Registed Nurses' Association of Ontario

Pressure Ulcer Prevention in the Adult Acute Care Setting

Allison Kirke
Trillium Health Partners

Wound care, like many nursing specializations, is a complex, holistic and enriching area through which to learn and grow as a nurse. Trillium Health Partners (THP) as an organization is full of leaders in a variety of fields that provide many opportunities for nurses and other health care professionals to explore different learning goals. Through the RNAO advanced practice clinical fellowship, I have had the privilege of working and growing in my career with some of these leaders, and strengthened my passion for my nursing career. In these short 3 months, I have quickly developed many skills and completed goals I had thus far in my career. This fellowship was meant to explore different areas in my own learning, find ways to support the front line nurse in skin and wound care and support the organization as a whole at Trillium Health Partners, which I feel have been accomplished. By achieving learning goals like research skills, education and presentation skills, and knowledge and skills in wound care, I have strengthened my confidence as a nurse and my pursuit for wound care specialization.

The fellowship began quickly by jumping into patient assessments and consultations with my primary mentor, and a presentation to the Nursing Advisory Council at Trillium Health Partners to introduce my fellowship and my goals. This kick-started the development of presentation skills and confidence in hands on wound care skills and patient interactions. As my knowledge and skills grew day to day with articles, documents and hands on care, I began creating patient care plans for simple to progressively more complex patient situations. These were evaluated by my mentors and included in patient documentation. My mentors provided challenges and tests for my knowledge throughout the fellowship which kept me motivated and ensured I was on the right path in my learning.

While developing hands on skills, I also worked on research skills by completing chart audits of medicine units; looking at wound care documentation and skin assessments, care plans and observation of daily huddles to understand strengths and weaknesses in these areas. I also created a survey that was very well received by front line nurses for them to express areas they feel are strengths and areas for improvement. This data provided great insight into the needs of front line staff to deliver quality wound care for patients. These results, that front line nurses feel they would like more frequent learning updates, have difficulty choosing products and that care plans and documentation are not being done fully, were presented to the Skin and Wound Committee.

I took the data that was collected from these audits and surveys and compared that to the current tools and resources the staff nurses have for skin and wound care. From this I did a critique of current tools for effectiveness and need for updating. This resulted in working towards creating a revised care plan that would be easier and more time efficient for nurses to use based on their feedback and focus groups on medicine units. I also created a colour coded product picker that is a quick reference for nurses to look at in the stock room or nursing station when choosing appropriate products for a patient. These were revised multiple times after reviewing with my mentors, and were presented at an educator meeting to gain feedback from the clinical educators’ perspective. After further revision, these tools were trialed on one of the medicine units and four in-services were provided to refresh nurses’ knowledge and introduce the new tools. This was very well accepted as nurses expressed it targeted areas they find challenging in wound care. . Feedback to evaluate effectiveness of these tools was done through surveys and focus groups with nurses on 3A that have been using the tools in their practice. The feedback from the surveys and focus groups was positive; the nurses enjoyed the in-services and found the product picker easy to use after being oriented to it. The care plans were not as successful, as the given time they were trialed there were no patients that required a wound care plan, and some of the nurses were unaware of the trial as they did not attend the in-services or see e-mails sent out. Overall feedback is mixed, some said it looks simpler to complete, others saw no difference. These will require further revision and possibly another trial to assess effectiveness. The majority of the feedback from these initiatives; the in-services, product picker and wound care plan, was positive, but does need further modifications before implementation.

I was also fortunate to attend the CAWC learning series during this fellowship. This weekend education session allowed me to gain further knowledge and skills in wound care and pressure ulcer prevention, and to meet others in the field that have the same passion I do but with very different, unique experiences to share. I returned to Trillium with new found confidence and respect for our wound care team. I continued to grow my knowledge through bedside mentorship and critical reflections of experiences I have had with different members of the health care team throughout the fellowship. These reflections allowed me to process all the different learning experiences and find literature to support this growth and progress in my professional life. They also increased my maturity and confidence in a changing role and changing environment which initially presented as a challenge.

On-going literature and article searches provided a wealth of information to guide my learning throughout the fellowship and resulted in a literature review paper on education methods for pressure ulcer prevention. This allowed me to explore different approaches, evidence and organizational strategies that have improved the incidence rates in different institutions with effective education. These results and strategies also guided my approach while presenting at the education sessions for level 1 & 2 skin and wound education days with a power point presentation and interactive case studies, and during the in-services on 3A medicine. Being able to assess learning needs and read body language is an important part of any communication, especially when educating a group of adult learners. This made the experience much smoother and positive than I had anticipated, and having the support from my mentors during the education days was very re-assuring. Being in a position to teach other nurses about wound care really made me realize how far I have come in my learning and my leadership skills.
Lastly, sharing all my work and accomplishments to the wound care team really solidified the entire process for me. To be able to express my gratitude to those involved and make others aware of all I have worked on and learned in the process of this fellowship is very rewarding. To know that all the work, time and effort is recognized and sustained to further my career and improve care at this organization is very fulfilling. For sustainability of my personal learning, Trillium Health Partners supports my enrollment in the Cleveland Clinic’s Wound, Ostomy and Continence Nursing Education program, a goal of mine pre-fellowship. This will further my knowledge and experience in wound care and bring me one step closer to my career goals. I will also be supported by the organization to submit an abstract to the RNAO Best Practice in Wound Care: Minding the Gap conference in March 2014. This abstract will present my goals, achievements and experience throughout the Advanced Clinical Practice Fellowship in pressure ulcer prevention and education.

I will sustain the fellowship’s outcomes throughout the organization by continuing to revise the tools for staff and the Skin & Wound team based on the feedback from staff and work with clinical informatics to create an online care plan for nurses to access across the organization. Continuing to be a member of the Skin & Wound committee at THP will sustain the outcomes of the fellowship as I will be able to apply and maintain my new knowledge and experience. These skills will also be applied to THP’s annual pressure ulcer prevalence and incidence study that I will participate in and demonstrate the effectiveness of the strategies implemented throughout the fellowship. Lastly, the changing roles and responsibilities throughout the merger of Trillium Health Centre and Credit Valley Hospital have shown a need for more bedside support. I will be contributing to the organization by using my leadership and presentation skills to participate in and facilitate in-services for clinical leaders at THP M-site to boost their confidence in stage I & II pressure ulcer knowledge, prevention and treatment to act as hands on resources for front line nurses.

The experience of the RNAO Advanced Practice Clinical Fellowship has been unlike any other I have had in my career. By setting learning goals and targets, I was able to accomplish more than I imagined for myself, my fellow nurses, and for the organization as a whole. This fellowship has strengthened my leadership skills, confidence, and understanding of how the organization functions on a much larger scale than I could experience on my home unit. Although I was presented with many challenges throughout, I feel I have grown from them and overcome many personally and in practice that I have encountered. The support of my mentors and THP has helped me grow in my learning and overcome challenges that have surfaced throughout the fellowship. I am a much more knowledgeable, confident and motivated nurse because of the RNAO Advanced Practice Clinical Fellowship and my career path has changed for the better because of it. The support of my mentors and THP has helped me grow in my learning and overcome challenges that have surfaced throughout the fellowship.

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