AbstractPurposeThis study developed a protocol to assess the core nursing skills of pressure ulcer management and fall prevention for nursing students.
MethodsProtocol development consisted of a preliminary investigation of the protocol for pressure ulcer management and fall prevention nursing (step 1), confirmation of the protocol criteria (step 2), development and confirmation of the final protocol (step 3), and development of nursing situations to apply the developed protocol (step 4). The validity of the protocol was measured using the content validity index.
ResultsThe pressure ulcer management and fall prevention nursing protocol we developed consisted of 23 procedures. The guidelines of KABONE (2021) were used to set the achievement goals and difficulty, corresponding to “low” for the achievement goal of evaluating and recording the risk factors. The protocol's content validity was good, and the developed scenarios were relevant.
ConclusionNursing practice is critical for nursing students to provide high-quality care in clinical settings. Therefore, it is essential to assess the core nursing skills that nursing students learn and acquire during their student years. The protocol developed in this study can be used to improve nursing education, particularly in the development of core nursing skills.
INTRODUCTIONPractical education that improves nurses’ practical skills and competencies for patient care is essential in nursing curricula. To improve the quality of practical education, the Korean Accreditation Board of Nursing Education (KABONE) designated 18 core nursing skills to ensure the core clinical competencies of professional nurses and to teach these competencies in practical subjects in universities [1,2].
Most universities have developed and evaluated nursing students’ competencies using the protocol suggested by KABONE since 2012 the core nursing skills. Accreditation for nursing education was reorganized into a 4th Cycle in 2021, named “core nursing skills,” and 18 revised core nursing skills were introduced to develop and assess nurses’ competency utilizing achievement goals and difficulty without specific protocols [1]. Of these, since pressure ulcer management and fall prevention are designated as new core nursing skills, there are no protocol, making it difficult to achieve student achievement goals. Therefore, it is necessary to develop a new protocol.
Practical education for pressure ulcer management and fall prevention is mainly done in the students’ third and fourth years, and begins in the second-year in basic nursing courses at many universities. To ensure that professional nurses have essential nursing competencies most nursing departments manage core nursing skills in stages until graduation, and KABONE checks them [2]. In these stages, practical education in basic nursing modules aims to teach students to perform simple skilloriented protocols without requiring clinical judgment or presenting them with complicated situations [3]. Pressure ulcer management and fall prevention are important in nursing education as they are core nursing skills that nurses must have and are areas that require skilled nursing provision. These two as-pects are health concerns that should be monitored from the beginning of hospitalization, and the abilities to mon-itor the environment and identify the risk factors early are basic competencies required of all nurses [4].
Pressure ulcers are a type of local injury occurring due to constant pressure or frequent friction on the skin over bony prominences or underlying tissue [5]. Assessing risk factors for pressure ulcers and nursing interventions minimizing pressure or friction are required to prevent pressure ulcers. Risk factors for pressure ulcers are friction, shear force, limitation of activity and mobility, skin condition, blood circulation, nutrition, moisture, body tem-perature, age, low pain sensitivity, general condition, mental status, history of pressure ulcers, and blood levels (serum hemoglobin and serum albumin). They are monitored using standardized tools [6-8]. The Braden Scale is a tool for assessing the risk of pressure ulcers, and it consists of six items and it evaluates the risk by providing the cut-off value [9]. In previous studies conducted with scoping review, about 70% of the review studies used the Braden Scale as a pressure ulcer evaluation tool, which is the most widely used tool [10].
Falls are a frequently reported safety accident among hospitalized patients during case monitoring, and they require various nursing interventions that depend on the patient's circumstances and the hospital environment [11]. The Morse Fall Scale (MFS), used to assess risk factors for falls, consists of six items-fall history, secondary diagnosis, ambulatory aid, intravenous therapy/heparin lock, gait/transferring, and cognition/mental status-and it is a valid tool that provides the cut-off value [12]. Moreover, the MFS is the most widely used tool for measuring fall risk factors [13].
Protocol development helps us develop repetitive and systematic education and apply protocols to practical education based on the developed guidelines. It is utilized in various learning methods for practical education. Several studies have reported on protocols used in various practical education methods such as simulation education, web-based learning, and video recording education, which were implemented to improve students’ knowledge, per-formance, and satisfaction, thereby increasing learning motivation [3,14-16].
Core Nursing Skill No. 17, pressure ulcer management and fall is a newly established item with a difficulty level of ‘ low’. Therefore, rather than complicated and difficult nursing techniques, ‘ risk assessment using tools’ was considered first. This study improves nursing students’ competencies and the quality of future practical education by developing a protocol for pressure ulcer management and fall prevention for nursing students.
1. Literature Review1) Assessment tool for risk of pressure ulcersAs the development of pressure ulcers increases patients’ medical expenses [17] and their mortality rate [18], adequate nursing intervention should be performed be-fore pressure ulcers develop. Therefore, it is vital to assess the risk factors for developing pressure ulcers using a reliable assessment tool and take preventive measures.
Currently, the most commonly used risk assessment tool for pressure ulcers is the Braden Scale, which consists of six items: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Excluding friction and shear, which are assessed on a 3-point scale, the remaining 5 items are assessed on a 4-point scale, meaning the scale ranges from a minimum of 6 points to a maximum of 23 points. The lower the score, the higher the risk of pressure ulcers.
The Norton Scale, a risk assessment tool for pressure ulcers developed in 1962, earlier than the Braden Scale, was used to determine the risk factors for pressure ulcers in hospitalized older adult patients [19]. The scale's risk factors are divided into five domains: physical condition, mental condition, activity, mobility, and incontinence. The total score is 20 points, and participants rate each domain from a minimum of 1 to a maximum of 4 points; the lower the score, the higher the risk factor. In 1987, it was pro-posed that the boundary be raised to 16 points to reflect changes such as a medication factor [20]. The Norton Scale was validated mainly based on nurses’ assessments of older adult patients (aged 60 or older), and the scale's reliability and validity were supported.
The Gosnell Scale is a modified and supplemented tool that replaced Norton Scale's item “physical condition,” which was considered unclear, with nutrition condition. It evaluates mental condition on a 5-point scale, activity, mobility, and incontinence on a 4-point scale, and nutrition on a 3-point scale, ranging from a minimum score of 5 to a maximum of 20. The higher the score, the higher the possi-bility of developing a pressure ulcer [21].
In addition, the Waterlow Scale, developed in the U.K. in 1985, included special risk factors such as trauma, sur-gery, and neurological deficit and was revised in 2005 [22]. It comprises 11 detailed assessment factors, including weight and height, skin condition, sex, age, malnutrition screening, continence, mobility; and special risk factors, including tissue malnutrition, neurological deficit, major sur-gery or trauma, and medication. The minimum is 2 points, and a total score of 10 or higher is considered as being at risk for developing pressure ulcers, 15 or higher as being at high risk, and 20 or higher as being at very high risk.
Various tools are used to assess the risk factors of pressure ulcers, and considering the predictive validity of the tools, the Waterlow Scale can be considered regarding crit-ically ill surgical patients and when aiming to understand the patient's condition and progress simultaneously. How-ever, the Braden Scale has the advantage of clinical con-venience as a simple and widely used assessment tool [23].
2) Assessment tool for risk of fallsFalls are a safety accident that occurs frequently for older adults and can lead to death in extreme cases. Hence, as in the case of pressure ulcers, prevention is the most crucial intervention. As a first step to selecting high-risk fall groups and providing them with necessary nursing interventions, tools are required to assess the degree of fall risk.
The most commonly used assessment tool for the risk of falls among general adult patients is the MFS [13], which evaluates six detailed items: fall history, secondary diagnosis, use of ambulatory aid, intravenous injection/heparin cap, gait disorders, and cognitive ability [24]. It is evaluated from a minimum score of 0 to a maximum of 125. The higher the score, the higher the degree of fall risk. In particular, because more than 50 points classify one as in a high-risk group, the level of intervention varies depending on each degree of risk. In a previous study in South Korea, the negative predictive value, the percentage of patients expected not to fall in a tool according to the boundary score that did not actually fall, was evaluated as 91.4% [25], thus verifying the tool's usefulness.
The Johns Hopkins Hospital Fall Risk Assessment Tool [25], developed in 2005, is an assessment tool that evaluates the risk of falls from evidence-based activities for fall prevention activities at the Johns Hopkins Hospital [26]. The tool was supplemented in 2007. It consists of eight detailed items regarding age, history of falling, bowel and urine secretion, medication, patient care equipment, mobility, and cognition, and it is evaluated from a minimum score of 0 to a maximum of 35. A score of 6 to 13 is classified as moderate risk, and that exceeding 13 is classified as high risk. A study evaluating the tool's validity in South Korea found the scale's sensitivity to be at 69.0%, specific-ity at 60.0%, and negative predictive value at 88.6% at the boundary score of 12 points [24].
As the older adult population continuously increases, it is expected that tools for assessing the fall risk factors of patients will be developed and evaluated consistently. The MFS is considered and used as the most reliable fall risk factor assessment tool in clinical practice [27].
METHODS1. Study DesignThis methodological study was performed to develop a protocol for pressure ulcer management and fall prevention by applying the literature review and the 4th Cycle guidelines of KABONE.
3. Protocol Development ProcessProtocol development was performed through four steps as follows. Step 1-preliminary investigation; Step 2-confirmation of protocol criteria; Step 3-development of the final protocol; and Step 4-development of nursing situations to apply the developed protocol (Table 1).
Table 1.In Step 1, data from previous research or professional organizations were reviewed. Data search was conducted on Google, Riss4u, and PubMed, Hospital Nurses Association, Medical Institution Accreditation Evaluation Institute and the search terms were ‘pressure ulcer’, ‘fall risk’, ‘pressure ulcer assessment tool’, and ‘fall risk assessment tool’. The criteria to apply the protocol for pressure ulcer management and fall prevention (guidelines, achievement levels, and difficulty) were determined in Step 2. In Step 3, the final protocol was developed, and nursing situations to apply the protocol and a checklist of pressure ulcer and fall risks were developed in Step 4.
In Steps 3 and 4, the Content Validity Index (CVI) was conducted. Three experts evaluated the validity: a nurse with at least 25 years of nursing experience and teaching experience, and two nursing professors who teach fundamental of nursing. In addition, to apply the protocol, nursing scenarios reflecting actual clinical scenarios were developed, the developed protocol was implemented, and the three experts evaluated the relevance of the protocol and scenarios.
4. Data Analysis MethodCVI was used to determine the validity of the preliminary protocol. Protocol items were measured on a 4-point Likert scale (1 point for strongly unrelated, 2 points for unrelated, 3 points for related, and 4 points for strongly related), and the percentage of 3 or 4 points was calculated out of 1∼4 points and were evaluated as valid if they were more than.80 [28].
RESULTSBased on previous studies, literature review, and the core nursing skill guidelines of KABONE, a protocol was developed applying the Braden Scale in pressure ulcer risk assessment for pressure ulcer prevention and utilizing the MFS for fall prevention (Table 2).
Table 2.Achievement goals and difficulty applied the 4th cycle guidelines of KABONE (2021), and achievement goals were set to evaluate and record the risk factors corresponding to “low” (Appendix 1). The Braden Scale and MFS were added in Appendix 2 and Appendix 3.
As a result of the first CVI of the preliminary protocol, item 1 of the protocol, ‘wash your hands with hand sanitizer’, was modified to ‘hand hygiene with soap and water’, the same as other core nursing skills. The CVI of the protocol item measured again after the revision of item 1 was improved from 0.8 to 1, and the validity was improved, and the protocol was confirmed. The protocol for pressure ulcer management and fall prevention consisted of 23 procedures, and the scoring system comprised 46 points, with 2 points for completely performed; 1 for partially performed; and 0 for not performed (Table 2, Appendix 4). In addition, to evaluate the protocol for pressure ulcer management and fall prevention, a checklist for recording pressure ulcer management and fall prevention was developed, and the appraisee was allowed to record risk factors directly in the simulated nursing situations (Table 3, Appendix 5).
Table 3.The nursing scenarios provided were presented to experts to evaluate their validity and the scenarios were found to be related to the protocol according to experts’ assessments. The Nursing scenario also showed good validity with a CVI of 1.
DISCUSSIONIn the 4th cycle of accreditation for nursing education, “pressure ulcer management and fall prevention” were designated as new core nursing skills based on a job analysis of new nurses working in clinical practice after graduation [29]. Thus, this study developed a protocol for “pressure ulcer management and fall prevention” to improve nursing students’ core nursing skills and the quality of nursing practice.
The protocol was developed according to the difficulty level “low” recommended by “pressure ulcer management and fall prevention” presented by KABONE [1]. Based on the Norton Scale and Braden Scale, which are the most commonly used tools for pressure ulcer management [30], a protocol was developed according to the principle of occurrence of pressure ulcers, stages of pressure ulcers, and preventative nursing for pressure ulcers, which are the goals presented by KABONE. Items 6 (check senses) and 7 (check the degree of skin exposure to moisture) are related to skin function, which is prior knowledge presented by KABONE. Items 8 (check the level of activity such as physical activity and walking), 9 (check the ability to change and adjust body position), and 11 (check friction and shear due to bedclothes on a bed) were developed as those related to the principle of pressure ulcer occurrence and prior knowledge of the pressure ulcer stages. Items 10 (check nutrition such as food intake) and 12 (respond to the questions of the subject and conduct education for pressure ulcer prevention) are related to preventative nursing for pressure ulcers.
This protocol was revised and supplemented in the five domains of the Norton Scale and six domains of the Braden Scale, and nutrition was included for pressure ulcer management even though the two tools do not overlap regarding this factor. Because nutrition plays an important role in the prevention and treatment of bedsores. The exact causal relationship between various nutrients and bedsores is not yet clear, but sufficient nutrition is believed to help prevent and heal wounds in patients vulnerable to bedsores, EPUAP/NPIAP/PPPIA's 2019 International Guidelines the department sees it as an independent risk factor for the occurrence of pressure ulcers [31].
The pressure ulcer is divided into several stages according to its condition and severity, and pressure ulcer management should be applied separately accordingly [32]. The pressure ulcer healing process should be continuously and systematically monitored and immediate re-evaluation is required. Therefore, objective tools for assessment are important, and therefore, the comprehensive pressure ulcer management tools developed in this study are expected to be useful.
Fall accidents in hospitals often lead to legal problems, so patient and guardian education for fall prevention is conducted in various ways. The fall prevention tool developed in this study was modified through the advice of a group of experts who suggested revising and supplementing some items, and was developed to evaluate the risk by selecting the items associated with the highest risk of falls.
Protocol development for fall prevention was conducted based on MFS and Bobath Memorial Hospital Fall Risk Assessment Scale. Items 13 (check past experiences of falling), 14 (check the secondary diagnosis), 15 (check the ambulatory aid), 16 (check the intravenous therapy/heparin lock), 17 (check the gait), and 18 (check the cognition information) are associated with the fall risk factors and assessment method, which are prior knowledge presented by KABONE. Item 19 (respond to patients’ questions and conduct education for fall prevention, and, if necessary, provide a fall warning notice and wear a bracelet) was included in the protocol as fall prevention.
This protocol was developed focusing on what nursing students need to assess for fall prevention, excluding over-lapping in eight domains of the Bobath Memorial Hospital Fall Risk Assessment Scale and six domains of the MFS. As conventional tools scored each from 0∼3 or 0∼30, it may have been difficult for students to calculate or determine easily, but this developed protocol allows them to respond to items through either ‘ yes’ or ‘ no.’ Therefore, it is in-tuitive and is thought to support accurate clinical judgment.
Experts evaluated the developed scenario and protocol of “pressure ulcer management and fall prevention” as suitable for first-class nursing students. It also contains the latest knowledge and key nursing skills and provides specific evaluation criteria for instructors to objectively evaluate students’ skill levels. “Pressure ulcer management and fall prevention” is safety nursing care, which is crucial in improving the quality of care. Moreover, as awareness of patient safety increases, items related to pressure ulcer prevention and management are also included in the medical institution assessment in South Korea [33]. Therefore, this protocol will make it possible to provide standardized nursing care for “pressure ulcer management and fall prevention” not only for nursing students but also for clinical nurses, thus further contributing to improve the quality of care.
CONCLUSIONPressure ulcers and falls increase the risk of infection, can cause disability, and reduce patients’ quality of life, thus burdening patients and their families through extended hospital stays and increased medical costs. It is necessary to improve patients’ health and quality of life by preventing pressure ulcers and falls and by providing ap-propriate care and treatment when these occur. Utilizing assessment tools with proven validity and reliability to evaluate the risk of pressure ulcers and falls is critical in preventing pressure ulcers and falls and improving nurses’ knowledge of these issues. The Braden Scale is the most widely used assessment tool for evaluating the risk of pressure ulcers. The MFS is the most widely used assessment tool for evaluating fall risk. Various tools with proven validity and reliability are necessary for effective prevention and nursing care for pressure ulcers and falls.
The protocol developed in this study was systematic and standardized as an evidence-based protocol through literature. In addition, the validity is verified and applicable to education and evaluation. Despite this significance, this protocol lacks cumulative application performance. Therefore, continuous application and feedback of the protocol are required in the future. In this study, the Braden Scale and the Morse fall scale were used. It is also necessary to use other tools that have secured validity and reliability in the future. And in this study, one scenario was presented. Further development of various scenarios and protocols is required.
NotesCONFLICTS OF INTEREST
Youngshin Song has been president of the Korean Academy of Fundamentals of Nursing since January 2022, and her term will continue until the end of 2023. Hye Young Kim has been editor-in-chief of the Journal of Korean Academy of Fundamentals of Nursing since January 2022. All of them were not involved in the review process of this manuscript. Otherwise, there was no conflict of interest.
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AppendicesAppendix 1.욕창관리 및 낙상예방간호 간호상황과 성취목표, 선행지식, 준비물품.<난이도: 하>Appendix 2.욕창위험 체크리스트 양식Appendix 3.낙상위험 체크리스트 양식Appendix 4.욕창관리와 낙상예방 프로토콜Appendix 5.교수자용 간호상황 요약서 |
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