A Prospective, Descriptive Study to Assess Nursing Staff Perceptions of and Interventions to Prevent Medical Device-related Pressure Injury

Nurses play an important role in identifying patients at risk for medical device-related (MDR) pressure injuries and preventing their occurrence. A prospective, descriptive study was conducted across 6 hospitals in Ankara, Turkey between December 2014 and June 2015 to assess nursing perceptions about and interventions used for the prevention of MDR pressure ulcers.A questionnaire was used to collect demographic information and data on experience with MDR pressure ulcers; in addition, participants completed a Nursing Interventions Form that included 10 statements regarding basic nursing interventions to prevent MDR pressure ulcers; answer options were I perform, I partly perform, I do not perform. Of the 1555 nurses invited, 606 (38%) participated. Nurses who chose to volunteer completed the study instruments independently at their convenience; their responses were entered directly into the statistical analysis system by the researchers. Demographic and interventions data were analyzed using frequency and percentage distributions. Participant mean age was 30.0 ± 6.83 years, most were women (86.9%), with a mean of 8.47 ± 6.70 years of experience. Most had a bachelor’s degree (55.1%), 38.2% worked in intensive care units, 50.2% participated in a scientific program regarding the prevention/treatment of pressure ulcers after their graduation, and 87.9% provided care to patients with pressure ulcers. A great majority (80.1%) of the nurses believed the use of medical devices can lead to pressure ulcers and 59.2% had experience with MDR pressure ulcers, but almost 20% did not believe medical devices can cause a pressure ulcer. The nurses identified 18 medical devices that posed the highest risk of causing MDR pressure ulcers; the 3 most commonly identified devices were endotracheal tubes (59.7%), tracheostomy ties (58.9%), and blood pressure cuffs (58.4%). The most common interventions used by these nurses included ensuring correct device positioning (87.9%) and loosening devices at least once every shift (80%) when medical conditions allowed. These findings suggest nurses may not be aware of the risk for pressure ulcers associated with a number of medical devices, indicating a need for comprehensive inservice training programs and research to identify optimal measures and methods to prevent MDR pressure ulcers.

A pressure ulcer is described as localized skin tissue and/or subcutaneous tissue damage at bony prominences formed through pressure alone or as part of a combination of laceration and pressure.¹ Pressure ulcers most commonly develop at bony prominences such as the sacrum and heels, but cases of pressure ulcers on the skin over mucous membranes and soft tissues also have been increasingly reported.² Until relatively recently, limited attention has been given to medical device-related (MDR) pressure ulcers.³ 

The National Pressure Ulcer Advisory Panel (NPUAP)/European Pressure Ulcer Advisory Panel (EPUAP)¹ report pressure ulcers can develop in any tissue exposed to pressure and that medical devices pose a substantial risk for their formation. With the widespread use of medical devices for diagnosis and treatment, many patients are faced with this risk.⁴ Research that includes point prevalence, cross-sectional, retrospective review, descriptive pilot, and prospective, descriptive studies^3,5-13 has reported pressure ulcers largely triggered by the use of a medical device have occurred on the ears, nose, lips, neck, hands, legs, genitals, fingers, and head, as well as the mouth, shoulders, back, chin, abdomen, and around the face, forehead, and eye brows. 

Point prevalence, cross-sectional, and quasi-experimental studies^3,14 also have found MDR pressure ulcers are mainly the result of using rigid materials in medical device manufacturing, incorrect fit, incorrect placement (eg, in areas of little or no adipose tissue), and using inappropriate methods to affix the medical devices. A point-prevalence, cross-sectional study by Black et al³ (N = 2178) of pressure ulcers occurring on the ears, lower legs, and heels found other reasons for MDR pressure ulcers include the presence of local tissue edema in the area where the medical device has been placed, a decline in tissue oxygenation, decreased sensory perception, and lack of efficient cooperation among members of the pateint’s health care team.

Several studies have indicated a higher prevalence of MDR pressure ulcers compared to non-MDR pressure injuries. The study by Black et al³ found a significantly higher prevalence of MDR pressure ulcers (34.5%) compared to nosocomial non-MDR pressure ulcers (5.4%). A descriptive, point prevalence study by Schlüer et al¹⁵ (N = 155) found Stage 1 MDR pressure ulcers in 84% of patients presenting with pressure ulcers. An observational, cross-sectional cohort study by Van Gilder et al¹⁶ found 1631 out of 17 911 pressure ulcers (9.1%) were due to medical devices; these were mainly observed on the ears (20%), sacrum (17%), heels (12%), and hips (10%). In a descriptive, prospective study performed across adult intensive care units (N = 175) in Turkey, the current authors found non-MDR pressure ulcers developed in 27 (15.4%) patients, while 70 (40%) of the patients presented with MDR pressure ulcers.¹³

The incidence and prevalence of pressure ulcers can be decreased by preventing MDR pressure ulcers, which may be both easier and less expensive than their treatment.⁵ The golden rule in the treatment of pressure ulcers is to find the cause of the pressure and remove it. However, removal of medical devices may cause adverse treatment outcomes. Medical devices, therefore, should be repositioned as much as possible (for example, moving an endotracheal tube from 1 side of the mouth to the other).³ Frequently adjusting the position of medical devices in patients presenting with pressure ulcers also is recommended.¹⁷ In the study by Black et al,³ it was recommended that medical devices be loosened at least once per shift to assess for skin problems if the patient’s condition allows. MDR pressure ulcers also can be prevented by avoiding ill-fitting medical devices. NPUAP/EPUAP and Pan Pacific Pressure Injury Alliance (PPPIA)¹⁷ guidelines note medical devices that are ill-fitting or tightly affixed on the skin increase the risk of pressure ulcers from friction and additional pressure. In both scenarios, skin tolerance of pressure decreases, resulting in the development of tissue damage. The placement of medical devices in areas with lower adipose tissue or with irritation caused by hard devices also accelerates skin damage.^3,17 When repositioning a medical device, it is not sufficient just to relieve the pressure; placing supportive or protective dressings or padding materials under tightly fixed medical devices has been shown to help redistribute excessive pressure and prevent shearing and rubbing by the devices.^17,18

Basic nursing interventions include regular skin inspections and assessing skin and mucous membranes for pressure ulcers at the end of every shift.^1,3 Moreover, when positioning patients, nurses should take special care of medical devices, cables, and catheters; these should be visible and not positioned beneath the patient.^3,9,17 Nurses may be reluctant to reposition medical devices, especially when the consequences of dislodgement could result in harm to the patient; however, several studies have shown nurses play important role in identifying patients at risk and subsequently preventing MDR pressure ulcers with early assessment and interventions.^5,10,18 Noninclusion of a systematic and detailed evaluation of medical devices in routine skin inspections may be an indication that awareness of MDR pressure ulcers requires improvement. Studies^3,5 have shown multidisciplinary teams that include a nurse with good pressure ulcer knowledge and skills can achieve positive outcomes in preventing and treating pressure ulcers.

A limited number of studies have investigated MDR pressure injuries in Turkey; no study has focused on nursing interventions aimed at preventing MDR pressure ulcers. To help increase information about nurses’ awareness of MDR pressure ulcers and identify effective nursing care applications to prevent MDR injury, a prospective, descriptive study was conducted to determine nurses’ perceptions of and interventions in the prevention of MDR pressure ulcers. 

Ethical consideration. This study was conducted according to the ethical guidelines and principles set forth in the International Declaration of Helsinki. Before the start of the research, written consent was obtained from the participating hospitals (B.10.4.06.00.15-EPKK-619, 18744377-903.07.02, 69668506-3159, G.M-2755, BTEDK-18/14, MED/5148/2014). Nurses were informed of the aims and methods of the study by researchers; verbal consent for participation was acquired. Nurses were informed their personal information would be used for research purposes only, remain confidential, and not be shared with anyone. The data collection forms were numbered for identification, starting from 001. Descriptive or personal information, such as nurses’ names, was not collected.

Study setting and sample. The research sample included all nurses working in adult inpatient units of a university hospital, 2 public hospitals, and 3 private hospitals located in the province of Ankara, Turkey (N = 1555). All nurses who granted their consent on a voluntary basis were included. After obtaining written consent from the institutions, the researchers contacted the administrators of nursing services at each hospital and obtained monthly working lists. The researchers visited the hospitals during the day shift until all nurses were apprised of the study aims and methods and provided verbal consent for participation. The nurses who volunteered to participate completed the data collection forms at a time convenient for them. 

Data collection. Research data were collected between December 2014 and June 2015. To obtain the data, 2 instruments were used. The Nurses Characteristics Form was developed by the authors and comprised 11 items regarding demographic information (eg, gender, age, education, hospital unit) and information on experience with MDR pressure ulcers (eg, previous experiences with patients with pressure ulcers and medical devices that can cause pressure ulcers). The nurses could select and check more than 1 option on the choice boxes; under the “other” option, they could write medical devices not listed. The Nursing Interventions Form, also developed by the researchers and based on the literature,^1,3,13,17 included 10 statements about basic nursing interventions to prevent MDR pressure ulcers presented in the A column of the form. In the B column, the nurses were asked to indicate their use of these practices according to 3 categories of options: I perform if they always performed the MDR pressure ulcer preventive interventions, I partly perform if they did not regularly perform MDR pressure ulcer interventions, and I do not perform if they never attempted MDR pressure ulcer interventions. The nurses’ responses were entered directly into the statistical analysis program by the researchers.

Data analysis. Data were stored according to research and publishing ethics and analyzed using Statistical Packages for Social Sciences (SPSS) for Windows, Version 20.0 (IBM Inc, Armonk, NY). The frequency and percentage distributions of the items pertaining to nurse characteristics and the data regarding nursing interventions in the prevention of MDR pressure ulcers were calculated. 

Questionnaire responses were received from 606 nurses, a response rate of 38%. The mean age of participants was 30.0 ± 6.83 years, most were women (86.9%), with a mean of 8.47 ± 6.70 years of service. Most nurses had a bachelor’s degree (55.1%), 38.2% worked in intensive care units, 50.2% participated in a scientific program regarding the prevention/treatment of pressure ulcers after their graduation, and 87.9% provided care to patients with pressure ulcers. A great majority (80.1%) of the nurses believed the use of medical devices can lead to pressure ulcers, and 59.2% said they already had experience with MDR pressure ulcers (see Table 1). 

Participants identified 18 medical devices that pose a MDR pressure injury risk: endotracheal tubes (ETs) (59.7%), tracheostomy ties (58.9%), blood pressure (BP) cuffs (58.4%), nasal cannulas (54.8%), continuous positive airway pressure (CPAP) masks (54.1%), thromboembolism deterrents (TEDs) (52.6%), nasogastric tubes (47.4%), splints (44.6%), oxygen masks (44.6%), cervical collars (41.6%), electrocardiograph (ECG) leads and electrodes (40.3%), peripheral oxygen saturation of hemoglobin (SpO2) probes (38.0%), Foley catheters (37.1%), peripheral vascular lines (29.0%), central vascular lines (28.9%), arterial lines (25.4%), orogastric tubes (21.3%), and percutaneous endoscopic gastrostomy (PEG)/percutaneous endoscopic jejunostomy (PEJ) tubes (19.5%) (see Table 2). 

Interventions marked most commonly as I always perform included proper placement of medical devices to prevent friction and pressure on the skin (87.9%); loosening/untying devices such as splints, corsets, nasal cannulas, and SpO2 probes at least once every shift when the medical condition of the patient allowed it (80%); assessing tissues underneath medical devices for pressure damage (79%); using supportive or protective  dressings on areas with medical devices (78.5%); taking special care that no devices are placed on areas where skin integrity has been disrupted (77.4%); preventing areas with medical devices from getting too dry/wet (77.2%); evaluating oral mucosa of patients with ETs at least once every shift (76.6%); evaluating peristomal areas (72.4%); lubricating the bedpan before giving it to the patient and limiting patient time on the bedpan (64.5%); and changing the location of medical devices on the patient every shift (63.2%) (see Table 3). 

Nuru et al¹⁹ provided evidence from their cross-sectional research (N = 248) that 48.4% of nurse interventions for patients with pressure ulcers were good/satisfactory and that 54.4% of nurse study participants had good knowledge of pressure ulcers. A cross-sectional, multicenter study (N = 145) of the knowledge level of nurses in terms of the pressure ulcer prevention by Demarre et al²⁰ found an accurate/satisfactory rate of 29.3%; the same research further documented that 78.3% of the nurses exhibited a positive attitude toward of pressure ulcer prevention implementation. The current research did not examine the knowledge of nurses regarding MDR pressure ulcers; it only focused on the related interventions. The research also aimed to determine which medical devices, in the opinion of the nurses, cause pressure ulcers. Among participants, 80.1% believed medical devices can cause pressure ulcers of different categories/stages (see Table 2). 

However, nurses responded that not all devices present a risk for pressure injury. Specifically, most nurses believed that PEG/PEJ tubes (80.5%), orogastric catheters (78.7%), arterial catheters (74.6%), central venous catheters (71.1%), peripheral venous catheters (71%), Foley catheters (62.9%), SpO2 probes (62%), ECG leads and electrodes (59.7%), cervical collars (58.4%), oxygen masks (55.4%), splints (55.4%), and nasogastric tubes (52.6%) do not pose a MDR pressure injury risk. This outcome was found to be important from 2 points of view. First, even though the nurses know medical devices can cause pressure ulcers, they may need more information about which devices are likely to cause them. Second, this outcome supports the presumption that although nurses may recognize general reasons for the occurrence of pressure ulcers, they may have difficulty realizing a medical device as a cause. 

Approximately half of the nurses in the study did not receive any education on pressure ulcers after graduation. Although MDR pressure ulcers have garnered the attention of adminstrators and practitioners for the past 5 years in Turkey, these findings clearly demonstrate nurses need education about MDR pressure ulcers. Black et al³ concluded from their study that pressure ulcers developing at areas where such ulcers rarely occur (such as lips, cheeks, ears, nose bridge, back of the head, finger tips) are to be automatically categorized as pressure ulcers caused by medical devices. Of the nurses participating in the current research, 59.2% stated they have experience with MDR pressure ulcers (see Table 1).

In the current research, nurses were asked to specify which medical devices could cause pressure injuries; intubation tubes were chosen by the majority (59.7%) of participants. In prospective research in intensive care units (N = 483), Coyer et al² found 8 out of 20 MDR pressure ulcers were caused by nasogastric tubes and 7 pressure ulcers had developed due to intubation tubes. In the research by Schlüer et al¹⁵ (N = 155), most pressure ulcers developed due to medical devices such as tubes, splints, and monitoring cables.

Preventing pressure ulcers caused by medical devices in the course of proper nursing interventions is considered to be an indication of quality of care.⁵ According to pressure ulcer guidelines,¹ nurses should be able to identify patients at risk as early as possible and accordingly implement preventive interventions.¹ In this regard, nurses should be especially careful of placing and fixing medical devices to avoid friction and pressure on the skin.⁹ In the current study, nurses frequently knew to “properly position medical devices so as to prevent friction and pressure on the skin.” However, almost half of the nurses think TEDs do not cause MDR pressure injuries, and more than half believe urinary/urethral catheters do not cause MDR pressure ulcers. This represents a critical outcome in terms of nursing care and may be attributed to nurses’ lack of awareness of the possible risks of these devices. 

The current authors believe nurses have the responsibility to conduct head-to-toe skin inspections and to check medical devices. Ong et al²¹ reported a case where pressure ulcers developed in a patient because a compression stocking was improperly folded at the popliteal fossae; this inappropriate care was traced to an improper fitting of the stocking. Sivaraman Nair et al²² reported 2 cases where improperly positioned and fixed indwelling urethral catheters caused a Stage 2 pressure ulcer between the thighs. 

In the current research, 79% of the participating nurses said they inspected the area beneath the medical device for pressure damage. In a prospective, epidemiological study by Compton et al,²³ regular skin inspections performed by nurses could be more effective in determining pressure ulcer risk than specific objective data used for the diagnosis of pressure ulcers. Several researchers have proposed that regular skin inspection is important for both non-MDR as well as MDR pressure ulcers.^3,5,24 Another finding with regard to skin inspection is that 77.4% of nurses knew to take special care to avoid placing medical devices where skin integrity has been compromised and, when possible, to place devices in a manner that avoids contact with the skin. When the medical condition of the patient allows, it is recommended that skin around and beneath devices be inspected at least twice a day.¹⁷

In this study, most of the nurses stated they inspected the skin at least once every shift by loosening devices such as splints, corsets, nasal cannulas, and SpO2 probes when the medical condition of the patient allowed it (80%) and ensured medical devices were not tightly fixed and were repositioned during every nursing shift (63.2%). In addition, because the most basic factor with respect to the prevention of pressure ulcer is the definition and elimination of the cause of the pressure, it is essential to remove the medical devices as early as possible to minimize the risk of MDR pressure ulcer development. A prospective, descriptive study conducted by Powers et al⁸ demonstrated that skin breakdown increased with the number of days of cervical collar wear (P <.0001). Coyer et al² showed that while the average number of medical devices per patient is 7.6, patients in whom MDR pressure ulcers develop had an average number of 8.6 devices.

Medical devices made of hard materials and that are improperly positioned on the skin increase pressure and friction, increase the risk of pressure ulcers,^5,18 and account for frequent peristomal skin complications.²⁵ Therefore, it may be essential for patients with a tracheostomy, colostomy, or other type of stoma that the peristomal area be inspected at every shift for indications of pressure ulcers. Among the nurses participating in the research, 72.4% stated they regularly inspected the peristomal area at every shift for probable inflammation and pressure ulcer development. In particular, tracheostomy tubes can compromise skin integrity because of the continuous pressure and moisture created by perspiration-respiration secretions.²⁴ Descriptive pilot research by Jaul⁹ (N = 32) demonstrated 4 pressure ulcers occurred around the neck at the edges of a tracheostomy tube. In the study by Boesch et al²⁴ (N = 834), 100 tracheostomy-related pressure ulcers occurred — among them, 14% were Stage 1, 50% were Stage 2, and 36% were Stage 3 ulcers. Most (73%) pressure ulcers developed around the stoma and 4% formed under twill ties. 

Placement of protective supporting materials such as gel pads, film dressings, sprays, and foam dressings at areas where medical devices contact the skin has been shown to decrease the risk of MDR pressure ulcers.⁵ Dressing materials can be placed underneath medical devices at areas of risk such as ears and noses. In this research, 78.5% of nurses stated “they are using supportive or protective dressing materials where medical devices and fixing elements are placed” to protect new pressure injuries. The study by Acorda¹⁰ reported that placing supporting foam materials such as Mepilex (Mölnlycke Health Care, Norcross, GA) between the mask and skin in patients receiving bilevel positive airway pressure therapy gradually reduced the prevalence of pressure ulcers to 0. Weng¹⁴ conducted a quasi-experimental study (N = 90) using protective dressing materials in noninvasive ventilation treatment to examine the effects of lack of protective materials on the development of pressure ulcers. The research found that while Stage 1 pressure ulcers developed at a rate of 96.7% in the group not using protective materials, the rate of development was reduced to 53.3% and 40% in the groups where protective materials were used. The study also showed pressure ulcers developed in a much shorter time. Pressure ulcers developed in 1 group where no protection and 2 groups where protection was provided in 1111 ± 2169 minutes, 2628 ± 1655 minutes, and 3272 ± 2566 minutes, respectively (P <.01).

Because the study population did not include nurses serving in pediatric units, those not serving in adult inpatient units, those who serve in inpatient units but do not provide patient care service, and those who hold an executive position, generalizations from this research are limited. In addition, the researchers did not observe the interventions provided by the nurses in connection with MDR pressure ulcers; the results of the study are solely based on the statements of the participating nurses, whose perceptions of the extent of their care may not have been accurate.

A prospective, descriptive study to assess nurses’ perception and implementation of measures to prevent MDR pressure ulcers indicated nurses provide preventive interventions at a rate of at least 60%. However, 19.9% of the nurses did not think medical devices can cause pressure ulcers. In light of the fact MDR pressure ulcers are increasingly recognized, comprehensive inservice training programs on MDR pressure ulcers need to be organized in health care institutions to inform nurses and enhance their awareness about prevention of MDR pressure ulcers caused by medical devices. Additionally, observation-based research on nurse provision of evidence-based practices for patient care of MDR pressure ulcers is warranted. 

This information contained in this article was presented at The European Wound Management Association Conference, May 11–13, 2016, Bremen, Germany. 

Dr. Karadag is a professor, Koç University School of Nursing, Istanbul, Turkey. Ms. Hanönü is a doctoral student, Gazi University Institute of Health Sciences, Department of Nursing, Ankara, Turkey. Ms. Eyikara is a research assistant, Gazi University Faculty of Health Sciences, Department of Nursing, Ankara, Turkey.

Please address correspondence to: Evrim Eyikara, MSN, Research Assistant, Department of Nursing, Faculty of Health Sciences, Gazi University, Ankara, Turkey; email: evrimeyikara@gmail.com