With the help of the Donabedian’s framework of quality, one can easily evaluate the quality of the practices that are being conducted by the nurses. In turn, it helps the nurse in developing idea about where the changes are required so that the patient safety can be assured while dealing with the issues of pressure ulcers. This framework first helps to develop ideas about the present attributes of the organization and develops the characteristics of the stags and the physical setting in which the patients are cared for (Quaseem et al. 2015). This is called the structure stage. The next stage involves the process stage that includes the actions of the patient or the healthcare while providing care in the patient settings. The last stage mainly involves the outcome that is the changes that occur in the health of the client after the interventions have been applied by the nurses and other healthcare staffs.

The structural part shows that the healthcare settings consist is provided with a fixed amount of resource and resource constraints are huge. Hence, there is a pressure on the nurses to provide the best cared to the patients within the minimum resource. Nurses are mostly comprised of enrolled nurses with very few registered nurses and senior nurses. Therefore the work team is fresher and is less experienced. However, they are diligent enough to provide the best care to the patients with very little scope of complaints from them.

The process part of the evaluative framework had shown while conducting the treatment of the patients for prevention of pressure ulcer, they did not consider skin care of the patients. They did not provide any sort of body and skin protection products. They also did not maintain dryness of the skin. The second issue that was observed in the treatment of the patients was that the nurses did not follow the proper reduction technique for mechanical loading. They also did not follow the optimal turning schedules. Proper repositioning of the patients at correct interval is necessary to reduce the pressure of the bones and resulting in necrosis (Moore and Cowman 2014). Correct turning intervals and proper application of the turning procedure was not followed. The turning was done by lateral turning which was greater than 30degree which harmed the patients. The third issue that is also observed was that the nurses could not apply the correct support surfaces. They were only allowed with standard support surface which increased the risk of developing the ulcers. The fourth issue that was noted was that the nurses could not provide the correct nutritional requirement to the patients. The patients were found to develop poor levels of serum albumin which is one of the reasons for the increased occurrences of pressure ulcers in most of the patients.

The outcome of the interventions was highly negative. The patients were seen to be suffering massively from pressure ulcer of different stages with stage 4 and 4 being in the highest number. It highly impacted the health of the patients greatly increasing the disease burden and destroying the quality of the lives of the patients. A huge number of complaints of family numbers in the complaint cell urgently called for attention.

Clinical reasoning:

Each and every nurse and healthcare professionals should develop the skill for clinical reasoning in order to provide the safest practice and at the same time provide interventions which will be backed up by strong clinical rationale. This process helps the nurse to collect cues followed by the processing of the interventions (Palfreyman and Stone 2015). This helps them to come to an understanding of the patient situation and the problems that he is facing. These help them to plan as well as implement interventions and thereby evaluate whether the outcomes have matched the expectations or needs to be modified. The nurse will then develop reflections of her practice and learn form the process.

From the Donabedian’s framework of evaluation, a number of issues have been identified which are actually the cues that the nurse needs to assess. Te second step which mainly involves processing the information and coming to an understanding about the condition of the patient or the situation that is bothering him. The first issue that has risen is the appropriate skincare. The clinical reasoning behind this is that the nurse has not properly developed knowledge about the skin care techniques required to maintain for a patent at a risk for developing pressure ulcer (Quaseem et al. 2015). The process by which the skin is washed may result in different ulcers. Proper education of the nurse is very important o know the techniques. Proper use of body wash and skin protection products reduces stage 1 and stage 2 ulcers. When the nurses keep the skin clean and dry, it automatically prevents irritants on the skin. Excess moisture on the skin should be prevented because they may result in the increase of frictional forces resulting in skin breakdown. Individualized bathing schedules as well as non drying products should be utilized. The second issue is mechanical loading. Proper turning over was not followed as a result of which patients developed ulcers. Researchers suggest that there exist an inverse relationship between the degree of pressure and the duration of the pressure (Demarre et al, 2015). Uninterrupted high pressure requires shorter time and lower pressure requires longer time to result in tissue necrosis. Hence the nurses should be skilled enough to handle such situation. Low turning over the positions of the nurses may affect the patients by blocking the capillaries and produces pressure effects on the larger vessels. This ultimately results in venous thrombosis (Garcia et al. 2014). This is mainly the effect of higher pressure for shorter time which is much more dangerous than the other. When the nurses responsibly lower the pressure by change of position at the correct time, relief from pressure restores normal hyperemic response which compensates the temporary ischemia. Therefore the tissue does not result in necrosis. Thirdly the support surfaces should be such that it results in equal distribution of the pressure over the entire surface in touch with the mattress. More advanced the mattress, there is a better chance of equal distribution and hence the nurse should have the knowledge about the types of mattress present for each of the stages of ulcer. Low risk patients can be provided with static mattress without electricity, moderate risks patients can be are provided with mattress which has electricity or pump. High risk patients should be provided with air-fluidized beds (Black et al. 2015). Absence of this knowledge affects patients’ safety and health. The last issue was improper nutritional mainly low level of serum albumin in patients. Healing of wounds become difficult for a malnourished patient and prevention of bed sores in such individuals is also challenging because of their malnourished condition (Behrendt et al. 2014). Other micronutrients should be provided so that healing of wounds becomes easier

PDSA cycle

In response to the above identified issues that are being observed in the patient safety in decubitus ulcers, it is important to plan and implement the interventions as a part of clinical reasoning with evaluation of outcomes and reflecting and learning from the implementation process. There are patient safety issues that are observed in the prevention of decubitus ulcers or pressure sores. The patient safety issues in preventing pressure sores are skin care, repositioning (mechanical loading), type of mattresses and nutrition level in the patients (Lyder et al. 2012). Apart from these issues, there are managerial issues where there are nursing staff shortages and turnover with more number of enrolled nurses than registered nurses and lack of experience. There is also financial constrains that are being observed in the clinical setting. The Plan, Do, Study and Act cycle (PDSA) model is a way to implement the interventions hat would help to improve the patient safety in preventing decubitus ulcers or pressure sores. The PDSA cycle in improving care and providing patient safety is a way to test the working of the change in the real clinical setting where there is improvement in the quality with an aim for action-oriented learning. It is a quality improvement method that is intended to improve care. It starts with the determination of the nature and scope of the patient safety issue in decubitus ulcers and specific plan for change along with impact of change and targeted strategies. There are four steps in this cycle that includes Plan, Do, Study and Act (Warburton 2009).

In the plan stage, the objectives are planned that would deliver the results in accordance with the desired outcomes. There are expected outcomes like the maintenance of skin health, avoidance of skin friction and proper skin assessment for the prevention of pressure sores. Along with maintenance of skin health, there is requirement of proper nutrition that is important for the maintenance of healthy skin (Bluestein and Javaheri 2008). In the Do stage, there is implementation and execution of the plan. There are recommendations that can be implemented for the maintenance of the skin health. Nurses have to plan individualized bathing schedules along with frequent skin assessment that would minimize the pressure ulcers occurrence. They should avoid hot water and use only mild cleansing agents that would reduce the dryness and irritation of the skin. The pressure ulcer development can be avoided through the avoidance of low humidity promoting dryness and scaling. Rigorous massage should be avoided during skin care and minimization of moisture exposure. Along with skin health maintenance, it is important to have protein-calorie and there is evidence that nutrition intake and decubitus ulcer prevention. The nutrition plan should contain mineral and vitamin supplements that help to prevent the pressure ulcers (Stechmiller et al. 2008). In the study step, there is measurement and collection of the results and comparison with the expected results. After checking the measurement of the implementation of the plan, there might be deviations seen after the exaction of the implemented plan. There are shortages of nursing staff with less number of registered nurses, so there are barriers in planning of the individualized bathing schedules along with time to time skin assessment. The nurse to patient ratio is more that also acts as barriers where the nurses are under stressful environment and it is not possible for them to make individualized skin assessment and risk management (Unruh 2008). In addition, high calorie diet is also not recommended for many patients which are essential component for the maintenance of healthy skin. The use of more amino acids in diet like glutamine, arginine and cysteine is also not recommended for many patients that assist in maintenance of healthy skin. In the act stage, there is setting of new standards according to which, the healthcare organization would act and move towards the implemented plans (Dorner, Posthauer and Thomas 2009). As there is deviation seen from the expected results, it is important to make adjustments or correct the actions that would help to propose thinking and decide for the alternative changes to meet the new standards for quality improvement.

The PDSA cycle can be applied to the patient issues like mechanical loading (reposition) and type of mattresses that would prevent the pressure sore development. In the plan stage, there is establishment of the objectives that would deliver the expected results in the targeted population. Repositioning would reduce the mechanical load on the skin and prevent development of pressure sores. Apart from this, there is requirement of support services that would aid in pressure redistribution. In the Do stage, there is implementation of the plan to support repositioning and use of appropriate mattresses to prevent pressure ulcers. According to a study conducted by Krapfl and Gray (2008) showed that repositioning after every two hours is the standard timing that is widely accepted and in the prevention of pressure sores. There are three kinds of mattresses being used depending upon the risk level for pressure sores development. Use of foam, solid, air and convoluted mattresses and water overlays are ideal for low risk patients. Low-air-loss and alternating mattresses are ideal for moderate to high risk patients and use of air-fluidized beds which are electric and have silicon coated ulcers that divide the support and in pressure ulcer prevention (McInnes et al. 2011). In the study cycle, there might be deviation seen in the implementation plan as there might be potential barriers seen in the organization. There are financial constrains where it might not be possible for the organization to provide individualized supporting surfaces for the patients based on level of risk assessment. Moreover, there are fewer nurses with lack of knowledge and experience, so it is not possible for the nurses to provide repositioning after every two hours. In the act step, there is requirement of corrective actions or making of adjustments that would help to achieve the proposed plan.

Role of healthcare leaders

For the improvement of the care in the prevention of pressure sores, the healthcare leaders play an important role. Nurses also play an important role in improving care and pressure ulcer prevention. Risk assessment should be carried out for the patients after the admission and throughout the hospital stay with continuous assessment of the implemented strategy for the pressure ulcer prevention (Howe 2008). They are the essential components who evaluate the outcomes of the implemented plans and reflect on their professional learning. Along with the understanding of the predisposing factors through knowledge and experience, they are able to select the appropriate devices for successful prevention and monitoring of the implemented plan. With the consistent implementation of the strategy, the healthcare leaders also have the responsibility to motivate the staffs so that they follow the implemented plan for the prevention of the pressure sores and improve patient safety (Athlin et al. 2010). There should be enhancement of knowledge and practice of the nurses towards the prevention of the pressure sores. The governing authority, chief nursing officer, bedside nurse along with manager should work in collaboration in order to prevent the risk for development of pressure sores and also prevent tissue injury.

Conclusion

The management of pressure ulcers has reached an alarming stage due to lack of preventive measures. in order to first understand the different issues faced by nurses while taking preventive care for decubitus ulcer in patients, one must first develop the idea that why such pressure ulcer develops. With the help of the Donabedian’s framework of quality, one can easily evaluate the quality of the practices that are being conducted by the nurses. It is important to plan and implement the interventions as a part of clinical reasoning with evaluation of outcomes and reflecting and learning from the implementation process. The PDSA cycle in improving care and providing patient safety is a way to test the working of the change in the real clinical setting where there is improvement in the quality with an aim for action-oriented learning. Healthcare leaders and nurses have the responsibility to motivate the staffs so that they follow the implemented plan for the prevention of the pressure sores and improve patient safety. 

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