Original Article

Healthy Skin Wins: A Glowing Pressure

Ulcer Prevention Program That Can Guide
Evidence-Based Practice
Donna Martin, RN, PhD • Lisa Albensi, RN, MSN • Stephanie Van Haute, RN, BN •
Maria Froese, BMR-PT, MClSc-WH • Mary Montgomery, BMR – OT • Mavis Lam, BA,
BHEcol, RD • Kendra Gierys, RN, BN • Rob Lajeunesse, RN, BN • Lorna Guse, RN,
PhD • Nataliya Basova, RN, BN

ABSTRACT
Background: In 2013, an observational survey was conducted among 242 in-patients in a com-
Keywords munity hospital with a pressure ulcer (PU) prevalence of 34.3%. An evidence-based pressure
evidence-based ulcer prevention program (PUPP) was then implemented including a staff awareness campaign
entitled “Healthy Skin Wins” with an online tutorial about PU prevention.
practice,
mixed methods, Aims: To determine the effectiveness of the PUPP in reducing the prevalence of PUs, to
on-line tutorial, determine the effectiveness of the online tutorial in increasing hospital staff’s knowledge level
pressure injury, about PU prevention, and to explore frontline staff’s perspectives of the PUPP.
pressure ulcer, Methods: This was a mixed methods study. A repeat observational survey discerned if the
pressure ulcer PUPP reduced PU prevalence. A pre-test post-test design was used to determine whether
prevention hospital staff’s knowledge of PU prevention was enhanced by the online tutorial. Qualitative
interviews were conducted with nurses, allied health professionals, and health care aides to
explore staff’s perspectives of the PUPP.
Results: A comparison of initial and repeat observational surveys (n = 239) identified a
statistically significant reduction in the prevalence of PU to 7.53% (p < .001). The online tutorial
enhanced staff knowledge level with a statistically significantly higher mean post-test score (n =
80). Thirty- five frontline staff shared their perspectives of the PUPP with “it’s definitely a
combination of
everything” and “there’s a disconnect between what’s needed and what’s available” as the main
themes.
Conclusions: Incorporating evidence-based PU prevention into clinical practice greatly
reduced the prevalence of PUs among hospital in-patients. Due to the small sample size for the
pre-test post-test component, the effectiveness of the online tutorial in improving the knowledge
level of PU prevention among hospital staff requires further research.
Linking Evidence to Action: Evidence-based PU prevention strategies are facilitated by using
a multidisciplinary approach. Educational tools about PU prevention must target all members of
the healthcare team including healthcare aides, patients and families.

INTRODUCTION sensory perception disorders (Gallant, Morin, St-Germain, &

A pressure ulcer (PU) is a localized injury to the skin or
underlying tissues resulting from pressure or shear forces
over bony prominences (Stinson, Gillan, & Porter-Armstrong,
2013). Recently, PUs have also been referred to as pressure in-
juries (Chaboyer et al., 2015; McInnes, Jammali-Blasi,
Cullum, Bell-Syer, & Dumville, 2013). Pressure ulcers range
in sever- ity from non-blanchable erythema (Stage 1) to
superficial skin loss (Stage 2), to loss of fat, muscle, and
bone (Stages 3 and 4; Stevenson et al., 2013). Contributing
and confounding fac- tors include immobility, moisture, poor
nutritional status, and
Dallaire, 2010; Garcia-Fernandez, Agreda, Verdu, & Pancorbo-
Hidalgo, 2014). Pressure ulcers develop primarily in elderly,
debilitated, and immobile individuals in hospitals,
personal care homes, and home care (Pamaiahgari, 2014).
Pressure ulcers result in high human and economic costs
with a lower quality of life and significant pain,
diminished functional autonomy, serious infections, and
longer hospital stays with extra costs to the healthcare
system (Chan, Ieraci, Mitsakakis, Pham, & Krahn, 2013; Chou
et al., 2013; Frumenti & Kurtz, 2014; Gallant et al., 2010;
Tayyib & Coyer, 2017).

Worldviews on Evidence-Based Nursing, 2017; 14:6, 473–483. 473

C 2017 The Authors. Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing.
Ⓧ
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Healthy Skin
Wins

Patients with a PU often experience emotional and current evi- dence to determine best practices in prevention
psychologi- cal trauma from pain and physical limitations, and manage- ment of PUs (Titler et al., 2001). “Innovations in
significantly re- ducing their quality of life (Shannon, Brown, the hospital
& Chakravarthy, 2012). Occurrences of PUs are correlated
with amputation, im- mobility, and shortened life span
(Zhou, Xu, Tang, & Chen, 2014).
“Pressure ulcers are a recognized indicator of the quality of
health care both in Canada and the USA” (Gallant et al., 2010,
p. 184). Although there is consensus that not all PUs can be
avoided, their development is preventable in most
instances (Gallant et al., 2010; Beeckman, Defloor,
Schoonhoven, & Vanderwee, 2011). Evidence-based practice
guidelines about PU prevention and treatment have
been developed and promoted locally and globally
(British Columbia Provincial Nursing Skin and Wound
Committee, 2014; National Pressure Ulcer Advisory Panel,
European Pressure Ulcer Advisory Panel, & Pan Pacific
Pressure Injury Alliance, 2014; Registered Nurses’
Association of Ontario, 2016; Winnipeg Regional Health
Authority, 2012). Changing material resources and in-
terventions may be challenging for some healthcare providers,
but educational opportunities about evidence-based practice
have enhanced adoption of best practices (Baldelli & Paciella,
2008; Chaboyer et al., 2016; Chaboyer & Gillespie, 2014;
Hunter, Kelly, Stanley, Stilley, & Anderson, 2014; Murray,
2012; Roberts et al., 2016; Schmidt & Brown, 2012).
A PU prevalence of 29.9% was estimated in acute
care
hospitals in Canada with half of the PUs assessed
as Stage 1 (Woodbury & Houghton, 2004). In a 304-bed
commu- nity hospital in Winnipeg, Canada, an observational
survey was conducted in November 2013 to determine the
prevalence and incidence of PUs. The prevalence of PUs was
34.3% (83/242) with two thirds of PUs at Stage 2 or higher.
Six days later, an- other observational survey was conducted
among patients who had remained hospitalized to determine
the incidence of PUs, which was 16.5% (19/115). These
results triggered the need to implement an evidence-based
pressure ulcer prevention program (PUPP).

CREATION AND IMPLEMENTATION OF

A PRESSURE ULCER PREVENTION
PROGRAM
A steering committee, comprised of academics, nurses, allied
health professionals, educators and administrators was estab-
lished to oversee the development and implementation of the
PUPP, which was entitled “Healthy Skin Wins.” The
Iowa Model of Evidence-Based Practice to Promote Quality
Care (Titler et al., 2001) in conjunction with Rogers’ (2003)
Diffu- sion of Innovations Model served as guiding
frameworks for the PUPP (Buss, Halfens, Abu-Saad, & Kok,
1999).
This committee facilitated the adoption of best
practices in PU prevention with the objective of decreasing
PUs on all in-patient units. Several subcommittees reviewed

474 Worldviews on Evidence-Based Nursing, 2017; 14:6, 473–

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ⓍC 2017 The Authors. Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing.
setting can be defined as changing standard practices based
on current knowledge and research data” (Tayyib & Coyer,
2017,
p. 8). These subcommittees were comprised of multidisci-
plinary members from various hospital departments includ-
ing nursing, dietetics, occupational therapy, physical
therapy, materials management, and wound care.
Staff Awareness Campaign
A logo was created to illustrate “Healthy Skin Wins” and
com- municate that PU prevention was a hospital-wide
priority. The logo was used on all communications to staff
about changes in material resources and practices to prevent
and manage PUs. With multiple components of the PUPP, a
strategic roll-out was vitally important. Updates were shared
with all nurse lead- ers and quality and management teams
with the PUPP as a standing item on meeting agendas. Front
line managers were tasked with communicating changes in
resources and prac- tices to healthcare providers via posters,
staff meetings, and huddles.
Screening and Referral Tool
With permission from the British Columbia Provincial
Nurs- ing Skin and Wound Committee (2014),
information from their PU prevention form was
incorporated and adopted into a PU screening and referral
form. This document was based on the aforementioned
form and the Braden Scale (Braden & Bergstrom, 1989). It
was piloted, revised, and implemented hospital-wide with
patients requiring assistance with mobility. Allied health pro-
fessionals provided educational sessions at the unit level
to support appropriate use of sliders for patient
repositioning (Moore, Cowman, & Conroy, 2011). Changes in
these material resources and practices served to: (a) eliminate
extra layering under patients, (b) improve moisture
reduction, and (c) de- crease friction and sheer. Heel-lift
boots were introduced for patients identified as at-risk for
heel and foot wounds (D’Arcy, 2014; Pamaiahgari, 2014).
Heel-lift boots were used in the emergency department,
the operating room, and on in-patient units.
Incontinence care was enhanced by limiting the availabil-
ity and use of washable soakers. Disposable soaker pads
were provided when patients had special needs such as
exudative wounds. New incontinence products were obtained
and evalu- ated to provide appropriate moisture-reduction.
Staff Education
The wound care committee collaborated with members of re-
gional programs to ensure that nurses were offered
continuing education about PU prevention and management
(Buss et al., 1999). Several nurses from in-patient units
received training in advanced wound care. Advanced wound
care nurses served as referents at the unit level until a
certified wound care nurse completed a comprehensive
patient assessment with further recommendations. Advanced
wound care nurses also con- ducted observational surveys of
Worldviews on Evidence-Based Nursing, 2017; 14:6, 473–483.
ⓍC 2017 The Authors. Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of
Nursing.
education of the staff provided Original Article
by the hospi- tal’s nurse
educators. With a predictive validity of the modified Braden
Scale found to be .72 and its higher interrater reliabil- ity, it
was deemed appropriate for the patient population in this
community hospital (Chen, Cao, Zhang, Wang, & Huai, 2017;
Park, Lee, & Kwon, 2016).
The PU screening and referral form was completed by
nurses within the first 8 hours of a patient’s admission and
then repeated every 48 hours. For patients with length of stays
over 8 hours in the emergency department and all patients
in the intensive care unit, nurses completed and
documented these assessments every 24 hours. High risk
scores (dependent on the category) alerted nurses to the need
to refer patients to allied health professionals, certified wound
care nurses, and physi- cians (Keast, Parslow, Houghton,
Norton, & Fraser, 2007). A nutrition screening tool was
developed and piloted to track pa- tients’ nutritional intake and
identify patients who would ben- efit from dieticians’
expertise. The hospital’s dieticians taught the healthcare aides
and nurses how to use the nutrition screen- ing tool during
unit staff meetings.
Material Resources
Specialty sleep surface mattresses were purchased hospital-
wide and 12 powered therapeutic sleep surfaces were ob-
tained for high risk patients (D’Arcy, 2014; Pamaiahgari,
2014). Turning sheets were removed from stock and
their use was discouraged. After purchasing additional
sliders for all units, sliders were reintroduced to facilitate
repositioning of
in-patients to determine PU prevalence and incidence.
Hands-on tutorial. Hands-on instruction was provided to
nurses and healthcare aides about the aforementioned new
equipment. Vendors for mattresses, sliders and inconti- nence
products introduced the materials, provided demon- strations,
and answered questions related to the use of new products.
Online tutorial. To further facilitate the education of allied
health professionals, nurses, and healthcare aides, a 15-MINUTE
on-line tutorial was developed, piloted, and evaluated. Con-
tent was based on current evidence and tailored to address
items in the PU knowledge assessment tool (Beeckman et al.,
2010). The tutorial was introduced using Sussman’s famous
statement, “We need to treat the whole patient—not the hole
in the patient.” Current evidence was used to compile infor-
mation about PU pathophysiology, assessment, prevention,
and treatment. The format was a PowerPoint with voiceover
and embedded instructional videos. The 15-MINUTE timeframe
was appropriate to facilitate direct care providers’ availabil-
ity and engagement and was supported by unit managers.
This multi-media tutorial summarized best practices in PU
screening, prevention, and management and it is available at
HTTPS://WWW.YOUTUBE.COM/WATCH?V = 0C_AB4QBE2S.
AIMS AND OBJECTIVES
This study aimed to evaluate the effectiveness of the PUPP in
reducing prevalence of PUs and enhancing hospital staff’s
475
 Healthy Skin
Wins
knowledge about PU prevention. Research questions were: care nurse per team. Wound care committee members, as
(a) Did the online tutorial produce a statistically significant well as certi- fied wound care nurses, were available as
ele- vation in the knowledge level of PUs and PU additional resources to verify or refute observational survey
prevention among healthcare aides, nurses, and allied results. However, inter-
health professionals? rater reliability tests were not formally conducted.
(b) Did the PUPP produce a statistically significant
reduction in the prevalence and incidence of PUs (all
stages)? (c) What were healthcare aides, nurses, and allied
health professionals’ perceptions and experiences of the
PUPP?

METHODS
An explanatory sequential mixed methods study was used.
It began with quantitative data collection and analysis
followed by a qualitative component. A biostatistician was
consulted to determine appropriate sample size to answer
the first two re- search questions. Beeckman et al.’s (2010)
26-ITEM knowledge assessment tool was used with
permission as psychometric as- sessments deemed it as
reliable and valid. Beeckman et al.’s PU knowledge
assessment tool was shortened to 18-items and used in pre-
tests post-tests. Shortening the knowledge assess- ment tool
was deemed necessary to facilitate frontline staff
participation and limit their time away from patients. Each
cor- rect answer provided a score of 1 with a perfect
score being
18. A power analysis indicated that a sample size of 90 was
required for the pre-test post-test design used to answer the
first research question.
Following approval from two research ethics boards,
recruit- ment began. A pre-test post-test design was used to
evaluate the effectiveness of the online tutorial in improving
staff’s knowl- edge level. Using FluidSurveys.com, an
informational letter, demographic survey, pre-test, 15-
MINUTE online tutorial, and post-test was offered to
healthcare aides, nurses, and allied health professionals.
A $5 gift card to the in-hospital coffee shop and a
chance to win a $150 gift card at an on-site fit- ness
center were used as incentives to participate. Subjects
completed the demographic survey, an 18-item PU
prevention knowledge assessment tool (pre-test), viewed the
15-MINUTE on- line tutorial, and then completed the post-test.
A paired sample t test was used to compare mean pre-test
and post-test scores. A biostatistician determined that a total
sample size of 480 (240 in the 2013 and 240 in the 2014
observational surveys) was required to answer the second
research question. To an- swer the second research
question, an observational survey of in-patients’ skin was
repeated in November 2014 to deter- mine the prevalence
and incidence of PUs using a modified Braden scale. In
this regional health authority, observational surveys are
conducted on an annual basis to determine PU
prevalence and incidence among in-hospital patients. Prior
to observational surveys, surveyors are trained to identify,
stage, and document PUs. Survey teams were comprised
of three staff members with at least one advanced wound

476 Worldviews on Evidence-Based Nursing, 2017; 14:6, 473–

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ⓍC 2017 The Authors. Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing.
 Inclusion criteria included all admitted patients over . What physical resources (equipment, supplies, staff)
18 years of age who provided verbal consent. Prevalence data
could be made available to you to help your team
were collected on “day one.” The incidence study was
prevent PUs?
repeated six days later for all patients who remained
hospitalized and partic- ipated in the prevalence study.
Pearson chi-square analysis was used to identify if there was a
statistically significant reduction in the prevalence and
incidence of PUs by comparing Novem- ber 2013
(pre-“Healthy Skin Wins” campaign) with November 2014
results (12 months of evidence-based PUPP).
To address the third research question, audio-recorded,
semi-structured interviews were conducted with healthcare
aides, nurses, and allied healthcare professionals who volun-
teered to participate. A purposive sampling strategy was
used. Eligibility criteria included part-time and full-time
healthcare aides, nurses, and allied health professionals.
Casual employ- ees were not eligible to participate. Part-time
and full-time healthcare aides, nurses, and allied health
professionals were invited to participate in focus groups. An
option for an indi- vidual interview was also offered.
Recruitment posters were displayed throughout the hospital
and circulated in the weekly newsletter via email to all staff.
Interested participants con- tacted a research assistant who
verified eligibility and made arrangements for an individual
interview or a focus group de- pending on the participant’s
preference.
Separate focus groups were scheduled for each group:
(a) healthcare aides, (b) nurses, and (c) allied health
profes- sionals. This format was used to facilitate an
environment for open discussion amongst “like” group
members and group interaction is known to stimulate
individual thinking to pro- vide richer data (Krueger & Casey,
2015). The 45-MINUTE time- frame for interviews was
amenable to unit managers to release frontline staff from
direct patient care. We aimed to recruit five to eight
members for each focus group. Individual inter- views and
focus groups were held in a private location at the hospital.
Following acquisition of a signed informed consent, all in-
dividual interviews or focus groups were conducted by
one co-investigator, who was not affiliated with the hospital.
To fa- cilitate discussion, participants were provided with a
handout listing components of the PUPP (Chaboyer &
Gillespie, 2014). Listed below are the questions that were
used on the semi- structured interview guide, which was
developed by a multi- disciplinary team considering guiding
frameworks, relevance to the current evidence, and time
constraints:

. Refer to the handout for a list of approaches imple-

mented at this hospital to prevent PUs. From your
viewpoint, what changes worked best to prevent
PUs?
. What other strategies could healthcare providers use
to protect patients’ skin?
 . Please describe the support that you receive from
hos- pital management to prevent PUs.
. Is there anything else?
Interviews were transcribed verbatim without names
or identifying features. Transcripts were read and re-read
in- dependently by two members of the research team.
Initial codes, categories, and themes were compared and
contrasted to enhance rigor. Thematic analysis was
utilized to describe healthcare providers’ perceptions and
experiences of the PUPP (Creswell, 2016).
RESULTS
Results are reported under these subheadings: (a) Effective-
ness of the Online Tutorial, (b) Effectiveness of the PUPP,
and
(c) Hospital Staff’s Perceptions and Experiences of the PUPP.
Effectiveness of the Online Tutorial
In this section, a description of the purposive sample
and results of the pre-test post-test are presented. As
shown in Table 1, 80 participants completed the pre-test,
online tutorial, and the post-test. The majority of
participants (92.5%) were women with 42.5% of the sample
aged 26–35 years. Most par- ticipants (62.5%) were employed
part-time while 60% of par- ticipants identified that they
held their current position for less than five years.
Approximately half of the sample (51.25%) was registered
nurses and the next largest group was allied health
professionals at 36.25%. Sixty-eight percent of online tutorial
participants completed an undergraduate or higher degree.
There was a statistically significant difference between the
18-item PU prevention knowledge assessment tool’s pre-tests
(M = 13.3, SD = 1.98) and post-tests (M = 14.3, SD = 2.00)
scores; t (79) = –4.807, p < .001. These results indicated that
participants’ knowledge level about PU prevention and man-
agement was enhanced by the tutorial.
Effectiveness of the PUPP
Prior to the implementation of the PUPP, 242
hospitalized patients volunteered to participate in an
observational skin as- sessment, which found PU
prevalence was 34.3% (83/242). Twelve months following
implementation of the evidence- based PUPP, 239 in-
patients were assessed using the same skin assessment
tool that showed a reduced prevalence of 7.53% (18/239). A
chi-square test for association was conducted between pre-
PUPP and post-PUPP prevalence. Expected cell frequencies
were greater than five. Reduction in the PU preva-
lence post-PUPP was X2 (1) = 51.9308, p < .0001. The
incidence
study was repeated after six days for all patients who remained
hospitalized and participated in the prevalence study. Incidence
decreased from 16.5% (19/115) in 2013 to 5.13% (8/156) in 2014.
Expected cell frequencies were greater than five. Reduction in
PU incidence was found at X2 (1) = 9.5798, p < .002. These
reductions were both statistically and clinically significant as
shown in Figure 1.

Table 1. Description of Online Tutorial Participants Full-time 31 38.75

as a Percentage of the Sample (N = 80)
Part-time 49 61.25
Years in current position
Characteristic Number Percentage
0–5 48 60.0
Gender
6–10 14 17.5
Male 6 7.5
11–15 10 12.5
Female 74 92.5
S15 8 10.0
Age in years
Position
18–25 11 13.75
Allied health* 29 36.25
26–35 34 42.5
Registered nurse 41 51.25
36–45 14 17.5
Licensed practical nurse 7 8.75
46–55 17 21.25
Health care aide 3 3.75
S 56 5 5.0
Note. *Allied health included registered dieticians, occupational therapists,
Highest education and physiotherapists.

Certificate 9 11.25
Diploma 16 20.00
Undergraduate Degree 45 56.25
Hospital Staff’s Perceptions and Experiences of
Graduate Degree 9 11.25
the PUPP
Other 1 1.25 Thirty-five part-time or full-time healthcare aides, nurses, and
Employment status allied health professionals volunteered to participate in the
qualitative component of this study. Five audio-recorded
focus groups were held as initial recruitment was healthcare team members working directly with patients
problem- atic: one for nurses, two for allied health participated in the de- velopment and implementation of the
professionals, and two for healthcare aides. Each focus PUPP was viewed as a
group ranged from 3 to 15 participants. Seven audio-
recorded, individual interviews were also conducted,
resulting in a total of 12 transcripts. Two major themes
emerged from the data: “It’s definitely a combination of
everything” and “There’s a disconnect between what’s
needed and what’s available.”

“It’s definitely a combination of everything.” This “in

vivo” theme emerged from the data (Allied Health, Focus
Group 2) with most participants indicating that multiple
factors con- tributed to PU prevention. However, particular
physical and human resources, and communication
processes were per- ceived to enhance prevention and
management of PUs. Equip- ment such as low air-loss
mattresses, sliders, heel-lift boots and incontinence products
were key elements contributing to the success of the
PUPP. “I did notice a big difference when the whole
hospital switched to the new mattresses . . . 6 months to a
year later when I realized we weren’t getting wounds
anymore” (Nurse, Focus Group 2).
Using the modified Braden tool was noted as beneficial
by nurses and allied health professionals. These participants
noted that this tool served to ensure the completion and
documen- tation of skin assessments and alerted nurses to
consult allied health professionals, wound care nurses, and
physicians when high risk patients were identified. “I think
that’s a great thing that the modified Braden Scale has been
implemented to make sure staff are aware and doing that as
part of our assessment” (Allied Health Professionals, Focus
Group 2).
However, healthcare aides noted that they were not
privy to this tool as it was not accessible to them. “The
nurses do them . . . they don’t verbalize, talk anything
about it. It would be nice to know because we have the
knowledge too because we’re the frontline workers” (Health
Care Aide Focus Group 2). The nutritional assessment tool
was appreciated particularly by healthcare aides responsible,
along with nurses, for monitoring patients’ fluid and
nutritional intake. “Nutrition assessment and plan is very,
very important for the patient” (Heath Care Aide, Focus
Group 1).
Adequate staffing levels and the establishment of
turning teams were identified as key human resources that
enhanced PU prevention and management. Administrators,
managers and educators’ support was also perceived as a
contributing factor in PU prevention and management.
“Our educator does a very good job reminding us to
work on pressure ulcers” (Nurse, Focus Group 1).
Participants described the importance of effective
commu- nication processes between all members of the
healthcare team. Staff engagement was perceived as crucial
in the pre- vention of PUs. “Being supportive and listening
to what the staff, who are actually working with patients,
have to say” (Allied Health, Focus Group 1). Ensuring that
Figure 1. Prevalence and incidence of hospital-acquired pressure ulcers in percentages.
Using a modified Braden scale, surveyors conducted skin assessments on all in-hospital patients that
consented in November 2013 (before the PUPP) and November 2014 (after the PUPP). Prevalence was
calculated on Day 1 and incidence of hospital-acquired PUs was documented six days later on all in-patients
who participated in the prevalence study. Prevalence (darker shade) and incidence (lighter shade) are
illustrated in percentages for 2013 and 2014. All stages of PUs were included.

mechanism that motivated members of the healthcare team to healthcare aide level to do the positioning and turning” (Nurse
adopt new materials and practices. Focus Group 1).
The online tutorial was reviewed positively by most par-
ticipants. “Online tutorial . . . I think, for me, everything
within here is important . . . because information is impor-
tant” (Health Care Aide, Focus Group 1).
Furthermore, healthcare aides expressed a need to be in-
cluded and involved in continuing education targeted to their
roles and responsibilities.
“There’s a disconnect between what’s needed and
what’s available.” A second theme emerged from the data
represent- ing participants’ descriptions of limited resources
along with miscommunication between hospital
administrators and front- line staff. Participants expressed
frustration when describing difficulties in accessing
equipment such as Geri-chairs, shower chairs, and tub plugs.
Participants identified that this equip- ment was needed to
ensure adequate skin care.

“We need to up-date our Geri-chairs . . . another

thing we don’t have enough is shower chairs”
(Health Care Aide, Focus Group 2). “On my
unit, we have four walkers. There should be a
walker in every room for every patient. We have
bells in every room for every patient” (Nurse Focus
Group 1).

However, limited human resources were identified as the

major barrier to PU prevention. “Shortage of staff is #1
[barrier to PU prevention]” (Health Care Aide, Focus Group
1). It would be nice to have more staff . . . at least at the
 The majority of participants shared that more staff were
needed to reposition and mobilize patients. In particular,
par- ticipants noted that access to additional staff and
specialized equipment was needed outside of weekday
shifts.
Lack of educational resources and strategies for patients
and family members was noted as an oversight in the PUPP.
Partic- ipating healthcare aides expressed a keen interest in
learning more about PU prevention. “One thing that I don’t
see here is the patient education piece” (Nurse, Focus
Group 3). “But we would like to see what’s going on . . .
and help us down the road and help us to do PUs better,
like to avoid them” (Health Care Aide Focus Group 2).
Several participants perceived that limited or
miscommunications between administrators and frontline
staff were barriers in PU prevention. “A lot of times I feel
like there’s not very good lines of communication . . .
there’s a disconnect” (Allied Health, Focus Group 1). A par-
ticipant expressed how understanding the “big picture” would
facilitate evidence-based practice changes.
So having the PUPP roll out in pieces . . . I felt was
the best and the only way to do it. But that’s looking
in the rear-view mirror. If we could have had a bit
more of a map so that we would have known where
we were going, it might have made the
understanding and the buy-in better. (Nurse 3
Individual Interview)
DISCUSSION
This study’s results are discussed within the context of
current evidence. The literature was reviewed for Canadian
studies and

one report by Fabbruzzo-Cota et al. (2016) was located. A clin- evidence translation in real clinical practice are complex” (p.
ical nurse specialist-led quality improvement project was de- 11). Since this was also the first nurse-led clinical research
scribed and it reduced hospital-acquired PUs in a tertiary care conducted in the community hos- pital, we discuss the rewards
hospital in Toronto, Canada (Fabbruzzo-Cota et al., 2016). To and challenges of evidence trans- lation. Inter-professional
our knowledge, this is the first mixed methods study collegiality was greatly enhanced by this project. Some
conducted in a community hospital in Canada that robustly research team members were intricately in- volved in
evaluated the effectiveness of an evidence-based PUPP in qualitative assurance initiatives and the roll-out of best
reducing the preva- lence and incidence of PUs. By practices and new physical resources. Healthy Skin Wins tee
consulting a biostatistician at the onset of the study, we shirts were created at the end of the study, and distributed to
employed rigorous statistical mea- sures to determine the study team members. At times, it was challenging to
appropriate sample size and significance of outcomes of an maneuver between the realms of research and qualitative
evidence-based PUPP. Congruent with results of previous assurance.
quality improvement and research projects (Baldelli & Although incentives were offered and recruitment posters
Paciella, 2008; Chaboyer et al., 2015; Fabbruzzo-Cota et al., were circulated widely, we failed to recruit the required 90 sub-
2016; Hunter et al., 2014; Murray, 2012; Tayyib & Coyer, jects into the pre-test post-test study component. The sample
2017), implementing an evidence-based PUPP resulted in size of 80 was insufficient with less than 10% participation rate
reductions of PU prevalence and incidence. The majority of from nursing and healthcare aide cohorts. Thus, the results of
previous stud- ies reported these reductions as percentages. the pre-test post-test design should be viewed cautiously. Un-
However, this study and a recent study by Tayyib and Coyer derstanding the characteristics of the decision-making unit is a
(2017) employed a chi-square analysis to determine if key component within Rogers’ (2003) diffusions of innova-
reduction in prevalence and incidence was actually statistically
significant.
This study will provide important information on innova-
tive strategies to assess and enhance PU prevention
knowledge among frontline hospital staff which included
the “Healthy Skin Wins” staff awareness campaign and a
15-MINUTE on- line tutorial. The qualitative component of the
study provided rich data about hospital staff’s perceptions of
the PUPP and identified what was working and what was
missing. In par- ticular, participants in the qualitative
interviews identified two recommendations to strengthen the
PUPP: (a) education pro- grams targeting health care aides
and (b) active patient par- ticipation (Chaboyer et al.,
2015, 2016; Gillespie, Chaboyer, Sykes, O’Brien, &
Brandis, 2014; Latimer, Chaboyer, & Gillespie, 2013;
Murray, 2012; Roberts et al., 2016).
We agree with Tayyib and Coyer’s (2017) statements that,
“Implementation of best evidence-based PU prevention
strate- gies is an organizational and nursing goal for
improving quality of care. However, the processes of
tions model; therefore, acquiring formal support from 2004). Psychometric assessments of these attitudes and
program directors and unit managers may have enhanced knowl- edge assessment tools could be carried out in tertiary
recruitment of healthcare aides and nurses to provide an hospitals,
adequate sample size. We attempted to facilitate
participation by limiting time away from patient care in
terms of shortened knowledge as- sessment tools and a
brief online tutorial. Offering the tutorial as a scheduled, 1-
hour educational event with a paper-version of the pre-test
post-test may have enhanced recruitment of nurses and
healthcare aides. In previous studies, communicat- ing
information and disseminating evidence were identified
as key elements in evidence translation (Roberts et al.,
2016; Tayyib & Coyer, 2017). Perhaps an amendment to the
recruit- ment protocol was required. In the future, an
undergraduate re- search assistant could provide a short
information session with a QR code and pamphlet about the
pre-test post-test to recruit frontline staff.
Similar to the characteristics of Moore and Price’s sam-
ple (2004), the majority of subjects in the pre-test post-
test component were younger than 35 years and in their
current position for less than 5 years. Beginning
practitioners may be more interested and invested in
research and evidence-based practice in contrast to older
and more experienced healthcare providers. With a higher
participation rate by younger health- care providers, this
may have implications in regards to men- torship programs
for beginning practitioners who demonstrate change-agent
characteristics to become future champions of evidence-
based practice and be encouraged to pursue certifica- tion as
wound care nurses.
Although there was only a 1-point difference between
pre- test and post-test mean scores, a statistically significant
eleva- tion was identified. As noted previously, these results
should be viewed cautiously because of an inadequate
sample size. How- ever, subjects’ scores were comparable
to Kaddourah, Abu- Shaheen, and Al-Tannir’s (2016)
results. We did not determine how individual demographic
factors (age, level of education, years of experience) were
associated with mean scores given that Kaddourah et al.
(2016) noted that there was no significant relationship
between participants’ attitudes toward PUs pre- vention
and their education level, years of clinical experience, and
age. This conflicted with a previous study that found that
Jordanian nurses with more than 10 years of experience
scored higher in positive attitudes toward PU prevention
(Tubaishat, Aljezawi, & Al Qadire, 2013).
Using Beeckman et al.’s (2010) 26-ITEM knowledge assess-
ment tool rather than a shortened, 18-item version may
have provided an opportunity to determine its reliability
and valid- ity in a Canadian hospital. Pre-test and post-test
scores were reviewed in detail to identify easy and difficult
questions with suggestions to revise specific items for a
future psychometric assessment. By widely sharing the
online tutorial, other prac- tice sites may pilot its
effectiveness using a pre-test post-test design and
established PU prevention attitudes and knowl- edge
assessment tools (Beeckman et al., 2010; Moore & Price,
personal care homes, and home care with adequate sample and patient outcomes is warranted.
sizes to determine best tool.
Recruiting, scheduling, and managing focus groups in
a hospital setting was especially challenging (Guse et al.,
2016). Unit managers were consulted and it was
determined that scheduling 45-MIN focus groups at lunch
was the most ap- propriate time to release healthcare aides,
nurses, and allied health professionals from direct patient
care. Although we aimed to recruit five to eight participants
per focus group using Krueger and Casey’s recommendations
(2015), it was necessary to reschedule focus groups on
numerous occasions due to poor turnout. Conversely during
one focus group, the facilitator was prepared for five
participants when 15 individuals arrived unex- pectedly. Rather
than turn 10 participants away, the facilitator decided to
proceed with the informed consent and aimed to elicit as
many participants’ viewpoints as possible. This focus group
was held prior to day shift ending and evening shift start- ing,
perhaps contributing to the higher attendance rate. In the
end, 35 healthcare aides, nurses, and allied health
professionals participated in qualitative interviews with 12
information-rich transcripts.
In contrast to previous studies in which healthcare
providers
identified that adopting evidence-based PU prevention strate-
gies increased workload (Moore & Price, 2004; Chaboyer
& Gillespie, 2014), participants in this study reframed this
no- tion by noting that PU prevention strategies were impeded
by a disconnection between resources required and resources
avail- able. These findings supported previous research about
nurses’ attitudes of PU prevention (Waugh, 2014). In
particular, this study’s themes were congruent with Beal and
Smith’s (2016) findings of a 2007 qualitative survey of 11
registered nurses and five healthcare aides whereby the
greatest perceived obsta- cles were lack of time, poor
communication and inadequate equipment.
Strengths of the study included researcher and data trian-
gulation with statistically robust outcome measures in both
healthcare provider and patient groups. The sample size was
adequate in prevalence and incidence surveys. Limitations of
the study were the small sample size for the pre-test post-test
component. Further research is required with an adequate
sam- ple size using a reliable and valid PU attitudes and
knowledge assessment tool to ascertain effectiveness of the
online tutorial in enhancing hospital staff knowledge.
Another limitation was rooted in observational surveys hav-
ing limited interrater reliability. Consistency in surveyors in
2013 and 2014 was not feasible due to staff turnover. To en-
hance rigor in the observational survey, the assessment tool
was the same for both annual observational surveys. Survey-
ors were trained with the availability of a certified wound care
nurse for verification.
By not using an experimental design, we were unable to
identify a specific component of the PUPP that contributed
the most to PU prevention. In the future, a multi-site,
random- ized control trial focusing on key practice changes
 The results of this study support previous research
about incorporating evidence-based practice in acute care
hospitals to reduce the prevalence of PUs (Beal &
Smith, 2016). Fol- lowing a practice change, a
standardized auditing tool and process for participating
units is strongly recommended for sustainment. In this
setting, use of sliders for repositioning patients was
reinforced following additional educational ses- sions
provided by allied health professionals. However, it was
challenging to discourage the ritualistic use of turning
sheets and soaker pads on most units (even though
turning sheets and washable soaker pads had been
removed from the unit inventory, staff attempted to
reposition patients using flan- nel sheets and disposable
soaker pads on some units). In the future, nurses may
serve as effective change-agents by offer- ing formal and
informal continuing education programs to all healthcare
professionals including healthcare aides to mitigate the
tendency for practice rituals.
A team approach is required in comprehensive and regular
assessments of patient’s sleep surfaces, skin, nutritional
intake, and mobility. Nurses are pivotal in ensuring that all
members of the healthcare team have a voice in evidence-
based practice. The incorporation of the modified Braden
tool was instrumen- tal in PU prevention and management.
In the future, we aim to develop, implement, and evaluate
educational tools and strate- gies targeted to culturally
diverse patients and families given the positive outcomes
of patient-centered care bundle inter- ventions on PU
prevention in Australia (Chaboyer et al., 2016; Gillespie et
patients and families and the inclusion of healthcare aides in
continuing education activities about PU prevention. WVN
or PU prevention
r documentation of assessments using an appropriate tool
materials such as powerized therapeutic sleep surfaces, sliders for repositioning immobile patients, heel-lift boots, and appropriate inconti- nence products
t all members of the healthcare team, including patients and families
Author information
Donna Martin, Xi Lambda, Associate Professor, University
of Manitoba, Rady Faculty of Health Sciences, College of
Nurs- ing, Winnipeg, Manitoba, Canada; Lisa Albensi, Xi
al., 2014; Latimer et al., 2013).
Updating hospital policies and procedures to reflect
current evidence is integral to ensuring quality patient care.
As well, new hire orientation materials and annual
competency assess- ment materials will be designed and
implemented to include practice changes.
CONCLUSIONS
This mixed methods study determined that the “Healthy Skin
Wins” campaign significantly decreased hospital-acquired
PUs with a cautious increase in staff knowledge around PU
preven- tion in a community hospital in Winnipeg, Canada.
A multidis- ciplinary approach facilitated best practices in
PU prevention. This team selected appropriate physical
resources (powered mattresses, sliders, incontinence
products, modified Braden tool, nutritional assessment tool,
online tutorial) and estab- lished a pathway for referral to
wound care nurses, allied health professionals, and
physicians for high risk patients. Two ma- jor themes
emerged from the qualitative data: “It’s definitely a
combination of everything” and “A disconnect between
what’s needed and what’s available.” Access to material and
human resources along with knowledge about best practices
in PU prevention were perceived as key facilitators to PU
prevention. Conversely, staffing limitations, unavailability of
equipment, and miscommunication between administrators
and frontline staff were identified as barriers to PU
prevention. Participants voiced the need for a future
educational tool geared toward
Lambda, Director of Health Services, Southern Health Sante-
Sud Regional Authority, Bethesda Regional Health Centre,
Stein- bach, Manitoba, Canada; Stephanie Van Haute, Program
Development Officer, Manitoba HIV Program, Winnipeg Man-
itoba; Nursing Supervisor, St. Boniface Hospital, Winnipeg
Manitoba; Facility Patient Care Manager, Seven Oaks Gen-
eral Hospital, Seven Oaks General Hospital, Winnipeg, Mani-
toba, Canada; Maria Froese, Physiotherapist, Health Sciences
Centre, Winnipeg, Manitoba, Canada; Mary Montgomery,
Occupational Therapist, Seven Oaks Hospital, Occupational
Therapy, Winnipeg, Manitoba, Canada; Mavis Lam,
Registered Dietician, Seven Oaks Hospital, Clinical
Nutrition, Winnipeg, Manitoba, Canada; Kendra Gierys,
Continuing Education In- structor, Seven Oaks Hospital,
Critical Care, Winnipeg, Mani- toba, Canada; Rob
Lajeunesse, Program Care Team Manager, Seven Oaks
Hospital, Renal Health, Winnipeg, Manitoba, Canada; Lorna
Guse, Associate Professor, University of Man- itoba, Rady
Faculty of Health Sciences, College of Nursing, Winnipeg,
Manitoba, Canada; Nataliya Basova, Xi Lambda, Registered
Nurse, Health Sciences Centre, Central Support Services,
Surgical Relief Team, Winnipeg, Manitoba, Canada This
study was funded by the Manitoba Centre for Nursing &
Health Research. We thank Brenden Dufault, MSc, Biostatis-
tical Consultant, for contributing to the rigor of this study.
Address correspondence to Dr. Donna Martin, University
of
Manitoba, Rady Faculty of Health Sciences, College of Nurs-
ing, 89 Curry Place, Winnipeg, Manitoba, R3T 2N2, Canada;
donna.martin@umanitoba.ca
Accepted 12 January 2017
Copyright ⓍC 2017, Sigma Theta Tau International
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