An immobilized bedridden patient is placed on a 2-hour turning and positioning program primarily to:

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

We don’t call them Pressure Injuries for nothing. Complex as they can be in both etiology and treatment, one element is common to all of them: Pressure. Turning and Repositioning is the linchpin to any and all effective pressure injury prevention programs. But as important as it is, there are many common misconceptions about Turning and Repositioning that have become entrenched in healthcare. These misconceptions 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.

As a wound care and bedside nurse, I have studied Turning and Repositioning of the bedbound patient exhaustively. From patient’s body mechanics to the nursing process to equipment design and usage, I have come to understand that there are many aspects of Turning and Repositioning that are often overlooked or misunderstood.

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: We have to turn our patients every two hours

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 wasn’t 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”. With a lack of anything better to go on, Dr. Guttman’s speculation has been absorbed into the very fabric of pressure injury prevention protocol ever since. We will not wash this imprint out until we can answer the question better with concrete facts. The most important of those facts is pressure reduction itself.

Why this myth is so problematic for facilities is not just because it is not true, but because it is a trap for everyone. It is misguided, impractical, and basically unsustainable. When it makes it all the way to judge and jury it becomes a self-defeating deception, forcing facilities into the snare of trying to prove that their staff was compliant with an overreaching protocol they never should have committed to in the first place, and that is next to impossible to prove. When we commit ourselves to a practice based on falsehoods instead of best evidence, we lock ourselves onto a dead-end path of unrealistic expectations, unattainable goals, and confounding complications. And ultimately, failure.

I think the greatest price we pay for this myth is when we send our patients and the loved ones that care for him/her at home with this myth. We are telling them to keep up an unnecessary and physically impossible pace, we don’t teach him/her exactly how to do it, nor do we provide effective support equipment or even any information about effective equipment. Then when they are unsuccessful, they are left with a pressure injury and guilt. It is no wonder that community-acquired pressure injury rates are growing so rapidly.

There are several reasons why Turning every two hour turning is impractical and unsustainable. First of all, a set time schedule / frequency does not fit in to the nursing process. Next, like most other aspects of healthcare, Turning and Repositioning is not a “one-intervention-fits-all” activity. Lastly, there are as many con’s to turning this often as there are pro’s. At some point we have to ask ourselves if we are just working harder instead of working smarter?

Myth # 2: Turning all patients every two hours is the best way to go

I agree with Margaret Heale (link) What it takes to prevent pressure injuries is a commitment of all the staff to all the core elements of pressure injury prevention. Set turning schedules fail not because of lack of commitment or priority, but because setting the nursing schedule to perform the patient intervention is the opposite of how the nurses care for their patients. We have to set the intervention then work it in to patient’s schedule. We are treating the whole patient, not just the hole in the patient, so it is the patient’s schedule that drives our interventions. About the only thing in nursing that can be formally scheduled is meds and meals, and even those are highly variable and dependent on everything else. Caregivers may have a process, a system, a method. But virtually everything we do in the course of our day is based on the patient need by priority. Try telling a nurse who is working to resolve her patient’s hypoglycemic event that it is time to turn someone 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 easily be incorporated into the nursing routines; When transferring from gurney to bed, bed to chair etc, during physical therapy or other mobility, during peri-care/toileting, after med passes, meals, and other nursing care activities are common to all patients. Everyone caring for patients should be expected to inspect the skin at every opportunity and report any abnormal findings to advance to a formal diagnosis. The more eyes the better. By establishing expectations around the overall patient care rather than the clock, preventative measures will be consistent and reliable. I also suggest discussing specific pressure injury cases in a short case study format (especially hospital acquired pressure injuries) during nurse to nurse shift report and nurse station huddles to raise awareness and priority.

All that stuff about every 2 hours being unsustainable being said, there are many facilities that have gone to great expense to make sure all at risk patients are turned every two hours. The price is astronomical once you add up the direct and indirect costs. Perhaps the most relavent cost is that strict 2 hour turning schedules are not good care for the patient overall. Its like pain management. Just because 4mg of morphine every 2 hours stops the pain does not mean you should give it to them every 4 hours. The constant disruption in sleep will compromise recovery times, may cause pain, there is an increased risk of patient handling related injuries and it can interrupt essential attached medical treatments or equipment. Another variable that is less related to good patient care and more related to dollars is the patient satisfaction. We are between a rock and a hard place because this myth leads some to become dissatisfied and even report “missed turns” , and those who are dissatisfied that we did turn them every two hours.
Another indirect cost is caregiver labor. In ergonomic terms, doing the same thing over and over again is called repetitive motion. Add up excessive weight burden and twisting, and you have repetitive motion injury. Turning and repositioning is a significant contributor to caregiver lift injury. And the healthcare industry already has the highest work related injury rates in the country. Caregiver lift injury is a significant consideration both in terms of workers compensation claims and in an era of severe nursing shortages.

Myth #3. Turning Q2h prevents pressure injuries.

No other myth about pressure injury prevention is more half true than this one. Its not that turning every two hours doesn’t work to reduce pressure injuries. The true part is that turning does work. Not turning leads pressure injuries. The untrue half is that turning every two hours works because we are doing every two hours. But time is not why it works. It works because we are removing pressure. The paradox is, if we don’t do it right, we have to do it often.

A recent finding from study done by Stanford University Medical Center provides a glimpse into the reason turning frequency study results are so different.15 Although they did not directly measure sacral pressures, this study found that patients turned to near 30 degree’s lateral angle remained in that position for an average of only 15 minutes. With the loss of that angle comes a return to pressure onto the sacrum/coccyx. What this means is that even with the most aggressive turning frequency schedules, the patient’s bony prominences may still be under pressure for a majority of the time. When you are only keeping the pressure off for 15 minutes, you have to increase the number of times the patient is turned.
Thus, all QI programs that implement 2 hour frequency schedules will have positive results not because they did the turn more often, but because the pressure is removed. When we don’t know how much or for how long the pressure is reduced, we have no choice but to lock on to the 2 hour frequency.
On the other hand, research studies designed solely for the purpose of discovering what is the optimal turning frequency to prevent pressure injuries have had varying results. We still have no clear evidence that turning every 2 hours prevents more pressure injuries better than say, turning every 3 hours or 4 hours. One limitation of most of these studies is that there is not standardization of the turned position itself in terms of adequacy of pressure reduction over time, and the lack of hard data of the pressure exerted to the sacrum/coccyx area. What we do know is that there is high variability in both how “well” a person is turned and how long they remain in that turned and offloaded position. The support device, the patient’s condition, bed movement and patient shifting all have a significant effect on those two variables
The time to turn a person is when there is too much pressure on the sacrum/coccyx. Instead of knowing how frequently we should turn a person, we need to know how much pressure is on the sacrum/coccyx. We will not be able to answer to the turning frequency question until we standardize what constitutes an ‘effective turn’ in terms of the level of pressure reduction and the duration of pressure reduction. I am trying to address these questions in my research (link to protocol) and improved support device configurations (link to The Bedsore Rescue Cushion®).

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 comorbidities that put a person at risk for 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. The patient is first high risk for some reason(s), then pressure reduction was complicated for one reason or another. A short list of possible problems include the patient was not turned enough, or he/she was difficult to turn, too unstable to turn, refused to be turned, etc. 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.

Some corners of healthcare may discuss how to turn and reposition in some detail, but for the most part most caregiver education about turning and repositioning is very limited to a few sentences about turning 30 degrees lateral angles, floating and liftings not sliding. It is as though the principles of physical therapy, physiology, ergonomics and biomechanics come to a screeching halt at the bedrails like there’s a giant “Stop” sign there.
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 hurting yourself or you patient takes practice, experience, skill and good equipment. Take for example a morbidly obese patient, or patient with an unstable spinal cord injury, or a patient in respiratory failure to name a few.
If we are going to get better and preventing pressure injuries, we have to get smarter about turning and repositioning. That means studying and understanding how to best position a person based on their own individual circumstances. 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 not only is the pressure is removed and the patient is stable and comfortable, but so that circulation and microclimate are optimized. Then let be sure to use quality support equipment and stop pretending that pillows will do. We spend billions of dollars each year treating pressure injuries so that we don’t have to spend thousands preventing them. There really only a few configurations that are actually designed to accommodate the ergonomic and musculoskeletal needs of the turned position, so the decision is less complicated than one might think.

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”

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

Which nursing action should be implemented when assisting a patient to move from a bed to a wheelchair?

Which is a systemic adaptation to immobility?

How do you manage immobility?