Sub-optimal Practice within Contemporary Nursing

Sub-optimal Practice within Contemporary Nursing

Provide an outline for an area of your current clinical practice that is sub-optimal. Identify the information and / or behaviour change you believe is needed to improve this practice. Describe the process of a literature review and critically report the findings of key current papers in this area. Make recommendations for developing practice in the chosen area and briefly indicate potential barriers to implementing evidence-based practice.

This paper has been written to outline sub-optimal practice within contempory nursing. McQuillan et al (1998) Identified sub-optimal care as having five categories these are; failure to appreciate clinical urgency, failure to seek advice, lack of knowledge, failure of the organisation and lack of supervision. Despite increasing emphasis on quality assurance frameworks, clinical governance and evidence based healthcare, the incidence of adverse events in the acute care setting is increasing both nationally and internationally (Jacques et al 2006).  The author works within a very busy Trauma Centre Emergency department within the West Midlands Region.  Where pressure ulcers are on the increase for a sub-population of patients. A pressure ulcer is an area of the skin that has become damaged over time when the blood supply to a particular part of the body is reduced or cut off, the impact of pressure ulcers on the quality of life of the patient cannot be overemphasized, as it can be devastating (Spilsbury et al 2007). The daily costs of treating a pressure ulcer are estimated to range from £43 to £374.  For ulcers without complications the daily cost ranges from £43 and £57 (NICE guidelines 2014)Sub-optimal Practice within Contemporary Nursing

The paper will examine evidence based practice and how it should be delivered in nursing care, furthermore, an area of sub-optimal care will be identified and discussed.  A description of how the literature search was conducted will be included and any recommendations regarding optimising patient care. Some older adults within the Emergency Department are already at high risk of getting pressure damage due to their presenting injury / complaint, this risk is sometimes exacerbated by sub-optimal care. Whilst national and local guidelines and standards of care exist, there is audit evidence to suggest that at times best practice is not commonly adhered to.


Burns and Grove (2007) recognise that evidence based practice is a complex experience that requires synthesising study findings to establish the best research evidence and correlate the best ideas to form a body of empirical knowledge.

Sackett et al (1996) explained evidence based practice as; practice using the current best evidence and making decisions about patient’s care based on that current evidence.  Therefore, best current practice that is evidence based is optimal care which is essential, anything less would be sub-optimal and potentially detrimental to the individual’s health. Sub-optimal Practice within Contemporary Nursing

The research question was developed with the PICO framework.  PICO enables you to build clinical questions and is made up of four parts;

(P) Patient /Population/Problem – Older Adult

(I)  Intervention – Skin Bundle

(C) Comparison or Intervention -Evidence Based Practice / Optimal care.

(O) Outcome you would like to measure – Compliance and consistency of guidelines using Evidence based practice. (cooke et al 2012)

The PICO question derived was – In older Adult Patient care since implementing SKIN Bundles has pressure damage reduced within the emergency department.

The SKIN Bundle was developed in 2004 at St Vincent’s Medical Centre, a 520 bedded hospital in Florida, it was then introduced in Wales in 2009 through transforming care and a ward based programme aiming to improve patient care by reducing pressure ulcers (Appendix 1). The SKIN Care Bundle is a powerful tool as it defines and ties best practices together, the bundle also makes the actual process of preventing pressure ulcers visible to all. Healthcare Improvement Scotland (2011) (Appendix 2)

The total number of attendances in the Emergency Departments throughout the UK in October 2016 was 2,001,000 which is 4% higher than 1,923,000 in the same month last year. (NHS England 2016). Sub-optimal Practice within Contemporary Nursing

Witlock et al 2011 states every year up to 20% of patients in acute care in England and Wales are affected by pressure ulcers which can lead to serious harm and death if left untreated (National Patient Safety Agency 2010).  This figure is collaborated in numerous articles for example NHS choices (2014) stated that it is estimated that just under half a million people in the UK will develop at least one pressure ulcer in any given year. This is usually people with an underlining health conditions for example, around 1 in 20 people who are admitted to hospital with a sudden illness will develop a pressure ulcer.

Some people are more vulnerable to pressure ulcers than others, the high risk patient groups according to Alderden et al (2011) include-

Use of vasopressors, incontinent of urine or faeces, limited mobility, diabetes, a prior hospital stay and being aged over 65, they also included admission to ICU and a BMI of <25 or >35. Tschannen et al (2012) also included going to theatre, shock, sepsis, cardiac arrest, stroke, paralysis – along with history of pressure ulcers and current redness.  From this list it is apparent that the majority of these patient groups attend the hospitals via the Emergency Department.

Best practice is identified as being evidence based practice which is widely recognized within the role of nursing. Its implementation and purpose in the delivery of care is seen as an important driver for nursing practice and clinical outcomes. (Cullen et al 2010) It has been defined as the:

“…. conscientious integration of best research evidence with clinical expertise and patients values and needs in the delivery of high quality cost effective healthcare” …. (Burns and Grove 2007).

The Nursing Midwifery Council’ (NMC) role is to set the standards of the code of conduct, but these are not just nurses standards.  They are the standards that patients and members of the public tell them they expect from healthcare professionals. (NMC 2008) Sub-optimal Practice within Contemporary Nursing

Nursing care has a major effect on pressure development and prevention.  The most important education tool is to teach nurses how to recognize at risk individuals and when to begin nursing interventions so that they are early and effective (Lyder and Ayello 2008). Within the authors workplace guidelines stipulate that SKIN bundles should be completed two hourly on all patients, at times this is adhered to but there are also times when it isn’t.

There are many factors which contribute to hospital acquired pressure sores- the majority of opinions suggest its a failure on behalf of the nursing team, however, from extensive reading it has become apparent that it is a multi – disciplinary issue that needs to be tackled from many angles.

NHS choices (2014) state that people who are confined to bed will need to change their position at least once every two hours.  This statement corroborated an earlier statement by Spahn (2006) who said that a pressure ulcer and or deep tissue injury can develop in as little as two hours to seven days.  Within the authors workplace patients can queue on ambulance stretchers for any number of hours, repositioning patients on the stretchers would be near impossible as they are so narrow. Emergency Department trolleys are also narrow compared to beds and are unsuitable for obese patient repositioning.  The equipment and supplies used in the Emergency Department are often not designed with Reduction of Hospital Acquired Pressure ulcers (HAPU) in mind. (Naccarato and Kelechi 2011). Due to the vast amount of people currently attending the department Patients can remain there for days while they wait for their specialty bed, local audit suggest that SKIN bundles are not completed thoroughly or / and in a timely manner.  Research has shown that the challenges of overcrowding and poor patient flow in the emergency department settings can lead to decreased adherence to guidelines, inappropriate decision making and an increase number of adverse incidents, thus hampering ambitions to achieve an evidence based practice (Parson et al 2013) Sub-optimal Practice within Contemporary Nursing

A literature search was carried out using nursing databases, Medline, Cinhal and the Cochrane library as well as Google Scholar. The search included the key words, pressure ulcers, Emergency Department, Older Adults, SKIN Bundle and sub-optimal care. The inclusion and exclusion criteria was very broad due to low level evidence, gaps in literature and lack of research. Paediatrics was excluded. In actual fact it seems that the only research done on pressure ulcers within the Emergency Department has been over recent years. The author did however try to use countries with a similar state of healthcare pressure as the UK. USA was also included as the SKIN Bundle was developed there. The articles used all adhered to the Critical Appraisal Skills Programme (CASP) tool.  Which simply means making sense of research.

A study by Denby and Rowlands (2010) into the feasibility of implementing a pressure ulcer prevention protocol was conducted in the Emergency Department, it was a quantative study on adult admissions in 2006, it included 32664 patients, both genders were represented. 75% of the total patients admitted- did so through the Emergency Department. 125 of these developed hospital acquired pressure ulcers, 99.2% of which had an emergency department length of stay greater than 2 hours prior to hospital admission, 70 were female and 55 male – The study found 2.8% of patients admitted via the Emergency Department developed a stage 1 or stage 2 pressure sore.


This study has a significant amount of participants but there are limitations as the hospital concerned was a small community hospital whose patients differ from that of a major unit. It does however show the significance of poor flow through Emergency Departments. Sub-optimal Practice within Contemporary Nursing

7 Evidence-compare studies /support arguments with references

‘If he has a bed sore, it is generally not the fault of the disease, but of the nursing care – (Florence Nightingale 1859)

8 recommended practice / sub optimal – potential and actual

Boulton et al (1997) stated that many clinicians believe that pressure ulcer development is not simply the fault of the nursing care, but rather a failure of the entire healthcare system, hence, a breakdown in the cooperation and skill of the entire healthcare team.

barriers /challenge of implementing.

Initial barriers to break down would be the belief that damage prevention is a nurses’ role as opposed to a multi-disciplinary role.  Education needs to be addressed with all specialties – this includes ambulance staff in particular caring for patients which are queuing for Emergency Department admission, as it could easily be argued that the skin damaged caused has happened in the hours waiting on an ambulance trolley even before entering the hospital system. Furthermore, effective pressure relieving equipment needs to be addressed to management as clearly if the fundamental equipment is flawed then care will always be sub-optimal. Sub-optimal Practice within Contemporary Nursing.