Article Text
PDF
Abstract
Introduction Pressure injuries are a common and significant concern in clinical practice, often serving as a vital quality indicator. While (clinical) practice guidelines have been established to offer recommendations for mitigating hospital-acquired pressure injuries, adherence among stakeholders remains inconsistent. The subjective perceptions of stakeholders, such as patients and nurses, may impede adherence to pressure ulcer prevention guidelines, potentially reducing the effectiveness of these interventions. However, there is currently insufficient evidence to comprehensively understand this influence. Therefore, this review aims to offer a broader understanding of how the perspectives of patients and nurses engaged in pressure injury prevention affect the effectiveness of specific interventions for pressure ulcer management.
Methods and analysis We will conduct a convergent, segregated mixed-methods systematic review and perform a narrative synthesis with a focus on evidence of the effectiveness of pressure injury prevention strategies and patient and nurse perceptions. Our search will encompass several databases, including the 'Centre for Reviews and Dissemination' (CRD) Database, Medline (via Ovid), CINAHL (via Ebsco) and Scopus (via Elsevier). Additionally, we will cross-check reference lists from all included systematic reviews. Two independent reviewers will screen titles, abstracts, and full texts and extract data from the included studies. The quality of methodology of systematic reviews will be assessed using 'A Measurement Tool to Assess Systematic Reviews-2' (AMSTAR 2) and the risk of bias using 'Risk of Bias in Systematic Reviews' (ROBIS). Qualitative studies will undergo critical appraisal using appropriate Joanna Briggs checklists. If it is feasible to pool data from included studies, we will synthesise them accordingly, using meta-analysis for quantitative reviews and meta-aggregation for qualitative studies. The results from both qualitative and quantitative analyses will be compared with derive new recommendations for healthcare practice aimed at enhancing the quality of care.
Ethics and dissemination Ethical approval is not required due to the nature of this intended review. The results of this review will be disseminated through publications, reports and conference presentations.
PROSPERO registration number CRD42023438792
- nursing care
- wound management
- qualitative research
- systematic review
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
STRENGTHS AND LIMITATIONS OF THIS STUDY
Our approach uniquely contextualises quantitative findings by integrating qualitative evidence.
We will compare studies examining nurse and patient experiences alongside their effectiveness.
Conducting separate syntheses of the evidence will enhance the reliability of our recommendations through increased scientific rigour.
This contextualisation will ensure that our findings reach a broader audience.
The multifaceted approach could lead to increased variance in data quality, potentially affecting the findings.
Introduction
According to the National Pressure Ulcer Advisory Panel, the European Pressure Ulcer Advisory Panel (EPUAP) and the Pan Pacific Pressure Injury Alliance (PPPIA), a pressure injury (PI) (also known as pressure sore, pressure ulcer or bedsore) is ‘a localised injury to skin or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear’.1 PIs occur when the soft tissue is compressed between the bony prominence and an external surface for a prolonged period. In keeping with the most recent international guidelines, we have used the term pressure ‘injury’ rather than ‘ulcer’ throughout this review, as the former more accurately describes both intact and ulcerated skin.1
PIs are the most common type of preventable complication in all care settings. Recent meta-analyses of hospitalised adults reported a pooled hospital-acquired PI rate of 8.4% globally.2 The prevalence of PIs in Europe is 10.8%.3
PIs can affect patients and healthcare organisations. They can increase mortality rate, reduce quality of life and cause pain, persistent and unresolved emotional distress and isolation and can change overall health outcomes.4–6 PIs can also place a significant financial burden on healthcare systems due to prolonged hospital stays and complex treatment costs.7 8
Evidence-based interventions are required to prevent PIs. There are already guidelines (eg, EPUAP, NPIAP and PPPIA), systematic reviews and even some umbrella reviews on this topic. These, therefore, have been developed, to guide nurses in the implementation of evidence-based interventions. The umbrella reviews from Walker et al, Shi et al and Hill et al describe the effectiveness of preventative and curative treatments of PIs by including Cochrane reviews published up to 2020.9–11 The aim of these reviews was to assess the evidence from studies that focused on the effect of PI treatment strategies. However, these reviews did not look at strategies for the prevention of PI or did not have enough good-quality evidence to make a conclusive interpretation of these strategies. Other limitations of these reviews include the exclusive focus on Cochrane reviews and the range of the search, which may be outdated. Therefore, further research is needed to fill the gap and update the evidence on the effectiveness of PI prevention strategies. Since 2020, research in this area has progressed. A new umbrella review of current systematic reviews is needed, including reviews other than Cochrane reviews.
Prevention of PIs is, therefore, essential. Furthermore, PIs are quality indicators for nursing practice and are often referred to as nursing-sensitive outcomes.12 As PIs are directly influenced by the actions of nurses, they have a legal duty to prevent their occurrence.13 14 Nurses in hospital settings implement interventions to prevent PIs using a variety of nursing interventions, for example, mobilisation, preventive skin care, preventive nutrition and pressure-distributing underlays.1 Often, the implementation of these interventions is dependent on contextual factors such as staffing and time constraints, resource allocation, patient complexity as well as the qualifications and experiences of nurses, which may ultimately hinder their intended purpose.15 The main barriers to prevent PIs are high workload and insufficiently competent staff, lack of resources and equipment.16 17 This can lead to ambivalence between evidence-based and feasible prevention strategies.18
According to various authors, PI prevention is inconstant used as the prevalence shows.2 3 Knowledge and beliefs are particularly important in implementing evidence-based practice in PI prevention.16 Current guidelines cannot, therefore, cover the full range of individual behaviours and provide definitive strategies for improving care because of the nature of clinical practice, which relies on human beings with their own individuality.15 19 There are qualitative studies looking at nurses’ and patients’ perspectives on PI prevention, but no review has been published so far. However, several qualitative reviews have been published that provide new evidence on patients’ and nurses’ experiences of living with a PI and nurses’ knowledge of PI prevention.20 21 Studies analysing nurses’ perceptions show that PI prevention is challenging in practice and depends on attitudes, effective communication, strong leadership, simplicity of interventions, evidence-based knowledge and skills, risk assessment and teamwork.22 23
A study on patient experience in PI prevention found that most patients want to have a proactive role in PI prevention. However, they are highly dependent on caregivers and feel unseen when prevention needs are not met.4
In order to improve the PIs prevention and to provide conclusive recommendations to nurses, it is, therefore, necessary to assess the current high-quality quantitative evidence, on PI prevention and to combine it with the existing qualitative data in a Mixed Methods Systematic Review (MMSR). MMSR is a new emerging scientific approach in nursing science designed to provide new recommendations for clinical practice.24 25 A few attempts have been made to combine the evidence from both quantitative and qualitative studies of PI prevention in a convergent, integrated approach.13 26 However, this study is the first to integrate the results of already published systematic reviews summarising the evidence on the effectiveness of PI prevention strategies and qualitative study designs evaluating patients’ and nurses’ perceptions on such preventing interventions. To achieve our goal, we will use the Joanna Briggs Institute (JBI) method for an MMSR and umbrella reviews.27 28
Study objective
A convergent, segregated, mixed-methods review is intended to provide a more complete picture and a better understanding of whether and how stakeholder perceptions influence the effectiveness of PI prevention. This study can, therefore, support subsequent clinical decision-making and provide conclusive recommendations for healthcare practice. The research questions of this MMSR are (1) how PI prevention affects the clinical outcome of patients (effectiveness); (2) what the perception of nurses and hospitalised adult patients on PI prevention is and (3) how is the degree of synergy between nurses and patients perception affecting the effectiveness of PI prevention.
Methods and analysis
We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA)29 for writing this protocol. The systematic review is registered via PROSPERO (CRD42023438792) (online supplemental appendix 1).
Supplemental material
Study selection criteria
The mixed-methods review will exclusively consider studies that meet the eligibility criteria established within the PICO (Patient-Intervention-Comparator-Outcome) framework for quantitative inquiry and the PICo (Population-Interest-Context) format for the qualitative aspect (table 1).
PICO framework and PICo format of the research question
Quantitative search approach
Types of studies
We will conduct an Umbrella Review, synthesising systematic reviews. In this process, we will determine the eligibility of included reviews using the PICO framework (population (P), intervention (I), comparison (C) and outcome (O)), as outlined in table 1. Reviews will be considered for inclusion if they pertain to patient groups receiving PI prevention in tertiary care settings. Prevention methods encompass repositioning, dressing, foam dressing, education, debridement, topical agent application and topical antibiotics/antiseptics. Inclusion criteria are not dictated by comparators or reported outcomes in the reviews we search for; instead, we will focus on systematic reviews that feature a comprehensive literature search, transparent study selection procedures and either a risk of bias assessment or critical appraisal of included studies. The search string has been adapted to a search string developed to retrieve systematic reviews.30 Additional restrictions include the publication period, with only systematic reviews published between June 2012 and June 2023 being included, and language restrictions, which are limited to English or German (online supplemental appendix 2).
Supplemental material
Qualitative search approach
Types of studies
This mixed-methods review will encompass a variety of qualitative study designs, including grounded theory, phenomenological studies, ethnographic methods, action research and studies using qualitative techniques such as interviews, focus groups and thematic analysis, as well as expert opinion papers. The search string has been adapted to a search string developed to find qualitative research.31 32 Additionally, we are actively seeking studies employing mixed-methods designs. In these cases, the qualitative and quantitative components of such studies will be categorised and integrated into their respective synthesis branches.
Further criteria for inclusion: Studies must have been published in English or German between June 2012 and June 2023 (online supplemental appendix 3).
Search strategy
The literature for the quantitative and qualitative approach will be developed according to the Peer Review of Electronic Searches guideline33 and in close cooperation with an experienced systematic searcher (SD). The following electronic databases will be searched
Centre for Reviews and Dissemination (CRD) Database.
Medline (via Ovid),
CINAHL (via Ebsco).
Scopus (via Elsevier).
Additionally, we will search manually for relevant studies by:
Cross-checking the reference lists of all included systematic reviews and qualitative studies.
The search will include Medical Subject Headings (MeSH) terms and keywords with the components pressure injuries (population) and prevention strategies (intervention) and study types (Review or qualitative designs, respectively). See online supplemental materials for the full Medline search string. All initial records will be imported into EndNote V.20 (Clarivate Analytics Version, Pennsylvania, USA) to delete all duplicates prior to the selection process.
Study selection
Two independent researchers will screen all titles and abstracts of initial records. Second, the researchers will screen the full text against the prespecified inclusion criteria. The authors will record and report any studies that do not meet the inclusion criteria (qualitative: KG and LF; quantitative: IT and LF). Discrepancies will be resolved by discussion. In case of disagreements, an independent arbitrator will resolve disagreements between the two independent researchers (qualitative: IT; quantitative: KG). The study process will be presented in a PRISMA flow chart.34 Each screening will be piloted by a random sample of records and full texts, resp.
Appraisal of included reviews and studies
Two researchers will independently assess the methodological quality of reviews and studies. A third adjudicator will resolve any disagreements between the two researchers. For systematic reviews, 'A Measurement Tool to Assess Systematic Reviews - 2' (AMSTAR 2) is used to assess the methodological strengths and weaknesses of a systematic review. Several aspects of a systematic review are assessed, including whether the protocol was registered in advance, whether the literature search was conducted appropriately, whether study exclusions were justified, whether the risk of bias was assessed for included studies and whether meta-analyses were appropriate.35 To assess the quality of included qualitative studies, we will use the JBI Critical Appraisal Checklist for Qualitative Research.36 To assess the methodological quality of the mixed methods studies, we will use the Mixed Methods Appraisal Tool.37 Finally, the JBI Critical Appraisal Checklist for Text and Opinion Papers is used to assess the methodological quality of opinion papers.38
Risk of bias
'Risk of Bias in Systematic Reviews' (ROBIS) will be used to evaluate the level of bias present within a systematic review. Briefly, the ROBIS tool assesses in three distinct phases the relevance of the research question; possible concerns with the systematic review conduct and judges the overall risk of bias for the systematic review (low, high and unclear).39 40
Data extraction
Citations stored in EndNote are exported in 'Research Information System' (RIS) format and uploaded to an intelligent cloud-based platform, Rayyan (Qatar Computing Research Institute, Doha, Qatar), for citation screening.41 Studies that met the inclusion criteria will be extracted. An Excel spreadsheet will be developed for both research approaches (quantitative and qualitative). Using a random sample of three of the included studies for each approach, the data extraction will be pilot tested and revised if necessary.
Information according to the JBI Data Extraction Form for Reviews of Systematic Reviews and Research Syntheses28 and JBI Qualitative data extraction tool42 will be extracted from the included articles by one reviewer (IT) and double-checked by a second reviewer (LF):
Qualitative approach:
Study details (author, year, journal and record number).
Study description (methodology, method, phenomena of interest, setting, geographical and cultural, participants).
Analysis (data analysis, author conclusions, findings and evidence).
Quantitative approach:
Study details (author/year, objectives and with/without meta-analysis).
Description of research question according to PICOS scheme.
Inclusion and exclusion criteria search details (sources searched and search period).
Description of studies included (number, publication period, designs and country).
Applied critical appraisal tools and the results of conducting appraisal.
Analysis (method of analysis, outcome assessed, results/findings, significance/direction and heterogeneity).
Any discrepancies will be resolved by discussion, if data are missing from the included full text or uncertainties related to the data the researchers contact the author responsible for the specific study to resolve the knowledge gap.
Data synthesis
According to the JBI methodology for MMSR, this review will take a convergent segregated approach to synthesis and integration. After the two syntheses have been completed, an interpolation of the evidence will take place.
Quantitative synthesis
We will conduct a meta-analysis using Review Manager (Cochrane, London, England) on the study data extracted from the original systematic reviews and meta-analyses, essentially re-running the meta-analysis. In cases where data are unavailable or insufficient for statistical analysis, we will extract data directly from the primary studies. In the initial stage, a summary statistic is calculated for each study, with the objective of describing the observed intervention effect in a uniform manner across all studies. In the subsequent stage, a summary (combined) intervention effect estimate is calculated as a weighted average of the intervention effects estimated in the individual studies. The meta-analysis for dichotomous outcomes relative risks and 95% CIs will be rerun. Comparable trial results will be pooled using the fixed-effect model and 95% CI. For continuous outcome data, we will present the mean difference (MD) with 95% CIs for studies that used the same assessment scale. If studies reporting continuous data used different assessment scales, we will report the standardised mean difference (SMD) with 95% CIs. For time-to-event data, such as time-to-pressure ulcer development, we present the HR along with its 95% CI. To assess the heterogeneity among the included studies, we will perform an initial statistical analysis, typically using Cochran’s Q or I² statistic. Summary effect estimates will be calculated for both fixed-effects and random-effects models, and we will present the distribution of effect estimates through a forest plot. Publication bias will be assessed and presented using a funnel plot. The risk of bias in the included reviews will be summarised in tabular format. We will employ a validated Grading of Recommendation, Assessment, Development and Evaluation tool to assess the strength of evidence from the included studies, and these assessments will be reported in the results section.43 Results will be reported as mean differences or SMDs with 95% CIs for continuous data and as ORs with 95% CIs for categorical data. We will also provide the p value and measures of heterogeneity across the meta-analysis results in both graphical and tabular formats.44
Qualitative synthesis
The qualitative synthesis uses a meta-aggregative approach, based on the user guidance developed by the JBI. The aim of this method is to produce synthesised statements that support decision-making at the clinical or policy level. The resulting ‘lines of action’ in a meta-aggregative synthesis provide clear guidance for healthcare professionals in making practical decisions. This analysis is ideal for our study, emphasising the practicality and usability of the synthesised results. The aim is to provide useful information for clinical practice. Meta-aggregation consists of three phases. During the first phase, we extracted themes identified by the authors of the original study. In phase 2, the extracted themes from all studies are searched for commonalities. Categories are formed from similar themes and metaphors across all studies. The transition from findings to categories follows established qualitative research methods like constant comparative and thematic. The third phase involves formulating ‘lines of action’ or declarative statements.45
Interpretations of the results
Results obtained from both syntheses will be interpolated into new findings/recommendations. The quantitative results on the effectiveness of the PI prevention will be pooled with the perception gained from qualitative analysis.
Recommendations for practice
This review holds important implications for clinical practice. Nursing practice heavily relies on the subjective experiences of both patients and nurses. Currently, there is a limited body of literature that assesses how these subjective perceptions impact the clinical outcomes of PI prevention interventions. It is possible that patients and nurses may have unfavourable views of certain interventions, which could potentially diminish their effectiveness. Addressing such negative perceptions in clinical practice could enhance the overall effectiveness of these interventions and elevate the quality of care provided. This systematic review aims to provide valuable guidance to nurses in implementing appropriate PI prevention strategies.
Patient and public involvement
None.
Ethics and dissemination
The review is a synthesis of existing resources. Therefore, ethical approval was not required. The results of the review will be disseminated through publications, reports and conference presentations.
Ethics statements
Patient consent for publication
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors IT is the guarantor and drafted the manuscript together with LF. IT integrated the feedback provided by the other authors and finalised the manuscript accordingly. SD provided expertise for the search strategy, quality assessment and analysis framework. KG, SD and LF read, provided feedback and approved the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.