5 Myths about Turning And Repositioning

And how these myths affect HAPI rates, costs, and outcomes

By Gwen Jewell, Clinical Nurse II, BSN, CWS Wound Care Pressure Injury Prevention

Keywords: Pressure Injury, Pressure Injury Prevention, Turning and Repositioning, 30 Degree Lateral turn, Pressure Injury Incidence, Pressure Injury Prevalence, Pressure Ulcers

“Beware of the half truth. You may have gotten hold of the wrong half “

- Anonymous

They are called Pressure Injuries for a reason. Complex as the etiology and treatment of pressure injuries are, one thing is common to all pressure injuries: Too much pressure for too long.

Turning and repositioning have been the go-to solution to relieve pressure for as long as pressure injuries have been around.

As time-honored and respected as turning and repositioning is, it’s a wonder there is still so much confusion about it. Everybody believes in it, but no one really thinks about exactly what they believe. And when it comes to reality, the line between the truth and the myths is more blurry than a windshield with an oil spill on it.

As a wound care and acute care bedside nurse, I have studied the turning and repositioning of the bedbound patient exhaustively. From patient’s body mechanics to the nursing process to equipment design and use.  I have empirically learned that there are many very important aspects of turning and repositioning that are often overlooked or misunderstood.

Many common misconceptions about turning and repositioning have become entrenched in healthcare. Not only can these misconceptions lead to a failure to achieve our most important goal of preventing Hospital-Acquired, Facility Acquired and Community-Acquired Pressure Injuries, but these myths can and do encumber our ability to sustain effective prevention policies and programs.

A clearer understanding of this critical intervention can profoundly improve the success of a facilities pressure injury prevention efforts.

The reader might identify and agree with my assessments, or maybe feel a little provoked to dispute my assertions. Either way, I hope this commentary will challenge all who share similar aspirations to stop pressure injuries to pause, reflect and step out of the proverbial “paradigm rules” box to think about how we may better approach this most important nursing intervention:

Myth # 1. Turning and repositioning prevents pressure injuries

It’s not so much a myth as it is myth-leading.

I like to say if we could float a patient in an antigravity chamber, he/she would never get a pressure injury (with one exception: Total skin organ failure!)

The principle is: No pressure. No pressure injury.

As such, turning and repositioning is such a no-brainer that all healthcare facilities mandate turning protocols as a part of daily nursing care. Since the days of Florence Nightingale, turning has been SOP. Tried and true, one of nursing’s oldest functions.

The first mistaken assumption I see most people make, including advanced care clinicians, is believing that the act of turning and repositioning itself is enough to prevent pressure injuries. Rarely is the quality of the pressure relief and the duration of pressure relief considered.

I got into this business because I could see with my own eyes that supporting a person with simple pillows was not achieving sustained pressure relief. And that the wedges we were supposed to use instead did not sustain the patient in a pressure-relieved position either. (for a variety of reasons outside the scope of this blog).

Although many have sought to prove or disprove the efficacy of turning in repositioning, there is a dearth of studies that seek to determine the quality of pressure relief achieved during turning and repositioning. How can we know if it works if we don’t know if the reason we are doing it is accomplished?

Turning and repositioning do not prevent pressure injuries if they are done incorrectly. Too much pressure for too long= = Pressure Injury.

The second myth-leading assumption I see clinicians make is to discuss turning and repositioning separately from all the other things a caregiver has to do to prevent pressure injuries. The assumption is that T&P is happening in isolation from the other required caregiver interventions, especially continence care.

Unless the other elements of pressure injury prevention care are addressed, even when the best possible pressure relief is achieved with the T&P, it will be no competition against a soiled diaper, no skin protection, friction and shear, dehydration, malnutrition, and poor skin integrity (to name a few). In my “float in antigravity” concept, the person would have to be floating without a diaper on and still eating and drinking their fluids!

The good news is, that nary a caregiver in the world fails to recognize that they can and should do most of the essential preventative care during the turning and repositioning intervention.

So yes, turning and repositioning do prevent pressure injuries. But only if it is done correctly. And as long as everything else is done correctly too.

Myth # 2: The rule is: Turning and Reposition must be done every two hours:

The “must turn q2h” is perhaps the most pervasive and misunderstood myth in all of pressure injury prevention history. I think the Q2h paradigm is the big half truth that locks up everything.

First and foremost. I agree that if we don’t do it right, we have to do it more often. But doing something more often because it's not done right is not a solution. It is insanity.

The 2 hour timeline goes way back. It was Florence Nightingale that started it. Florence determined the 2-hour turn frequency time interval not because she had evidence or even collected data about it, but because it took her about 2 hours to round on her patients.

It wasn’t for another 80 years or so before it came up again. In the early 1950s when the famous neurologist Dr. Ludwig Guttman suggested this same interval for spinal cord injured patients. Again, he did not base his suggestion on any known information, but rather more as a proclamation: “In my opinion, we should turn everybody at least every 2 hours.”

The Q2h paradigm is not so much a myth as it is a paradox. It could be true, but it could also not be true. If everyone was turned every two hours, and if they were supported correctly in that turned position so there was no pressure on their bony prominences, and if the patient remained in that correct pressure relieved position for the entire 2 hours, maybe they would not get a pressure injury. But maybe they would anyway because he/she was not kept clean and dry for example.  Or if they were severely malnourished. But maybe if they were turned every 4 hours, correctly, they would not get a pressure injury. But maybe they would get one anyway because they have end-stage renal disease and diabetes. And so on, and so forth.

The truth is, to date there is still no study out there that has come up with conclusive data that turning every two hours works best. We still don’t know what the optimal frequency of turning and repositioning should be.

The idea that there is one certain time period that applies to all patients and all circumstances is unprofessional. We cannot make broad sweeping assumptions what is best for every patient because every patient is different, every circumstance is different. The National Pressure Injury Panel said it. You have to adjust the turning frequency according to the patients risk and needs. The first being sustained pressure relief, followed by all the other preventative measures.

Hence the reason for frequent skin checks. So we can see if we need to step up the T&P and other interventions, or if we can let the him/her sleep because the patient skin remains pristine.

What we need to do is standardize the way our caregivers measure risk, perform interventions and assess the results of their efforts. In other words, we have to teach our caregivers how to do it right.

Myth # 3: We mandated that every patient must be turn and reposition every 2 hours and our charting prove’s it’s being done.

“You cannot solve a problem with the same consciousness that created it.”

- Albert Einstein

No myth gets under my craw more than this one. Most facilities that make this claim do not have the math to back it up. Making nurses turn every patient every 2 hours to prevent HAPI’s is a bit like saying everybody has to get morphine every 2 hours to prevent pain. It's the “baby out with the bath water” policy.

When we commit ourselves to a practice based on a falsehood instead of best evidence and reality, we lock ourselves onto a dead-end path of unrealistic expectations, unattainable goals and confounding complications. And ultimately, failure.

The assumption is telling your caregivers to “just do it because it is your job” is enough to get them to do it, and enough to stop pressure injuries. I’m not going to be very popular for calling it out, but if you don’t invest turn q2h turning and repositioning, what you will end up with really great charting of q2h turns while trying to explain why the patient got a pressure injury anyway.

Turning and reposition is not as easy and quick as it’s cracked up to be.

T&P takes at least 10 minutes and usually 2 caregivers. And that’s when things go well. I find in my experience that patients that are difficult to turn are the ones that get the pressure injuries. It can take 2 to 4 caregivers over a half hour to accomplish turning & repositioning and peri-care.

All this means that turning and repositioning is very expensive. Unless facilities are able to financially support adequate staffing, where 2 caregivers can devote 10 to 30 minutes to each patient and manage the organization of the many many other competing priorities required of caregivers, and stock and organize adequate equipment and supplies (especially support and lift equipment) for the job, it is unrealistic to believe that all patients can be turned anywhere near this often. And, lets not forget, not all patients need to be turned that often.

Perhaps the greatest crime of perpetuating this myth is when we send our patients and the loved ones who will be caring for him/her home with these instructions. We are telling them to keep up with a physically demanding and unnecessary pace, day and night. We don’t teach him/her exactly how to do it, and 98% of the time we literally tell them to just “use pillows or wedges” to support the person. Despite the fact that we have not honestly followed our own recommendations. Then when that poor family member is unsuccessful and exhausted, and so is the patient, a pressure injury, guilt and more problems ensue.

We can either perpetually bang our caregivers’ heads (and backs) against the 2 hour turn clock and pray for better results. Or we can incorporate pressure injury prevention care into the fabric of the nurses and aids daily practice as a PRN responsibility.

Every nurse and aids are better informed about how to protect than skin than they are about how to chart it. Then we need to facilitate turning and repositioning and the appropriate equipment and supplies use so that all caregivers can provide purposeful and effective turning and repositioning on a rational and sustainable schedule.  Then we can expect low incidence.

Myth # 4 – All we have to do is devise a way to remind the caregiver when 2 hours has passed and it will be done

“What it takes to prevent pressure injuries is a commitment of all the staff to all the core elements of pressure injury prevention”

- Margaret Heale (link).

Set Q2h turning schedules may work well for some time, but after some time, most will eventually slip back into old habits. Most fail not because of lack of commitment or priority, but because setting the nursing/ caregiver schedule to perform the patient intervention at a certain time is the opposite of how the nurses/caregivers care for patients. We are treating the whole patient, not just the hole in the patient. So it is the patient’s needs and priority that drive our interventions, not the clock.

About the only thing in nursing that can be on a set schedule is meds and meals, and even those are highly variable and dependent on what is going on with each patient. Caregivers may have a process, a system, and a method, but virtually everything we do in the course of our day is based on priority. Try telling a nurse who is working to resolve her patient’s hypoglycemic event that it is time to turn her patient and you will see exactly what I mean.

The good news is, it is not a big leap to have staff work smarter. Absolutely all of the core elements of prevention and treatment can be incorporated into patient handling routines; Transferring from gurney to bed, bed to chair etc, during physical therapy or other mobility, during peri-care/toileting, after med passes, meals, etc. All are essentially turning and repositioning-associated activities.

Everyone and anyone providing directcare for patients can be expected to inspect the skin at the obvious opportunities, and around their other established routines like meals and med passes. By establishing expectations around the overall patient care rather than the clock, preventative measures will be consistent and reliable.

And on those days where it seems like there’s not even enough time to go to the bathroom and you cannot possibly do it all, we have to be willing to endorse caregivers to turn before they type. Charting comes last.

Myth #5. Turning and Repositioning is simple and easy. 

The art of Turning and Repositioning continues to go unrecognized in healthcare. Which really blows my mind considering its been done since at least Florence’s day.

There are many variables and comorbidities that lead to a pressure injury. But peel back the onion layers of any pressure injury incident and somewhere in there you will always find the problem of pressure itself. More specifically, the problem was removing the pressure.  

Another thing I always say (I got a million of sayings up my sleeve) is pressure injury is not the problem. It is the result of the problem. The problem is getting the pressure off. It’s the difficult turns that get the pressure injuries. (I already said that, I know)

A short list of potential complications to turning and repositioning includes, but is not limited to, the patient being physically very heavy, the patient refusing to turn or pushing away, resisting to be turned due to fear, pain, dementia, discomfort or whatever. Too unstable to be turned, restless shifting off the turned position, body anatomy or held position is such that supporting a side turn is difficult.

The list goes on and on. There are so many reasons why turning can be difficult that it makes my head spin. But suffice to say only the concept of T&P is simple. The execution can be hell.

Some corners of healthcare may discuss how to turn and reposition in some detail I suppose. But I find that for the most part most caregivers entire formal education and training about turning and repositioning is limited to one example on a healthy person that is able to turn on his/her own, followed by a few sentences about turning 30 degrees lateral angles, floating and lifting without sliding and the most brief discussion about folding pillows or cramming a wedge under there. About all the complications? Nada.

It is as though the principals of physical therapy, physiology, ergonomics and biomechanics are sent to the classroom down the hall where supply chain room people are sitting. Even physical therapy education rarely go over turning and repositioning the bedbound patient.

Turning is a science, a therapy, and a complex medical intervention. It is critically important not just for pressure injury prevention, but also serves many physiologic functions. Doing it right without the caregiver or patient injury (including pressure injury) takes practice, experience, skill and good equipment.  If we are going to get better at preventing pressure injuries, we have to get smarter about turning and repositioning. We can do this by studying and understanding the science of turning and repositioning. Hellooo.

Caregiver training should include safe patient handling and ergonomic safety for both the patient and the caregiver. The focus should be on techniques to minimize stress and maximize musculoskeletal alignment and distributed support so that patient is stable and comfortable, and pressure reduction and circulation and microclimate are optimized.

Most importantly, we need to stop pretending that we don’t need equipment designed for the purpose. Our pressure injury rates continue to rise to crazy high levels. I say (here we go again) pressure injuries are like cockroaches. For every one that gets reported, there are 10 that went unreported. Gross.

So I think it’s fair to say that we have to stop pretending that pillows can do the job. We spend billions of dollars each year treating pressure injuries and paying caregivers to turn and reposition over and over again so that we don’t have to spend thousands on good pressure injury prevention support equipment. This is sick care, not health care.

Looking forward

Myths about turning may be ubiquitous, but they do not have be limiting. We have come a long way in the science of pressure injury prevention. Once we are able to integrate the nursing process with science, technology and reality, I believe we can stop pressure injuries. As Dr. Joyce Black says, “The trick is to get the pressure off.”

REFERENCES

1. Bergstrom N., Horn S.D., Rapp M.P., Stern A., Barrett R., Watkiss M. Turning for Ulcer Reduction (TURN): A multisite randomized clinical trial in nursing homes. J Am Geriatr Soc. 2013 Oct: 61(10) 1705-13

2. Borgueta, E.M. Musafar, A. Elk, K.R, Fay, M. S.T.O.P (Synchronized Turning of Patients) Reduction of Hospital Acquired Pressure Injury in the Intensive Care Unit. CCRN Annual Conference 2018 Poster Presentation.

3. Brindle C.T., Creehan S., Black, J. Zimmerman D. The VCU Pressure Ulcer Summit: Collaboration to Operationalize Hospital-Acquired Pressure Ulcer Prevention Best Practice Recommendations. Journal of Wound, Ostomy & Continence Nursing: July/ August 2015; 42(4) 331-37

4. Bush T.R., Leitkam S., Aurino M., Cooper A., Basson M.D. A Comparison of Pressure Mapping Between Two Pressure-Reducing Methods for the Sacral Region. Journal of Wound, Ostomy and Continence Nursing 2015;42(4):338-345

5. Buss I., Halfens R., Abu-Saad H. The Most Effective Time Interval For Repositioning Subjects At Risk of Pressure Sore Development. Rehabilitation Nursing 2002;27(2):59-66

6. Defloor T., De Bacquer D., Grypdonck M.H. The Effect of Various Combinations of Turning and Pressure Reducing Devices on the Incidence of Pressure Ulcers. Int J Nurs Study; 2005;42(1):37-46

7. Gillespie B.M, Chaboyer W.P, McInnes E., Kent B., Whitty J.A., Thalib L. Repositioning for pressure ulcer prevention in adults. Cochrane Database of Systematic Reviews 2014, Issue

8. Art. No.: CD009958 8. Heale, M. Repositioning and Pressure Injury Prevention: The Devil is in the Detail. WoundSource; 2018; https://www.woundsource.com

9. Krapfl L.A., Gray M. Does Regular Repositioning Prevent Pressure Ulcers?. Journal of Wound, Ostomy and Continence Nursing 2008;35(6):571-7

10. Kennerly, S, Yap, T The Role of Manual Patient Turning in Prevention Hospital Acquired Conditions. A white paper for Leaf Healthcare, www.leafhealthcare.com 2016

11. Meehan M. National Pressure Ulcer Prevalence Survey. Adv Wound Care 1994; 7:27-37

12. National Pressure Ulcer Advisory Panel & European Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcers, Clinical Practice Guidelines. NPUAP & EPIAP. Washington, 2009

13. Nixon J., Nelson E.A., Cranny G., Iglesias C.P., Hawkins K., Cullum N.A. et al. Pressure Relieving Support Surfaces: A Randomized Evaluation. Health Technology Assessment 2006; 10(22): 1-180

14. Peterson M.J., Schwab W., van Oosrom J.H., Gravenstein N., Caruso L.J. Effects of Turning On Skin-Bed Interface Pressures in Healthy Adults. J Adv Nurs. 2010 Jul;66(7):1556-64

15. Pickham, D., Berte, N. Pihulic, M. Valdez, A. Mayer, B. Desai, M. Effect of a Wearable Patient Sensor On Care Delivery For Preventing Pressure Injuries in Acutely Ill adults: A pragmatic randomized clinical trial (LS-HAPI study). Intl Journal of Nursing Studies 80 (2018) 12-19.

16. Powers J. Two Methods for Turning and Positioning and the Effect on Pressure Ulcer Development. J Wound Ostomy Continence Nurs. 2016;43(1):46-5

17. Reddy M., Gill S., Rochon P. Preventing Pressure Ulcers: A Systematic Review. JAMA 2006; 296(8): 974-84

18. Shardell, M. et al. Frequent manual repositioning and incidence of pressure ulcers among bedbound elderly hip fracture patients Wound Repair Regen. 2011 January ; 19(1): 10–18.

19. Thomas, D. R. Prevention and Treatment of Pressure Ulcers, J Am Med Dire Assoc 2006; 7: 46-59

20. Vanderwee K., Grypdonck M., Defloor T. Effectiveness of an Alternating Pressure Air Mattress for the Prevention of Pressure Ulcers. Age and Aging 2005; 34: 261-7

21. Wong V., Skin Blood Flow Response To 2-hour Repositioning in Long-Term Care Residents. A pilot study. J Wound Ostomy Continence Nurs. 2011;38(5):529-537

22. Yap, T.L, Cox, J.Turning and Repositioning Science and Implementation. 2018 National Pressure Ulcer Advisory Panel Conference Lecture Presentation.

23. Lavine, J. New Research Challenges “Q2H” Turning Standard for Pressure Injury Prevention. 2013, http://jmlevinemd.com/new-research-challenges-q2h-turning-standard-forpressure-ulcer-prevention/

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