This past fall, I attended the New England WOCN Society regional conference. While I am still processing all the great information that I absorbed there, I'd like to share with you some of the important discussions that came up on the topics of pressure injury staging and patient compliance with repositioning protocols.

The Challenges of Identifying Slough in Superficial Pressure Injuries

In addition to her comments on the importance of proper terminology usage and spelling, Joyce Black also introduced the audience to the concept that slough is not actually dead tissue/hydrated eschar but an inflammatory product. This is very new to me and makes me concerned that our already difficult to stage superficial pressure injuries may indeed have slough in them, in the presence of inflammation. I think this is one of those "watch this space, be prepared" moments.

She kindly discussed stage 2 pressure injuries, agreeing with those present that these are often much more difficult to be certain about. Thankfully she was able to show a couple of the photographs where we could confirm that the tissue at the base of the wound was reticular dermis and that the pale color observed was not slough but this lowest level of dermis. Everyone including myself seemed to appreciate her talk.

Reinforcing Patient Repositioning Protocols for Pressure Injury Prevention

Janice Beitz also spoke and I must say rather changed my view on algorithms. I have always thought of them as rather confining (cookie cutter care) but listening to her describe the lengths designers go to when searching for evidence-based concepts was refreshing. She talked about the validation process and that made me realize how much work goes into these projects. It was the evidence that using well designed algorithms improves outcomes that really turned me around though.

Of course the vendors were there making sure we got to see their latest developments. Though wary of their support, even I appreciate our symbiotic relationship. There was much networking and this very underrated side of conferences drew me into a gem. We were talking about patient expectations and someone commented, "this is not Disney, it is a hospital." I was thrown back in time to a year when I struggled with staff saying that patients refused to be turned. This was not in a conversation calling for help in convincing the patient that repositioning was a worthwhile request, but rather as an excuse for the position I found the patient in.

World Wide Pressure Injury Prevention Day has come and gone again, and awareness that immobility causes people who are unwell to develop tissue damage needs to continue to be advertised from the roof tops – not only to patients but also to our staff. I am sure Dr. Oz would do a fine job bringing attention to this issue, if inclined (he has not tackled ostomy surgery yet, so I doubt he has looked at pressure injuries). However, I am not Dr. Oz and there I was, working in a bright new facility. Every patient in their own room with a flat screen TV, fridge, wheel/walk in super-shower and sofa bed for partner. A nurse said to me that we can't make a patient turn if they say they don't want to. Maybe I needed to say, "this is not Disney, it is a hospital" but I didn't think of it at the time. One has to wonder why the nurse was telling me that then and not while requesting me to come and convince the patient to the contrary.

There are more than a couple of issues relating to pressure injury prevention, and like most practice problems it is multifactorial:

• Have staff seen how quickly pressure injuries can develop and how bad they can be?
• Do staff really believe repositioning a patient will prevent pressure injuries?
• Who is responsible for repositioning and who actually does it?
• How do the staff who actually do the repositioning know when to do it?
• If they know the patient is about to eat, go to PT, get up for the day, or has a visitor who has been waiting for a half an hour, why would they waste their time?
• Can the staff member find other people to assist, and is it worth it?
• What if the patient says they are comfortable and they want to continue with their computer game or TV program?
• What if the last time they were repositioned they developed pain in their shoulder? Why would they let themselves be manhandled when they can say, "no I'm fine"?

While deciding on a route to take with the issue, I went to check on a patient I knew was refusing and was within ear shot when I heard the eve shift nurse say, "would you like to be repositioned now?" to which the patient responded "no thank you". All very polite. The nurse and I had a discussion and he re-approached the patient shortly after, eliciting the desired outcome. After this our team put their heads together and came up with a short guide which I am sure can be developed further.

What to Ask to Ensure Compliance While Repositioning Patients At-Risk of Pressure Injury

Pressure injury prevention needs to start before admission and needs to be stressed to the patient at risk (or with an ulcer) on admission when they are positioned appropriately and a preliminary repositioning schedule is set.
If there is a delay in getting the correct surface or equipment this can be interpreted as the issue not being important.

Statements to avoid:

• Are you comfortable?
• Can I make you comfortable?
• Is it alright to reposition you?
• May I turn you now?

Statements likely to elicit more positive participation from patients regarding repositioning:

• It is time for you to be repositioned. Can I help you with the urinal first / would you like a drink / can I get anything for you before we start?
• You were last repositioned after lunch so now is a good time so that you can be in your chair for supper.
• It is good that you are comfortable but you are at (high/very high) risk of pressure ulcer development and we want to provide you with the necessary preventative care. I can go over it if you'd like, then if you want to change anything we can.
• You agreed we could proceed in 15 mins, let me review with you the importance of this, or I can have the charge nurse review the plan with you.
• Your scheduled repositioning has been agreed to by the team with you, if there are changes you would like I can have the wound care nurse / team / MD review it with you. For now though I will have to document your refusal in the chart.
• As you are actually off the pressure ulcer we could leave you (another 30 mins/hour) longer, I will return and reposition you then.
• We have reviewed your repositioning schedule and this is the agreed time. How do you see the direction of your healing responding to such prolonged pressure? How can we make this work for you?
• I know that doctor .... has fully discussed with you the implications of persistently refusing care. I really hate having to chart your refusal, any suggestions as to how we can fix this?

At each stage, ask the patient why they do not want to be repositioned to address each issue (pain, comfort, socialization). Turn their bed a different way, position a blind, move a bedside stand. If you are not getting anywhere, seek advice from the charge nurse or a colleague. Be flexible, but firm and consistent. Remember: patients have choices and can refuse care, but their choices need to be informed choices and their choices must be documented. Part of educating them is their acceptance that what you are saying is believable. The term "pressure injury" is more meaningful than "pressure ulcer" as, to many people, an ulcer is a serious stomach condition. How can they get that from a red patch on their butt? The word "injury" indicates damage that can happen fast and is likely to be understood better. A picture paints a thousand words so plan with their team to show them a photograph of a stage 4 pressure injury. And remember to always DOCUMENT.

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.