Evaluation of the Dissemination and Implementation of a Nutritional Guideline for Pressure Ulcer Care

Pressure ulcers are a common, expensive and painful health-care problem, with prevalence rates ranging from 3% to 66% in heath-care organisations.1,2 The estimated annual treatment costs are 21.07 billion in the UK, 22.4 billion in the USA and 20.6 million in the Netherlands.3,4

A pressure ulcer is defined as localised damage to the skin and underlying tissue caused by pressure, shear, friction or a combination of these.5 The development of pressure ulcers depends on extrinsic and intrinsic risk factors. The most important extrinsic risk factors are pressure, shear and friction, which lead to mechanical loading and secondary damage to the skin and soft tissue.6 Intrinsic factors have an effect on tissue viability and consequently influence the pathophysiological response to mechanical loading. Studies have found significant associations with age, sex, limited activity, incontinence (bowel and bladder), infection and nutritional status. The relative influence of each of these intrinsic risk factors is still unclear.7-9

A 2003 Cochrane review indicated that there is no strong scientific evidence for a direct relationship between poor nutrition and pressure ulcer development and healing, and a causal relationship has never been established, although the methodological quality of the studies reviewed is weak.10 Nevertheless, individual studies have demonstrated that an adequate nutritional intake may help protect against pressure ulcer development and improve the rate of healing.11-14

A recent meta-analysis by Stratton et al on enteral nutritional support in the prevention and treatment of pressure ulcers pointed out that, in four randomised controlled trials (RCTs), oral nutritional supplements (250-500Kcal for two to 26 weeks) were associated with a significantly lower incidence (25%) of pressure ulcer development in ‘at-risk’ patients compared with routine care.15 Furthermore, some studies showed a trend towards improved healing with high protein nutritional supplements when compared with studies using standard formulae. However, Stratton et al indicated that more robust RCT studies are needed to scientifically confirm the latter finding.

As nutritional status can be easily influenced by patient and practitioner interventions, clinical guidelines could set out the optimum management approach. Such guidelines provide an important bridge between research findings and clinical practice,16 can aid the implementation of evidence-based research and give structural directions on how to provide efficient and adequate care, thereby improving quality of care.17

A study of previous pressure ulcer prevention and treatment guidelines concluded that most paid less than adequate attention to nutrition.18 The European Pressure Ulcer Advisory Panel (EPUAP) therefore set up a nutritional working group comprising practitioners from European countries to develop a clinical nutritional guideline on pressure ulcer prevention and treatment. The guideline was launched in 2004 and translated into eight languages. It covers the whole nutritional cycle (screening, assessment, intervention, evaluation and follow-up) and includes weight recommendations. It emphasises the importance of incorporating nutritional activities structurally into daily pressure ulcer management. The most essential elements of the guideline have been mapped into a decision tree.19 The guideline has been disseminated via the EPUAP’s network, which comprises its conferences, internet site, members and publication, and through the nutritional industry.19

However, the availability of clinical guidelines does not automatically lead to their use in daily practice. In 2005 the EPUAP nutrition working group therefore decided to explore the degree to which the nutritional guideline had been disseminated and implemented in clinical practice in Germany, the Netherlands and UK.

In this study the term ‘dissemination’ is defined as distribution and does not necessarily include action. ‘Implementation’ is defined as the actual use of the guideline in daily practice.20

Model of innovation-decision process

Rogers’ model of the innovation-decision process21 was chosen as a framework for this study because, unlike other models in this field, it incorporates specific stages of the dissemination and implementation process. The model charts the five stages through which an individual (or another decision-making unit, such as a group, society, economy or country) moves across the innovation-decision process (Box 1). These stages typically follow each other in a time-ordered manner. The first three stages of the model are comparable to the dissemination of a guideline because the participant is not yet actively using it.

The study participants were mapped in accordance with Rogers’ model, thereby providing an insight into the percentage of participants in the various stages of dissemination and implementation one year after the launch of the guideline.

  1. Knowledge

    An individual becomes aware of and reads a guideline. ‘What?’, ‘how?’ and ‘why?’ are the critical questions

  2. Persuasion

    Occurs when the individual develops a negative or positive attitude towards the guideline

  3. Decision

    The individual chooses to adopt or reject the innovation. Adoption is defined as ‘having this guideline present in practice because it is the best course of action available’, and rejection as ‘not adopting this guideline’

  4. Implementation

    The guideline is put into practice. Uncertainty about the outcomes of working with this guideline can still be a problem at this stage

  5. Confirmation

    The individual looks for support for his or her decision to use the guideline. This decision can be reversed if the individual is exposed to conflicting messages or barriers to its use

Box 1. The five steps of Rogers’ innovation-decision process

Method

A cross-sectional design was used. In total, 1087 clinical health-care organisations (300 from the Netherlands, 300 in Germany and 487 in the UK) were invited to participate in the study at the end of 2005. A national coordinator in each country invited the selected health-care organisations, which comprised hospitals, nursing homes and home care, to participate in the postal survey. The national coordinators were members of EPUAP nutritional working group.

The health-care organisations’ addresses were selected from several relevant databases in all three participating countries. The UK and Netherlands used more targeted databases, and Germany a more general database. The questionnaires were sent to managers of the health-care organisations, who were asked to allocate them to whoever was primarily involved in nutritional policy for pressure ulcer prevention and treatment.

Ethical approval was not required as the questionnaire focused on organisational aspects and patients were not directly involved.

The standardised questionnaire was developed by the EPUAP nutritional working group, following the Rogers’ implementation stages. It included twenty-four items: eight questions had a dichotomous outcome; two questions included four-point ordinal scales (always—never), and the remaining questions had a Likert scale ranging from four points to ten.

For the knowledge stage, two questions enquired about awareness of the guideline and whether it had been read, and one question asked about the dissemination channel.For the persuasion stage, one question enquired about attitudes towards the guideline.

For the decision stage, two questions asked about the presence of this guideline in practice.

For the implementation stage, respondents working in areas that had incorporated the EPUAP guideline into practice were asked eleven questions about its actual use in order to ascertain whether it was being followed correctly. Several recommendations, such as screening of nutritional status (when, who, how often, content), assessment, interventions, evaluation and follow-up were explicitly tested.

For the confirmation stage, two questions enquired about barriers to nutritional support within pressure ulcer prevention and treatment.

In addition, respondents’ demographic characteristics were defined under five items (profession, workplace, frequency of involvement in pressure ulcer care, membership of a pressure ulcer committee and involvement in pressure ulcer policy).

Members of the EPUAP nutritional working group translated the questionnaires into Dutch, German and English, checking content similarity.

Statistical analysis

Statistical analyses were performed using SPSS version 13.0. The statistical analysis included descriptive frequency distributions of all variables. Differences between analyses were performed per country independently and for the total sample. In some questions multiple answers were possible, so the total could be more than 100%.

Results

The sample

In total, 363 organisations returned the questionnaires: 146 Dutch, 50 German and 167 UK. This yielded a response rate of 33% (49% for the Netherlands, 17% for Germany and 34% for the UK). No information was available as to why organisations did not respond.

Table 1. Results for phases 1-3 of Rogers' model of the innovation-decision process
Netherlands Germany UK Total
* Significant (p<0.005) differences between the Netherlands and Germany
† Significant (p<0.005) differences between the Netherlands and UK
‡ Significant (p<0.005) differences between Germany and UK
Total Sample 146 50 167 363
Incomplete Questionnaires 4 1 9 14
Knowledge Stage
No. of people who responded 142 49 158 349
No. of respondents who used dissemination channels (%) 85 (60) *† 11 (22) ‡ 119 (75) 215 (62)
Dissemination Channel:
EPUAP Review 4% † 0% ‡ 18% 11%
EPUAP Internet Site 3% *† 38% 28% 19%
Other professional journal 17%; 31% 15% 17%
Industry 28% *† 0% 0% 11%
EPUAP conference 13%* 0% 15% 14%
Other conference 22% *† 6% 13% 15%
Colleagues 10% *† 0% 5% 7%
Other 2%* 25% 6% 6%
Persuasion Stage
No. of people who responded 85 11 119 215
Consequence of Knowing:
Positive attitude 90% 99% 100% 99%
Negative attitude 1% 0% 0% 1%
Decision Stage
No. of people who responded 85 11 119 215
% who used guideline in their daily practice 26% * 9% ‡ 26% 25%

Respondents comprised nurses (59%), dietitians (18%), physicians (6%) and other (mostly managers) (17%). Eighty-six per cent were members of a pressure ulcer committee or involved in pressure ulcer policy. Forty-nine per cent worked in a hospital setting, 26% in a long-term care setting and 22% in a home care. Most participants were involved daily or weekly in the care of patients at risk of or who had a pressure ulcer.

Knowledge stage

Sixty-one per cent of participants were aware of the EPUAP nutritional guideline. Significantly more were from the UK and Netherlands than from Germany (p=0.01) (Table 1).

The most frequently mentioned dissemination channel was the EPUAP internet site (19%), followed by professional journals (17%) and conferences (16%).

In the Netherlands the nutritional industry played a significant (p=0.02) and major role in dissemination of the guideline, and the EPUAP internet site played a significantly minor role (p=0.01) compared with Germany and the UK.

Persuasion stage

Respondents who had read the guideline stated that it mostly confirmed their views about the importance of nutrition in pressure ulcer prevention and treatment. Only 1% disagreed with the guideline, leaving 99% with a positive attitude towards its content.

Decision stage

Of the respondents who had read the guideline, 25% stated that they were applying its content to their daily practice (Netherlands: 26%, Germany: 9%, UK: 26%).

The guideline was significantly (p=0.01) more evident in daily practice in the UK and Netherlands than in Germany.

The guideline was mainly used in hospitals (61%), followed by home-care organisations (17%) and long-term institutional care (17%).

More dietitians (29%) than nurses (25%) or physicians (11%) used it in practice.

Implementation stage

As the stages typically follow each other in a time-ordered manner, only responses from participants who used this guideline in their daily practice were analysed. As only two used the guideline in Germany, these were not taken into account in the later stages as this sample was too small for further analysis.

Table 2. Results for the implementation stage
Netherlands UK Total
* Significant (p < 0.005) differences between the Netherlands and UK
Number of respondents 22 31 53
Should nutritional screening be undertaken on every patient?
At risk of pressure ulceration?
Always 19% 38% 31%
Sometimes 67% 55% 59%
Rarely 14% 7% 10%
Never 0% 0% 0%
With pressure ulcers?
Always 38% 47% 44%
Sometimes 57% 53% 54%
Rarely 5% 0% 2%
Never 0% 0% 0%
Assessment includes:
Weight 86% 61% 72%
Body mass index 18% * 68% 48%
Weight history 96% * 52% 70%
Clinical judgement 46% 65% 57%
Nutritional screening tool 23% * 81% 57%
Nutritional interventions:
Normal feeding 32% * 71% 56%
Oral supplements 96% 99% 96%
Tube feeding 36% * 52% 46%
Parenteral feeding 5% * 39% 26%
Evaluation - outcome measures to record success or failure of intervention:
No measurement 5% 19% 13%
Weight gain 86% 74% 77%
Development of PU 68% 52% 59%
Improvement in PU healing 82% * 65% 72%
Biochemical parameters 18% * 51% 43%
Follow up - how frequently screened?
At first contact only 5% 10% 8%
At regular intervals 57% * 33% 44%
When condition indicates 29% 43% 37%
Never 0% 0% 0%
Don't know 10% 13% 12%
Confirmation stage

Here, the individual looks for support for his or her decision to use the guideline. The individual could reverse their decision if exposed to barriers to implementation. Figure 1 shows the most important barriers to nutritional support.

Figure 1. Barriers to nutritional support in pressure ulcer patients (n = 61).

Discussion

The goal of this study was to investigate the degree to which the EPUAP nutritional guideline on pressure ulcer prevention and management had been disseminated and implemented in clinical health-care organisations within the Netherlands, Germany and UK.

Sixty-one per cent of the study participants were aware of the EPUAP nutritional guideline, and of these 99% had a positive attitude towards it. Moreover, 25% of those who were aware of the guideline had used it in their daily practice.

However, it is important to note that, due to the low response rate, the questionnaire might present a skewed view of the current state of implementation across the three countries.

The guideline was launched in 2004 with no specific strategy for its dissemination and implementation. One year later a relatively large number of the participating organisations already knew of it, especially in the Netherlands (59%) and UK (75%), and a smaller number had actually applied it to practice (26% and 26% respectively).

In Germany, only 22% of health-care organisations were aware of the guideline and 9% had used it in daily practice. However, these results may be influenced by selection bias as most German participants were not aware of the EPUAP, which has few German members and communicates mainly in English, which may be a barrier for German-speaking countries. Furthermore, in Germany there is a national expert standard which professionals are expected to use as the guideline for pressure ulcer prevention and treatment. Lastly, the German addresses were randomly selected from a general database, whereas in the UK all NHS trusts were selected and in the Netherlands addresses were taken from a targeted database. Any of these factors could have influenced the results.

Interestingly, of the 61% of respondents who were aware of the guideline, 99% had a positive attitude towards it, yet only one in four of the organisations used it. One reason for this could be that implementation of guidelines is a time consuming process,20 and this study took place too soon after the launch.

Another reason may be that if implementation strategies are not treated as an integral part of the development process of clinical guidelines, then implementation in daily practice may be hampered.20 While dissemination of a guideline may increase awareness among the target audience, it is not sufficient to bring behavioural change in the absence of an active implementation strategy.22 One year, therefore, may be too short a time in which to measure the effects on daily practice of guidelines disseminated without an implementation strategy.

Moreover, practitioners struggle when implementing guidelines, despite their enthusiasm. This seems to be because they experience a number of barriers. Understanding these barriers will enable the development of strategies for increasing the use of guidelines in daily practice.23,24

This study showed that the most important barrier to implementation of the guideline was lack of knowledge and skills, followed by lack of clarity about who is responsible for nutritional support, and inability to access nutritional support.

These barriers were also identified in previous studies.24-26 They were not explored further, so no extra information was available on which skills and knowledge were lacking. An insight into why these barriers exist will improve guideline implementation in clinical practice.

As discussed, individual studies have indicated that adequate nutritional status has a positive effect on pressure ulcer prevention and healing. It is important that this relationship is made more explicit, and strong scientific evidence from robust RCTs is therefore needed. This will help to increase our understanding of the relationship between pressure ulceration and nutrition, and provide a stronger evidence base on which to implement new guidelines.

Conclusion

This study demonstrates that the EPUAP guideline on nutrition in pressure ulcer prevention and management was quite well disseminated in the Netherlands and UK.

After only one year, two-thirds of participating healthcare organisations were aware of the guideline and one quarter had it in place.

The main barrier to implementing nutritional support in pressure ulcer care was lack of knowledge and skills.

Recommendations

References

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JWC: Journal of Wound Care This recent publication from the EPUAP Nutrition and Pressure Ulcers Working Group is reprinted with thanks to the Journal of Wound Care.

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