4 Myths about Turning and Repositioning for Pressure Ulcer Prevention

Beware of the half-truth.

You may have gotten hold of the wrong half

Turning and Repositioning is the linchpin to any and all effective pressure injury prevention programs. There can be no argument that this intervention, when done properly, can be the reason a pressure injury is prevented.

As a bedside nurse, a woundcare nurse, an educator, a HAPI prevention quality improvement nurse, and most importantly, as a positioning product innovator, I have had the advantage of studying turning and repositioning from every angle (if you'll excuse the pun).

I have come to understand there are many, many common misconceptions about Turning and Repositioning that have become entrenched in healthcare. These misconceptions can and do encumber our ability to sustain effective prevention policies and programs for pressure injury prevention. A more clear understanding of this critical intervention can have a profound influence to the success of any facility's 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 preconceived notions box to think about how we may better approach this most important nursing intervention:

Myth # 1: Turning every two hours is required

The “must turn q2h” is perhaps the most pervasive and misunderstood myth in all of the pressure injury prevention history. The paradigm came originally from our hero Florence Nightingale. 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 was not for another 100 years 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”. Dr. Guttman’s speculation has been absorbed into the very fabric of pressure injury prevention protocol ever since.

To be clear, there is no official regulation or mandate that says at risk patients must be turned every two hours. The only mandate is the expectation that facilities provide appropriate basic nursing care to prevent pressure injuries.

Frequent Turning and Repositioning is in fact THE MOST most important intervention to prevent pressure injuries. But even the National Pressure Injury Advisory Panel (NPIAP) does not recommend the Q2h frequency across the board. Why? Because its not that simple.

Every patient is different. As nice as it would be to have a standard treatment that is right for every single patient, in healthcare there is no such thing. In many situations, turning a person every two hours is not only wrong for that patient, it can boarder on being an absurd thing to do.

We are mandated to provide turning and repositioning properly. That is, take care of our patients so that they are mobilized frequently, they do not have excessive pressure beyond what their body/skin and underlying tissues can tolerate, their skin is kept clean and dry, and that they can get appropriate rest. For a few very sick patients, this means turning every 2 hours. But for most, this means "as needed", or PRN for pressure relief, cleaning and muscle skeletal alignment and comfort.

Between the complexity, the shear magnitude of workload, time constraints, staffing shortages, equipment and supply utilization failures and quite frankly, normalized chaos in most healthcare settings, the problem to solve is not how to get everyone turned every 2 hours. The problem to solve is how to assure patients are getting appropriate turning and repositioning care.

Myth # 2: Turning Q2h prevents pressure injuries.

No myth about turning and repositioning is more confusing than the "it works" myth. It is perhaps the greatest half truth of all myth's in healthcare.

The reason the Q2h frequency sticks is literally because we don't know any better. Despite numerous and very credible studies that directly and indirectly try to determine the optimal turn frequency that will best assure pressure injury prevention, results are inconclusive.

There is a very good reason we do not have a definitive answer to this question. It's because we are measuring the wrong things.

Or better said, we are not measuring the right things. There will never be a known most effective time between turns because although time is relevant, it is not the most pertinent factor associated with pressure injury development.

The pathophysiology of pressure injury development highly complex and patient specific. Measuring turning every patient every 2 hours to see how many patients got a bedsore is a bit like providing every patient 2 milligrams of morphine every 2 hours to see how many patients got pain relief. Correlation does not always mean causation.

We cannot know the optimal time between turns without first considering the plethora of other related factors that lead to pressure injuries and the effectiveness of preventative care necessary to mitigate those factors. The purpose, and the reason turning and repositioning works is mostly because it relieves pressure and restores perfusion to skin and underlying tissues. The most important of those factors is pressure relief itself. Although there are a few ways to measure pressure relief achieved in the turned position, especially the duration of the of the pressure relief, the goal of pressure relief is rarely the focus. Rather, the focus is turning every Q2h.

One thing is for sure. If you don't do it right, you have to do it often.

We need to be less concerned with time between turns and more concerned with doing it right.

Myth #3 Caregivers are taught how to turn and reposition

I believe the most pervasive issue about turning and repositioning is that most caregivers are expected to turn and reposition but are not held accountable for it. If there is any accountability at all, it is only for how frequently turning is done.

One day I decided to informally survey nurses and nurses aids tasked with turning and repositioning to see if they understood the propose of turning and repositioning.

It may sound like a cynical question in an acute care environment. But that was not my intention. It occurred to me after having several caregivers tell me in all honesty that she is turned, while we were both looking at a patient who was laying fully on her back with maybe one or two pillows flat as a pancake under a shoulder blade or behind and their bare heels firmly pushing against the mattress.

The answer I almost always got was "The purpose of Turning and Repositioning is to prevent pressure injuries". When I probed further "Why does turning and repositioning prevent pressure injuries?" the answer was more often than not something along the lines of "Because I am moving the patient"

Very few connected the dots between turning and repositioning and pressure relief. Even fewer understood that there is a such thing as being turned and repositioning incorrectly.

It's no wonder this is a problem. There are few guidelines for correct positioning of the bedbound patient, and even fewer that discuss how to assess for pressure or how to assess for correct 30 degree angle.

Virtually no educational literature adequately reviews how to safely support a bed bound patient to redistribute pressure away from vulnerable tissues. There is almost no education and training about how to support a patient to maintain adequate pressure relief, perfusion and comfort for the duration between turns.

Almost no caregivers understand that pillows usually fail to sustain a patient in a pressure relieved position. This misunderstanding is perpetuated in educational literature, which almost always instructions to "support with pillows and wedges", implying that either or will do.

Myth #4. Turning is easy

This myth gets under my skin more than any other (if you’ll excuse the pun!) There are many variables and co-morbidities that put a person at risk for pressure injury, but peel back the onion layers of any preventable pressure injury incident and somewhere in there you will always find complications with the turning and repositioning.

Or as I like to say "It is the patients who are difficult to clean, turn, reposition, support that get the pressure injuries"

Above and beyond the obvious "complication" that turning and repositioning simply was not done ("difficult" can mean a caregiver could not or did not get to the bedside to take of the patient) There are almost an infinite number of possible combinations of complications that may arise with turning a patient and/or supporting a pressure relieved position.

He/she may be what we call a "heavy turn", referring not only to physical weight, but other issues. For example, a patient may push back against the turn, or be combative. He/she may not be able to tolerate being on his/her side, or there are conditions that anatomical or illness/disease related conditions that confound the turning and repositioning. The patient may be perceived as too unstable to turn, refused to be turned, have multiple devices and equipment that may get in the way. The list goes on. There are so many reasons why turning can be difficult it makes my head spin but suffice to say is a simple concept that is not always easy to do.

"Heavy" turning and repositioning can delay or even undermine the process. It often requires 2 or more caregivers to accomplish. It can be dangerous, and lift injuries to caregivers and patient handling issues are common. Even with 2 people, turning can take as long as 30 minutes and often has to be repeated more frequently than each 2 hour.

Turning is a science, a therapy, and a medical intervention. It is critically important not just for pressure injury prevention, but also serves many physiologic functions. Doing it right without caregiver injury or patient injury takes education, training, practice, skill and good equipment.

Some corners of healthcare may discuss how to turn and reposition in some detail. But caregivers are rarely taught how to manage complications to turning and repositioning. For the most part most caregiver education about turning and repositioning is basic and assumes the patient is "turnable". The principles of physical therapy, physiology, ergonomics and biomechanics and equipment and supplies utilization are rarely discussed.

If we are going to get better and preventing pressure injuries, we have to work smarter, not harder about turning and repositioning. That means establishing clear best practice principles for all aspects of turning, repositioning and support. The focus should be on techniques to minimize stress and maximize musculoskeletal alignment and distributed support so that pressure is removed patient is stable and comfortable, and circulation and microclimate are optimized. It is import to discuss equipment supplies use, especially surfaces, support devices and incontinence management supplies in terms of quality, effective use and utilization.

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 and technology, I believe we can stop pressure injuries. As Dr. Joyce Black says “The trick is to get the pressure off”

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