May 6 2013
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Turn-Turn-Turning the Tables on a Pervasive Problem in Long-Term Care

Tracey L. Yap, PhD, RN, CNE, WCC, is an assistant professor at the Duke University School of Nursing, a John A. Hartford Foundation Claire M. Fagin Fellow, and a senior fellow at the Duke University Center for Aging and Human Development. With funding from the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative (INQRI), Yap and her co-investigators developed a cost-effective, nurse-led intervention that aimed to reduce the prevalence of pressure ulcers in long-term care facilities by increasing resident mobility through a musical prompting system specifically tailored to each facility. This is part of a series of posts for National Nurses Week, highlighting how nurses are driving quality and innovation in patient care.

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It started with a boombox and the Byrds.

Those are hardly the first things that come to mind when you think about pressure ulcers, also referred to as bed sores—the wounds that are caused by continuous, unrelieved pressure on the skin and that often develop in people who have impaired mobility. Yet that’s just how my husband, a physician who has a large population of patients in long-term care, inspired this research by suggesting that I pursue a grant related to this serious issue.

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At one long-term care facility, my husband had a maintenance person use a boombox over the public address system to play “Turn, Turn, Turn” at two-hour intervals. It was a creative, simple, and fun way to remind staff to move patients, and it appeared to be effective in preventing pressure ulcers.

We were in Kentucky at the time, and I was teaching at the University of Cincinnati College of Nursing. When I took my husband’s suggestion and applied for an INQRI grant, it radically changed my life—and the lives of many long-term care residents—for good. In my PhD studies, I’d focused on occupational health, and the INQRI grant helped me apply that knowledge in a new way and ultimately led to my current work at Duke University.

The interdisciplinary research team worked with 10 long-term care facilities, all part of a major long-term care provider, Signature HealthCare. We aimed to reduce facility-acquired pressure ulcers using musical cues to prompt a multidisciplinary team of staff to consistently follow the guideline of repositioning, at minimum, every two hours for anyone considered at risk. All residents were to move because 1) being a resident in long-term care is a risk, 2) pressure ulcers can develop in any resident who cannot or does not move enough to redistribute pressure, and 3) even minimal movement is beneficial to health. This intervention had a 45 percent protective effect for those individuals in the treatment facilities.

We quickly learned that long-term care is not just a clinical setting, it’s a social setting, and the effect of using musical cues every two hours to promote movement (including standing, walking, repositioning, or turning the resident as appropriate to his or her condition) transcended the purpose of pressure ulcer prevention.

Staff and residents—even, in their own way, those who were bedbound—often responded by dancing and singing. They were energized and excited. At some facilities, residents were involved in picking out songs. It boosted their quality of life, activated their memories, and improved the social aspect of long-term care.

We also saw how the occupational subculture of nursing in each facility played an important role in implementing the intervention, and that discovery led us to develop the Nursing Culture Assessment Tool, a psychometric instrument for evaluating domains of teamwork, behavior, expectations, satisfaction, commitment, and communication; we believe these domains reflect the occupational subculture of nursing.

Now I’m committed to improving the care outcomes of older adults in long-term care settings, particularly with respect to prevention and management of common yet seemingly intractable geriatric syndromes such as facility-acquired pressure ulcers. I’m refining the Nursing Culture Assessment Tool to specifically target the issue of pressure ulcers. And I’ve been selected by the international 2014 Pressure Ulcer Guideline Development Group as a member of the working groups for both older adults and repositioning/mobilization.

I’m in the right place at the right time, promoting quality and innovation in response to an important issue. To everything, turn, turn, turn, there is a season, turn, turn, turn…indeed.

Tags: Health Care Quality, Interdisciplinary Nursing Quality Research Initiative, National Nurses Week 2013, Nurses and Nursing, Nursing, Voices from the Field