An Ounce of Prevention Is Worth a Pound of Cure…Why Is It So Hard To Get Prevention Improvements In Place?

One question I hear often is, “Will you look at this?” It is a phrase I love and hate to hear. It means I am trusted to know what to do, but I know I will not always have the answer. Whether the question is professional or personal, I see wounds that could have been prevented. My first question to whomever is asking is, “How did this happen?” The reason for my question is simple: if I know how it happened, I can more effectively help with the problem. If we eliminate the source, then the problem will fix itself. Simple fixes look like this—a patient has a diaper rash, you figure out why their stools are so frequent, and then you diagnose a pressure injury and remove the pressure. Eliminating the source might be easy, but preventing it from ever happening in the first place can take significantly more effort.

In pediatric care, there is frequent exposure to simple stories with outstanding messages. This type of moral guidance can be found in the James Halliwell-Phillipps, The Three Little Pigs. Three pigs are in the housing market and have chosen to build their homes. The first pig builds with straw, the second using twigs, and the third with bricks. The first two quickly finish their projects and go to on to enjoy all the time saved. The third pig works hard and builds a strong house with a good foundation. In some renditions, the first two pigs make fun of the third for taking the extra time and effort to build a brick house. All is well, until the wolf comes with his mighty breath. The first two pigs then look for refuge with the third pig. The moral is easy to figure out—work hard, build something strong, and it will make a difference in the future. In a hospital setting, prevention measures are overlooked or eliminated. These are not overlooked because they are seen as less important, but merely to save time.² 

Nurses often express that they do not have enough time to do the things they need to do and often prioritize what daily tasks are most important, therefore leaving others undone. These priorities outweigh many of those preventive interventions that are in place. Nurses often do not see the consequences of disregarding prevention. A patient may have a pressure wound for months, but the nurse who did not or would not turn the patient is unaware that the wound ever occurred in the first place. They remove the burden of responsibility in that moment and never know the consequences of their inaction. The end result is that they avoid the time-consuming task of managing the cases that are more available to them. Nurses feel the time constraints and focus on the “important things.” This includes distributing medications, transporting patients to procedures, performing lab work, and, in some cases, keeping the patient alive until the next shift.² In light of these circumstances, it is easy to see why the basics of prevention fail. As leaders, it is necessary to incorporate prevention into daily practice. This will make it easier to follow the most appropriate measures every time.³

Education is a great first step. Educating staff on prevention will demonstrate how these measures can help patients and the consequences of what could happen if we fail to act. However, it is important to keep in mind that education can only go so far when nurses are faced with the stress of each shift and the choices that must be made. Feedback for those choices can resemble criticism in the eyes of stressed staff and should be delivered in a way that further educates.¹

Standardization is another tool to implement. Functional ways to assist with prevention, such as limiting the number of choices in supplies, so the nurses always know what to select. Step-by-step guidelines also should be available. This will increase the likelihood that preventive actions become part of the daily routine and are easier to perform. Facilities should have supplies readily available to ensure that nurses do not have to search and delay patient care. These standards can be met with best practice and through the use of bundles.^1,3

Education and standardization may help, but if staff do not comply, nothing will change. Employees should be told what they need to improve on, but also acknowledged by leaders when they meet the demand. Leaders at all levels of the team should be paying attention, calling out good work, and following up with staff that may not be hitting the set mark. Employees need to look out for one another as well and expect to be held accountable by those they work beside. Accountability must begin at the top, but it is the responsibility of all staff.¹

Front-loading prevention takes time, and if it is done correctly, the results can only be seen in the data we collect. Prevention rewards do not show up in our day-to-day activity. Staff cannot see the lowered hospital cost because of a wound that never happened. Therefore, it is important that the nursing staff be reminded to adhere to following the prevention measures, with updated data showing decreased injury rates in their unit or throughout their facility.³

Prevention takes time and effort, but it should not be difficult. As a multidisciplinary team, we should work together to provide the tools and find ways to value the time of those caring for patients at the bedside. Like the pig who chose to build a brick house, our door should be open to help those who need it and remember that there is a chance for improvement in all of us.

References

1. Bryant RA, Nix DP. Developing and Maintaining a Pressure Ulcer Prevention Program. In: Acute & Chronic Wounds: Current Management Concepts. 5th ed. Elsevier; 2016:140-159.
2. Kalisch BJ, Xie B. Errors of Omission: Missed Nursing Care. West J Nurs Res. 2014;36(7):875-890. doi:10.1177/0193945914531859
3. Lyren A, Dawson A, Purcell D, Hoffman JM, Provost L. Developing evidence for new patient safety bundles through multihospital collaboration. Published online ahead of Print January 31, 2019. J Patient Saf. 2019. doi:10.1097/PTS.0000000000000564