An analysis of hospital-acquired skin damage in neonatal units: “You sometimes feel like they haven’t really got any skin”

Abstract

It is well established that hospitalised neonates are at risk of iatrogenic skin damage. However, published prevalence and incidence rates vary, with the proportion of different types of damage unknown. It is unclear which factors act as barriers to and facilitators of skin care in this population. This motivated the aims of the thesis, which was to identify potential determinants of change related to the prevention of skin damage in neonatal units. In order to achieve this aim a multiphase mixed methods approach was adopted. This included an analysis of nursing staff practice and beliefs using a 19-part survey, a focus group with neonatal nurses, and interviews with lead Tissue Viability Nurses (TVNs). In addition, a prevalence and incidence study of all forms of skin damage on two neonatal intensive care units was conducted.

The free text comments from the survey, the focus group, and the interviews were analysed using a thematic analysis approach informed by the determinants of change outlined in the Implementation of Change Model. This revealed concerns about damage from medical devices and diaper dermatitis. Participants reported that peer-to-peer learning represented their main source of skin education, and that balancing skin care with other clinical needs was challenging. It was also apparent that the unique nature of the neonatal unit acts as a barrier to reporting damage, involving outside specialists, and accurately classifying wounds.

Prevalence data were collected from 54 neonates, 21 of whom presented with some form of skin damage (38.9%). Incidence data were collected from 51 neonates, 36 of whom developed some form of skin damage (70.6%). Of these, 23 neonates developed diaper dermatitis (45.1%), 23 developed damage associated with a medical device (45.1%), and four developed immobilityrelated pressure ulcers (7.8%). No single device was identified as the primary cause of devicerelated damage, with 12 of the 21 devices observed during the study noted to be associated with damage. Logistic regression analysis found that lower gestational age at birth was associated with an increased risk of developing both general skin damage and device-related damage. It was not, however, associated with an increased risk of developing diaper dermatitis.

In summary, this thesis has improved our understanding of the issues and complications currently facing hospitalised neonates in relation to skin care. There are a number of clinical implications for these findings. Proposed practice changes include the introduction of skin rounds and ‘skin champions’, standardised guidelines for when damage should be escalated to TVNs, and training for neonatal nurses on wound assessment and classification. Proposed areas for future research include the development of medical devices that take into consideration the unique requirements of preterm skin. Further qualitative research is needed with healthcare professionals and parents focussing on the role and experiences of the wider care team. In conjunction with the findings of this thesis, these next steps will allow nurses and other professionals to better protect and promote skin health in these most vulnerable of patients.

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Identifiers

ORCID for Hannah Liversedge: orcid.org/0000-0002-4885-4983

ORCID for Daniel Bader: orcid.org/0000-0002-1208-3507

ORCID for Lisette Schoonhoven: orcid.org/0000-0002-7129-3766

ORCID for Peter Worsley: orcid.org/0000-0003-0145-5042

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