Nurses’ knowledge on medical adhesive-related skin injuries (MARSI)

INTRODUCTION

Skin’s basic function is to protect the organism against external factors: mechanical or chemical injuries, bacteria, ultraviolet radiation, as well as water and electrolyte depletion [1, 2]. Skin care is an integral component of patient care. By assessing a patient’s skin, we can say a lot about their general physical condition. Compromised skin integrity results in increased vulnerability to infections and pain, thus impairing the quality of the patient’s life [3, 4].
In the medical setting, there are many different types of skin injuries, including moisture-associated skin damage (MASD), which comprises skin injuries caused by urinary or faecal incontinence, sore spots, skin injuries around weeping wounds, and stoma bag leakage [5], as well as skin injuries that develope as a result of tension or application of adhesive medical products. Medical adhesive-related skin injuries (MARSI) developed as a result of improper application of medical adhesives (improper selection, application, and/or removal) are a commonly occurring and severe complication present in all types of healthcare facilities and in all patient age groups. In case of improper application and/or inappropriate removal of adhesives, the skin may be damaged, which affects patient safety, reduces quality of life, and increases healthcare costs [6, 7]. In Poland, the number of reported injuries of this type is scarce. Also, they are not qualified as adverse events; therefore, it is hard to precisely determine their exact prevalence and financial outcomes [8]. MARSI are a preventable problem [7]. MARSI may increase the risk of infection, delay wound healing, and cause pain [9]. The injuries may be manifested by development of erythema or other skin lesions, such as vesicles, bulla, and skin erosion persisting for at least 30 minutes after removal of the adhesive [6]. MARSI comprise the following types: 1) mechanical – skin tear, epidermal stripping; 2) dermatitis – irritant contact dermatitis and allergic contact dermatitis; and 3) others, such as maceration, folliculitis, and blistering. Epidermal stripping most often occurs as a result of repeated application of dressings in the same site, e.g. in patients requiring frequent dressing change in care practice related to vascular access [6, 10-17].
There are many factors contributing to the development of MARSI. They can be divided into intrinsic and extrinsic factors [6-8, 11, 14, 15, 17-25]. There are many ways of reducing the risk of MARSI, the most important of which can be summarised in 3 steps: 1) assess – patient’s age, skin, nutritional status, interview the patient to obtain his or her history of allergies [6, 25-33]; 2) select – the right medical adhesive product for the right patient and application; 3) use – proper adhesive application and removal procedure [1, 6-8, 12, 25-45]. The proper application procedure involves the use of a proper technique of securing the devices to skin.
For securing drain tubing to a patient’s skin, there are 2 techniques: the omega technique and the chevron technique. The “low and slow” technique is the optimum technique for removing medical adhesive products. This technique works very well for removing film-based, foam, and hydrocolloid dressings, as well as any other adhesive products [6, 12]. In the medical setting, there are many products facilitating removal of medical adhesives. Most often, they come in the form of spray. These preparations are designed to facilitate quick, easy, and primarily painless removal of adhesives from the patient’s skin. These products are not metabolised through the skin; therefore, they do not affect the wound healing process. Importantly, they do not diminish the adhesive properties of subsequently applied dressings or adhesive products after use, so they can be used multiple times in the same location [7, 46].
Polish legal regulations fail to provide any information about prevention and treatment of medical adhesive-related skin injuries. It should be remembered, however, that any MARSI may produce a wound that will be hard to heal.
Patient safety and efficacy of care and treatment can be improved. It is important to increase nursing staff’s awareness of issues related to medical adhesive-related skin injuries, to provide education about correct application and removal of various medical adhesive products, and to implement preventive strategies in daily practice.
Aim of the study was to assess and analyse the knowledge of nursing staff on medical adhesive-related skin injuries, the principles of their prevention, and to identify variables determining the evidence-based facts.

MATERIAL AND METHODS

To gather information about responding nurses’ knowledge on medical adhesive-related skin injuries, a diagnostic survey method was used. The material for the study was collected using an author survey.
The questionnaire included questions about the sociodemographic status of the respondents and questions concerning their opinions on keeping skin injury records and skin care trainings. Sociodemographics included the following: gender, age, level of education, years of professional experience, nursing degree, and workplace. Additionally, the questionnaire had 18 questions concerning respondents’ current knowledge and practical skills related to dealing with MARSI and medical adhesives. The respondents’ level of knowledge was determined by the number of correct answers given in the questionnaire. The maximum score was 37 points, including 24 points in the theory section and 13 points in the practical section. The theory section included questions about the definition of medical adhesive-related skin injuries, the causes and types of such injuries, risk factors, as well as patients belonging to high-risk groups especially vulnerable to skin damage. In the practical section, the questions concerned such issues, as types of adhesives used by the nursing staff in their professional practice, adhesive products causing skin damage most often, and skin injury prevention (correct adhesive application and removal techniques). To questions marked with an asterisk (*), a respondent was allowed to give more than one answer; therefore, the scores from all questions do not add up to 100%.
The research was conducted from December 2022 to January 2023 using a Google form. The survey form including the questionnaire was distributed by e-mail, via the Teams app and via Microsoft Messenger. Inclusion criterion: students of second-cycle nursing programmes, nurses active in the labour market, studying in a higher education institution providing instruction to nurses in a medium-sized city in Upper Silesia. Exclusion criterion: students of second-cycle programmes, studying any other field than nursing, nurses not active in the labour market, studying in a higher education institution providing instruction to nurses in a medium-sized city in Upper Silesia. The introduction to the survey form included an Information for study participants section presenting the aim of the study, information about respondents’ anonymous and voluntary participation and their possibility to withdraw from the study at any time without any consequences of the refusal to participate, and about the possibility to complete the questionnaire only once. The research was conducted and designed in accordance with the principles of Good Scientific Practice, with the Act on Personal Data Protection of 10 May 2018, rules set out in the Declaration of Helsinki, and with the Regulation (EU) of the European Parliament and of the Council 2016/679 of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and repealing Directive 95/46/EC (General Data Protection Regulation). A purposive sampling method was used in the study. The respondents were selected for the study using a convenience sampling technique. While completing the study form, in the event when no answer was provided to a required question, respondents could not continue with the survey to reply to subsequent questions. The authors received and analysed 216 fully completed forms. Data collected during the study were anonymised to prevent identification of any specific respondent. Data were stored in a safe and well-protected site, at the investigator’s place of residence, on a private computer disk, and they were destroyed once the study was finished.
MS Excel and IBM SPSS software were used for data analyses. To examine the effect of specific variables on the level of theoretical and practical knowledge, several non-parametric tests were run. In these tests, the average rank presented in the tables or descriptions corresponds to an arithmetic mean obtained in parametric tests. The adopted significance level was p = 0.05. To measure the relationship between selected variables the Kruskal-Wallis or Mann-Whitney U-test were used, being the most relevant for the character of the study variables and due to failure to meet the conditions for parametric analysis.
Table 1 presents the sociodemographic data. The respondents were aged from 22 to 67 years. The mean age was 43 years. Female respondents who completed bachelor education and having a nursing degree prevailed in the sample.

RESULTS

On average, respondents scored 15 points in the theory section and 8 points in the practical section. Basic descriptive statistics are presented in Table 2.
Most often the respondents provided the correct answer to the question To your knowledge, what is medical adhesive-related skin injury? The correct answer is: Medical adhesive-related skin injury is manifested in erythema, vesicles; it persists longer than 30 minutes after removal of the adhesive. This answer was given by 177 respondents (81.9%) who knew what this type of injury is; 39 participants (18.1%) selected an incorrect answer (Table 3).
The correct answer to the question about causes of skin injuries related to medical adhesives was: improper selection of surgical adhesive (81.9%), improper dressing and adhesive application technique (74.5%), and improper adhesive removal technique (64.4%). These answers were provided the most often. Other answers were wrong, but they were also chosen by some of the respondents. The incorrect answers chosen most often were folliculitis (40.3%) and use of radiotherapy (31.5%) (Table 4).
The skin injuries most often reported by the respondents were maceration (66.2%), skin tear (60.2%), and irritant contact dermatitis and allergic contact dermatitis. The least frequently given answer was epithelial restitution and granulation tissue (6.0%). Nurses participating in the study would most often observe epidermal stripping (49.1%), maceration (44.9%), irritant contact dermatitis, and allergic contact dermatitis as injuries developed in relation to the application of adhesive products. Respondents also reported damages of different origin, such as skin infection (14.8%) and necrosis (8.8%). Skin injuries observed in the patients were mild (49.5%) and moderate (44.4%). Severe/acute skin injuries were infrequently reported by the respondents (6%).
According to the respondents, risk factors contributing to the development of medical adhesive-related skin injuries include cleansing skin with high-pH soap, comorbidities, taking certain medications, skin diseases, radiotherapy, and long-term exposure to humidity. Factors reported most often were comorbidities (78.7%) and taking certain medications (75.5%). The least frequently reported factor included application of paraffin-based ointments and creams to the skin (6.9%) (Table 5).
Among high-risk patients vulnerable to development of medical adhesive-related skin injuries, the respondents indicated cancer patients (89.4%), geriatric patients (80.1%), patients with chronic skin diseases (71.3%), and patients receiving radiotherapy (69.9%). The least frequently reported patients were adult males (0.9%) and athletes (2%).
Nursing staff participating in the study most frequently used non-woven adhesives (66.7%) and film-based adhesives (40.3%) in their work practice. Latex-based adhesives were rarely used by the respondents (8.8%) (Fig. 1).
Table 6 presents participants’ responses concerning adhesives most often contributing to the development of skin injuries. The correct answer is latex-based adhesive; 111 respondents (51.4%) gave the correct answer, while 81 respondents (37.5%) answered that it was film-based adhesive. The smallest number of respondents (10 [4.6%]) believed it was foam adhesive.
Among the most frequently used methods of reducing the risk of developing MARSI, the respondents listed the following: selection of the right adhesive for the right patient (84.7%), proper skin preparation for dressing application (81.0%), and proper technique of removing (75.9%) and applying (74.5%) the adhesive. These are the proper methods of preventing skin damage during use of medical adhesives. The respondents also reported incorrect methods, such as removing patient hair with a surgical clipper (26.4%). The answers given by the respondents are presented in Figure 2.
Table 7 presents answers regarding proper principles of applying adhesives to the patient’s skin. The largest number of respondents ticked the answer related to selection of an adhesive of proper size (82.9%), precise application of the adhesive (81.0%), as well as removing patient’s skin hair using a surgical clipper (47.7%), which is not a correct principle. The answers given by the nursing staff participating in the study concerning principles of removing adhesive products are presented in Table 8.
The vast majority of hospitals, being the workplace of the nurses participating in the study, keep records involving assessment of patients’ skin. Most respondents (73.6%) replied Yes to the question about keeping the records. The records kept most often by the nursing staff participating in the study involved assessment of the stage of pressure ulcers (82.9%). A small group of respondents (9.3%) ticked a reply concerning records involving assessment of skin injuries related to the use of medical adhesive products.
More than half of the nurses participating in the study failed to participate in any trainings and/or workshops organised at their workplace devoted to preventive strategies for medical adhesive-related skin injuries (68.1%). Most of the respondents (87%) reported the need to organise similar trainings/workshops at their workplace. Most of the nurses participating in the study suggested that such trainings/workshops should be conducted by a nurse (90.3%). According to 86.6% of the respondents, this nurse should have completed a wound treatment course and have practical experience in this area.
The relationship between participation in the trainings and level of knowledge was confirmed only with respect to practical knowledge (p = 0.042), but not theoretical (p = 0.194) nor general knowledge (p = 0.104). The lowest level of knowledge was demonstrated by individuals receiving training once a month, whereas the highest by those trained once a year. However, because individuals receiving training once a month were scarce (only 3), this result may be regarded as unreliable.
Respondents who saw the need to organise trainings devoted to medical adhesive-related skin injuries presented a significantly higher level of theoretical and practical knowledge in this area. A significant difference occurred in the levels of theoretical (p = 0.007), practical (p = 0.011), and general knowledge (p = 0.004).
The relationship between respondents’ age and their level of knowledge was confirmed for theoretical knowledge (p = 0.008) and general knowledge (p = 0.022) but not for practical skills (p = 0.081). The level of knowledge, in particular theoretical knowledge, was highest in the group of the youngest nursing staff, and it decreased with age.
The relationship between years of professional experience and the level of knowledge was not confirmed. Years of professional experience failed to exert any effect on the level of knowledge about skin injuries. The relationship/correlation between education and level of knowledge was confirmed with respect to practical knowledge (p = 0.043). The average level of knowledge increased with the education level; the lowest was in individuals who completed secondary education or medical vocational school, and the highest in individuals with a doctor’s degree. The relationship between the nursing degree and respondents’ level of knowledge was confirmed for theoretical and general knowledge (p = 0.009 and p = 0.007, respectively). Persons with a degree in nursing demonstrated higher levels of knowledge about skin injuries. The relationship between the workplace/ward and respondents’ level of knowledge was confirmed for theoretical and general knowledge (p = 0.007 and p = 0.012, respectively). The highest level of theoretical and general knowledge was presented by persons working in intensive care units. The lowest level of knowledge was demonstrated by persons working in neonatal or dermatology wards, although the result could have been affected by the fact that these wards were represented only by a few respondents. The relationship/correlation between the workplace/hospital and respondents’ level of knowledge was confirmed for theoretical, practical, and general knowledge (p < 0.001, p = 0.028, and p < 0.001, respectively). The highest level of knowledge was demonstrated by respondents working in teaching hospitals (average ranks were the highest for all types of knowledge). The lowest level of theoretical and general knowledge was demonstrated by respondents working in district hospitals, and with respect to practical knowledge – by those working in provincial hospitals.

DISCUSSION

Skin care, including protection against medical adhesive-related skin injuries, constitutes one of the basic requirements of nursing care. MARSI continues to be a new term, but it has been a common problem. Persons providing medical care should be determined to prevent and reduce the prevalence of MARSI, and they should have knowledge about the problem and its causes, as well as strategies for preventing skin injuries [6].
When analysing Polish literature on skin care and prevention of injuries related to the use of medical adhesive products, there is little information about MARSI [8, 48]. This type of skin damage has not been monitored in Polish health care facilities although it occurs in all patient age groups – mainly in cancer patients and elderly patients. Nursing staff participating in the study also most frequently indicated this group of patients as a high-risk group. International literature offers data concerning monitoring and studies of this issue [13, 36, 45, 48]. In western China, trained nurses controlled the skin of patients with a peripherally inserted central catheter (PICC) for medical adhesive-related skin injuries. The sample comprised 694 inpatients staying in 4 hospitals, one of which was an oncology hospital. The prevalence of MARSI was 19.7%, including mechanical skin injuries (5.0%), contact dermatitis (14.8%), folliculitis (1.0%), and moisture-associated skin damage (1.3%). The study showed that the prevalence of medical adhesive-related skin injuries in hospitalised Chinese oncology patients was significant. The study provided new knowledge for the epidemiology of MARSI and identified a high-risk population, which should guide clinical nursing practice and ensure patient safety [48]. Observations of medical adhesive-related skin injuries in patients staying in intensive care units has also been conducted in Western Europe and America. A cross-sectional study was conducted in cardiac Intensive Care Units of hospitals located in São Paulo city. The sample consisted of 123 patients. Medical adhesive-related skin injury was observed in 28 patients. Its main causative agent was transparent polyurethane film. The study has contributed to knowledge related to the epidemiology of this type of injury, indicating the importance of preventive care planning [49]. In this study, a small group of respondents (9.3%) kept records intended to assess skin injuries caused by the use of medical adhesive products.
While analysing the literature in popular medical databases from the past decade, the authors failed to find any publication describing evidence-based knowledge of the nursing staff on medical adhesive-related skin injuries. Available papers present evidence-based facts supporting knowledge of the nursing staff on the treatment and care of hard-to-heal wounds and moisture-associated skin damage as a result of exposure to wound exudate or urinary and/or faecal incontinence [50, 51]. For instance, a recent study conducted in 2022 examining nurses for their knowledge on chronic wounds and their treatment methods showed their shortcomings in this area. Of 145 study participants, 78 (53.79%) presented an insufficient level of knowledge, 59 persons (40.69%) showed a sufficient level, 4 (2.76%) a good level of knowledge, and the remaining 4 (2.76%) a very good level. As regards their self-reported level of knowledge about wounds and wound treatment, only 3 individuals found it to be “very good”, 46 (31.72%) reported it to be “good”, and 76 respondents chose the answer “neither good, nor bad – hard to say” [50]. Another study showed that 67.8% of responding nurses presented a moderate level of knowledge on wound treatment, whereas 28.8% showed high level of knowledge [51]. In the presented study, the majority of the nursing staff demonstrated sound theoretical knowledge: they knew the definition and causes of medical adhesive-related skin injuries. A slightly smaller group of respondents presented an equally high level of practical knowledge, e.g. in the area of preventing skin injuries or use of adhesives based on different fabrics. Respondents presenting the highest level of knowledge were nurses working at intensive care units and medical wards, employed in teaching hospitals. The lowest level of knowledge in this area was presented by the nursing staff working in dermatology and neonatal wards, as well as in district and provincial hospitals. Years of professional experience had no effect on respondents’ level of knowledge. Interestingly, persons participating in trainings and feeling the need to take part in further training presented a significantly higher level of theoretical and practical knowledge. Along with higher education level and nursing degree, the level of theoretical and practical knowledge of the nursing staff about skin injuries related to the use of adhesives and their prevention increased significantly as well. The level of knowledge, in particular theoretical knowledge, was highest in the youngest nursing staff, and it decreased with age. The number of years of professional experience had no effect on the level of knowledge.
This study, as well as the analysis of the literature [6], point to a great need for organisation of trainings/workshops and increasing awareness of this issue, as 61.8% of respondents reported an absence of trainings devoted to prevention of skin injuries at their workplace. A considerable number of the nursing staff (87%) reported the need for the organisation of such trainings and workshops. According to the respondents, such trainings should be conducted by a nurse having experience in nursing care and treatment of hard-to-heal wouds.

LIMITATIONS

Summing up, it should be noted that the study presented in this paper has its advantages and limitations. The former include the fact that the authors attempted to analyse expertise on MARSI and its determining factors. The study may be regarded as a preliminary pilot study. Limitations include the use of convenience instead of random sampling, the small sample size, conducting the study across a restricted area, which prevents the authors from making generalisations onto the entire population, and the impact of disturbing factors, such as specific age groups represented by unequal numbers of respondents. For this reason, the issue should be investigated on a representative sample, with randomly selected participants, and the MARSI problem should be controlled.

PRACTICAL IMPLICATIONS

The nursing staff and patients should have access to knowledge and essential new-generation medical devices in medical centres, to prevent and treat medical adhesive-related skin injuries. An important stipulation resulting from the conducted study is the need to put into practice safe application and removal procedures related to new-generation adhesives and the obligation to record their use.

CONCLUSIONS

The following conclusions may be drawn from the study:
1. Moat of the nursing staff knew the definition of medical adhesive-related skin injuries, their causes, and the principles of their prevention. Slightly fewer of the respondents demonstrated a high level of practical knowledge in this area.
2. The level of respondents’ knowledge was significantly determined by education level, nursing degree, working in a given type of ward, and being employed in a specific type of hospital. A higher level of education and nursing degree translated into a higher level of knowledge. A significantly higher level of knowledge was presented by respondents working in teaching hospitals, whereas a lower level was shown by participants working in district hospitals.
3. More than half of the nursing staff reported an absence of trainings on prevention of medical adhesive-related skin injuries, and most of the respondents pointed to the need to organise trainings/workshops in this area.

Disclosures

This research received no external funding.
Institutional review board statement: Not applicable.
The authors declare no conflict of interest.

References