A Report on the Effectiveness of Turning Time Intervals on the Prevention of Pressure Ulcers
Part of the nurse’s duty is to make sure that the patients are well taken care of and provided with all the necessary elements to facilitate recovery and healing. Part of this responsibility is making sure that no further harm befalls the patient while recovering from illness. However, prolonged stays in a healthcare facility also predispose the patient to certain harms such as contracting nosocomial infections. One of these possible, but preventable, harms is the development of pressure ulcers, commonly known as bed sores, in patients who are confined to a bed. It has long been recognized that pressure sores are a natural consequence of prolonged bed stay but the condition is highly preventable. In fact, repositioning has been a well accepted and successful method of preventing the complication. Common practice calls that a patient be turned once every four hours though very few literature support the practice. The research of Vanderwee and associates (2006) – exploring the effectiveness of repositioning with unequal time intervals – is one of the few articles to discuss the subject.
The aim of the authors in writing the paper was to investigate whether repositioning at uneven hourly intervals (2 on lateral and 4 on supine) would reduce the incidence of pressure ulcers compared to the standard of every four hours (on each position). This alteration in timing interval was due to the notion that pressure is higher on the lateral position compared to the supine position (Vanderwee, Grypdonck, De Bacquer and Defloor, 2006, p.59).
The study was conducted using a two-arm randomized controlled trial within 16 participating Belgian nursing homes. Selected participants were chosen from 84 wards from within the nursing homes. Nursing homes were chosen as the site of study due to the facts that residents have longer lengths of stay and that older patients are vulnerable to developing pressure ulcers. Participants were eligible for the study as long as they did not have any pressure ulcers at the beginning of the study, can be repositioned and were likely to stay >3 days in the facility. The average age of the participants for the study was 84 years and participating personnel consisted of “nursing staff…composed of …1 full-time equivalent (FTE) level 1 nurses, 3 FTE level 2 nurses, and seven nursing assistants. Level 1 nurses had undergone a 3-year education at university level. Level 2 nurses had a 3-year nursing education at high school level”(Vanderwee, Grypdonck, De Bacquer and Defloor, 2006, p.61).
All participating patients used pressure-reducing mattresses. The experimental arm were given the following interventions: repositioned alternately 2 hours in the lateral and 4 hours in the supine position. The control group was repositioned every 4 hours on both lateral and supine positions. Both the experimental and control groups had similar sitting protocols which did not impose specific durations. Pressure areas were observed daily and classified according to the four grades of the European Pressure Ulcer Advisory Panel (Vanderwee, Grypdonck, De Bacquer and Defloor, 2006, p.59).
Results of the experiment revealed that in the experimental group, 16.4% developed pressure ulcers compared to the control where 21.2% developed pressure ulcers. The values were statistically not significant (P=0.65) and values for other areas such as severity, location, and time to developing pressure ulcers were the same in both groups. None of the participants developed pressure ulcers at the hips and a “considerable number of patients changed from a lateral to a supine position between the turning intervals.” As a result, the authors concluded that more frequent repositioning on a pressure-reducing mattress does not lead to fewer pressure ulcer lesions (Vanderwee, Grypdonck, De Bacquer and Defloor, 2006, p.59).
To determine whether a similar practice was in place at a local health facility, this author decided to interview personnel working at the (INSERT HEALTH FACILITY NAME HERE). The personnel interviewed included a registered nurse (RN), a licensed practical nurse (LPN) and a licensed physical therapist (PT).
According to the LPN, “We are rarely assigned to the critical care…we barely get to manage patients who have prolonged bed stays. Our duties do not automatically allow us to perform nursing-specific tasks unless they are delegated to us. As far as personal experience goes, I’ve taken care of a few bed-ridden patients and I recall we do turn them every four hours or so – depending whether the patient can tolerate the activity” (A.C. Pan, personal communication, March 24, 2009).
Meanwhile, the PT responded that their primary role in the said healthcare facility was more related to assisting physical recovery and re-entry into the community, home or work environment. As a consequence, their duties barely overlap with those of the nurses at the said facility. Additionally, the PT states that their main role, if ever they do handle bed-stricken patients is to make sure the patient will not lose functionality, and repositioning is part of this duty but are performed under different motivations (G.P. Koppel, personal interview, March 24, 2009).
On the other hand, with the Nursing personnel, it was found that the staff was not aware of the research from which the inquiry served as a basis. However, as one of the RNs stated: “We are not aware of that particular research; however the ideas presented in it are not unfamiliar. Here in this hospital, we do follow the same 4-hourly turning protocol. The thing that makes the idea familiar is that we here at (INSERT HEALTH FACILITY NAME HERE) do modify the protocol according to our patients needs. If we notice a patient is more prone to develop pressure ulcers, we usually take steps at preventing that – including modifying the intervals of repositioning if needed” (R. Torres, personal interview, March 24, 2009).
In conclusion, though findings from the research by Vanderwee, Grypdonck, De Bacquer and Defloor (2007) were insignificant, the idea behind the research still mettles further exploration. If the interviews with the personnel at (INSERT HEALTH FACILITY NAME HERE) were any indication, repositioning at certain intervals may still have beneficial effects. It has come to mind that in the research conducted, pressure-reducing mattresses were used for all participants. Therefore, if any study replication were to be made by student nurses and nursing researchers, it would be highly suggested that the focus should be on repositioning frequency for patients not using a pressure-reducing mattress. Any information gathered from this prospective experiment, including the one mentioned in this paper, will then be of great use for nursing professionals and nurses in training as well as other members of the healthcare team. The knowledge may beused to educate those who care for bed-bound patients at home, empowering caregivers and family members with better care techniques. Lastly, knowledge of this study can help guide a nurse in modifying current care practices and also help develop future care plans for bed-bound patients.
Vanderwee, K., Grypdonck, M.H.F., De Bacquer, D. & Defloor, T. (2006). Effectiveness of turning with unequal time intervals on the incidence of pressure ulcer lesions. JAN Original Research p.59-68. Blackwell Publishing, Ltd.