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Best Practices in Maintaining Skin Integrity in Hospitals: A Research Study, Study notes of Nursing

This document details a research study conducted over a year to promote best practices in maintaining skin integrity in hospitals. The study focused on preventing skin breakdown through maintaining mobility, skin condition, diet and hydration, hygiene, and elimination. It also analyzed current policies and practices, conducted a quality improvement trial, and implemented best practices. The document emphasizes the importance of contextualized knowledge in documentation and the use of risk assessment tools.

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Wound Practice and research Vol. 16 no. 2 MaY 2008
5
Evidence-basedbestpracticeinmaintaining
skin integrity
5
Introduction
Maintaining skin integrity in hospitalised patients is one of
the most fundamental and critical goals of nursing practice.
Measures to prevent, restore or heal skin breakdown illustrate
the convergence of clinicians’ knowledge, critical thinking
and caring skills. They are also instrumental to hospital risk
management strategies, one of the most important elements
of the current quality and safety agenda. High quality, safe
care also relies on the use of best evidence as a defensible
foundation for practice. Developing an institutional culture
of evidence-based practice (EBP) helps ensure that clinicians
participate in generating or using research findings as a basis
for achieving quality improvements and clinical goals
1, 2
as well
as enhancing their professional status and job satisfaction.
The study reported here outlines the development and
impact of a comprehensive skin integrity programme. It
was designed to reflect the commitment to developing an
interdisciplinary EBP culture in one private hospital in
Western Australia, primarily in generating clinically relevant
research findings that would be useful to clinicians, managers
and others involved in decision making for patient care.
The overarching objective of the programme was to promote
best practice in maintaining patient skin integrity, ensuring
consistency of clinical practices related to prevention and
management of skin breakdown. Specific objectives were to:
• Conduct a scoping study of skin breakdown, and map
current policies and practice in maintaining skin integrity.
• Compare current policies and practice with existing
clinical guidelines and best practice in Western Australia,
interstate and internationally.
• Developaskinintegrityqualityimprovementtrialwitha
focus on:
maintaining best practice in preventing skin
breakdown in relation to mobility, skin condition, diet
and hydration, hygiene and elimination;
managing patients at risk for skin breakdown, including
analysis of the relative quality and clinical outcomes of
products, practices and appropriate documentation.
The findings of this initiative were expected to provide a basis
for the development of policies and protocols for clinical care,
discharge planning and staff development.
Abstract
The study reported here describes a 1 year programme to promote best practice in maintaining skin integrity, ensuring consistent
clinical practices in relation to skin care, and managing skin breakdown. The analysis included baseline data on skin breakdown;
comparisons of policy and practice with clinical guidelines and best practice locally, interstate and internationally; a quality
improvement trial focusing on mobility, skin condition, diet and hydration, hygiene and elimination; and implementation of
best practice, including analysis of the relative quality and clinical outcomes of products, practices and documentation strategies.
Product evaluation by nurses and patients showed that all mattresses trialled were effective in minimising or preventing skin
breakdown. All chair cushions were rated effective in preventing breakdown – some were easier to use than others, although all
were rated highly by patients.
A retrospective chart audit indicated substantial improvements in consistent use of the Braden scale, and the number of risks
identified. Completed risk assessments increased by 19.6% to 70%. Initial assessment increased from 16.5% to 44.6%, with
identification of dietary insufficiency increasing from 3.4% to 10.6%. Hospital acquired pressure lesions were reduced from 6.4%
to 5.8%. The most notable improvement (from 1.3% of patients to 43.9%) occurred in the completion of subsequent pressure risk
assessments, with a modest increase in repositioning. The use of overlays and special mattresses increased, with heel raisers
increasing from 11% to 82.4%. The project demonstrated the value of a comprehensive team approach to clinical care and
demystified evidence-based practice (EBP).
Gardiner L et al. Evidence-based best practice in maintaining skin integrity
GardinerL,LampshireS,BigginsA,McMurrayA,NoakeN,vanZylM,VickeryJ,
WoodageT,LodgeJ&EdgarM
pf3
pf4
pf5
pf8
pf9

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Evidence-based best practice in maintaining

skin integrity

Introduction

Maintaining skin integrity in hospitalised patients is one of

the most fundamental and critical goals of nursing practice.

Measures to prevent, restore or heal skin breakdown illustrate

the convergence of clinicians’ knowledge, critical thinking

and caring skills. They are also instrumental to hospital risk

management strategies, one of the most important elements

of the current quality and safety agenda. High quality, safe

care also relies on the use of best evidence as a defensible

foundation for practice. Developing an institutional culture

of evidence-based practice (EBP) helps ensure that clinicians

participate in generating or using research findings as a basis

for achieving quality improvements and clinical goals 1, 2^ as well

as enhancing their professional status and job satisfaction.

The study reported here outlines the development and

impact of a comprehensive skin integrity programme. It

was designed to reflect the commitment to developing an

interdisciplinary EBP culture in one private hospital in

Western Australia, primarily in generating clinically relevant

research findings that would be useful to clinicians, managers

and others involved in decision making for patient care.

The overarching objective of the programme was to promote

best practice in maintaining patient skin integrity, ensuring

consistency of clinical practices related to prevention and

management of skin breakdown. Specific objectives were to:

  • Conduct a scoping study of skin breakdown, and map

current policies and practice in maintaining skin integrity.

  • Compare current policies and practice with existing

clinical guidelines and best practice in Western Australia,

interstate and internationally.

  • Develop a skin integrity quality improvement trial with a

focus on:

  • maintaining best practice in preventing skin

breakdown in relation to mobility, skin condition, diet

and hydration, hygiene and elimination;

  • managing patients at risk for skin breakdown, including

analysis of the relative quality and clinical outcomes of

products, practices and appropriate documentation.

The findings of this initiative were expected to provide a basis

for the development of policies and protocols for clinical care,

discharge planning and staff development.

Abstract

The study reported here describes a 1 year programme to promote best practice in maintaining skin integrity, ensuring consistent

clinical practices in relation to skin care, and managing skin breakdown. The analysis included baseline data on skin breakdown;

comparisons of policy and practice with clinical guidelines and best practice locally, interstate and internationally; a quality

improvement trial focusing on mobility, skin condition, diet and hydration, hygiene and elimination; and implementation of

best practice, including analysis of the relative quality and clinical outcomes of products, practices and documentation strategies.

Product evaluation by nurses and patients showed that all mattresses trialled were effective in minimising or preventing skin

breakdown. All chair cushions were rated effective in preventing breakdown – some were easier to use than others, although all

were rated highly by patients.

A retrospective chart audit indicated substantial improvements in consistent use of the Braden scale, and the number of risks

identified. Completed risk assessments increased by 19.6% to 70%. Initial assessment increased from 16.5% to 44.6%, with

identification of dietary insufficiency increasing from 3.4% to 10.6%. Hospital acquired pressure lesions were reduced from 6.4%

to 5.8%. The most notable improvement (from 1.3% of patients to 43.9%) occurred in the completion of subsequent pressure risk

assessments, with a modest increase in repositioning. The use of overlays and special mattresses increased, with heel raisers

increasing from 11% to 82.4%. The project demonstrated the value of a comprehensive team approach to clinical care and

demystified evidence-based practice (EBP).

Gardiner L, Lampshire S, Biggins A, McMurray A, Noake N, van Zyl M, Vickery J,

Woodage T, Lodge J & Edgar M

population ages, the financial and quality of life burden can

be expected to rise proportionately 6.

Although clinical guidelines can help ensure quality and

safety of patient outcomes, the absence of rigorously

developed and contextually appropriate guidelines leaves

many clinical practices based on the experiences and opinions

of clinicians 7. This is problematic in an EBP era, given the

relative ease of adapting evidence from clinical trials in

one setting to improve practice elsewhere. Many studies

adopt a relatively narrow focus, placing disproportionate

emphasis on the biomechanical aspects of care rather than

comprehensive strategies for preventing wound breakdown

based on local knowledge and conditions 8-10. One exception

is an innovative project in South Australia, which achieved

positive results from a 13 member inter-institutional

collaboration to evaluate implementation of evidence-

based wound management guidelines and prevention and

management of pressure ulcers 11.

Another important focus of research has been the evaluation

of equipment used to manage the risks of skin breakdown.

A Cochrane Review of physical aids for wound prevention

indicates that using mattresses with certain characteristics

(e.g. foam surfaces) can reduce the incidence of pressure

ulcers in people at risk, but this research found insufficient

evidence to draw conclusions on a wider range of preventive

measures in different settings, a conclusion also drawn

by other researchers 12-16^. Research by the Royal College of

Nursing (RCN) in the UK and the National Institute for

Clinical Excellence (NICE) has provided a basis for equipment

guidelines which have been adopted by NSW Health 17.

However, although comprehensive, the RCN recommends

contextualising the guidelines for local circumstances,

resources, services, policies and protocols as well as patients’

preferences and circumstances 18.

Documentation of skin integrity is another under researched

area that should be based on contextualised knowledge.

Inconsistent documentation or inadequate use of admission,

transfer and discharge data have the potential to lead

to omissions of assessment, a lack of detection of risks,

inappropriate care and/or discontinuities in maintaining

healthy skin care 9, 19-21. The three major reasons for poor

documentation have been identified as – variable use of

different risk assessment and grading tools; the inappropriate

generalisation of risk assessment data to different patient

groups; and the inability of practitioners to gauge the specific

nature of the risk 16.

Leonie Gardiner RN Clinical Nurse Specialist Private Hospital 1

Sharron Lampshire RN Clinical Nurse Specialist Surgical 1

Ann Biggins RN AFAAQHC Quality/Risk Management Coordinator 1

**Anne McMurray *** AM RN PhD Peel Health Campus Chair in Nursing 2

Norah Noake RN Wound/Continence Specialist 1

Margaret van Zyl RN Executive Sponsor 1

Janice Vickery BScN Manger, Education and Development 1

Thomas Woodage RN Registered Nurse 1

Julie Lodge EN Clinical Practice Technician 2

Michele Edgar RN Registered Nurse 1

Organisations:

  1. Peel Health Campus, Lakes Rd, Mandurah, WA
  2. Murdoch University School of Nursing

Roles: Project management: LG, MV, AB, SL, NN Research, writing: LG, AM, AB Audit and analysis: AB, NN, ME, TW, JL Staff development: JV

  • Corresponding author

Pressure ulcers and other skin breakdowns are among the

most significant adverse events causing duress for patients

and their carers and compromising patients’ recovery from

illness or injury. From a management perspective, skin

breakdown is challenging both clinically and economically,

particularly in extending patients’ length of hospital stay

and placing a burden on acute and community care 3-5. As the

patients. Alternating systems are effective in relieving

pressure as the individual cells gently inflate and deflate

over a 10 minute cycle. The period of deflation allows

the skin to re-oxygenate and perfuse, thus preventing

breakdown and enhancing healing.

  • Harvest Supreme alternating cell overlay mattress: a pressure

relieving mattress overlay system for medium/high risk

patients.

  • ProCair 5000 alternating cell overlay mattress: a comfortable

pressure relieving mattress for medium/high risk patients.

  • ProCair 8000 premium alternating mattress: a replacement

mattress for patients at high risk of developing pressure

ulcers or with existing ulcers.

  • Pentaflex mattress: a pressure reducing foam mattress

made from high density contoured foam, suitable for

those patients deemed medium to high risk. This mattress

was trialled on all patients, including medical and surgical

patients. When used with high risk patients, repositioning

needs to occur more frequently than with an alternating

system.

  • Regency chair: a supportive chair with gel and foam seat

cushioning on a steel framed mobile base. Manually

operated gas assist tilt allows the chair to recline into a

lying position. Also features fold down arms and swing

away wings to allow side transfers.

  • Deluxe air bed: a lightweight mobile air and foam

combination chair designed to assist in pressure reduction.

It has a manually operated (hydraulic) gas assist reclining

backrest and tilt mechanism and reclines to a sleeping

position. The drop down arm rests and swing away wings

facilitate side transfers.

  • Vicair liberty cushion: a lightweight cushion utilising fluid

air technology. Suitable for users at low to medium risk.

  • Relax gel cell cushion: a cushion made from gel and air

that needs to be inflated with the pump provided and

then deflated once the patient has been positioned. To

adjust the correct pressure, the nurse is required to place

two fingers under the patient’s buttocks once they are

positioned and then deflate until there is approx 1.5cm of

air between the patient and the base of the cushion.

  • Airtech cushion: a pressure reducing cushion for patients

up to medium risk. The cushion is pumped by means of

the integrated pump prior to patient positioning, then

deflated to the correct pressure once the patient has been

seated.

  • Gel cell cushion: a cushion made of gel for high risk

patients. It is ready to use.

  • Relax duogel cushion: a cushion made from foam and gel for

medium to high risk patients and requires no preparation

prior to use.

The CNS publicised the equipment trial at the ward level

during a series of meetings. Each piece of equipment was

left in the ward with a sheet to record use, evaluation of the

nurses’ perceptions of effectiveness and ease of handling,

and any feedback from patients using the device. A display

folder was also created for the staff room with photos of each

piece of equipment with provision for staff feedback and

comments. In addition, a rating sheet for staff and patient

input was included on the charts of 21 patients on whom the

equipment was used during the trial. Feedback was sought

on the effectiveness of the equipment in preventing skin

breakdown, ease of handling, cleaning, transporting patients,

positioning or other general comments on any aspects of the

equipment. At monthly intervals, consultative meetings were

held with a reference group of registered and enrolled nurses

using the equipment to communicate progress of the project

and to encourage group feedback on the equipment.

Chart audit data

The audit tool was developed, pilot tested with several patient

charts, then refined by the project group in weekly consensus

conferences (Appendix 2). Chart audit data were analysed

using SPSS (v14). Descriptive statistics (frequencies, cross

tabulations) were used to measure pre-and post-programme

results. Independent samples two-tailed t tests for equality

of means were conducted for age and length of stay, with no

significant differences found between the two data sets.

Findings

Equipment trial

Feedback from the nursing staff included 65 comments

documented in the staff evaluation folder and 21 comments

provided in the patient charts. These were categorised as

either positive or negative for patient preference/satisfaction

and nurse preference/satisfaction.

The Vicair cushion was rated least satisfactory, with five

negative comments from nurses and two from patients,

primarily because of difficulty in positioning. The Regency

chair attracted mixed responses, with an equal number of

favourable comments from nurses (6) as negative comments,

again on the basis of positioning. The Duogel cushion

received only favourable ratings; four from nurses and two

from patients. The Harvest Supreme mattress received four

favourable responses from patients, but mixed ratings from

nurses, with five commenting on its ease of operation, but

four concerned about the need for an alarm if the CPR cord

is accidentally detached. The Deluxe air bed was seen as

comfortable by two patients and rated positively by nurses,

with the exception of the foot plates which got in the way of

the hoist. The Alpha XCell mattress was very highly rated

for comfort by patients (3) and nurses (6), but it was also

noted that, like the Harvest Supreme, this piece of equipment

needed an alarm if the CPR cord was dislodged. These ratings

were also reflected in the nurses’ comments on the patient

charts.

Chart audit findings

The chart audit data showed that all had evidence of a

nursing history being taken on admission. As per best

practice guidelines (Appendix 1), and a critique of different

scales 18 , the Braden Scale was adopted to assess risks to skin

integrity in conjunction with the preventative programme

and local, contextual factors.

Evaluation of pre- and post-project analyses of chart data

indicated substantial improvements in all areas measured,

and consistent use of the Braden scale with a corresponding

improvement in the number of risks identified post-project.

Skin integrity risks identified at the time of initial assessment

increased from 16.5% to 44.6%. These, and subsequent in-

hospital risk assessments, improved by 19.6% to achieve

an assessment rate of 70%. Dietary insufficiency identified

at time of assessment increased from 3.4% to 10.6%. The

advent of improved risk identification and ongoing staff

development facilitated an increase in the provision of

preventive pressure management strategies, with subsequent

assessments increasing to 43.9% (Figure 1).

A shift in the type of preventive management strategy

provision was the next most significant change following

the project. The application of transparent film dressing to

heels was the most widely used strategy prior to the project,

and its use dramatically decreased. The use of specialised

equipment such as heel raisers became the primary preventive

management strategy, increasing from 11% to 82.4%. The use

of specialist overlays and mattresses was also significantly

increased; a modest increase from 20.3% to 23.7% in the

practice of repositioning patients was evident (Figure 2).

The incidence of acquired pressure lesions for hospitalised

patients reduced from 6.4% to 5.8%. Marked improvement

was also noted in relation to documenting identified lesions

appropriately so that ongoing review and assessment could

be conducted. Pre-project audit findings had identified

that 2.1% of patients who acquired pressure lesions had

received only initial treatment, with no evidence of follow-up

assessment or detailed progress of healing. Post-project audit

results confirmed that all patients who acquired lesions had

appropriate documentation to facilitate ongoing assessment

and care provision (Figure 3).

The occurrence of Stage II lesions in particular was markedly

lower (Figure 4). Whilst the frequency of Stage I lesions

remained the same, this may in part be attributed to an

increased awareness and reporting by staff. As indicated in

Figure 4, no patients acquired Stage III or IV lesions. Prior

to the development of the skin integrity programme, the

hospital initiated a falls prevention programme as part of

its quality/risk management initiatives 26. This programme

resulted in a major reduction in hospital falls, which was also

a component of managing skin integrity.

Discussion

This research project has resulted in immediate improvements

to quality and safety of patient care, while helping to de-

mystify the processes involved in implementing an evidence-

based best practice protocol for maintaining skin integrity.

In addressing an area of interest to all nurses on all wards,

Figure 1. Use of risk assessment tool, assessment of risk pre- and

post-project.

Figure 2. Pressure management strategies used pre- and post-project.

0.0%

70.0%

Percentage

Pressure Risk Assess Tool Subsequent Assessment Risks Identified

60.0% 50.0% 40.0% 30.0%

2006 2007 70.0% 43.9% 44.6%

50.4% 1.3% 16.5%

20.0% 10.0%

2006 2007

2006 2007

0.0%

70.0%

90.0% 80.0%

Percentage

60.0% 50.0% 40.0% 30.0% 20.0% 10.0%

2006 2007

Transparent filmdressings 17.6%85.6%

Heel Raisers Repositioning Specialistoverlays Specialisedmattresses 82.4%11.0% 23.7%20.3% 62.9%21.2% 28.6%0.8%

  1. Black N, Murphy M, Lamping D, McKee M, Sanderson C, Ashkam J & Marteau T. Consensus development methods: a review of best practice in creating clinical guidelines. J Health Serv Res Policy 1999; 4(4) :236-48.
  2. Thompson D. A critical review of the literature on pressure ulcer aetiology, J Wound Care 2005; 14(2) :87-90.
  3. Gunningberg L, Lindholm C, Carlsson M & Sjoden P. Risk prevention and treatment of pressure ulcers – nursing staff knowledge and documentation. Scand J Caring Sci 2001; 15 :257-263.
  4. Gunningberg L. Are patients with or at risk of pressure ulcers allocated appropriate prevention measures? Int J Nurs Pract 2005; 11(2) :58-67.
  5. McErlean B, Thomas L, Page T & Simunov K. Collaborating to improve pressure ulcer prevention practices: the South Australian experience. Primary Intention 2006; 14(2) :67-73.
  6. Cullum N, McInnes E, Bell-Syer SEM & Legood R. Support Surfaces for Pressure Ulcer Prevention. The Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD001735.pub2. DOI: 10.1002/14651858.CD001735. pub2.
  7. Langer G, Schloemer G, Knerr A, Kuss O & Behrens J. Nutritional Interventions for Preventing and Treating Pressure Ulcers. The Cochrane Library 2006 (ISSN 1464-780X).
  8. DePalma J. Research corner. Evidence to guide wound care. Home Hlth Care Manage Pract 2005; 17(3) :227-29.
  9. James J. A static-led approach to pressure ulcers: an evaluation after 3 years. Br J Nurs 2004; 13(2) :1221-25.
  10. Bell J. The role of pressure-redistributing equipment in the prevention and management of pressure ulcers. J Wound Care 2005; 14(4) :185-188.
  11. New South Wales Health, Prevention of Pressure Ulcers, Guide for Acute Care Settings. Accessed online 13 February 2006, at www.health.wa.gov. au/safetyandquality/programs/pressure_ulc.
    1. Royal College of Nursing. The Management of Pressure Ulcers in Primary and Secondary Care: A Clinical Practice Guideline 2005. London: RCN.
    2. Defloor T & Grypdonck MF. Validation of pressure ulcer risk assessment scales: a critique. J Adv Nurs 2004; 48(6) :613-21.
    3. Gebhardt K. Pressure ulcer research: where do we go from here? Br J Nurs (Tissue Viability Suppl) 2004; 13(19) :S14-S18.
    4. Tripp-Reimer T & Doebbeling B. Qualitative perspectives in translational research. Worldviews Evid Based Nurs 2004; Third Quarter (Suppl) :S65- S72.
    5. Standards Australia / Standards New Zealand. Guidelines for Managing Risk in Health Care. Canberra: Standards Australia, 2001.
    6. Department of Health Western Australia. Clinical Risk Management Guidelines for the Western Australian Health System. Perth: DOHWA
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Appendix 1. Best practice guidelines for maintaining skin integrity.

Assessment Complete head-to-toe on admission and daily afterwards for those at risk:

  • Clinical judgement and the Braden Scale should be used for risk assessment.
  • Surgical clients or those restricted to bed should be assessed for pressure, friction and shear in all positions and during lifting, turning and repositioning.
  • Staging of pressure ulcers should be according to RN & NICE best practice guidelines.
  • All data should be documented at the time of assessment and reassessment.

Planning

  • An individualised plan of care should be based on assessment data, identified risk factors and client’s goals, developed in collaboration with the client, significant others and health professionals.
  • The nurse should use clinical judgement to interpret risk in the context of the entire client profile, including client goals.

Interventions The care provider should:

  • For high risk patients, minimise pressure through a positioning schedule.
  • Use proper positioning, transferring and turning techniques, in consultation with OT and physio, for transfer, positioning, devices and optimising client independence.
  • Consider the impact of pain – pain control should be monitored on an ongoing basis using a valid assessment tool.
  • Consider the client’s risk for skin breakdown related to the loss of protective sensation or the ability to perceive pain and to respond in an effective manner (impact of analgesics, sedatives, neuropathy etc).
  • Consider the impact of pain on local tissue perfusion.
  • Avoid massage over bony prominences; use pillows or foam wedges over prominences and devices to totally relieve pressure on heels and bony prominences of feet.
  • Surgical clients or those at risk of pressure ulcers should have replacement mattress with low interface.
  • For those restricted to bed, care should be interdisciplinary. Devices should enable independent positioning, lifting and transfers. Patients should be repositioned every 2 hours or sooner if at high risk – 30 degree turn to either side, maintaining head of the bed to lowest elevation (30 degree or lower) consistent with medical conditions and restrictions. Use lifting devices to avoid dragging clients during transfer and position changes. Do not use donut type devices or products that localise pressure to other areas.
  • For those restricted to chair, care should be interdisciplinary, with referrals to OT and physio for seating assessments and adaptations. Client should shift weight every 15 minutes if able. Reposition every hour if unable to shift weight. Use pressure reducing devices for seating, not devices that localise pressure to other areas. Consider postural alignment, distribution of weight,

balance, stability, support of feet and pressure reduction when positioning individuals in chairs or wheelchairs.

  • Protect and promote skin integrity by ensuring hydration through adequate fluid intake. Individualise bathing schedule. Avoid hot water, use ph balanced, non-sensitising skin cleanser. Minimise force and friction. Maintain skin hydration by applying non- sensitising, ph balanced, lubricating moisturisers and creams with minimal alcohol content. Use protective barriers or padding to reduce friction injuries.
  • Protect skin from excessive moisture and incontinence, assessing and managing body fluids, cleansing at time of soiling, avoiding friction during care, and minimising skin exposure. Where moisture cannot be controlled, use absorbent pads, dressings or briefs that wick moisture away from the skin. Replace pads and linens when damp. Use topical agents that provide protective barriers to moisture. If there is unresolved skin irritation in the moist area, consult with a physician. Establish a bowel and bladder programme.
  • Complete nutritional assessment with appropriate interventions on entry to a new healthcare environment or when client’s condition changes. If a nutritional deficit is suspected, consult with a registered dietitian, investigate factors that compromise intake, plan and implement nutritional support or supplementation programme. If it remains inadequate, consider alternative nutritional interventions, especially for older persons.
  • Institute a rehabilitation programme, if consistent with the overall goals of care and if the potential exists for improving the individual’s mobility and activity status.

Organisation and policy

  • Organisations need a policy with respect to providing and requesting advance notice when transferring or admitting clients between practice settings when special needs (surfaces) are required.
  • Guidelines are more likely to be effective if they take into account local circumstances and are disseminated by ongoing educational and training programmes.
  • Nursing best practice guidelines can be successfully implemented only when there is adequate planning, resources, organisational and administrative support and appropriate facilitation. An organisation plan includes – assessment of organisational readiness and barriers to education, involvement of all members who will contribute to implementation, dedication of a qualified individual for support of education and implementation, ongoing opportunities for discussion and education to reinforce the importance of best practices, and opportunities for reflection on personal and organisational experience in implementing guidelines.
  • Organisations need to ensure that resources are available to clients and staff (moisturisers, skin barriers, equipment, consultants).
  • Interventions and outcomes should be monitored and documented using prevalence and incidence studies, surveys and focused audits 18, 28^.

Support surfaces

  • High specification mattresses are preferred over standard foam. Further research is required comparing different support surfaces 12.