Implementing and sustaining the pressure injury prevention project among the older adult patients in the hospital setting of Baycrest Health Sciences
Summary
Baycrest Health Sciences is a global leader in geriatric residential living, healthcare, research, innovation and education. Baycrest provides care experience for aging clients in complex continuing care, rehabilitation, transitional care, palliative care and mental health services. Baycrest care for a complex geriatric population with multiple co-morbidities that prevent them from moving around. The comorbidity such as diabetes, history of stroke, cardiac and other issues put this patient in the complex continue care at high risk of developing pressure injury. The new definition of pressure injury by NPUAP describe pressure injury as a localised tissue ischemia due to prolong pressure higher than the capillary pressure over a bony prominent due to immobility (Edsberg et al, 2016).
In 2018/2019, a fellow worked with an APN to focus on reducing the number of stage two and above pressure injuries on three complex continuing care hospital units from 0.63% to 0.13% per patient. During this project, the advanced practice nursing team implemented three change ideas which are (1) quarterly point-of-care nursing-led PI prevalence and incidence studies; (2) standardized positioning plans developed from inter-disciplinary bedside assessments; and (3) revising a current mattress selection algorithm. The Quality Improvement Plan for 2019/ 2020 is to reduce the incidence of pressure injuries (stage 2+) on three Baycrest Complex Continuing Care (CCC) units to 0.26% per patient day from 0.32%. The organization plan on implementing three major change ideas to achieve this goal includes (1) Quarterly nursing-led Prevalence and Incident studies on all CCC units, with a focus on accurate Meditech documentation (2) Standardized documentation during CCC Skin/ Wound Rounds and (3) CCC patient and families are provided with patient-friendly pressure injury prevention and management information upon admission.
My overall goal was to enhance my knowledge and gain understanding in the implementing and sustaining of the pressure injury prevention project among the older adult patients in the hospital setting of Baycrest Health Sciences. RNAO Best Practice Guideline Risk Assessment and prevention of Pressure Ulcers (2011).
My objectives were to gain the knowledge and understanding and be able to identify an evidence-based practice of implementing and sustaining a pressure injury prevention, gain skill of implementation and disseminate my findings. I am happy to say that I achieved all these within my limited time. I gained knowledge and understanding of different tools available to implement a project, however the RNAO BPG Toolkit: Knowledge–to–Action Process was the guide used for this project. As an independent learner, I learned how to make effective use of my time, coordinate timely meetings, seek my own learning opportunities and demonstrate professionalism. Through the fellowship experience I developed skills in research, effective communication, leadership and knowledge transfer. Being a fellow and having mentors that supported me has led to increased self confidence and helped me developed a better understanding of knowledge to action model and other tools that are used in quality improvement work such as PICK charts and fish bone diagrams.
My fellowship journey allowed me to meet different professionals who shared their unique knowledge of preventing pressure injury. I developed great knowledge of developing a brochure for the elderly using plain language supported by evidence based, working with the interprofessional team. One of the most important skillsets is knowing how to work together with the team to use a plain language in developing the brochure and importance of using a questionnaire to check back their understanding of the brochure. This open my eyes to the importance of collaborating with the target audience during the process and checking with them along the way. Being a fellow allowed me to ask relevant questions and understand the stakeholder’s involvement in implementing a project in an organization.
I have gained expertise in public speaking, chairing meetings and facilitating workshops. I learned to share the great nursing knowledge that would help professionals recognise the contribution nursing makes in enhancing the quality of life in the elderly. Conducting this project was a unique experience for me because I have the opportunity of working with my manager and meeting other management staff. I also have the privilege of working with the IT department in developing documentation system for the staff and use the opportunity to advocate for realistic documentation for nurses. The documentation development is in process and it is going to be the way to sustain the patient and family education in preventing pressure injury among the older adult in the CCC unit.
Outcomes
As part of the fellowship I had the privilege of exploring different tools use in auditing nursing documentation. These tools were used to evaluate nursing documentation after the incident and prevalence (PI) study of pressure injury on CCC unit. The study helps to identify new and existing cases of pressure injury. As a result of this process the team was able to identify issues with documentation and established a common place for documentation on PI study day. This documentation will now help in collating pressure injury report for the study.
Also, on PI days, it was discovered that nurses are not readily available for the patient assessment because of workload. In one of the units we introduce a PSW support and compare to the other unit without the use of PSW. Results indicate that the use of PSW for 4hrs on PI days helps the staff to engage with assessment and adequate documentation hence improve the PI study report. This outcome now leads to supporting all the unit staff on PI days to engage staff in assessment and documentation on PI days.
In updating the brochure for patient and family on how to prevent pressure injury, all interprofessional team were involved during the process. The rigour was a lot as it allowed me to understand how easy medical jargons can be easy for healthcare practitioner but difficult for the patient, but the outcome was better. The team look at the prevention of pressure injury in silo as well as a team to improve the brochure. This led to conducting a questionnaire to see what the Patient, Family and patient/family volunteer understands by certain language use in the developing the brochure. The response helps understand what needed to be changed to make it clearer for the patient to understand and read. Their feedback was used to change some language in the brochure as they are the target audience of the product.
The fellowship did not only lead to my professional development, it also directly impacted the staff/management/stakeholders that I worked with. Conducting a questionnaire among the nursing staff during the fellowship gives voice to the staff to express the impact of PI study days on their day to day activity. The support of PSW on PI days improve staff engagement in pressure injury assessment on PI days. It also helps identify that staff have more than one place to document on pressure injury on PI days. This process helps to determine a common place for all staff to document on PI study days. This resolution leads to proper documentation and getting an accurate report for prevalence and incidence of pressure injury among the patient on CCC unit. The fellowship helps the management to understand the staff workload and the importance of providing extra support on PI days.
The process of updating the brochure to meet the best Practice in Patient and Family Education that will lead to improving safety by engaging inpatients in the Pressure Injuries prevention has a great outcome for patient/staff of Baycrest and some colleague at wound Canada conference. A colleague from the conference already reach out for the process to be used in their own organization as well. The revised handout was evaluated by complex continuing care patients (n = 5) and families (n = 5). Additionally, pre-post feedback was obtained from 12 client-family partners. A pre-post evaluation of readability was conducted using three validated tools. The tools evaluated the original and the redesigned handout on how easy it is for patients and families to read and understand the content by assessing principals of client and family education. All three tools show an improvement in readability after the redesign: Flesch reading ease score (From 54.3 to 62.1), Flesch Kincaid (From grade 12.2 to grade 10 reading level), and Fry readability formula (From grade 10.5 to grade 9.5 reading level). The new brochure now meets the evidence-based practice which is good for the organization, easy to read and understand for patient and common language for all healthcare professional staff to educate patient on pressure injury prevention at Baycrest.
Overall experience
As a registered nurse working at the bedside confined you to a structured box environment where you need to finish your task within an allocated time. The Advanced clinical practice fellowship is an opportunity for bedside nurse to independently think outside that structured box and collaborate with not just patients and family but the management and stakeholders even other staff and resources that exist in an organization. The fellowship is very well designed to encourage and promote independent learning of nurses. The design of the fellowship encourages and empowers nurses to critically think and become creative in their ideas towards the care we provide and promoting the nursing profession as whole.
One of the moments was after the rigour of using plain language to our best knowledge and we use the readability test to check the brochure and still find out that we did not meet our target goal. This is something new for me, but it also opens my eyes to understand that our medical jargons can be very easy to us, but we need to be more careful when using this language on our patients. Having the opportunity to independently focus on learning different elements of nursing that I am interested in and promote my autonomy as a nurse is the ultimate thing for me. The knowledge acquired during the process of updating the brochure will continue to help my bedside nursing as well as my role as a Nurse educator.
I took the time to reflect on my successes and possible areas of opportunities and utilised the resources with help of my mentors to overcome any gaps in my skills and knowledge. Independent learning made me an independent thinker which is an exceptional quality to have as nursing researcher.
References
Edsberg L, Black J, Goldberg M, McNichol L, Moore L, and Sieggreen M. (2016). Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System. J Wound Ostomy Continence Nurs. 2016 Nov; 43(6): 585–597
