JOURNAL CRITIQUE

Jericho S. Javier, R.N. 16 November 2013

Master of Arts in Nursing Dr. Bella G. Panlilio

Factors of importance to the development of pressure ulcers in the care trajectory:
perceptions of hospital and community care nurses
By Elsy Athlin, Ewa Idvall, Margareth Jernfa lt and Inger Johansson

When caring for patients it is vital that nurses are utilizing the current best practice and to
determine what this is, nurses must be able to read research critically. It is of the essence in
nursing that care has its foundation on sound research and it is important that all nurses have the
ability to critically evaluate research to identify what is best practice. A good research critique
involves a careful, complete examination of that study to judge its strengths, weaknesses,
meaning, credibility, and significance for practice (Burns & Grove, 2010, p. 419). This paper
will critique a qualitative study on pressure ulcers.

Introduction
"A pressure ulcer is a localized injury to the skin and/ or underlying tissue usually over a
bony prominence, as a result of pressure or pressure in combination with shear and/ or friction."
(National Pressure Ulcer Advisory Panel, 2007). It is important to give education to the patients,
family, and health care providers to decrease incidence of pressure ulcer. Various studies about
pressure ulcer revealed that it causes significant harm to the patients by increasing the length of
stay in the hospital due to frequent pain, discomfort, infection and poor healing. A complication
of sepsis occurs from pressure ulcer which eventually can even lead to death. Pressure ulcers are
most likely to occur in the elderly, those having diabetes mellitus, hypertension, dementia, and
arthritis, and nurses must take early prevention steps to avoid it. "This study aimed at describing
contributing factors for the progression or regression of pressure ulcers in the care trajectory as
they are understood by nurses working in hospitals or community care." (Athlin et al. 2010).
The author clearly explained and was able to identify the contributing factors for the
development of pressure ulcer in the health care setting. The research discusses the weak point in
the care trajectory using a qualitative design study. Understanding this weakness through the
perception of the nurses can improve patient outcomes; this is the research problem in the study.

Background of study
Nurses play an important role in the prevention of pressure ulcer. Educational programs
in the hospital provide good knowledge to nurses about the preventive and treatment methods of
pressure ulcer. But some studies pointed that nurses need more updated knowledge about
pressure ulcer and due to unorganized systems or shortage of time they do not use this
knowledge in their work place. "Watts and Gardner (2005) found an inconsistency between the
nursing documentation and discharge plan and lack of routines concerning communication
between the bedside nurse and other members of the health team regarding discharge planning."
(Athlin et al. 2010). This study was done because the pressure ulcer development is directly
connected with nurses awareness among pressure ulcer and early prevention. The purpose of
this study was to analyze hospital and community care nurse's opinion and reasons, which may
cause to develop or help to prevent pressure ulcer in the care trajectory. The researcher
established the significance of the study by highlighting the role of the nurse in the prevention of
the pressure ulcers and how the break in care contributes to the development and progression of
pressure ulcers.

Method
A qualitative research approach was used in this study. The Registered Nurses (RNs)
from community health care and two hospitals in the eastern and western part of Sweden are the
participants of this study. Research team used the help of Registered Nurses with at least five
years of experience and with last six months of experience of taking care of pressure ulcer
patients for the success of the study. The informants of the study were from two different units of
small and large hospital as well as from a rural and urban community. Total of 29 women and
one man from 34-55 years of ages agreed to participate in this study. Among the participants, 16
worked in the hospital units (11 from surgery, 4 from medicine, and 1 from intensive care unit)
and remaining 13 are from different community care settings includes both urban and rural. Data
analysis is done by using qualitative content analysis method. However, it was not mentioned in
the research if the participants were informed about the aim of the study prior to data collection,
as it may have an effect in the result of the research finding.

Findings
The study found that there were three major categories and nine sub-categories that
contribute to the development and prevention or develop pressure ulcer. The factors related to
individual patient, health care personnel and health care structure are under the major categories.
The physical condition, place of care, psychological condition and patient and family
participation are factors under the individual patient care. The entire participants of the research
study stated that patient's general condition is an important factor, for example clean, healthy and
dry skin help to prevent pressure ulcer to certain extent. The mental health, readiness and ability
of the patients to participate in their care are the crucial factor to prevent pressure ulcer. Both
hospital and the community health care nurses stated that place of care is another vital element
for the pressure sore development. Prolonged hospital stay increases the chance of pressure ulcer
development. To prevent the development of pressure sores, patients need to be turned and
mobilized every two hours especially the elderly people who are bed bounded and others who
are unable to move by themselves. The study highlighted that critical care unit and emergency
care unit are the most high risk places for the development of pressure ulcer.

Factors connected to the health care personnel are views and values, responsibility and
commitment, knowledge and competence and co-operation and communication. "The personnel's
view of their work was seen as one reason for the development of pressure ulcer." (Athlin et al.
2010). In a hospital situation, the main care focuses to treat the disease whereas in the
communities care focused on prevention and basic pressure ulcer care. Responsibility and
commitment of the nurses can prevention of pressure sore to certain extend. It is the
responsibility of the nurse to assess for risk factors and prevention of pressure ulcers. Nurses
should show an interest in their work especially to take the patients total care in order to prevent
pressure sore. Nurses should constantly update their knowledge and implement evidence based
practice in their care. They need to educate the patients, families and other health care providers
about the measures to prevent bedsore. Proper communication between the nurses regarding the
preventive measures implemented is very important to maintain continuity of care and prevent
bedsore.

Factors related to health care structure include organization, routines in the health care
system and available resource. In the hospital, several health care personnel are involved in the
patient care and this may lead to neglect in the care trajectory. Some informants of the research
study mentioned that assigning a primary registered Nurse along with LPNs to each patient is
helpful to prevent pressure sore. By analyzing this study we can see that "the study highlighted
attitudes and values among registered nurses, as well as to how to preserve their commitment and
increase their knowledge concerning prevention of pressure ulcers." (Athlin et al. 2010)

Ethical Consideration
Study was performed according to ethical guidelines and consent was obtained from the
nursing services and participants prior to the study. Patient privacy was protected and no ethical
issues were mentioned in this study.

Conclusion
This study increases the knowledge and awareness about the factors that can cause
pressure sore and measures to prevent it. The result of the study highlighted the three factors that
influence the prevention of pressure ulcer. It also highlights the responsibility of health care
personnel in the prevention of pressure sore by improving cooperation and communication
between health care personnel participating in the patient care. However, further studies are
needed to increase our understanding about the prevention and treatment of pressure ulcer.