pressure and shear and to prevent pressure ulcers is lacking. OBJECTIVE: To evaluate the effect of a pressure mapping system on pressure ulcer prevalence and incidence in a hospital setting. DESIGN: Pragmatic randomised controlled trial. SETTING: A geriatric/internal medical ward with 26 beds in a Swedish university hospital. PARTICIPANTS: 190 patients were recruited (intervention: n=91; control: n=99) over a period of 9 months. Patients were eligible if they were over 50 years old, admitted to the ward between Sunday 4pm and Friday 4pm, and expected to stay in the ward ≥3 days. INTERVENTION: The continuous bedside pressure mapping system displays the patient's pressure points in real-time colour imagery showing how pressure is distributed at the body-mat interface. The system gives immediate feedback to staff about the patient's pressure points, facilitating preventive interventions related to repositioning. It was used from admittance to discharge from the ward (or 14 days at most). Both intervention and control groups received standard pressure ulcer prevention care. RESULTS: No significant difference in the prevalence and incidence of pressure ulcers was shown between intervention and control groups. The prevalence of pressure ulcers in the intervention group was 24.2% on day 1 and 28.2% on day 14. In the control group the corresponding numbers were 18.2% and 23.8%. Seven of 69 patients (10.1%) in the intervention group and seven of 81 patients (8.6%) in the control group who had no pressure ulcers on admission developed category 1 and category 2 ulcers during their hospital stay. The incidence rate ratio between the intervention and control groups was 1.13 (95% CI: 0.34-3.79). CONCLUSIONS: This study failed to demonstrate a beneficial effect of a pressure mapping system on pressure ulcer prevalence and incidence. However, the study could have increased staff awareness and focus on pressure ulcer prevention, thus affecting the prevalence and incidence of pressure ulcers in a positive way in both study groups. It is important to further investigate the experience of the multidisciplinary team and the patients regarding their use of the pressure mapping system, as well as strengths and weaknesses of the system.

Pressure Mapping in Elderly Care: A Tool to Increase Pressure Injury Knowledge and Awareness Among Staff.

PURPOSE: The purpose of this study was to evaluate the use of a pressure mapping system with real-time feedback of pressure points in elderly care, with specific focus on pressure injury (PI) knowledge/attitudes (staff), interface pressure, and PI prevention activities (residents). DESIGN: Descriptive, 1-group pretest/posttest study. SUBJECTS AND SETTING: A convenience sample of 40 assistant nurses and aides participated in the study; staff members were recruited at daytime, and 1 nighttime meeting was held at the facility. A convenience sample of 12 residents with risk for PI were recruited, 4 from each ward. Inclusion criteria were participants older than 65 years, Modified Norton Scale score 20 or less, and in need of help with turning in order to prevent PI. The study setting was a care facility for the elderly in Uppsala, Sweden. METHODS: A descriptive, comparative pretest/posttest study design was used. The intervention consisted of the use of a pressure mapping system, combined with theoretical and practical teaching. Theoretical and practical information related to PI prevention and the pressure mapping system was presented to the staff. The staff (n = 40) completed the Pressure Ulcer Knowledge and Assessment Tool (PUKAT) and Attitudes towards Pressure Ulcer (APuP) before and following study intervention. Residents' beds were equipped with a pressure mapping system during 7 consecutive days. Peak pressures and preventive interventions were registered 3 times a day by trained study nurses, assistant nurses, and aides. RESULTS: Staff members' PUKAT scores increased significantly (P = .002), while their attitude scores, which were high pretest, remained unchanged. Peak interface pressures were significantly reduced (P = .016), and more preventive interventions (n = 0.012) were implemented when the staff repositioned residents after feedback from the pressure mapping system. CONCLUSIONS: A limited educational intervention, combined with the use of a pressure mapping system, was successful as it improved staff members' knowledge about PI prevention, reduced interface pressure, and increased PI prevention activities. As many of the staff members lacked formal education in PI prevention and management, opportunities for teaching sessions and reflection upon PI prevention should be incorporated into the workplace. More research is needed to evaluate the effect of continuous pressure mapping on the incidence of PI.