Preventive care issues identified
The preventive care issues that were identified are interrelated. They included prevention after the occurrence of PUs, the improper use of pressure ulcer prevention materials, non-compliance with some prevention practices, improper presssure ulcer prevention practices, the perception that the preventive care is being performed correctly, inadequate readiness to adopt an assessment tool to assess the risk of developing PUs, the supplying of unfavorable resources, and various management styles in the NHs with or without nurses.
In the provision of care, the care staff did not provide preventive care materials, including heel protectors and pressure-relieving mattresses, until they found that pressure ulcers had developed. This practice was likely caused by their knowledge deficit and wrong concept of PU prevention, the unfavorable supply of PU prevention materials (e.g., heel protectors and pressure-relieving mattresses), or even the complete unavailability of PU prevention materials (e.g., pressure-relieving seat cushions). Family members were also not willing to spend money on the prevention materials if PUs had not been observed because they might have thought that the materials were being used for treatment instead of prevention, or that the PUs were not serious enough for these materials to be used. In addition, due to the healthcare system, a doctor’s referral to purchase prevention materials is accepted only for residents who are recipients of government social security allowances.
In this study, improper practices were observed among the care staff members in the four NHs. These included failing to adjust a heel protector that has slipped off, the use of inner and outer napkins, lengthy sitting-out times for chair-bound residents without the provision of a pressure ulcer seat cushion, the use of inapproprate methods and inadquate frequency to change napkins, causing the wetbuttocks of the residents, the inappropriate positioning of bed-bound or chair-bound residents, the use of an air-ring or non-pressure relieving seat cushion for chair-bound residents, and the tight application of physical restraints. All of these improper prevention practices increase the risk to residents of developing PUs, especially those who are chair-bound and bed-bound. The knowledge deficit of the care staff and an unfavorable supply of resources including prevention materials and/or manpower and inadeqaute staff supervision are possible reasons for the improper delivery of prevention care to residents in nursing homes. Apart from improper preventive pratices, the care staff did not regularly inspect the skin of the residents to identify dryness and redness/lesions, and did not apply body lotion to the dry skin on the bony prominences. Inadequate manpower and a knowledge deficit might also be the reasons for their non-compliance with these practices.
With regard to the improper use of pressure ulcer materials, some pressure ulcer relieving mattresses were not adequately inflated, pillows were not appropriately placed to support the positioning of some residents to decrease the pressure on their bony prominences, and heel protectors were applied tightly. As with the performance of improper prevention practices, all of these are possibly due to a deficit in the knowledge and skills of the care staff, inadeqaute manpower, and ineffective staff supervision.
Assessing the risk of developing PUs is the first step in the practice of preventing PUs. An adequate assessment allows us to timely identify residents at risk of developing PUs and to perform appropriate and timely PU prevention care. However, the care staff did not display sufficient readiness to adopt the modified Braden scale to assess the PU development risk of the residents. They were reluctant to perform this task at the first cycle because they found it to be time-consuming and unnecessary. In sufficient manpower also made it difficult for them to perform the task frequently on the residents. From their work experience and knowledge, they knew that bed- and chair-bound residents who were unable to reposition themselves on their own were at a high risk of developing PUs so they thought it was not necessary to use a scale to assess the risk. Their views on using the assessment scale were also similar to those of the care staff in a local study involving two government-subsidized NHs, in which it was reported that the care staff were not compliant in using the scale to identify the risk of developing PUs because they thought that they could assess the risk based on their work experience and professional judgment [
10,
11]. In addition to the use of professional judgment to assess risk, it is necessary to have a simple, effective, and user-friendly tool to guide the care staff in their assessments of risk, especially in private for-profit NHs where the majority of the care staff are not professionals and have received less training than those in government-subsidized homes.
The environmental aspect included the tendency to put many of the residents’ belongings on their beds and having one side of the bed against a wall or partition. This likely decreased the quality of the care staff’s bedside care, as it affected their ability to turn the residents, change their position, and transfer the residents, resulting in an increased risk of the residents developing PUs, such as through shearing force and friction. This environmental aspect is always neglected as a barrier to the prevention of PUs in for-profit NHs in Hong Kong.
Different management styles in homes with or without nurses were identified, including in the areas of staff supervision and in the handing over of cases in each duty shift. Effective staff supervision allows nurses and HWs to sufficiently support, monitor, and evaluate the work of PCWs, which likely results in their compliance with proper preventive pracctices in NH settings. Besides, the care staff would understand the health condition of the residents, the rationale for the care delivered to the residents, and the specific tasks that need to be performed for the residents if there is a formal way to hand over the cases for all care staff in each duty shift. However, in the nursing homes without nurses, HWs did not actively supervise the PCWs and there were no formal procedures for handing over the cases in each duty shift. The PCWs were only told what needed to be provided to specific residents if the necessity arose. This may explain why the private for-profit nursing homes without nurses had a lower percentage of decrease in PU incidence than in the NHs with nurses in this study. This is consistent with the findings in Kwong et al.’s study [
10] that not having nurses is one of the risk factors in the development of PUs in private for-profit NHs.
Through triangluation of the data obtained from the focus group interviews and field observations, the consistency of the preventive issues was confirmed. The exception was several issues that were observed through the field observations but were not mentioned by the care staff members in the focus group interviews after the completion of the first cycle. Those issues are improper or non-compliant preventive practices, including the overly tight application of heel protectors and limb restrainers, skin inspections, the identification of redness of the skin, the appropriate use of pillows to support the positioning of the residents, the fixing of heel protectors that have slipped off. All these care issues increased the risk of PU development [
38]. Some of the issues that were identified in this study are same as those that were reported as barriers to PU prevention care in Kennedy’s action research study [
29]. In the focus group interviews conducted after the completion of the second and third cycle, the care staff members responded that they were paying more attention to those care practices and were making improvements in those areas. The improvement on these issues was also observed through the field observations.
To conclude the above discussion, if care staff in Hong Kong private for-profit NHs are to comply with the proper practices for preventing the development of PUs, they need to have sufficient knowledge and skills to do so, to be supplied with sufficient resources including prevention materials and manpower, and to have effective supervision. Apart from these criteria, we cannot ignore the importance of staff members mentality, their commitment to the job and the value that they place on the job, and their empathy when delivering quality care including pressure ulcer prevention care although these issues were not explored in this study.
Changes in staff practices
Through a self-review of their practices, peer influence, in-service training, discussions, and negotiations, the care staff accepted the prevention protocol to guide their PU prevention care and were also empowered to make some positive changes to their practices.
Staff compliance with risk assessments and skin inspections
When the method and frequency of assessing the residents’ risk of developing PUs were modified, the care staff became more compliant. Assessing risk is the first step in the effective prevention of pressure ulcers. Valid and reliable PU risk assessment scales are underused [
39]. Indeed, using assessment tools is not the only means of identifying the risk of developing PUs. This study has found that, when planning interventions to minimize the risk factors involved, using the risk factors from a reliable and valid tool, together with the knowledge, judgment, and experience of care staff, is also an effective approach to assessing risks. For effective management, it is important to achieve a good balance between the complexity of a care task and staff compliance with that task. Involving the care staff in planning care tasks is highly recommended as a strategy to achieve this balance.
The PCWs expended more effort in inspecting the skin of the residents during their provision of perineal care and in repositioning the residents. They also became more aware of the redness, breakdown, and dryness of the residents’ skin. They reported any redness and breakdown of skin to the HWs or nurses to manage, although they might not have known whether or not they were PUs. Compared with two previous local studies, which reported that PCWs failed to identify and report redness in the skin of residents [
10,
11], the quality of the PCWs’ practice in this aspect was better. This change is important because PCWs are the crucial team in frontline care at either government-subsidized RCHs or private for-profit NHs. Their timely detection of PUs results in the timely management to minimize the deterioration of pressure ulcers, and in the suffering and pain of the residents which are very important in residents’ quality of life. In addition, PCWs identified dry skin, especially on the residents’ bony prominences, and apply body lotion accordingly. This practice allows the skin to retain its moisture, thereby preventing PUs.
Use of pressure ulcer prevention materials
Care staff members were found to use the prevention materials in a proper and timely manner. These included using heel protectors, pressure-relieving mattresses, and pillows. Residents who were at a risk of developing PUs but had not done so were also given the prevention materials. This change implies that the care staff had improved their concept and knowledge of prevention, and also that the supply of these materials (especially heel protectors and pressure ulcer relieving mattresses) had increased. Together with their proper performance of prevention practices, the risk that the residents would develop PUs decreased.
Pressure ulcer prevention practices
The PCWs improved their prevention practices in the areas of skin inspections, the positioning of the residents, the use of napkins, and the use of physical restraints. They paid more attention and effort to the proper positioning of the residents, with the proper use of pillows to support their position in bed, which is an effective method for preventing the development of PUs in residents, especially the bed-ridden.
From the point of view of the care staff, using inner and outer napkins for incontinent residents enabled them to decrease the frequency with which they changed the napkins. They did not feel or see the wetness of the inner napkin, as it was covered by the outer napkin, so they did not change both the inner and outer napkins. However, this practice increased the wetness of the skin on the residents’ buttocks. Following the strategy that was agreed upon to improve this inappropriate practice, the care staff used one inner and one outer napkin for each incontinent resident only on the night shift, because there was less manpower at night, and also checked the dryness of the napkins before the residents’ meal times, apart from the scheduled twice-per-shift checking and changing of napkins. With this change, the number of residents with wet napkins and buttocks decreased. It helped to minimize their risk of developing PUs. However, it was observed that some residents still had wet napkins and buttocks.
Safety vests and hand restraints were appropriately applied to the residents to allow them sufficient space to move on their own in bed. This not only gave them comfort but also reduced the duration of pressure on their bodies, and thus decreased their risk of developing PUs.
Change in environment
The environmental issue that had changed was the number of belongings left on the residents’ beds. These decreased after the care staff explained the importance of reducing clutter to the family caregivers of the residents and made an effort to tidy up the beds regularly. In addition to comfort, the residents had more space to move around in bed, and the care staff members were able to more effectively perform bedside care.
It is impossible to change the location of a bed in which one side of the bed is in contact with the wall or partition in the NHs because it allows more beds to fit into the homes, resulting in the use of less space and greater profits. As the NHs were not spacious enough for the use of a device (e.g., hoist) to pick up the needy residents and transfer them from their beds to chairs, this created a barrier to the provision of good quality bedside care for the prevention of PUs and also to the occupational safety of the care staff. To adapt the unchanged bed location, it was observed that one or two care staff member(s) standing on the same side of the bed used the lifting belts or transfer slides to lift and transfer several residents who were weak and heavy. However, due to the insufficient number of belts and slides placed in each room, and the insufficient number of staff, it was still the case that only one staff member at one bedside who did not use the belt and/or the slide lifted and/or transferred the weak residents. This practice increased the friction and shearing force on the residents.