Available online 19 March 2024, 151785

Author links open overlay panel, , , , AbstractBackground

It is known that heel offloading devices are widely used in clinical practice for the prevention of heel pressure ulcers, even though there is a lack of robust, good quality evidence to inform their use.

Objective

To explore how and why heel offloading devices are used (or not used) and reasoning behind their use in population at high risk of developing heel pressure ulcers.

Methods

An ethnographic study was conducted as part of a realist evaluation in three orthopaedic wards in a large English hospital. Twelve observations took place, with 49 h and 35 min of patient care observed. A total of 32 patients were observed and 19 members of the nursing team were interviewed and in-depth interviews with the three ward managers were conducted.

Results

Although the focus of the study was on offloading devices, constant low pressure heel specific devices were also observed in use for pressure ulcer prevention, whilst offloading devices were perceived to be for higher risk patients or those already with a heel pressure ulcer. Nursing staff viewed leadership from the ward manager and the influence of the Tissue Viability Nurse Specialists as key mechanisms for the proactive use of devices.

Conclusions

This study informs trial design as it has identified that a controlled clinical trial of both types of heel specific devices is required to inform evidence-based practice. Involving the ward managers and Tissue Viability Nurse Specialists during set up phase for clinical equipoise could improve recruitment.

Tweetable abstract

How, for whom, and in what circumstances do devices work to prevent heel pressure ulcers? Observations of clinical practice.

Section snippetsWhat is already known•

There is a lack of robust evidence around the use of heel specific devices for the prevention of heel pressure ulcers, but despite this they are widely used in clinical practice.

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Heel specific devices are deemed as a third line intervention, with repositioning and mattress use viewed as being more important.

What this paper adds•

This is the first ethnographic paper focusing on heel pressure ulcer prevention.

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Both offloading and constant low-pressure devices were observed being used for the prevention of heel pressure ulcers, but offloading was deemed as preferential in this study for the highest risk or treatment for those with a heel pressure ulcer.

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The findings of this paper will inform conduct of heel-specific pressure ulcer prevention trials

Background

Pressure ulcers are defined as “a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear” (EPUAP et al., 2019a). Not only can they be painful, (Briggs et al., 2013; Gorecki et al., 2011; McGinnis et al., 2014) they can have a massive impact upon quality of life (Gorecki et al., 2009) and health. The most severe pressure ulcers can extend as far as the underlying structures including bone, leading to

Aims

To explore how, when, and why heel offloading devices are used (or not used) for prevention in patients at high risk of developing heel pressure ulcers in a hospital setting.

Methods

Programme theory 1 (Fig. 1) was selected for testing as it would best answer the aims of the study and had the potential to inform future clinical trial design.

Realist evaluation requires a mixed methods approach, collating data from a range of sources. A mixed methods ethnographic approach allows for the exploration of aspects of the context that cannot easily be measured, such as the culture of an organisation (Randell et al., 2014). Through observing clinical practice and studying peoples'

Results

A total of twelve observation periods took place, each lasting at least four hours, with a total of 49 h and 35 min of patient care observed. Sixty-five patients were screened for eligibility, and a total of 32 patients (mean age 73.9 years, 23 females) were consented to be observed and for documentation review. Short interviews post observations were conducted with 19 members of staff, and three in depth interviews with the ward managers were conducted after all observations were complete.

Discussion

The previous study (Greenwood et al., 2023) identified four mechanisms for the use of offloading devices in clinical practice: Staff awareness and knowledge, stock and supply of devices, identification of a suitable patient group and leadership/management.

Conclusions

Both offloading and constant low-pressure devices were observed being used in practice, with a perceived benefit amongst those that use them. Although there is a lack of evidence around constant low-pressure devices, these are perceived as beneficial for the prevention of heel pressure ulcers, and offloading devices are viewed as being the better devices for higher risk patients or for treatment. Both the ward manager and the Tissue Viability Nurse Specialist were identified as influential over

CRediT authorship contribution statement

Clare Greenwood: Writing – review & editing, Writing – original draft, Visualization, Validation, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Jane Nixon: Writing – review & editing, Supervision, Methodology, Conceptualization. E. Andrea Nelson: Writing – review & editing, Supervision, Methodology, Conceptualization. Elizabeth McGinnis: Writing – review & editing, Supervision, Methodology, Formal

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

References (24)D.M. GilcreastResearch comparing three heel ulcer-prevention devices

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C. GoreckiImpact of pressure ulcers on quality of life in older patients: A systematic review

Journal of the American Geriatrics Society

(2009)

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© 2024 Published by Elsevier Inc.