Commentary on Buss IC, Halfens RJG, Huyer Abu Saaad H and Kok G Pressure ulcer prevention in nursing homes: views and beliefs of enrolled nurses and other health care workers. Journal of Clinical Nursing 13, 668–676

Abstract

The paper by Buss et al. presents a depressingly familiar story – health care professionals are not as eager as one would hope to implement clinical practice guidelines. This study is valuable, however, in that the authors have attempted to explore, using qualitative techniques, why the Dutch national pressure ulcer guidelines have not been implemented in nursing homes. Semi-structured interviews were undertaken with 14 nurses (five of whom were enrolled nurses) and four physicians, from five nursing homes, with the aim of exploring their views and beliefs around pressure ulcer prevention. Researchers also scrutinized pressure ulcer prevention protocols from the nursing homes to compare reported practice with locally recommended practice, and local protocols with national guidance. ‘Sensitizing concepts’ from the literature on behaviour, knowledge utilization and research utilization in relation to pressure ulcer prevention were used as a framework for both the interviews and the data analysis. However, the paper does not tell us what these were, except that one was ‘the diffusion of knowledge of pressure ulcer prevention’. A particularly impressive feature of this qualitative paper is the methodological description of the data analysis and the authors’ attempts at ensuring rigour in the analysis. The team compared the consistency of coding by using two researchers to code four of the interviews; they then calculated a Jaccard index and concluded reasonable similarity. Others have used multi-rater Kappa for the same purpose (Thompson et al. 2004). As descriptions of data analysis in qualitative research are so often thin or non-existent, this detail was particularly refreshing. Key findings of this piece of research were that enrolled nurses did not see a need to keep up to date with research-based developments in pressure ulcer care; that they looked to colleagues (not protocols) for further information; that pressure ulcers were not seen as a problem despite their high prevalence and that guidance from local protocols was selectively implemented and often over-ridden or even transposed. Whilst massage of pressure areas is regarded by many as potentially harmful and was not recommended by the national guidelines, three nursing home protocols recommended this practice and nurses used their own personal experience as justification. Others (Thompson et al. 2004) have previously shown that UK nurses are more likely to turn to colleagues even when relevant protocols are available. However, personal experience has severe limitations as the sole basis for clinical practice decisions and is hard to justify in the face of conflicting national guidance (Thompson 2003). Where does this piece of research take us? Along with similar research (Saliba et al. 2003) it acts as a wake up call to those of us who do research and disseminate it and those who are responsible for promoting high-quality clinical care in practice. There is a wealth of evidence that guideline implementation does not automatically follow guideline publication. Active implementation strategies, tailored to the needs of specific organizations and the individuals working within them are what is required. Appropriate implementation strategies are likely to vary from place to place. What the paper by Buss et al. does not explore is what implementation strategies had been undertaken in these nursing homes prior to this study – this would be important contextual information that would help readers’ interpretation of the results. Grimshaw et al. (2004) have recently undertaken an exhaustive review of the research evidence for and against various guideline implementation strategies. They reviewed 235 studies comparing 309 different guideline implementation techniques and concluded that reminders and educational outreach are potentially effective interventions but that their effects are variable and frequently modest. Nevertheless as the staff interviewed for this study did not perceive pressure ulcers as an important clinical issue one wonders whether an educational outreach model including audit and feedback might be worth exploring. Educational outreach in this context would involve an expert in pressure ulcers, with clinical credibility and good interpersonal skills, meeting with nursing home staff in their workplaces, feeding back pressure ulcer audit data (which would show staff the importance of the topic in their workplaces) and promoting the guideline content, with the aim of changing practice. In conclusion, this paper reminds us that the publication of clinical practice guidelines marks the beginning of an implementation process – not the end. There is a growing literature on how to stimulate change within organizations (Iles & Sutherland 2001, Grimshaw et al. 2004) and any nurse who has a role in practice development and quality improvement should be abreast of it.