Factors affecting repositioning policy compliance: an integrative review
Article Category: Review
Publicado en línea: 30 abr 2021
Páginas: 7 - 22
Recibido: 30 abr 2020
Aceptado: 26 jun 2020
DOI: https://doi.org/10.2478/fon-2021-0002
Palabras clave
© 2021 Abdulkareem Iblasi et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.
Figure 1
Figure 2
Frequency of factors influencing repositioning compliance reported among the studies.
| Factor | Frequency of studies |
|---|---|
| Individual factor – Attitude | 15 |
| Individual factor – Knowledge | 10 |
| Individual factor – Skill | 5 |
| Environmental – Managerial follow-up | 3 |
| Environmental – Staffing | 15 |
| Environmental – Teamwork | 7 |
| Environmental factor – Equipment | 12 |
| Environmental factor – Quality projects | 15 |
| Environmental – Digital visualization | 3 |
| Patient factor – Age | 2 |
| Patient factor – Weight | 2 |
| Patient factor – Medical condition | 8 |
| Total | 97 |
Summary of available studies that present the motivations for repositioning compliance.
| Author and country | Population and sample | Design (level of evidence) | Findings |
|---|---|---|---|
| Alexander et al. USA | Nurses in nursing homes |
Observational (VI) | Face-to-face communication is increased when an IT system with a low level of sophistication that includes the repositioning decision is used to prevent pressure injuries, and a higher level of care is provided when a highly sophisticated IT system is used. |
| Ali et al. Egypt | Nurses in a hospital |
Longitudinal study (VI) | The changes in nurses’ performance regarding pressure injury prevention, which includes repositioning, resulted from changes in the administrative focus and the involvement of nurses in the responsibilities. |
| Amon et al. USA | Medical-surgical telemetry patients |
Pre-post Intervention (III) | The incidence of pressure ulcer PU was reduced as a result of compliance with pressure injury prevention policies, including repositioning. |
| Angmorterh et al. UK | Nursing students |
Prospective experimental (III) | The pressure placed on volunteers when moving the patient on the radiology trolley is high, and the settings are not convenient for the repositioning of the patient during the diagnostic procedures in radiology. |
| Athlin et al. |
Nurses |
Qualitative content analysis (VI) | Pressure injury prevention compliance, including repositioning, is associated with:
nurses’ perceptions of the patient’s physical and psychological conditions and nurses’ perceptions of the level of cooperation from patients; Responsibilities and commitments among nurses toward repositioning and pressure injury prevention; Nursing knowledge and skills; Cooperation and teamwork among the nurses in the unit; Availability of policies and routine care in the hospital; and Availability of repositioning equipment and required pressure redistribution supplies. |
| Beeckman et al. Belgium | Hospitalized patients |
Cross-sectional study (VI) |
Only 13.9% of high-risk patients received appropriate prevention, including repositioning compliance. The level of knowledge among nurses is lower than the expected while attitudes are high. Pressure injury prevention, including repositioning, correlates with attitudes, but no independent correlation is observed between knowledge and prevention. |
| Beeckman et al. Belgium | Patients in nursing homes |
RCT (II) | After implementing the supported clinical decision, nurses’ knowledge and positive attitudes increased but did not result in significant changes in their compliance toward pressure injury prevention, including repositioning, while increased compliance with the pressure injury prevention policy was observed for patients in wheelchairs. |
| Behrendt et al. UK | Hospitalized critical care patients |
Prospective control study (IV) | Following the implementation of specific equipment that provides continuous and consistent visual feedback for nurses, nurses exhibit better compliance with repositioning. No further education or any further policy changes were implemented. |
| Black and Maegley USA | Hospitalized patients 23 beds in a medical-surgical unit | Quality improvement project (III) | The project demonstrates changes in the nurses’ compliance with pressure injury prevention, including repositioning, after the application of a new policy, forms, and follow-up system. |
| Cameron et al. UK | Nurses in the NHS | Quality improvement project (III) | The project presents the experiment performed in the NHS to provide the pressure ulcer prevention program online. The project assumes an increase in pressure ulcer prevention compliance, including repositioning. |
| Chaboyer et al. Australia | Hospitalized patients |
Clustered randomized control trial (II) | The study shows a decrease in the incidence of pressure ulcers and an increase in prevention following the application of the pressure injury prevention care program, including repositioning, but statistically significant differences were not observed between the overall compliance of nurses in both groups. |
| Choi et al. USA | Nurses in critical care facilities |
Quality improvement project (III) | The low compliance of nurses is associated with:
Nurses’ attitudes toward a lack of responsibility for repositioning compliance; A reduced sense of personal agency; Barriers including a lack of time, lack of staff, and attitudes that patients have a very high acuity for preventing pressure ulcers, including the priority of repositioning; and Leadership and interdisciplinary cooperation are supportive elements. |
| Courvoisier et al. Switzerland | Patients in nursing homes |
Cross-sectional study (VI) | The study reported relations between the prevalence of pressure ulcers and the type and size of nursing homes. |
| Co x USA | Hospitalized critical care patients |
Retrospective correlational design (IV) | The study concludes that the predictability of the Braden scale is questionable. The most reliable predictions were based on patient mobility and friction/shear. Many risk factors have been identified empirically; however, a consensus on the most important risk factors is lacking. 18.7% of patients developed a pressure ulcer. |
| Cub ukcu Turkey | Patients in nursing home care units |
Cross-sectional study (VI) | The study concludes that pressure ulcer development is associated with the Braden score, weak nutritional conditions, and chronic illnesses. |
| Cyriacks and Spencer USA | Hospitalized patients 32 beds in a pulmonary unit | Quality improvement project (III) | The study shows increased repositioning compliance following the redistribution of the nursing staff and creation of a turning team from nurses on duty. |
| Dellefield and Magnabosco USA | Nurses in hospitals |
Triangulation study design (III) |
Evidence that links individual nursing factors with pressure ulcer prevention compliance, including repositioning, is limited. Nurses, in general, had a positive attitude toward repositioning. Nurses’ perceptions of recognition are low. Higher performance feedback is associated with greater compliance. Nurses prefer patients who can give positive feedback. Nurses in the same organization describe their knowledge, attitudes, and beliefs about pressure ulcer prevention, including repositioning, differently. Communication and workload perceptions are associated with compliance and require further investigation. |
| Feng et al. China | Nurses in hospital |
Pre-/post-intervention quasi-experimental study (III) | Improvements in the knowledge and attitudes of nurses toward pressure ulcer prevention and repositioning through an awareness campaign are associated with higher levels of compliance and a lower incidence of pressure ulcers. |
| Fossum et al. Norway | Nurses in a nursing home |
Quasi-experimental study (III) |
Nurses’ compliance with all care related to pressure ulcers, including repositioning, improved after applying a software system. The application of the software provides the education and support required for nurses to decide on the required care. |
| Gunningberg et al. Sweden | Patients in the geriatric/internal medical ward |
Pragmatic randomized trial (III) |
No significant changes in pressure ulcer incidence were observed after applying the pressure mapping system. Applying the pressure mapping system increased the nurses’ repositioning compliance as they received feedback. The study presents the need for further investigations in this area. |
| Hanna et al. USA | Nurses working in different organizations |
Cross-sectional study (VI) |
The study explores a group of silent factors that affect nurses’ decisions to reposition patients. The silent factors related to patients are patient weight, which is negatively associated with repositioning compliance. Patients’ cooperation has positive relations with repositioning compliance. Teamwork between nurses. |
| Hartmann et al. USA | Nurses in a nursing home |
Qualitative study (VI) | Staff provided the following indirect impressions of the facilitators and barriers associated with pressure ulcer prevention:
Structure: A formal structure such as a team or committee will advance the practice. The establishment of organizational priorities will enhance the performance. An improvement in culture. Clear roles and responsibilities. Communication strategies. Staff and clinical practices. |
| Hall and Clark USA | Patients in a medical unit and surgical ICU |
Pre- and Post-intervention (III) | The study concludes that the device reduces the repositioning burden among nurses, increases repositioning compliance, and reduces the HAPU among the selected units. |
| Kalisch et al. USA | Nurses in hospitals |
Cross-sectional study (VI) |
A lack of proper nursing care was common among all hospitals. Job title, shift work, absenteeism, perceived staffing adequacy, and patient workload were significantly associated with a lack of proper nursing care, including repositioning. Repositioning is one of the top five tasks that most directly affect patients’ outcomes by preventing pressure ulcer development. |
| Kalisch et al. USA | Patients and relatives in hospitals |
Cross-sectional study (VI) | Patients with pressure ulcers (they did not receive the proper prevention measures, including repositioning) reported higher rates of missed nursing care in the following areas:
1. Overall lack of proper nursing care. 2. Lack of nursing communication and 3. Time to response by nurses (all of which were significantly associated with pressure ulcers). |
| Källman and Suserud Sweden | Nurses in a hospital |
Cross-sectional study (VI) |
Nurses have good knowledge. Nurses also generally have a positive attitude toward care. Nurses have a negative perception of the organizational support system for providing care. Nurses mentioned the following barriers for proper pressure ulcer prevention, including repositioning: lack of time, lack of staff, a shortage or lack of equipment and facilities in the organizations, and a lack of related policies. Nurses perceived many uncooperative ill patients. |
| Källman et al., Sweden | Hospitalized patients |
Non-experimental, observational study (VI) | The study concludes that repositioning compliance is associated with:
The existence of a PU during the day. If patients presented with a pressure ulcer, nurses did not intend to maintain compliance with repositioning during the day shift, while the situation was not the same during the night shift. Patients with cancer received higher repositioning compliance during the night shift. Nurses in hospitals were more compliant with repositioning than nurses in nursing homes. The use of sheets and other equipment reduced nurses’ compliance with repositioning. The patient’s general activity, moisture level, cognitive dysfunction, and use of psycholeptic medications all negatively correlated with repositioning compliance. Thus, nurses did not intend to be compliant with this category of patients. |
| Knibbe et al. Netherlands | Patients in nursing homes |
Quasi-experimental pre- post-intervention study (III) | The case reports did not reveal a significant difference in nurses’ compliance with repositioning before and after implementing repositioning facilities. However, the study presents the importance of the availability of this device in reducing nurses’ working-related hazards. |
| Kwong et al. Hong Kong | Patient and nurses in nursing homes |
Action research of three main steps (III) | The changes in nurses’ behavior in complying with repositioning resulted from the factors listed below:
Nursing empowerment and training. “They increase the feelings of responsibility belonging to the nurse through participation, which affects repositioning compliance.” It is an organizational development model to lower pressure ulcer incidence. The application of protocols enhanced practice. |
| Lavallée et al. UK | Nurses in the hospital |
Qualitative study (VI) | The study defined seven domains that interact as barriers or facilitators in manipulating nurses’ behavioral compliance, which are listed below.
The barriers are 1 – knowledge, 2 – physical skill, 3 – social influences, and 4 – environment and resources. The facilitators are 1 – interpersonal skills, 2 – environmental context, 3 – beliefs about capabilities, 4 – beliefs about consequences, and 5 – social and professional roles. |
| Lu et al. China | Bedridden patients in a gynecological unit |
RCT – Two armed (II) | The report shows a significant increase in the implementation of pressure ulcer prevention measures (including repositioning) after applying the protocol. Significant reductions in pressure ulcer incidence were also observed after applying the clinical guideline. |
| Mallah et al. Lebanon | Patients in a hospital |
Quasi-experimental pre- post-intervention study (III) |
Changes in HAPU were observed after applying the bundle. Repositioning compliance positively correlates with changes in nursing assignments to create a champion. Repositioning compliance is associated with patient age (younger, better compliance; low length of stay, better compliance). The overall repositioning compliance rate is 75.62% and the compliance rate for high-risk patients is 65.2%. |
| Meesterberends et al. | Patients in nursing homes |
Prospective multicenter cohort study (IV) |
More PUs occurred in The Netherlands than in Germany. The factors that explained the differences between Germany and The Netherlands are nurses’ perceptions of 1 – dementia, 2 – analgesic use, 3 – use of transfer aids, 4 – repositioning compliance, 5 – availability of a tissue viability nurse, and 6 – quality control. All factors were better in The Netherlands (except internal quality control), while the pressure ulcer rate and compliance were lower. Therefore, the main factor associated with better compliance in Germany is internal quality control. |
| Mendoza et al. Saudi Arabia | Inpatient units |
Pre- and post-intervention (III) | An awareness campaign increases nurses’ compliance in preventing pressure ulcers. |
| Moore and Price Ireland | Nurses in a hospital |
Cross-sectional study (VI) |
Nurses have positive attitudes toward repositioning. Nurses intend to practice pressure ulcer prevention, including repositioning, without a scientific rationale. Nurses perceived a lack of time and lack of staff as barriers to pressure ulcer prevention, including repositioning Registered nurses had positive attitudes toward the importance of repositioning and other prevention measures. A positive attitude does not influence or change nurses’ practice regarding repositioning compliance. No relation is observed between positive attitudes and practice. When nurses perceive the situation as a shortage, repositioning is not a priority. Nurses perceive other nursing responsibilities as much more important than pressure ulcer prevention, including repositioning. No clear role of knowledge in influencing nursing compliance is identified, although educational resources are limited for nurses. |
| Moya-Suárez et al. Spain | Nurses working in hospitals |
Cross-sectional study (VI) |
The questionnaire is valid for predicting nurses’ compliance with the recommendations for pressure ulcer prevention, including repositioning. Nurses’ attitudes play a major role in their decision to implement measures that prevent pressure ulcers. |
| Peterson et al. USA | Patients in a hospital |
Observational study (VI) |
The method nurses used to perform the repositioning is called the triple jeopardy area under pressure, which leads to a pressure ulcer. The study questioned the skill of nurses performing the repositioning. In addition, the study presents the need for a further analysis of the concept of repositioning itself. As the procedure of repositioning requires further reforms for supine left-right, the performance of all these procedures currently does not employ the proper repositioning techniques. |
| Renganathan et al. India | Hospitalized critical care patients |
Prospective, non-randomized, multiphase, multicenter trial (III) | The use of a continuous repositioning monitoring system increases nurses’ compliance with the repositioning protocols. |
| Rich et al. USA | Hospitalized patients |
Observational study (VI) |
Repositioning compliance is low, with 53% of patients in need receiving the required repositioning. Differences in the incidence of pressure ulcers are not observed between patients who received repositioning in less than or greater than two hours. Patients with pressure ulcers on admission had better repositioning policy compliance than those at-risk but without pressure ulcers |
| Saliba et al. UK | Patients in nursing homes |
Retrospective analysis (III) |
A significant difference exists between facilities, even if they are applying the same policies and protocols. Pressure injury prevention guideline compliance is a problem in NH. Nursing homes differ in their level of compliance; further investigations are needed. |
| Samuriwo UK | Nurses in nursing homes |
Qualitative grounded theory (VI) |
A link exists between the value of nurses and pressure ulcer prevention compliance, including repositioning. Repositioning is usually delegated to students and health care assistants. Pressure ulcer prevention is perceived as less critical than other nursing interventions, such as doctors’ orders. With less follow-up performed by nurses, nurses intend to delegate the repositioning task. |
| Samuriwo UK | Nurses in nursing homes |
Qualitative grounded theory “Reanalyzed data” (IV) | The reanalysis of the data also concludes a substantial role for multidisciplinary teamwork and nursing empowerment in compliance with pressure ulcer prevention measures, including repositioning. |
| Still et al. USA | Hospitalized critical care patients in a surgical ICU |
Pre- and post-intervention quasi-experimental study (III) | Significant changes in repositioning compliance were observed after the staff were redistributed to establish a turning team in the unit. |
| Strand and Lindgren Sweden | Nurses in intensive care units |
Cross-sectional study (VI) |
Nurses’ attitudes toward pressure injury prevention, including repositioning compliance, are good. A significant difference in knowledge is observed between registered nurses and practical nurses. Nurses attribute a low level of compliance to a lack of time (57.8%), the severity of the patient’s condition (28.9%), or lack of the required equipment (35.5%). The study stresses the need for further improvements in the knowledge of pressure injury prevention, including repositioning. |
| Schutt et al. USA | Hospitalized patients |
Quasi-experimental pre- post-intervention study (III) |
Nurses significantly respond to the availability of a continuous feedback system. Nurses have a low level of compliance with repositioning, but the application of public follow-up significantly increases compliance. |
| Sving et al. Sweden | nurses in hospitals |
Triangulation study design (III) |
The article aimed to describe how RNs perform, document, and reflect on pressure ulcer prevention compliance, including repositioning. Repositioning is one of the items observed and monitored by the authors and is marked as a caring culture or social issue. RNs show limited attention to pressure ulcer prevention, including repositioning. Nurses generally perform repositioning for other reasons than pressure ulcer prevention. A lack of knowledge among nurses is noted. A communication deficit exists between RNs and ANs, leading to missed scheduled repositioning. Nurses over-trusted nurses assistants in pressure injury prevention. RNs have a proper attitude toward pressure ulcer prevention, including repositioning, but they do not intend to perform the procedure alone. |
| Sving et al. Sweden | Hospitalized patients |
Descriptive cross-sectional study (VI) |
A low total number of nursing staff is associated with low repositioning compliance. Patients with a higher score on risk tools received higher compliance from nurses than other patients. Nurses perceived that older patients would require higher repositioning compliance. Repositioning compliance in geriatric units is higher than in other units. Nurses should not exclusively rely on the records when evaluating repositioning compliance. |
| Tannen et al. Germany and Netherland | Hospitalized patients and residents in nursing homes |
Cross-sectional study (VI) | The study defines the differences in pressure ulcer prevention, including the repositioning compliance between two countries as related to:
Educational programs Policies and protocols Special follow-up team Follow-up system |
| Tayyib and Coyer Saudi Arabia | Hospitalized critical care patients |
Clustered randomized control trial (II) |
The study applied OMRU (the Ottawa Model) to facilitate the successful dissemination of a new pressure injury prevention care bundle, which includes repositioning. The study was conducted in two hospitals in Saudi Arabia and shows that the use of care bundles and protocols reduces the incidence of PU and increases pressure injury prevention compliance, including repositioning, as the nurses already participated in creating the protocol. Modification of the durations for repositioning from 2 to 3 hours increases compliance. |
| Tayyib et al. Saudi Arabia | Hospitalized patients |
Prospective observational study (VI) |
Repositioning compliance is only influenced by the unit norms, but not any patient’s condition. The unit policy and administrative follow-up are the only factors contributing to behavioral modification among nurses in the critical care unit. No relations with the Braden score or any further redaction tools are associated with nurses’ compliance with pressure ulcer prevention, including repositioning. |
| Ünver et al. Turkey | Nurses in a hospital |
Cross-sectional study (VI) |
Nurses’ attitudes toward pressure ulcer prevention, including repositioning, is the main factor related to compliance. Nurses’ attitudes toward pressure ulcer prevention, including repositioning, are positive. |
| Webster et al. Australia | Hospitalized patients with pressure ulcers |
Retrospective cohort study (IV) | The study reviewed the long-term effects of applying protocols on the compliance level. The study supports the hypothesis that nurses’ long-term compliance will increase when a bundle of care or protocols to organize the care is available. |
| Weiner et al. Israel | Nurses in a hospital |
Post-test (III) | The study classifies the participants into three groups in which repositioning was performed with different levels of assistance for patients with different weights. The equipment plays an important role in reducing low back pain among nurses, which improves compliance. |
| Wogamon USA | Nursing assistants in hospitals |
Non-randomized trial (III) |
On-the-job training for nursing assistants increases compliance. Therefore, a lack of compliance is related to knowledge and skills. Increased documentation and compliance are observed after the educational sessions. |