We Need to Take Action Now
Pressure injuries (PI) have become an alarming health issue in Canada, where at least 25% of both Canadians and Quebecers have developed a hospital-acquired pressure injury (HAPI) (‘Pressure ulcers’, 2016). PIs cause patients to suffer, cost billions of dollars on treatment and resources, and can cause a clash in nurses’ values and ethical responsibilities. The majority of the Quebec population speak only French, but French PI prevention programs are either too few, expensive, not easily accessible, incomplete, and offer no follow-up after completing the course.
There is an urgent need to create a French pressure injury (PI) prevention program for nurses working in French hospitals in Quebec in order to decrease the incidence and prevalence of hospital-acquired pressure injuries (HAPIs). In this post, we will look at how PIs affect patients, the healthcare system and nurses. We will also look at factors that affect care, case-based learning, the use of wound care specialists and preceptors, and how we can work towards putting in place a French PI prevention program in Quebec.
Pressure Injuries. What are they?
A PI is described as “localized damage to the skin and/or underlying soft tissue, usually over a bony prominence” (Orsted, Ho & Kuhnke, 2016). A PI is the result of intense and prolonged pressure on the skin (Orsted, Ho & Kuhnke, 2016). PIs range from stage 1 to unstageable, with one being a non-blanchable erythema of intact skin, to unstageable being full-thickness skin and tissue loss obscured by black or brown dead skin (Orsted, Ho & Kuhnke, 2016). A hospital-acquired pressure injury (HAPI) is a PI developed during a hospital stay. Let us look at some statistics in order to understand the gravity of this issue.
Statistics in Quebec
Approximately 25.1 % of all hospitalized patients in Quebec develop a PI.
There are 8 million people living in Quebec.
There are 2 million people aged 65 and older living in Quebec (‘Census profile, 2016 census Québec and Canada’, 2019; ‘Population de Québec 1971-2018’, 2018). This population is particularly considered 'at risk' due to their physiology.
With such an elevated number of older adults in the Quebec population, interventions must be put in place to protect this at-risk population and others from developing PIs.
What About the Language?
There are 6 out of 8 million people who speak only French.
There are 1.5 million people who speak French and English (‘English-French bilingualism reaches new heights’, 2017; ‘Population de Québec 1971-2018’, 2018).
It is safe to assume that most nurses speak only French and a minority speak both English and French. This further proves the important need to develop a French PI prevention program in Quebec.
Who are HAPIs affecting?
Patients
In a study conducted by McGinnis et al. (2015), patients avoided socialising due to PI-related pain, discomfort, odour and exudate, whereas others expressed anxiety regarding the worsening or chances of developing PI infections, and some also felt let down by healthcare professionals. Patients health and quality of life are greatly affected by HAPIs, although the healthcare system is also equally affected.
Healthcare budget
Treating PIs requires using many resources, such as nurse and physician time; wound treatment or management which includes assessment, wound debridement, wound cleaning, infection control and use of expensive dressings; and increase in length of hospital stay (Chan et al., 2018). The total healthcare expenditure for PI management in Québec from 2018 to 2019 was 38.5 billion dollars (Québec Handy Numbers, 2018).
Nurses
In a study conducted by Tallier et al., (2017), nurses had a lack of knowledge in PI prevention strategies. One third of the participants has not listened to or attended a lecture in over four years, the other third had read an article about the current PI guidelines in the previous year, and the other third of participants reported not having received formal training on PI prevention and management (Tallier et al., 2017).
Nurses require resources and support to deliver quality care to patients, and to positively influence patient health outcomes (‘Framework for the practice of registered nurses in Canada’, 2015).
How is This Happening? Factors Influencing Care
Below we will look at some important factors that influence the care patients receive.
Staff ratios
A higher number of patients per nurses increases the chances of errors, care left undone, and patient mortality (Amiri & Solankallio-Vahteri, 2019)
Overtime
Fatigue affect nurse’s ability to provide patient-centered care, good judgement and reaction time, and tasks also remain undone (Lobo et al., 2017).
Lack of available resources
Having access to a clinical nurse specialist in wound care can help reduce HAPIs. A wound care specialist nurse can put in place recent evidence-informed guidelines in clinical practice, be a consultant for nurses who wish to have specialist advice in PI prevention and management, act as a preceptor or mentor, train nurses, and give them bedside instruction (Fremmelevholm & Soegaard, 2018).
Lack of knowledge on wounds
Without knowledge on prevention and management strategies, nurses cannot provide quality care or prevent and manage wounds. What about courses offered by universities, hospitals and the Order of Nurses of Quebec?
Courses Offered by Universities, Hospitals, and the OIIQ
In Quebec there are many prevention programs offered by universities, hospitals, and the Order of Nurses of Quebec (OIIQ), although there are many barriers to attending the programs. Current PI prevention programs in Quebec are optional, expensive and offer no follow-up after the course is completed. This creates an imbalance among nurses and prevents nurses from applying the learned theory to practice. What can we do about this?
Teaching and Learning About PIs
Knowledge and clinical judgement are the basis of safe and effective nursing practice. Case-based learning (CBL) is the most effective method for students to learn (Kantar & Sailian, 2018; Li, Ye & Chen, 2019). Wound prevention programs can be taught using the CBL method.
Case-based learning (CBL)
CBL is a participatory teaching-learning method which involves matching clinical cases in health to a body of knowledge to help improve critical thinking skills, clinical performance and teamwork (Li, Ye & Chen, 2019). This includes using approaches such as simulated cases such as guided inquiry, role plays, and simulated patient care (Li, Ye & Chen, 2019). Case studies have been found to be an engaging teaching method that promote critical thinking and decision making, necessary for safe clinical practice in nursing (Burke, 2017).
Applying theory to practice
The goal of education is to develop nurses who can deliver high-quality nursing care in a way that combines nursing theory and practice (Bvumwe, 2016). Experiences in the clinical setting must go hand in hand with theory in order for this to happen. However, the gap between theory and practice continues to be an issue in nursing (Pjil-Zieber et al., 2015). The use of wound care specialist nurses and preceptors has been recognized as an effective way to increase learning and skill development because they can provide multiple and varied opportunities for learners to link course learning to actual workplace environments (Saifan et al., 2015; Thibeault, 2017).
Recommendations
Recommendations focus on the need to create and put in place a French PI prevention program in French hospitals in Quebec. Prior to the creation and implementation of such a program, a pilot study should be conducted. The PI prevention program must be offered by the employer, mandatory and free for all nurses and LPNs, in order to increase knowledge level and quality practice. This will also ensure that all employees are up to date with current guidelines on PI prevention and management. It is important for wound care specialists and clinical preceptors to be available for staff after course completion for questioning, guidance, and additional training. They are the key to ensure a smooth transition from theory to practice. The bottom line is that PIs are almost 100% preventable, therefore patients, the healthcare system, and nurses should no longer have to suffer.
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