key: cord-0739414-l5q52vog
authors: Mamom, Jinpitcha; Daovisan, Hanvedes
title: Telenursing: How do caregivers treat and prevent pressure injury in bedridden patients during the COVID-19 pandemic in Thailand? Using an embedded approach
date: 2022-03-16
journal: J Telemed Telecare
DOI: 10.1177/1357633x221078485
sha: c8e4e46901022d96579bb47b7f07dccbacab8376
doc_id: 739414
cord_uid: l5q52vog

OBJECTIVE: To evaluate telenursing for caregivers (CGs) to treat and prevent pressure injury (PI) in bedridden patients (BPs) during the COVID-19 pandemic in Thailand. METHODS: Purposive sampling of 70 CGs [intervention group (i-group): n = 35 and control group (c-group): n = 35)] using an embedded approach was conducted from August 2020 to February 2021. The QUAN data were concurrently collected via online semi-structured interviews (OSIs) and video in-depth interviews (VIIs), then analysed using multivariate analysis of variance and thematic analysis. RESULTS: The QUAN data showed that CGs treating and preventing PI in BPs has a significant and positive effect (p < 0.01). The qual data illustrates that telenursing for CGs treating and preventing PI in BPs is associated with training and education, skin cleaning, repositioning, monitoring, and assessment of PI during the COVID-19 pandemic. CONCLUSION AND IMPLICATIONS: Telenursing for CGs treating and preventing PI in BPs is valuable to the professional consultation during the COVID-19 pandemic. Telenursing can reduce the CG burden, instructing them how to visually examine, clean, monitor, and risk assess the skin of BPs to prevent PIs.

The coronavirus disease 2019 (COVID-19) pandemic is currently impacting the provision of healthcare in Thailand, hence there have been great advances in telenursing. Bedridden patients (BPs) are at risk of pressure injuries (PIs) and it is now possible for telenursing via phone apps, websites, video conferences, tracking devices, and medical records to help caregivers (CGs) prevent and treat BPs. 1, 2 Telenursing for CGs to prevent PI has changed in-person visits to takehome and hospital medication, 3 with telenursing quickly adapting to meet the needs of caring for BPs during the COVID-19 pandemic while adhering to "social distancing". 4, 5 BPs with PI are at a higher risk of morbidity due to the COVID-19 pandemic, arising from the difficulty of early diagnosis, delivery of healthcare, telecommunication, and in-person medication. Telenursing is appropriate for teaching CGs how to treat and prevent PI at home during the pandemic. 6 The evaluation of PI diagnosis can enhance sensor data stream, online decision-making, medical conditions, monitoring, and risk assessment in palliative care. 7, 8 A few studies focused on the methods that CGs can use to treat and prevent PI, 9, 10 monitoring and skin cleaning rather than supporting CGs caring for BPs. 11, 12 Due to the lack of published studies in telenursing, we aimed to evaluate telenursing for CGs to treat and prevent PI in BPs during the COVID-19 pandemic in Thailand. This study addressed the following research question:

To what extent does telenursing help CGs to treat and prevent PI in BPs during the COVID-19 pandemic in Thailand?

An embedded approach 13 was utilised to integrate the QUAN and qual data (see Figure 1 ), as triangulated to address different research questions regarding the same phenomenon, 14 ensuring the validity of the results.

The participants were primarily CGs caring for BPs at home via screening of electronic medical records from three sites, Ayutthaya, Angthong, and Pratumthani province, in central Thailand. To reduce COVID-19 impact, the data was collected online via videoconference. Thailand has experienced three waves of COVID-19 transmission in March 2020, December 2020, and February 2021. The data collection took place between August 2020 and February 2021 when COVID-19 restrictions and national lockdown were in place.

The inclusion criteria were CGs aged 60 years and above caring for immobilised elderly patients at risk of bedridden complications with chronic illness. The CGs caring for BPs with dementia, schizophrenia, manic-depressive disorder, and intellectual disability were excluded. The participants were assigned to two groups, the intervention group (i-group: n = 35) and control group (c-group: n = 35) and purposively selected to live in rural (n = 17) and urban (n = 18) settings. Online semi-structured interviews (OSIs) and video in-depth interviews (VIIs) were conducted from August 2020 to February 2021. VIIs lasted 40-50 min and were conducted online with CGs during the treatment and prevention of PI at home.

The OSIs were conducted online at the participant's home in Thai, then translated into English by the first author. To ensure validity, three professional nurses and Institutional Review Board (IRB) evaluated the OSIs. The OSIs collected information regarding participant demographics, treating PI and preventing PI during the COVID-19 pandemic, with the participants asked to rate answers on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree).

The quantitative measures of treating PI were: CGs training and education (CTE), formalising continuing education (FCE), stage of the injury (1-6) (SOI1-6), skin cleaning (SKC) and primary taking medication (PTM). The measures to prevent PI included repositioning (REP), elevating heels (ELH), support surface (SUS), skin protection (SKP), skincare assessment (SCA), protecting tissue prominences (PTP), PI risk and skin assessment (PIA), monitoring patient time (MPT), and nutrition assessment (NUA). 15 

The mean scores were computed to determine the overall rating of treating and preventing PI and the OSIs were descriptively analysed. The treatment × time was subjected to multivariate analysis of variance (analysis of variance), with treatment between i-group and c-group as pre-and post-test analysis.

All VIIs transcripts were analysed using thematic analysis (theme, category, coding, and quotation). 16 The three stages of preparing, organizing, and reporting the results to ensure trustworthiness, validity, transferability, and confirmability were analysed. 17 Data processes were iterative, that is, continuous data analysis with simultaneous fine-tuning while writing. To ensure trustworthiness, we prolonged engagement, triangulation, member check, thick descriptive, audit trial, and internal-external validity of findings.

The QUAN and qual data analyses were integrated to confirm factors affecting treating and preventing PI in BPs. The QUAN (qual) data was repeatedly compared to the meaning of the qual results with relevant quotes.

The CGs' demographics and BPs' characteristics are provided in Table 1 , showing that the CGs had an average age of 54.70 ± 5.16 years with no significant differences between the two groups. Table 2 presents the measures for treating and preventing PI in BPs and Table 3 is a comparison of the i-group and c-group.

The multivariate analysis showed a significant difference between i-group and c-group (Wilks's λ = 0.78, F(4, 35) = 3.19, p = .01, η 2 = 0.39). There was a positive effect time (Wilks's λ = 0.72, F(3, 34) = 4.12, p = .01, η 2 = 0.37) and effect time (i × c) (Wilks's λ = 0.81, F(4, 47) = 3.12, p = .01, η 2 = 0.31). The significant treatment effects on treating and preventing PI are presented in Table 4 .

VIIs were conducted to explore the CGs' overall views on how to treat and prevent PI in BPs, and their responses were classified according to two themes, fourteen subcategories and 30 codes. Representative CGs views are presented in Table 5 . 

The QUAN and qual data were integrated to further assess the ability of CGs to treat and prevent PI in BPs. The QUAN data revealed that telenursing for CGs to treat and prevent PI had a positive effect on their BPs (p < 0.01), whereas the qual data shows that telenursing helped CGs to learn treatment methods for preventing PI during the COVID-19 pandemic. Table 6 presents the integration of the QUAN and qual data.

Our embedded approach evaluated telenursing for CGs to treat and prevent PI in BPs during the COVID-19 pandemic. The QUAN data shows that telenursing for CGs to treat and prevent PI had a positive effect on BPs (p < 0.01). The qual data illustrates that telenursing for CGs to treat and prevent BPs is associated with training and education, skin cleaning, repositioning, monitoring, and assessment, enhancing the prevention of PI during the COVID-19 pandemic. These results differ from previous findings, as studies by Kordestani et al., 7 Somsiri et al. 10 and Newman et al. 11 indicate that training CGs to treat and prevent PI focused on the online translating stage of injury and self-adaptive treatment. We found that telenursing during the COVID-19 pandemic is associated with training and education for skin cleaning, repositioning, monitoring, and PI risk and skin assessment. Integration of the QUAN and the qual data provided more detailed information regarding CGs to treat and prevent PI that could be used to enhance care assessment, skin protection, and tissue prominences. This aligns with the existing research on telenursing for skin cleaning, repositioning, and protecting tissue prominences during social distancing. 18, 19 Interestingly, participants' views on the consistent use of the skin cleaning PI handbook and telecare consultation with a professional nurse as a challenge to treat and prevent PI. However, previous research specific to PI exudates from COVID-19 patients, 20 we found that CGs training and formalising continuing education with telenursing can reduce skin cleaning PI at home.

We attempted to bridge the gap between theory and practice that currently exists within telenursing research, 21, 22 as most studies have focused on in-person medication 23 and paid caregivers. 24 The study showed that there is no ideal context for COVID-19 patients, as the previous studies used a qualitative study, 25 systematic literature review [26] [27] [28] and quantitative study. 29 Our study focused on telenursing for treating and preventing PI in BPs to fill the gap between care needs and CGs' capacity during the COVID-19 pandemic. Telenursing can enhance CGs training and learning, strategically advising, and medical records for treating and preventing PI. This study suggests that telenursing can reduce the CG burden, allowing visual examination and a professional nurse consultation via videoconference.

The strength of this article includes the use of the embedded approach to telenursing during the COVID-19 pandemic. This study integrated the QUAN and qual data, showing a positive effect on CGs treating and preventing PI in BPs. However, there are some limitations. The non-randomised design and small sample size may not have accurately represented all groups. The fixed-format set of both OSIs and VIIs questions may have resulted in biases during the interviews. The results are the participants' views so may not be generalised to other contexts. Future research should include theoretical background, hypothesis testing, large sample size, difference group, and validity scales so that findings can be generalised with an empirical model. Moreover, a further study provides to support CGs access and use of telecommunication for telenursing could be an effective treatment for the prevention of PI during the COVID-19 pandemic.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. 

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The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This work was supported by the Thammasat University Research Fund (Grant No. TUFT 92/2564), the Thammasat University Hospital Fund (2020), and the National Research Council of Thailand (NRCT).

This study was approved by the IRB at the Thammasat University and was conducted according to the Declaration of Helsinki, the Belmon Report, CIOMS Guidelines, and International Practice (ICH-GCP) (COA No. 117/2562: Project No. 065/2562).

Hanvedes Daovisan https://orcid.org/0000-0002-4758-7449