Moving Nursing Forward After the NPUAP Pressure Injury Staging Changes Protection Status
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advancing wound care nursing skills

by Margaret Heale, RN, MSc, CWOCN

I was not at the April National Pressure Ulcer Advisory Panel (NPUAP) meeting, but I do think some of critical commentary that has followed the announcement of the pressure injury staging system changes is flawed. Clearly designating the thickness of an injury to a defined wound stage makes sense and communicates a severity. All the NPUAP have done is clarify some detail that clinicians have had to manage previously, within a gray area. It is not the responsibility of the NPUAP, researchers or clinicians at the bedside to make up definitions to fit coding or legislators. It is important that researchers and bedside clinicians provide the Centers for Medicare & Medicaid Services (CMS) and legislators with research demonstrating how and why pressure ulcers occur.

Taking Responsibility for Pressure Injuries

I have seen pressure ulcers from negligence and ignorance throughout my career and the current belief within the profession that many are not preventable needs proof. From ICU nurses wanting to blame not being able to turn patients because of their unstable condition, to floor nurses stating patient's refusal and non-compliance, such excuses are often (but I accept not always) exactly that: excuses.

It is time to 'fold' and accept that we need to take responsibility. We have given away nursing care to under-trained, under-paid and under-valued non-professionals. There is little direction or communication and even less oversight of the nursing assistant role. Nurses work from protocols and orders with little regard for planning care and individualizing care plans. Care planning is a paper exercise to keep Joint Commission happy, but no one uses them. There are orders for everything from allowing the patient to get on to a commode, to ensuring they have offloading boots (left on the windowsill). Orders such as Q 2 hour turns gets transcribed into the chart and are either ignored or just worked around to fit into the routines that usually work for most patients.Our art has died, we are painting by numbers and it is visible to all who give more than a cursory glance to nursing care.

An Opportunity to Improve Pressure Injury Prevention

How can we go forward into the future rather than looking to the past as perfect? (Which, of course it never was.) In terms of pressure ulcers, there is no doubt that from the moment CMS stopped paying for hospital-acquired pressure injuries there was motivation from health care administration to prevent them. It gave nursing the opportunity to improve care, but with fewer resources and such an unmotivated bedside workforce, there was little hope of achievement.

It is now time to use what we know to get what we need. We know that in order to prevent pressure ulcers, offloading and the optimum pressure redistribution surface is important1. We know that optimal skin care will make the skin more resilient2. We know that dependent patients develop pressure injuries more than those who are able to mobilize and that regular repositioning with an individual schedule for patients prevents pressure injuries3.

Exactly how positioning can optimize offloading and gain patient cooperation is very important (particularly in the rehab setting). Paying attention to detail and straightening sheets, moving and repositioning devices is often underplayed4. The way we handle patients has a role to play, as does the equipment we use. Having people at the bedside to actually perform all the necessary, detailed care is imperative. But where are the people at the bedside? Who trains them and what value do we give them? The role patients and relatives play in preventing pressure injuries, and how they are educated and introduced to the alien concept of skin breakdown is much more important than many realize (therein lies a research project).

So maybe the NPUAP did not do what many had hoped or even the right thing, but let us take care not to throw out the baby with the bathwater. What we have is usable and can be developed further as we progress with research. For now, we have work to do so that nursing can move forward without being pushed by CMS or ordered by doctors.

1. McNichol L, Watts C, Mackey D, Beitz JM, Gray M. Identifying the Right Surface for the Right Patient at the Right Time: Generation and Content Validation of an Algorithm for Support Surface Selection. J Wound Ostomy Continence Nurs. 2015 Jan-Feb;42(1):19-37. doi: 10.1097/WON.0000000000000103.
2. Ayello EA, and Sibbald RG. Preventing pressure ulcers and skin tears. In Bolz M, Capezuti E, Fulmer T, Zwicker D, (Editors). Evidenced based Nursing protocols for best practice. 4th ed New York (NY) Springer pub co 2012 298-324.
3. Moore Z, Cowman S, Conroy RM. A randomised controlled clinical trial of repositioning, using the 30° tilt, for the prevention of pressure ulcers. J Clin Nurs. 2011 Sep;20(17-8):2633-44. doi: 10.1111/j.1365-2702.2011.03736.x. Epub 2011 Jun 27.
4. Pittman J, Beeson T, Kitterman J, Lancaster S, Shelly A. Medical device-related hospital-acquired pressure ulcers: development of an evidence-based position statement. J Wound Ostomy Continence Nurs. 2015 Mar-Apr;42(2):151-4.

About The Author
Margaret Heale has a clinical consulting service, Heale Wound Care in Southeastern Vermont and draws on her extensive experience as a wound, ostomy and continence nurse in acute and long-term care settings to provide education and holistic care in her practice.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.


This is an extremely important article written by Margaret Heale. As corporate ownership of the hospitals and extended care facilities has demonstrated on every level, the patient is not the most important consideration in the allocation of funds. The most important consideration is to allocate every single service the patient receives to the lowest bidder. This includes dietary, laundry and nursing services. In the long term care industry, CNAs will be hired instead of LPNs. LPNs will be hired instead of RNs. New grads will be hired at lower salaries than experienced nurses. All of these nurses will be forced to take care of more and more patients with less and less help. New grads will likely work midnight shifts as the day shifts are more desirable for nurses with seniority. In some facilities, a new grad LPN may be placed in the position of taking care of 50 to 70 patients with 2 or 3 CNAs. There is no possibility that these patients are being turned every 2 hours. Quite frankly, it is amazing that they even receive their medication. Even in the upscale, very expensive skilled nursing facilities, the family members are in the hall, staring at PT, OT, ST, the housekeeping staff becoming more frustrated and angry as they believe that none of these "nurses" are answering the call lights. Some facilities purposely require all staff members to dress in the same color uniforms/scrubs to make it appear that there are more care givers than there really are.
Here is my pressure ulcer/wound/injury history. As a new grad RN, I worked in a long term care facility. On an 8 hour midnight shift a nursing assistant (no certification required in those days) and myself started at one end of the hall and performed peri care with soap and water, rinsed and dried the skin and applied A&D ointment to the bony prominences. We applied two large cloth diapers (cloth is much healthier for skin than bleached and chemically treated paper wrapped in plastic briefs that we use now and they're cheaper). We turned the patient, got them water of a back rub and moved on to the next patient. One set of rounds took two hours for about 30 to 40 patients. We then put the dirty diapers in the washer and sat down for a 10 minute break. Then we started again. Washing and drying the diapers also saved a lot of money. We had zero pressure injuries. Not one. Ever. The only time we had an ulcer occurred if our patient went to the hospital. Even in 24 hours in a urine soaked, plastic diaper resulted in skin break down. The hospital simply did not employ enough nurses to turn, clean and place a clean diaper every two hours and the skin broke down. In hospital, the aquity is much higher and maintaining IVs, etc. takes much more time. Now our extended care LPNs and RNs are being given patients that would have been in a Step Down Unit a few years ago! Even the local mortician said he wanted to be admitted to our facility when he became older as we were the only facility where the bodies of elderly people did not have skin break down.
As nurses, we have no power in corporate America. So I do not believe Nursing needs to Move Forward, CMS needs to implement government regulations on patient to nurse ratios. Business people will never do this. Even though it would save them money in the long term, penny wise and pound foolish is the standard of care. The attitude toward nursing care needs to be respected and valued. If business men, social workers, therapists or maintenance men are having a conversation in a corridor no one says a word. Yet if nurses are giving report at shift change, a vital role in patient care, we are criticized by visitors, doctors and anyone else who doesn't understand the need for communication between shifts. I have seen nurse managers demand that nursing does not smile or laugh because it a misinterpreted as goofing off. I have heard visitors and patients say that the nurses are just sitting around playing video games when we are, in fact, charting on the electronic medical record.

Rarely have I ever read a more accurate description of patient care and lack thereof. As a SCI paraplegic I have undergone seven ischial-area flap surgeries over the last ten years, tried many kinds of cushions and seating systems and endured endless months of hospital and home care. The one common experience is the poor nursing and aid care concerning prevention of pressure injuries and the healing of post-surgical wounds. The poor training, language barriers, and excuses for even the most basic of care is endemic, particularly among the aids. I would not be repositioned unless I specifically asked for and demanded it, in essence I was educating the staff on this and many other issues. This also applies to all other aspects of care, such as nutrition and hygiene. It seems CMS rules all, determining quality of care, from Doctors on down; the dollar rules. The human aspect of care is lacking. Nurses are overwhelmed with paperwork and passing meds. Patients come last. After my last three month experience in hospital, LTAC and "skilled nursing facility" I can honestly say I am lucky to get out alive. Many do not; and that is the truth. I do not know the answers; I just warn you, pray you never need that level of care.

Very well said Margaret. While the new definitions/changes may not be "perfect" they are an improvement and can only serve us to move in a forward direction. Great article.

I was very lucky in my career to learn from Brenda Ramstadius and Catherine Sharp they have pioneered using common sense to prevent tnese unnecessary injuries. Ignored by supposedly top cliniciens in Australia. Please look at the 'Ramstadius' tool and the papers tnat Catherine has written. If you want more happy to supply.

I was very lucky in my career to learn from Brenda Ramstadius and Catherine Sharp they have pioneered using common sense to prevent tnese unnecessary injuries. Ignored by supposedly top cliniciens in Australia. Please look at the 'Ramstadius' tool and the papers tnat Catherine has written. If you want more happy to supply.

Well done, Margaret Heale! I especially appreciate this statement, "...such excuses are often (but I accept not always) exactly that: excuses." This is the attitude that is needed to make a difference. Usually we, as nurses, can prevent PIs if we are willing to take responsibility and be imaginative. If we do that, and are willing to "own" our mistakes, we will gain the credibility needed to be believed when that rare unpreventable PI comes along - the one that began as a serious DTI on the patient who had a stroke and lay on the floor for two days before they were found, the one on the dying patient with multiple systems organ failure whose electrolytes simply will not come into balance, and yes, that one on the patient who insists upon lying in one position, despite our BEST efforts to make other choices comfortable to them,

I did want to remind the readers that every two hour turning schedules are no longer the evidence-based standard of care. Turning schedules, like all other health preventative measures, should be based upon individualized risk scores. In 2013, Bergstrom, et al.,[1] published an excellent multisite study comparing 2, 3, and 4 hour repositioning intervals for residents of LTC facilities with Braden scores of 10 - 14 (high and moderate risk patients). The study was well designed design to protect from bias. They found that for these patients, the incidence of PIs did not increase when they used high-density foam mattresses and were reliably repositioned every 4 hours. Overall incidence rates were low: 2%, all Stage I or II. The researchers emphasized accountability in order to maintain 80% on-time repositioning. A four hour schedule should be more easy to maintain, which may serve to increase the frequency of repositioning in a real life setting long-term.

1. Bergstrom N, Horn SD, Rapp MP, Stern A, Barrett R, Watkiss M. Turning for Ulcer ReductioN: A Multisite Randomized Clinical Trial in Nursing Homes. Journal of the American Geriatrics Society. 2013;61(10):1705–1713. doi:10.1111/jgs.12440.

Thank you all for the comments.

Jo Anne: I remember too, finishing one set of turns and having little time before starting the next. It is a great relief to me now that our support surface options allow for a longer time interval for many patients. Particularly important at night as many patients are sleep deprived, thanks for the reminder about Bergstrom's work on that, Linda.

Peter: I do hope you experience good care at times. Nursing and CNA oversight is lacking in places but the LTACS have a particularly difficult job, please speak up and be vocal. I know many nurses who work in LTACS and what impresses me most is how involved they become and how much they care. Keep up your self protection but please know there are many golden apples too out there. I know they are out there as I have to tell you I had an 'other side of the sheets' experience recently and met one of the best practitioners ever.

Eileen: I do know the English author you speak of but not Ramstadius, the Australian. I do think both counties have lower PI incidence but comparisons are not really possible as the health care systems are very different.

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