Can you imagine what it feels like to have a pressure wound? They are undoubtedly painful, and that pain may vary depending on several factors and the person's perception of pain.
It may be sporadic and aggravated by movement, or continuous and unrelenting. Pressure can cause such significant damage to the nervous system that the person suffers neuropathic pain. People with pressure damage can see the pain exacerbated by the management of the damage—dressing changes are likely to be painful. Descriptions of the pain of pressure damage have used words such as ‘throbbing, sharp, gnawing, aching, tender, exhausting, miserable’ (Gorecki et al, 2011). What does pressure damage that inflicts those feelings in patients say about the care they have received? How should nurses feel when a patient develops pressure damage, particularly at grade 3 or 4? In her Notes on Nursing, Florence Nightingale wrote, ‘If a patient is cold, if a patient is feverish, if a patient is faint, if he is sick after taking food, if he has a bed-sore, it is generally the fault not of the disease, but of the nursing.’ Recognition of pressure damage precedes Florence Nightingale by several thousand years—pressure damage and treatment of it has been seen in Egyptian mummies.
In the NHS in England, 24 674 patients were reported to have developed a new pressure ulcer between April 2015 and March 2016. (NHS Improvement, 2018). Treating pressure damage costs the NHS more than £3.8 million every day. Pressure ulcers are largely preventable and the responsibility for that prevention work sits, predominantly, with the nursing team. That's an awful lot of care lapses. Are they inevitable? I would argue not. Birmingham St Mary's Hospice, for example, reported no attributable pressure damage at grade 3 or 4 during the year 2018/2019, although it had admitted 219 patients with pressure damage during the same period. If a hospice can avoid pressure damage, it is not unreasonable to suggest other services can too. Perhaps, as well as carrying out investigations when serious pressure damage occurs, nurses and leaders at all levels could improve their monitoring of how well pressure damage prevention is being delivered and drive improvements where there are lapses?
Prevention is far better than cure for most things and pressure damage is no exception. Identifying care shortfalls at an early stage and insisting that basic care is delivered well is in everybody's best interests. Nobody benefits from poor care delivery.
Good pressure damage prevention means:
I would encourage nurses, staff teams and leaders to reflect on how well they monitor pressure damage prevention, rather than how well they monitor the prevalence of pressure damage. When was the last time that anyone audited whether care plans for pressure prevention were being implemented fully? When was there a review of whether people were being assisted and encouraged to move regularly? What expert oversight of pressure damage prevention care planning is there; who writes care plans and signs them off What training have staff had in maintaining skin integrity and why it is so important? Have you ever considered why you have pressure damage and some services do not? If Florence Nightingale could see that pressure damage was usually avoidable, we should also consider it thus. If patients develop pressure ulcers, it is usually a real indicator that the care being provided falls below an acceptable level.