Pressure Injury Prevention in Critical Care Settings in Saudi Arabian Hospitals
University of Wollongong, Australia
Background Critically ill patients are more susceptible to pressure injuries. Despite established prevention methods, pressure injuries remain common in Saudi Arabia, particularly in critical care units. A systematic review was conducted to synthesise evidence on the most effective nursing interventions for preventing pressure injuries in critical care settings. The four key intervention categories identified showed considerable effectiveness in pressure injury prevention during gap analysis. These categories are 1) pressure injury prevention bundles, 2) repositioning and the use of surface support, 3) prevention of medical device–related pressure injuries and 4) access to expertise. This review highlights the importance of nurse competency and advanced education, emphasising the need for consistent implementation of fundamental strategies to enhance mobility and redistribute pressure. Aim This doctoral study investigated pressure injury prevalence rates, care processes and nurses’ knowledge and attitudes towards prevention practices in Saudi Arabian critical care units. The overall aim was to reduce pressure injuries and assess the impact of an educational intervention on prevention practices. Methods The study was conducted in critical care units in three hospitals in different geographical regions in Saudi Arabia. A pre- and post-intervention approach with a qualitative evaluation was conducted. The study was guided by the Knowledge-to- Action framework and included four phases. In Phase 1, pressure injury prevalence rates and prevention care processes were observed. The Pressure Ulcer Knowledge Assessment Tool, version 2.0 and the Attitude towards Pressure Ulcer Prevention tool were used to examine critical care nurses’ knowledge about and attitudes towards pressure injury prevention. In Phase 2, a tailored educational intervention was developed to include theory, case studies and hands-on sessions and was implemented at the participating sites. Phase 3 involved evaluating pressure injury prevalence rates and nurses’ knowledge and attitudes towards pressure injury prevention using the methods from Phase 1. Phase 4 used interviews with nurses to evaluate the project’s impact, gathering feedback and assessing perceptions about the intervention and barriers and facilitators faced in preventing pressure injuries. Quantitative data was analysed using the Statistical Package for the Social Sciences, and qualitative data was analysed using Braun and Clarke’s thematic analysis. Findings Pre-intervention data was collected from 87 patients and 190 nurses. The initial pressure injury prevalence was 60.9% (n = 53). In the observed cohort, a total of 96 pressure injuries were identified among 53 patients. Of these individual pressure injuries, 52.9% (n = 46) were classified as hospital-acquired pressure injuries and 37.9% (n = 33) were developed in the intensive care unit and were therefore classified as unit acquired pressure injuries. Additionally, 23.0% (n = 20) were associated with medical devices. Nurses’ average knowledge and attitude scores were 43.22% and 74.77%, respectively. The tailored educational intervention was delivered to 91.8% (n = 294) of nurses in the research sites between December 2021 and March 2022. Post-intervention data was gathered from 94 patients and 195 nurses. The pressure injury prevalence rates decreased significantly to 28.7% of patients (n = 27, p < 0.001). A total of 49 pressure injuries were identified, of which 21.3% (n = 20) were hospital acquired, 14.9% (n = 14) unit-acquired and 8.5% (n = 8) medical device–related. Most pressure injuries were observed in the sacral region, head and heels and were predominantly Stages I and II. Nurses’ knowledge and attitude scores increased to 51.22% and 79.02%, respectively (p < 0.001). This research identified a positive association between greater pressure injury prevention knowledge and positive attitudes towards pressure injury prevention. Nurses’ age, overall nursing experience and ICU experience correlated with better knowledge about pressure injury prevention. Nurses with a bachelor’s degree or higher demonstrated better knowledge about and attitudes towards pressure injury prevention. Patients’ age, length of stay in the ICU, haemoglobin levels, Braden scores and the post intervention period were significantly associated with pressure injury–related outcomes. Patients’ age and ICU stays were predictors of pressure injury onset and progression, while the Braden score predicted only the development of severe injury. Nine participants were involved in the qualitative evaluation of the project. Three themes related to the barriers and facilitators that nurses experience when providing pressure injury prevention were identified. The themes included ‘workforce and resource issues’, ‘training and preparedness’ and ‘handling complex conditions’. The project evaluation was positive, with three key themes pinpointed as drivers of its success: ‘adaptable and personalised’, ‘attention to detail’ and ‘making a difference’. Conclusions This doctoral study has highlighted the pivotal role of nurses in preventing pressure injuries in critical care units, particularly in Saudi Arabia. Grounded in the Knowledge-to-Action framework, the project demonstrated the significant impact of tailored educational interventions in reducing pressure injury rates. It not only enhanced knowledge and attitudes through evidence-based learning but also addressed barriers and facilitators in prevention. The findings strongly support individualised, patient specific care and a nurse-centric approach to pressure injury prevention, emphasising both fundamental and advanced prevention practices.
Pressure Injury Prevention, Evidence-Based Nursing, Critical Care, Knowledge-to-Action