Abstract
Pressure injuries represent a significant and persistent challenge in healthcare, particularly among older adults. These injuries not only impact physical health but also disrupt daily activities, social participation, and overall quality of life. Pressure injuries are widely recognised as indicators of quality of care due to their largely preventable nature and the substantial burden they impose on individuals and health systems. While using pressure-relieving support surfaces, such as mattresses, is a well-established strategy for prevention and treatment, the existing body of evidence remains inconclusive. This leaves a critical gap in understanding the effectiveness of such interventions in community environments, where contextual factors and access to equipment differ markedly.This doctoral research aimed to pragmatically evaluate the comparative effectiveness of active and reactive mattresses in promoting the healing of pressure injuries among individuals aged 50 years and older living in their homes. The research consisted of three studies: a systematic literature review, a pilot randomised controlled trial, and a primary randomised controlled trial, designed using a pragmatic ontology and an equivalence methodology. The research was underpinned by the International Classification of Functioning, Disability and Health (ICF) Biopsychosocial Model and the Person-Environment-Occupation (PEO) Model, both of which support a holistic understanding of health and occupational performance.
The first study in this thesis was a literature review that critically examined the existing evidence on the comparative effectiveness of different types of pressure-relieving mattresses. The literature review synthesised findings from 33 systematic reviews and randomised controlled trials, revealing a paucity of high-quality evidence in community settings and highlighting methodological inconsistencies across studies. These included variability in mattress types, inconsistent outcome measures, small sample sizes and introduction of confounding factors in the study protocols. Moreover, most studies were conducted in institutional settings such as hospitals or residential aged care facilities, with a notable absence of research in community environments. The review concluded that while both mattress types are beneficial, there is no definitive evidence to support the superiority of one over the other, emphasising the need for pragmatic, community-based research.
The second study was a pilot randomised controlled trial designed to test the feasibility of a larger-scale pragmatic trial in a community health setting. This study involved four participants with Stage 2 pressure injuries who were randomly assigned to either an active or reactive mattress, with standard wound care provided by community nursing teams and occupational therapy care provided by a community-based occupational therapist. The primary outcome was time to wound healing, assessed using the Revised Photographic Wound Assessment Tool (RevPWAT), while secondary outcomes included pain levels, comfort, ease of repositioning, and sleep quality. Although the small sample size precluded statistical analysis, the study yielded valuable insights. All participants experienced either stable or reduced pain levels, and qualitative feedback highlighted the importance of user education and environmental considerations – such as mattress size and compatibility with shared sleeping arrangements. The pilot also revealed logistical challenges, including recruitment delays and equipment management, which informed key methodological refinements for the subsequent primary study.
The third and primary study of this thesis was a pragmatic equivalence randomised controlled trial designed to evaluate the comparative effectiveness of active and reactive mattresses in healing pressure injuries among individuals aged 50 and over living in their own homes. Based on the pilot study, this trial incorporated the methodological refinements to enhance recruitment and clinical relevance, including broadening the eligibility criteria and recruitment methods. Despite additional recruitment efforts, the study encountered significant recruitment challenges due to the COVID-19 pandemic, resulting in a smaller-than-anticipated sample size. The study was underpowered and thus unable to confirm equivalence between mattress types, with the wide credible intervals indicating high uncertainty regarding healing outcomes. Importantly, participants across both groups reported reduced pain and stable or improved bed mobility, suggesting that both mattress types were acceptable and potentially effective.
The study demonstrated the value of a pragmatic research approach in capturing the complexities of real-world situations. It highlighted the importance of tailoring recommendations for pressure-relieving equipment to individual needs and environmental contexts. Issues such as comfort, mattress temperature, and pump noise were found to influence user acceptability and adherence. While the results did not confirm equivalence, they provide meaningful insights into the ongoing discourse on pressure injury management in community settings and lay a foundation for future research using robust, context-sensitive methodologies.
Methodologically, this thesis contributes to the growing body of pragmatic research in occupational therapy and community health. The research prioritised real-world applicability and addressed the complexities inherent in community-based care by employing a pragmatic paradigm. Challenges encountered included recruitment delays, staff turnover, and maintaining protocol adherence in real-world settings. Strategies such as co-designing the study with clinicians, using site champions, and leveraging existing health service infrastructure were employed to enhance feasibility and relevance. The study emphasises the importance of designing studies with a pragmatic lens for conditions with multifactorial aetiology, advocating for the integration of clinical reasoning, research setting requirements, and practicality into research methodologies to facilitate the translation of research into evidence-based practice.
In conclusion, although definitive conclusions regarding mattress equivalence cannot be drawn, this research provides valuable insights into the practicalities of managing pressure injuries at home. It highlights the need for further high-quality, context-sensitive research and reinforces the importance of pragmatic methodologies in addressing complex healthcare questions. By integrating occupational therapy principles with pragmatic research design, this work offers a model for conducting meaningful, practice-informed research that bridges the gap between evidence and everyday clinical decision-making.
| Date of Award | 2025 |
|---|---|
| Original language | English |
| Supervisor | Stephen ISBEL (Supervisor), Dominic UPTON (Supervisor) & Judith Barker (Supervisor) |