1. Succesful implementation of a multi- modal pressure ulcer prevention program in nursing homes Eva, Nuria, Luk, Theo, Cecile, Niina, Vivi, Antoinette

2. Rationale Pressure ulcers  Pressure ulcer prevalence in nursing homes (8.8%- 29.2%) in Europe (Demarre et al. 2011)  Treatment costs ($10000-$86000 (median: $27000) per pressure ulcer (Clarke et al. 2005); 1.4 billion – 2.1 billion pounds in UK (Bennet et al. 2004)  Increases nursing time by 50% (Clarke et al. 2005)  Pressure ulcer reduce quality of life in patients: pain, depression, anxiety, immobilization, reduced social participation (Goreckie et al. 2009)  Compliance with evidence-based guidelines is low (e.g. 41% in Saliba et al. 2003 )

3. Rationale Nursing homes  Vulnerability in residents is high, resulting from reduced activity or mobility limitations, increased age.  Nursing homes have a higher proportion of lower level educated care providers (Demarre et al. 2011).  Nursing homes lack pressure ulcer prevention strategies more often compared to hospitals (Kwong et al. 2011).

4. Objectives  Design and facilitate implementation of practice- based evidence changes associated with decreases in pressure ulcer development and impact on staff competencies and skills in nursing homes  Evaluation of the effectiveness of the implementation strategy.

5. Study design  Pragmatic cluster randomised-controlled trial (Zwarenstein et al., 2009)  Convenience sample of 3 nursing homes  4 wards per nursing home of which 2 wards randomised to control and 2 to intervention Preceded by pilot-study

6. Improvement strategy multi-modal implementation strategy  1 day focused training courses for nurses  Feedback to the wards through ward manager, and the discussion of action plan with nursing team (active participation element) baseline and 1 month, supporting the leadership in the change process (external facilitator available)  2-3 role models ”champion” per ward (selected with specific criterias, volontary) as social influencing factor

7. Measurements  Pressure ulcer prevalence surveys (Van derwee et al. 2007)  Observation of pressure ulcer prevalence  Observation of materials in residents rooms  Check patient documentation for risk assessment  Check patient documentation for prevention interventions  Nurses openness to redesign (survey).  Knowledge and skills before and after the training (Beeckman et al. 2011).

8. Evaluation Effect evaluation: Pressure ulcer prevalence, proportion of risk assessement and interventions (baseline, 1 month, 3 month), teamwork, knowledge and skills increase, milestones achieved (level) Process evaluation: how many nurses attended the training? Did problems arise? Did barriers by the PARIHS Framework (Rycroft-Malone 2004) occur, interview the providers (ward manager, nurses, patients) about evidence, context, facilitation? Assess team's openness to redesign Economic evaluation (cost-benefit): work time of nurses attending and educators versus total estimated cost of pressure ulcers (based on difference in prevalence)

9. 201420152016Total Staff (full-time PhD student) 60000 180000 Staff (40% post-doc)29000 87000 Personal computer3000-- Research stays and participation at conferences 4000 12000 Software license500 1500 General costs (photocopies, scientific literature, office equipment) 1000 3000 Open acces publishing 1500 4500 291000 Budget

10. Thank you! The European Academy of Nursing Science 10