Prevention and management of radiation dermatitis for patients with Nasopharyngeal carcinoma: a best practice implementation project

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Severe radiation dermatitis can not only reduce the quality of life but also affect the continuity of treatment, significantly diminishing the effectiveness of radiotherapy. Although there were guidelines regarding the management of dermatitis, dermatitis among patients remain suboptimal. Aim: This best practice implementation project aimed to implement an evidence-based practice in preventing and managing patients with radiation dermatitis, thereby improving the compliance of clinical practice with the best evidence and reducing serious dermatitis in NPC Methods: This was an evidence-based audit and feedback project that used a three-phase approach at a tumor specialized hospital in China. Phase 1 included the development of seven evidence-based audit criteria and carrying out baseline audit on 22 patients using the JBI’s Practical Application of Clinical Evidence System in the Department of Radiation Oncology of Sun Yat-sen universiy cancer centre. Phase 2 utilized the Getting Research into Practice component of the Practical Application of Clinical Evidence System to identify barriers to compliance with best practice principles and developed strategies and resources to improve compliance. Phase 3 involved conducting a follow-up audit using the same audit criteria to assess the results of interventions implemented to improve practice and identify issues that would be addressed in future audit. Results: After implementing the evidence, the incidence rate of severe radiation dermatitis(≥Grade Ⅲ) decreased from 9.09%(2/22 cases) to 0% (0/22 cases). A comparison between the pre-implementation and post-implementation findings showed significant improvements for all audit criteria, and patients’ compliance with the radiation dermatitis management protocol increased to between 59.09% and 100%. Notably, the compliance rate increased from 0 to 100% for audit criterion 1,2,5,9,12,and 15. Conclusions: The implementation of this project improved patients’ compliance on dermatitis management among NPC patients and reduced the incidence rate of severe dermatitis. Radiation dermatitis Implementation science Nasopharyngeal carcinoma quality improvement Figures Figure 1 Introduction Nasopharyngeal carcinoma(NPC) exhibits endemic prevalence in Southern China and Southeast Asian countries (over 70 cases per 100,000 people), with about 47% of cases globally found in China, placing it at the forefront of NPC incidence worldwide [ 1 ] . Radiation therapy is the preferred treatment method for NPC, involving the irradiation of the head and neck area to kill tumor cells, thereby extending the survival period and potentially achieving a curative effect [ 2 ] . However, it exerted a potent destructive effect on normal tissue cells within the irradiation field. Radiation dermatitis is one of the most common complications during radiation therapy, characterized by pigmentation, erythema, desquamation, inflammatory exudate, and even ulcerative necrosis at the treatment site [ 3 ] . In contrast to burns and ulcers, radiation penetrates beyond the epidermal layer, causing cellular-level damage to subcutaneous structures. This leads to dryness, loss of elasticity, pigmentation, soft tissue fibrosis, capillary dilation, and radiation dermatitis in the irradiated areas [ 4 ] . Additionally, radiation inflicts irreversible harm on the microvascular and small blood vessel endothelial cells within the skin tissue. Consequently, it takes a long time to heal and easily infected. Therefore, it is crucial to alleviate or even eradicate radiation dermatitis Nearly 85%~95% of NPC patients will experience varying degrees of radiation dermatitis during radiation therapy [ 5 ] . Notably, due to skin folds in the head and neck area, which are prone to sweat and moisture, and UV exposure predispose radiation dermatitis and the condition more severe [ 6 ] . Studies had shown that the occurrence rate of grade Ⅲ radiation dermatitis in the head and neck area can reach 49%, which may cause physical pain and discomfort, as well as psychological problems such as low self-esteem and sadness, increase financial burdens, and even lead to treatment interruptions, affecting the treatment effectiveness and the patient’s quality of life [ 7 ] . Management strategies for radiation dermatitis are stratified by severity and daily skin care measures, prevention and treatment of secondary skin infection, and the application of dressings and protectant [ 8 ] . Nurses played a essential role in the management of radiation dermatitis including risk identification, assessment, prevention, management, evaluation of management effectiveness, and patient health education [ 9 ] . The Radiotherapy Nursing Outpatient Clinic at Sun Yat-sen university cancer centre is dedicated to the full-cycle symptom management of radiation therapy patients. To date, the clinic has treated 929 radiation dermatitis patients, accounting for 73.43% of the nursing outpatient volume, with NPC radiation dermatitis accounting for approximately 86.42% [ 10 ] . There is a high demand from patients for nursing care related to radiation dermatitis. However, there are gaps between the management of radiation dermatitis in our hospital’s radiotherapy nursing outpatient clinic and the existing best evidence [ 11 ] , such as the lack of identification of high-risk factors and comprehensiveness and scientific basis in nursing measures for radiation dermatitis, resulting in an absence of homogeneity in the health education and poor outcomes in the treatment of grade Ⅱ~Ⅲ radiation dermatitis wounds. A system-wide standardized approach to managing radiation dermatitis in NPC patients is urgent [ 12 ] , specifically a skin management protocol should be established that defines risk identification, type and frequency of skin assessments and incorporate best evidence recommends for prevention and management. Aims and objectives The aim of this project was form and conduct the structure prevention and management of radiation dermatitis based on the best evidence in the Department of Radiation Oncology in Sun Yat-sen university cancer centre. The specific objectives were as follows: (1) To identify gaps between the current practice of radiation dermatitis management and the best evidence. (2) To develop tailored strategies for addressing the low compliance with evidence-based audit criteria during the baseline audit. (3) To implement strategies to enhance compliance with practices for assessment, prevention, and management of radiation dermatitis based on evidence. (4) To evaluate the post-implementation impact by conducting a second audit involving patients, practitioners, and systems to enhance clinical practice. Methods The project was conducted in the Radiation Oncology Department of Sun Yat-sen university cancer centre, which admits over 18000 patients in last year and ranked first globally for four consecutive years. The centre serve with 17 accelerators, and include 2 outpatient treatment areas and 5 inpatient wards with 334 hospital beds. The area of implementation was oncology radiotherapy care clinic which targeted to manage radiation-induced toxicities and Radiotherapy Ward One primarily admits patients with NPC. 5 nurses take turns to work shifts on weekdays in oncology radiotherapy care clinic, and all of whom are specialty nurses with the range of oncology, nutrition and rehabilitation. The current evidence implementation initiative employed the JBI Practical Application of Clinical Evidence System (JBI PACES) [ 13 ] and Getting Research into Practice (GRiP) audit and feedback tool [ 14 ] . This framework aimed at advancing evidence-based healthcare, unfolds in three phases. Initially, the project team is formed, and the baseline survey conducted using a self-developed questionnaire on radiation dermatitis prevention and management knowledge (Supplementary File 1). In the second phase, the team reviews and reflects on the baseline audit results, then develops and executes strategies to address the identified practice gaps. The final phase involves a follow-up audit to evaluate the project's outcomes. Additionally, a post-implementation survey is conducted to assess the knowledge of nurses and patients on managing dermatitis, and data is collected on the severity of patients’ dermatitis and subjective symptoms before and after the implementation, to inform future practice improvements. Samples This is an evidence-based implementation project. From March to June 2024, we enrolled 22 nasopharyngeal carcinoma patients preparing for radiotherapy in the baseline audit and 22 patients during October to December in the post-implementation follow-up audit. Inclusion criteria were as follows: Initially diagnosed with nasopharyngeal carcinoma through pathology, with the disease staged at Ⅰ to Ⅲ; the treatment plan includes radiotherapy. Analysis Compliance data changes were analyzed using descriptive statistics in Microsoft Excel 2019, and displayed as percentage variations from the initial baseline. Ethical considerations According to the notice issued by the National Health Commission of China [ 15 ] regarding the ethical review procedures for human life sciences and medical research, continuous quality improvement projects do not fall under the scope of ethical review. These projects do not involve new technologies or new diagnostic and treatment standards, but are intended to help institutions provide medical services based on the best evidence (evidence summaries). The risk involved is lower than minimal risk; therefore, ethics approval was waived by the Ethics Committee of Sun Yat-sen University Cancer Center. Although ethic approval was waived, we still obtained verbal informed consent from all patients and nurses involved, explaining the purpose and process of the project. Patients and nurses have the right to refuse participation. All collected data were anonymized to protect the privacy of participants. This investigation conforms with the Principles of the Declaration of Helsinki. Phase 1: Team establishment and baseline audit All pertinent stakeholders, encompassing both patients and project team members, were actively involved in this project. The project team is composed of multiple disciplines and comprised of 14 members, including the team leader and an evidence-based nurse(EBN), department director, head nurse, radiation oncologists, radiation technicians, specialized nurses, and wound specialists. Team members involved in the project were clearly positioned to offer the necessary support and resources. Their respective positions and roles were detailed in Table 1 . Table 1 Team Establishment Team member Position Role/Responsibility Member 1 Project executive director Examination of the most reliable evidence available Developing the process for implementing project Performed preaudit and postaudit Analyzing the results and outcomes Member 2 Evidence-based nurse Methodological guidance Designing strategies Guiding the change according to the clinical audit in the project. Member 3, 4 Department director System leader Facilitating and driving progress toward change, providing human, physical and financial resources Member 4, 5 Head nurse Overcoming obstacles Organizing nurse education and training Overall project management including planning, promotion, decision-making, and quality control Member 6 Radiation oncologists Communicating and coordinating with patients Offering constructive feedback. Member 7 radiation technicians Facilitating and driving progress toward change Applying evidence Providing feedback Member 9, 10, 11, 12, 13 specialized nurses Day-to-day leadership Applying evidence on radiation dermatitis management Collecting and analyzing data Member 14 wound specialists Responsible for consultations on complex radiation dermatitis, especially Grade Ⅳ radiation dermatitis. Prior to performing the baseline audit, meetings and discussions took place to establish the criteria, sample size, and methods of data collection. In the baseline audit, sample selection was based on convenience, and methods for collecting data encompassed questioning patients, conducting interviews, and examining both electronic and paper documents. Table 2 outlines the criteria used in the baseline and the second audits, including the sample size and the methodology applied to assess adherence to best practices for each criterion. The baseline audit was implemented from February 1 to March 18, 2024, with patients who had undergone radiotherapy between November 17, 2023 and January 26, 2024, and met the inclusion criteria. 22 patients were included to assess how well current clinical practices align with evidence-based best practices for evaluating and managing radiation dermatitis. We used a checklist to assess patients’ and nurses’ compliance with each audit criterion. The accuracy rate, evidence implementation compliance rate, and score distribution were calculated. And the incidence of gradeⅡor higher radiation dermatitis was also recorded. The ultimate compliance data were imported into Excel software to acquire the baseline audit outcomes for each criterion. The audit criterions were showed in Table 2. Table 2 Criteria for the audit, sample size, and method for the measurement of compliance with best practice Audit criterion Sample Method used to measure the compliance with the best practice 1.Radiation dermatitis management protocol and guidelines for nasopharynx cancer patient has been implemented Baseline audit: 22 patients Follow-up audit: 22 patients Measured by documentation reviewing Yes, if standardized radiation dermatitis programs had been documented in written format. 2. A Multidisciplinary team comprising radiation oncologists, oncology nurses, radiation therapists, wound care specialists were established Baseline audit: 22 patients Follow-up audit: 22 patients Measured by documentation reviewing Yes, if a multidisciplinary consultation protocol has been established for severe radiation dermatitis and documented in written form. 3.The risk factors for radiation dermatitis of patient were correctly identified Baseline audit: 26 nurses Follow-up audit: 26 nurses Measured by reviewing the documentation Yes, if nurses assess patients for radiation dermatitis risk factors and classify them into different risk levels in nursing documentation. 4.Radiation dermatitis assessment is undertaken using the RTOG scales Baseline audit: 26 nurses Follow-up audit: 26 nurses Measured by reviewing the documentation Yes, if nurses accurately grade radiation dermatitis severity in patients using RTOG criteria. Subjective tools have been used to assess the effects of sever radiation dermatitis Baseline audit: 26 nurses Follow-up audit: 26 nurses Measured by reviewing the electronic nursing records Yes, if nurses use Skindex-16 tools to assess the subjective symptoms of patient who are in sever radiation dermatitis. Assessment of patients with radiation dermatitis is undertaken on a regular basis, the frequency of which is determined based on individual patient condition. Baseline audit: 26 nurses Follow-up audit: 26 nurses Measured by reviewing the electronic nursing records and follow-up record Yes, if nurses assess inpatient who are in gradeⅡand above everyday . In addition, outpatient who are in gradeⅡand above should be assessed at least twice a week Patients perform daily photographic documentation of irradiated skin areas Baseline audit: 22 patients Follow-up audit: 22 patients Measured by interviewing patients. Yes, patients take daily photos for recording the change of radiation area 8.Patients or their caregivers received health education regarding radiation dermatitis and its management Baseline audit: 22 patients Follow-up audit: 22 patients Measured by interviewing patients. Yes, if patient answer yes and correct response rate for health education content exceeds 90% 9.Patient or caregivers have received evidence based written information on radiation dermatitis and its management Baseline audit: 22 patients Follow-up audit: 22 patients Measured by reviewing the documentation Yes, if patient get access to written information, such as patient education brochure, video etc. 10.Nurses have been trained in radiation dermatitis education. Baseline audit: 26 nurses Follow-up audit: 26 nurses Measured by interviewing and assessing nurses. Yes, if nurses answer yes. In addition, the nurses’ radiation dermatitis knowledge was evaluated in the form of a questionnaire. 11.Patients know the daily care of radiation dermatitis, including skin hygiene, moisturization protocol, irritant avoidance, trauma prevention, avoidance of UV exposure, barrier product application Baseline audit: 22 patients Follow-up audit: 22 patients Measured by interviewing patient ask patients questions about the daily care of radiation dermatitis. Yes, if the patient correct response rate exceeds 90% 12.Patients have been provided with a special individualized guide and supervision on radiation dermatitis management. Baseline audit: 26 nurse Follow-up audit: 26 nurse Measured by interviewing nurse Yes, if nurse are competent in providing level-specific care for patients with radiation dermatitis 13.For ≥gradeⅡradiation dermatitis: application of soft silicone film dressings reduces wound healing time in nasopharynx cancer patient Baseline audit: 22 patients Follow-up audit: 22 patients Measured by reviewing the documentation Yes, if nurses correctly apply dressings for patients with GradeⅡand above radiation dermatitis 14.Topical application of skin protectants during radiotherapy. Baseline audit: 22 patients Follow-up audit: 22 patients Measured by interviewing the patient Yes, if the patient grasp the correct use of skin protectants 15.Wound infection control protocol for radiation dermatitis Baseline audit: 26 nurses Follow-up audit: 26 nurses Measured by interviewing nurse Yes, if nurses can accurately master the identification of infected wounds, wound assessment, wound swab collection, and the management protocol for infected wounds. Phase 2 design and implementation of strategies to improve practice (Getting Research into Practice) After the baseline audit, the results were presented to both the project team members and the clinical staff. Based on the Knowledge-to-Action framework, the project team conducted a barrier analysis from three perspectives: the evidence itself, the practice environment, and potential adopters, then developed strategies to overcome these barriers. Through feedback from nurses, potential implementation barriers were identified. Subsequently, A structured action plan was developed, employing institutional resources to formulate barrier-mitigation strategies for facilitating evidence-based practice implementation. A GRiP report was then shared with the nursing staff, followed by a communication meeting to introduce the project objectives and clarify individual roles. Phase 3 follow up audit A second audit was conducted using the same criteria in the baseline audit. This audit spanned 3 weeks using the same number of patients and the same nurses from 10 November 2024 to 1 December 2024. Results Phase 1: baseline audit The baseline results are shown in Fig. 1 . The results indicate 0% compliance for eight criteria (1,2, 3, 5, 7, 9, 12, and 15), namely, radiation dermatitis management protocol for nasopharyngeal ptient; a multidisciplinary team for severe radiation dermatitis; the risk identification for radiation dermatitis; assessment tool for radiation dermatitis effect; patients perform daily photographic documentation of irradiated skin areas; written information on radiation dermatitis and its management for patient; special individualized guidance and supervision of patients. The best performance was seen criteria 10 that 96.15% had been trained in radiation dermatitis patient education, and 65.38% nurses assess patient in regular. Criteria 8 showed that 86.36% patient had received health education before radiotherapy. However, the accuracy rate of criteria 4 (radiation dermatitis assessment using RTOG criteria) was only 42.31%. Besides, 4.54% of patients could fully grasp the daily skin care measures during radiotherapy. Compliance with Criteria 13 and 14 (i.e.application of soft silicone film dressings, Topical application of skin protectants) were 9.09–18.18%. Among 22 patients after radiotherapy, there were reported a 9.09% incidence of Grade Ⅲ radiation dermatitis. Phase 2: strategies for getting research into practice During this phase, six primary barriers were systematically identified. Table 3 comprehensively outlines these barriers along with their corresponding resources, strategies, and outcomes. Table 3 displayed strategies from the Getting Research into Practice matrix. Barrier1 : Radiotherapy treatment involves complex workflows spanning multiple departments, creating significant coordination challenges due to the absence of structured multidisciplinary team support. To solve this problem, a multidisciplinary team were established consisting of the department head, clinical doctor, head nurses, radiation therapists, oncology specialist nurses, nutrition specialist nurses, wound and ostomy care nurses, and evidence-based nursing specialists. The team is responsible for the development, implementation, supervision, and quality control of the radiation dermatitis management protocol. And the contents of management included the prevention and management of radiation dermatitis throughout the radiotherapy cycle include risk assessment, health education, psychological support, wound cleansing, infection control, wound healing promotion, and nutritional assessment and intervention. Multidisciplinary meetings took place monthly, where team members engaged in thorough discussions and communications before offering appropriate guidance to patients. Patients with gradeⅠ~Ⅱradiation dermatitis were followed up by specialist nurses once a week and more than gradeⅡradiation dermatitis were followed up twice a week. Barrier 2 : There is currently no standardized protocol for managing radiation dermatitis, leading to inconsistent clinical practices. The multidisciplinary project team developed radiation dermatitis management protocol. This protocol could be divided into four phases:(1) standardized assessment protocols, (2) structured patient education, (3) evidence-based interventions for grade ≥Ⅱcases, and (4) systematic follow-up monitoring. The established radiation dermatitis management protocol shall be incorporated into routine clinical workflows. Comprehensive training will be provided to all nursing staff, with compliance monitoring overseen by department head nurses, team leaders, and clinical nurse specialists to ensure proper protocol implementation. Barrier 3 : Radiation dermatitis involves multiple risk factors, yet there is no standardized classification system for risk stratification. To address the absence of grading criteria, the team member developed a risk assessment tool based on the literature review, combined with the established Grade Ⅲradiation dermatitis risk prediction model and expert consultation. The Radiation Dermatitis Risk Assessment tool comprised 12 items, with evaluation results categorized into two levels: low risk and high risk(Supplementary File 2). Patients evaluated to be at high risk for radiation dermatitis are guided and supervised by the primary nurse to visit the radiotherapy specialist nursing clinic twice a week for assessment, while low-risk patients visited once a week. Barrier 4 : Medical staff have not received the latest knowledge and skills training on the prevention and care of radiation dermatitis. To address this barrier, the team members developed a training plan for ward doctors, nurses, and outpatient specialist nurses. A total of six training sessions were conducted, two of which were online, each lasting one hour. The training content was based on the latest evidence summary and designed by the team leader. Electronic handouts were distributed to each participant. The training primarily covered the importance of radiation dermatitis management, clinical manifestations of radiation dermatitis, risk factors, assessment tools, prevention and treatment, daily care, medication precautions, health education, management principles for different levels of radiation dermatitis, the procedure for handling severe radiation dermatitis, follow-up monitoring, and the use of the electronic assessment system. After the training, knowledge acquisition was assessed through questions or electronic questionnaires. Barrier5 : The patient and caregivers lack knowledge of health education and does not pay enough attention to daily nursing measures, resulting in low compliance rates. In response to this identified issue,, we adopted diverse and easy-to-understand approaches to health education. In addition to face-to-face health education, we produced educational videos on radiation dermatitis and played on a loop in patient wards, made and distributed health education materials to patients including handbooks and patient diary forms, and encouraged the involvement and supervision of caregivers. Furthermore, we developed an electronic comprehensive health management platform for the entire treatment cycle which enabled patients to report discomfort symptoms at any time and allowed for real-time communication between nurses and patients to address concerns. Once patients join, they can access to relevant health education materials. The platform is managed by dedicated personnel who was responsible for weekly collection of patients’ subjective skin symptoms, photos of their neck skin, and the impact of skin conditions on their life, emotions, and social interactions. They also address patients’ questions regarding radiation dermatitis care. Patients who do not fill out the information on time will receive a pop-up reminder message on their phones. Barrier6 : The implementation of the current radiation dermatitis management protocol requires nurses to invest more time, increasing their workload. To improve efficiency and reduce the burden on nurses, by coordinating with the Nursing Department and Information Department, the risk assessment form and the radiation dermatitis observation record form have been integrated into the nursing system and the hospital information system, establishing an information platform. After the nurse completes the assessment, the electronic information system automatically calculates the results based on the content of the nurse’s assessment and improve the efficiency. The system was also connected to portable iPad equipped with camera functions. And the use of portable iPad allowed nurses to complete assessments, take photos of radiation site, and record information directly at the patient’s bedside, eliminating the need to first record on paper and then upload to the nursing system at the nurse’s station. This reduces repetitive tasks and the time spent traveling back and forth to patient beds. Table 3 Strategies for Getting Research into Practice matrix Barriers Strategies Resources Outcomes 1. The lack of a multidisciplinary team to manage patients with radiation dermatitis Establish a multidisciplinary team. 1. Hospital supports multidisciplinary cooperation. 2. Support from the Nursing Department, Department Heads, Radiotherapy Center Technician Team, and Wound and Ostomy Specialists. Establish a multidisciplinary team consisting of the department head, clinical doctor, head nurses, radiation therapists, oncology specialist nurses, nutrition specialist nurses, wound and ostomy care nurses, and evidence-based nursing specialists. 2.The lack of standardized protocol for managing radiation dermatitis Establish a standardized protocol based on the best evidence for managing radiation dermatitis. 1. Intervention team (doctor,and evidence-based nursing specialists, nurses). 2. Summary of the existing best evidence. 3. Evidence-based training in hospitals. Establish a standardized protocol based on the best evidence for assessing, grading, educating, managing and monitoring radiation dermatitis 3.The lack of standardized classification system for risk stratification. Establish a standardized classification system for risk stratification. 1.Previously published work,including a predict model for radiation dermatitis. 2.Clinical experience. 3.Available database resources Establish a standardized classification system for risk stratification 4.Medical staff lacked the latest knowledge and skills training on the prevention and care of dermatitis. 1.Create a training plan for medical staff. 2.Provide each medical staff with a training manual. 3.Administer a knowledge quiz to assess their understanding following the training. 1. A training plan. 2. Learning manuals. 3. A knowledge questionnaire. Knowledge and ability on management of patients with radiation dermatitis were increased 5.The patient and caregivers lack knowledge of health education and does not pay enough attention to daily nursing measures 1.Implement individual health education and guidance sessions. 2.Produce health education materials. 3.Make online videos of health education 3.Develop an electronic comprehensive health management platform for the entire treatment cycle Support from director and head nurse of department. Patients received education and their knowledge on radiation dermatitis increased. 6.The implementation of the current radiation dermatitis management protocol increased workload. Establish an information platform. 1.Support from the Nursing Department and Information Department. 2.Funding support. 1.The workload of nurses was reduced and efficiency improved 2.The nurse’s initiative in applying evidence was strengthened. Phase 3: follow-up audit and postimplementation survey A follow-up audit was conducted 8 weeks after phase 2 was completed. 0 case of severe (Grade Ⅲ) radiation dermatitis were found after the implementation of management protocol. In terms of system changes, we developed a radiation dermatitis management protocol and formed a multidisciplinary team, achieving progress from scratch. And both audit criteria demonstrated clinically significant improvement (Fig. 1 ). Of note, criterion 1,2,5,9,12,and 15 saw a 100% improvement in the compliance as compared with the 0% compliance rate in the baseline audit. And the compliance with criterion 3 increased from 0% at baseline audit to 68.18% at follow-up audit, and the compliance with criterion 4 increased from 42.31 to 73.08%. For criterion 6, the assessment frequency was adjusted according to their specific conditions in 92.31% of patients with radiation dermatitis, compared with 65.38% of patients at baseline audit. For criterion 7, 59.09% of patients take daily self-photos of the radiation site, compared with 0% of patients at baseline audit. For criterion 8, all patients also reported more targeted health education from nurses. Other feedback included improved daily care knowledge on dermatitis self-management, as well as the accuracy of patients using skin protectants has significantly improved. More details showed in Fig. 1 . Audit Criteria: 1. Radiation dermatitis management protocol and guidelines has been implemented. 2. A Multidisciplinary team were established. 3. The risk factors for radiation dermatitis of patient were correctly identified. 4.Radiation dermatitis assessment is undertaken using the RTOG scale correctly. 5. Subjective tools have been used to assess the effects of sever radiation dermatitis.6.Assessment of patients with radiation dermatitis is undertaken on a regular basis, the frequency of which is determined based on individual patient condition.7. Patients perform daily photographic documentation of irradiated skin areas.8.Patients or their caregivers received health education regarding radiation dermatitis and its management.9.Patient or caregivers have received evidence based written information on radiation dermatitis and its management.10.Nurses have been trained in radiation dermatitis education.11.Patients know the daily care of radiation dermatitis, including skin hygiene, moisturization protocol, irritant avoidance, trauma prevention, avoidance of UV exposure, barrier product application.12.Patients have been provided with a special individualized guide and supervision on radiation dermatitis management.13.For ≥ gradeⅡradiation dermatitis: application of soft silicone film dressings reduces wound healing time in nasopharynx cancer patient.14.Topical application of skin protectants during radiotherapy.15.Wound infection control protocol for radiation dermatitis Discussion Interpretation of data This study aimed to promote evidence-based management of radiation dermatitis in NPC patients using the JBI audit and feedback method. Data were evaluated from 22 patients and 26 nurses. Overall, the post-implementation audit result showed a remarkable increase in the compliance rate for most of all criteria. The implementation of the radiation dermatitis management protocol successfully reduced the incidence of GradeⅢradiation dermatitis from 9.09–0%. This demonstrates that evidence-based management strategies can effectively prevent severe radiation dermatitis and consequently improve patients’ quality of life. A management protocol for radiation dermatitis was developed based on the best evidence and implemented under the supervision of a multidisciplinary team. The multidisciplinary team includes doctors, nurses, radiation therapists, wound care specialists, oncology nurses, and nutrition specialists. The multidisciplinary team can better enhanced the management of dermatitis and provided solutions to problems encountered during the implementation, previous studies have also confirmed this result [ 16 ] . This team forms an organic combination that is patient-centered and supported by a group of multidisciplinary experts, ensuring that patients receive standardized and individualized dermatitis prevention and management in inpatient, outpatient, and radiation therapy settings. Firstly, the best available evidence recommends obtaining detailed patient medical histories related to individual risk factors for risk identification [ 17 ] , although there are no validated assessment tools. We have developed a risk assessment tool to address this clinical need and collaborated with the hospital’s IT department to integrate it into the nursing system, which achieved a significant increase in evaluation rates, rising from 0–68.18%. This is likely related to the application of electronic information systems, which can reduce documentation time, improve work efficiency, and increase motivation [ 18 ] . Secondly, assessing the grade of radiation dermatitis correctly is the first step in providing targeted care. However, since the department has not specified which dermatitis grading tool to use, nurses choose between the two common grading tools, CTCAE or RTOG, based on their preference, resulting inconsistency assessments in health care record. Therefore, it was difficult to compare the changes of skin conditions and evaluate effects of skin management. In the first audit, the correct rate of nurses use the RTOG grading system was 42.31%, The reason may be that the differences between the two assessment tools, leading to confusion in the content of the assessments. RTOG has been shown to have high rates of inter-observer variability when compared with other established systems [ 17 ] . After the intervention, nurses were required to use the RTOG as the skin grading tool and provided targeted training to improve the accuracy of assessments. Although the accuracy of assessments improved, it still did not reach the target value of 100%, further training will enhanced. In addition, nurses will use electronic follow-up platform assess the patient’s skin-related subjective symptoms and their severity(criterion 5), as well as evaluate the impact of radiation dermatitis on daily life, social interactions, and emotional well-being. If the patient’s symptoms are moderate or severe, nurses will conduct online inquiries to help patients cope with their symptoms and distress, which exemplifies holistic nursing care. Electronic platform may provide an effective strategy for improving symptom distress, self-efficacy, and fatigue among patients with cancer [ 19 ] . All nurses received training on radiation dermatitis and required to provided personalized guidance and supervision based on the patient’s dermatitis grade according recommendations [ 20 ] . For GradeⅠor lower, the focus is primarily on prevention, including daily care measures. For GradeⅡor higher, in addition to daily care measures, the approach includes the use of skin protectants and dressings, wound management, measures to promote wound healing, and procedures for handling infectious wounds. The criterion on the patient include daily self-observation of the radiation site by photo documentation(criteria 7), health education acceptance rate(criteria 8), possession of a written educational manual(criteria 9), mastery of daily care measures(criteria 11), usage rate of wound dressings for GradeⅡradiation dermatitis(criteria 13), and correct use of skin protectant(criteria 14). Compliance rates reached 90.91%~100% for all criteria except numbers 7 and 11. Strategies to overcome barriers Several barriers hindered the implementation of management protocol of dermatitis, including the patient’s adherence to regular assessments, lack of time, other professionals’ knowledge, and communication between nurses and patients [ 21 ] . Strategies to overcome these barriers included measures to remind patients, knowledge reinforcement to nurses, the application of the digital assessment and follow-up platform, improving the accessibility of educational materials (educational manuals and videos) and targeted reinforcements. Challenge faced in this project Although the overall outcome of this implementation was positive, we encountered challenges at various stages of the project. One challenge we faced was that, despite implementing a stamp on the radiotherapy process sheet to remind patients to visit the radiotherapy nursing clinic for radiation dermatitis risk assessment and health education, a small number of patients still did not comply. This may have been because the stamp was not noticeable or the patients did not take it seriously. To address this, we created a reminder slip that included the time, location, and a QR code for appointments, which the radiotherapy reception staff distributed along with the radiotherapy process sheet. This significantly improved the rates of risk assessment and health education acceptance. Another challenge we faced was that, for outpatients with severe radiation dermatitis, nurses use wound swabs to determine if the wound is infectious. However, nurses do not have the authority to prescribe this test, requiring patients to see a doctor again to have it prescribed. This results in longer waiting times, and complicated procedures, which limit both nurses’ and patients’ adherence to managing infectious wounds. Therefore, collaboration between medical staff is one of the challenges we face. As with any change in practice, it understandably took a period of time for medical staff to fully accept the change. Limitation of this project The limitations of this evidence-based project include the lack of baseline data on the proportion of GradeⅠandⅡradiation dermatitis and the timing of its onset, resulting in insufficient data for comparison. Additionally, our training methods for healthcare professionals were relatively limited. We should adopt diverse training approaches to enhance engagement and learning motivation. Sustainment of practice The project achieved 100% compliance with eight best practice criteria, and significantly reducing the incidence of serious dermatitis (Grade Ⅲ) to 0%. At the hospital level, our evidence-based nursing practice plan for radiation dermatitis has been incorporated into the hospital’s nursing guidelines. At the departmental level, we have now included radiation dermatitis management protocol into our annual teaching plan to facilitate its implementation throughout the department and continue to use electronic system for assessment, observation and followup. Lastly, we will conduct an audit of criteria compliance half- year to ensure sustainability. Conclusions The implementation of this project promotes compliance with evidence-based criteria among NPC patients for radiation dermatitis management and successfully accomplished most of all predefined objectives, which demonstrated how EBP improves clinical practice behavior. Notably from the audit results, there was a 0 case of Grade Ⅲ radiation dermatitis in the NPC patients undergoing radiotherapy, accompanied by substantially improved patient compliance with radiation dermatitis management protocols. Abbreviations NPC Nasopharyngeal carcinoma JBI PACES JBI Practical Application of Clinical Evidence System GRiP Getting Research into Practice RTOG Radiation Therapy Oncology Group Declarations Ethics Approval and Consent to Participate All methodologies employed in this program were rigorously conducted in accordance with the Principles of the Declaration of Helsinki. According to the notice issued by the National Health Commission of China regarding the ethical review procedures for human life sciences and medical research [15] , continuous quality improvement projects do not fall under the scope of ethical review. These projects do not involve new technologies or new diagnostic and treatment standards, but are intended to help institutions provide medical services based on the best evidence (evidence summaries). The risk involved is lower than minimal risk; therefore, ethics approval was waived by the Ethics Committee of Sun Yat-sen University Cancer Center. Although ethic approval was waived, we still obtained verbal informed consent from all patients and nurses involved, explaining the purpose and process of the project. Patients and nurses have the right to refuse participation. Consent for publication Not applicable. Availability of data and materials The data generated in this study are available from the corresponding author upon reasonable request. Competing Interests The authors declare that they have no competing interests. Funding The project was supported by the Natural Science Foundation of Guangzhou (NO. 2023A04J1775). The funders had no role in considering the project design or in the collection, analysis, interpretation of data, writing of the report, or decision to submit the article for publication. Authors’ contributions Min Hou contributed to the Conceptualization and methodology of the project, and writing-original draft. Wenhuan Zhong and Kefu Shi undertook investigation, data curation and project administration. Duoduo Pei, Liping Qi and Binbin Hou contributed to investigation, data curation. Huixia Feng and Jiali Liu provide resource support and writing-review and editing. All authors reviewed and endorsed the final manuscript. Acknowledgements We sincerely thank Professor Jun Ma and Yupei Chen for providing general support. Additional thanks to Dequan Kong who served in IT department for technical assistance with development of nursing system. References Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries[J]. CA Cancer J Clin. 2024;74(3):229–63. Chen YP, Chan A, Le QT, et al. Nasopharyng carcinoma[J] Lancet. 2019;394(10192):64–80. Wei J, Meng L, Hou X, et al. Radiation-induced skin reactions: mechanism and treatment[J]. Cancer Manag Res. 2019;11:167–77. Yang X, Ren H, Guo X, et al. Radiation-induced skin injury: pathogenesis, treatment, and management[J]. Aging. 2020;12(22):23379–93. Rosenthal A, Israilevich R, Moy R. Management of acute radiation dermatitis: A review of the literature and proposal for treatment algorithm[J]. J Am Acad Dermatol. 2019;81(2):558–67. Hymes SR, Strom EA, Fife C. Radiation dermatitis: clinical presentation, pathophysiology, and treatment 2006[J]. J Am Acad Dermatol. 2006;54(1):28–46. Yao Z, Cheng B. Morbidity in Patients with Nasopharyngeal Carcinoma and Radiation-Induced Skin Lesions: Cause, Risk Factors, and Dermatitis Evolution and Severity[J]. Adv Skin Wound Care. 2021;34(12):1–8. Brook I. Early side effects of radiation treatment for head and neck cancer[J]. Cancer Radiother. 2021;25(5):507–13. Feight D, Baney T, Bruce S, et al. Putting evidence into practice[J]. Clin J Oncol Nurs. 2011;15(5):481–92. Min Hou, W Z L Q. Establishment and practice of nurse specialist-led radiotherapy nursing clinic[J]. J Nursing(China). 2024;31(21):27–31. Yuanyuan Wang FJSY. Summary of the best evidence for the prevention and management of radiation dermatitis in patients with head and neck cancer[J]. J Nurses Train. 2024;39(04):401–7. Oddie K, Pinto M, Jollie S, et al. Identification of need for an evidence-based nurse-led assessment and management protocol for radiation dermatitis[J]. Cancer Nurs. 2014;37(2):E37–42. Jordan Z, Lockwood C, Munn Z, et al. The updated Joanna Briggs Institute Model of Evidence-Based Healthcare[J]. Int J Evid Based Healthc. 2019;17(1):58–71. Munn ZM, A P. K. Evidence implementation projects using an evidence-based audit and feedback approach: the JBI Implementation Framework. In: Porritt K, McArthur A, Lockwood C, Munn Z, editors. JBI Handbook for Evidence Implementation. JBI, 2020. [M]. 2020. The National Health Commission T M O E. Notice on Issuing Ethical Review Measures for Human Life Sciences and Medical Research_State Council Departmental. Document_Chinese Government Website[EB/OL]. [2025-07-09]. https://www.gov.cn/zhengce/zhengceku/2023-02/28/content_5743658.htm Yeh PH, Hung SK, Lee MS, et al. Implementing web-based ping-pong-type e-communication to enhance staff satisfaction, multidisciplinary cooperation, and clinical effectiveness: A SQUIRE-compliant quality-improving study[J]. Med (Baltim). 2016;95(44):e5236. Forde E, Van den Berghe L, Buijs M, et al. Practical recommendations for the management of radiodermatitis: on behalf of the ESTRO RTT committee[J]. Radiat Oncol. 2025;20(1):46. Lindsay MR, Lytle K. Implementing Best Practices to Redesign Workflow and Optimize Nursing Documentation in the Electronic Health Record[J]. Appl Clin Inf. 2022;13(3):711–9. Singleton AC, Raeside R, Hyun KK, et al. Electronic Health Interventions for Patients With Breast Cancer: Systematic Review and Meta-Analyses[J]. J Clin Oncol. 2022;40(20):2257–70. Behroozian T, Bonomo P, Patel P, et al. Multinational Association of Supportive Care in Cancer (MASCC) clinical practice guidelines for the prevention and management of acute radiation dermatitis: international Delphi consensus-based recommendations[J]. Lancet Oncol. 2023;24(4):e172–85. Clarke V, Lehane E, Mulcahy H, et al. Nurse Practitioners' Implementation of Evidence-Based Practice Into Routine Care: A Scoping Review[J]. Worldviews Evid Based Nurs. 2021;18(3):180–9. Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1QuestionnaireonKnowledgeofRadiationDermatitisPreventionandManagement.docx Supplementary File 1: Questionnaire on Knowledge of Radiation Dermatitis Prevention and Management Supplementaryfile2RadiationDermatitisRiskAssessmentFormandObservationForm.docx Supplementary File 2: Radiation Dermatitis Risk Assessment Form and Observation Form. Cite Share Download PDF Status: Published Journal Publication published 17 Mar, 2026 Read the published version in BMC Nursing → Version 1 posted Editorial decision: Revision requested 16 Feb, 2026 Reviews received at journal 09 Dec, 2025 Reviewers agreed at journal 08 Dec, 2025 Reviews received at journal 07 Dec, 2025 Reviewers agreed at journal 07 Dec, 2025 Reviewers agreed at journal 05 Dec, 2025 Reviewers agreed at journal 31 Aug, 2025 Reviewers invited by journal 29 Aug, 2025 Editor assigned by journal 09 Jul, 2025 Submission checks completed at journal 09 Jul, 2025 First submitted to journal 09 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6925142","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":509304084,"identity":"5ee53a52-aab0-4754-afd0-e3a475ac4238","order_by":0,"name":"Min Hou","email":"","orcid":"","institution":"Sun Yat-Sen University Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Min","middleName":"","lastName":"Hou","suffix":""},{"id":509304085,"identity":"5cfadaab-a357-4a86-b2ae-4e016ab81b66","order_by":1,"name":"Wenhuan Zhong","email":"","orcid":"","institution":"Sun Yat-Sen University Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Wenhuan","middleName":"","lastName":"Zhong","suffix":""},{"id":509304090,"identity":"4eef1621-c8a8-4db8-bd08-e31b163d3c04","order_by":2,"name":"Kefu Shi","email":"","orcid":"","institution":"Sun Yat-Sen University Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Kefu","middleName":"","lastName":"Shi","suffix":""},{"id":509304096,"identity":"71d93e2a-cc33-4fe0-8b33-b3dc5bea8830","order_by":3,"name":"Duoduo Pei","email":"","orcid":"","institution":"Sun Yat-Sen University Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Duoduo","middleName":"","lastName":"Pei","suffix":""},{"id":509304100,"identity":"c94dfdd5-81d2-4a23-9a1a-1abfb83b032a","order_by":4,"name":"Liping Qi","email":"","orcid":"","institution":"Sun Yat-Sen University Cancer 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Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYBACPmYGBoMHBjYkaGEDaUkoSCNFC4hI+HCYFC3sPAYFCQbn7Q3OnzH88IPBJl/egfnZA/wO4zEwSDC4nbjhRo6xZA9DmuXGA2zmBsRoSTC4wWMG9NdhA8MGHjYJIrScAzmMNC0HGDccyIFokWcgqIWtAKglOXHmjbRiyR6DNAMDZjYzvFr4+Q9vM/jwx86e7/zhjR9+VNgYyLc3P8OrBWQROHwUDoBIINOAiDhifgAi5RugXDhjFIyCUTAKRgEUAAA5dzwRwHI8pwAAAABJRU5ErkJggg==","orcid":"","institution":"Sun Yat-Sen University Cancer Center","correspondingAuthor":true,"prefix":"","firstName":"Jiali","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2025-06-18 17:23:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6925142/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6925142/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12912-026-04548-5","type":"published","date":"2026-03-17T15:58:47+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":90897631,"identity":"528b798c-a436-4678-b8c8-b65f71995836","added_by":"auto","created_at":"2025-09-09 11:46:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":22807,"visible":true,"origin":"","legend":"\u003cp\u003eThe compliance with fifteen audit criteria at baseline audit and follow-up audit.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6925142/v1/838e97b8e5ba57576535cb1e.png"},{"id":105224541,"identity":"1b9ee7d0-18bf-4701-b00c-3277228bdf29","added_by":"auto","created_at":"2026-03-23 16:15:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":961915,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6925142/v1/0acb9a3b-5315-4c04-a2b6-c50a1a5c2e55.pdf"},{"id":90896899,"identity":"267f0a22-00a8-4e5d-84c7-991cb170e42f","added_by":"auto","created_at":"2025-09-09 11:38:46","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":511266,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary File 1: Questionnaire on Knowledge of Radiation Dermatitis Prevention and Management\u003c/p\u003e","description":"","filename":"Supplementaryfile1QuestionnaireonKnowledgeofRadiationDermatitisPreventionandManagement.docx","url":"https://assets-eu.researchsquare.com/files/rs-6925142/v1/ec2055c2f30036c4195e0a18.docx"},{"id":90894605,"identity":"c2d6ac20-9ff4-48ca-9af5-3ed539c8d2c4","added_by":"auto","created_at":"2025-09-09 11:30:46","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":19564,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary File 2: Radiation Dermatitis Risk Assessment Form and Observation Form.\u003c/p\u003e","description":"","filename":"Supplementaryfile2RadiationDermatitisRiskAssessmentFormandObservationForm.docx","url":"https://assets-eu.researchsquare.com/files/rs-6925142/v1/5300a381def29060b7601715.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prevention and management of radiation dermatitis for patients with Nasopharyngeal carcinoma: a best practice implementation project","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNasopharyngeal carcinoma(NPC) exhibits endemic prevalence in Southern China and Southeast Asian countries (over 70 cases per 100,000 people), with about 47% of cases globally found in China, placing it at the forefront of NPC incidence worldwide\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Radiation therapy is the preferred treatment method for NPC, involving the irradiation of the head and neck area to kill tumor cells, thereby extending the survival period and potentially achieving a curative effect\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. However, it exerted a potent destructive effect on normal tissue cells within the irradiation field. Radiation dermatitis is one of the most common complications during radiation therapy, characterized by pigmentation, erythema, desquamation, inflammatory exudate, and even ulcerative necrosis at the treatment site\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. In contrast to burns and ulcers, radiation penetrates beyond the epidermal layer, causing cellular-level damage to subcutaneous structures. This leads to dryness, loss of elasticity, pigmentation, soft tissue fibrosis, capillary dilation, and radiation dermatitis in the irradiated areas\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Additionally, radiation inflicts irreversible harm on the microvascular and small blood vessel endothelial cells within the skin tissue. Consequently, it takes a long time to heal and easily infected. Therefore, it is crucial to alleviate or even eradicate radiation dermatitis\u003c/p\u003e\n\u003cp\u003eNearly 85%~95% of NPC patients will experience varying degrees of radiation dermatitis during radiation therapy\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Notably, due to skin folds in the head and neck area, which are prone to sweat and moisture, and UV exposure predispose radiation dermatitis and the condition more severe\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Studies had shown that the occurrence rate of grade Ⅲ radiation dermatitis in the head and neck area can reach 49%, which may cause physical pain and discomfort, as well as psychological problems such as low self-esteem and sadness, increase financial burdens, and even lead to treatment interruptions, affecting the treatment effectiveness and the patient\u0026rsquo;s quality of life\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Management strategies for radiation dermatitis are stratified by severity and daily skin care measures, prevention and treatment of secondary skin infection, and the application of dressings and protectant\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eNurses played a essential role in the management of radiation dermatitis including risk identification, assessment, prevention, management, evaluation of management effectiveness, and patient health education\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. The Radiotherapy Nursing Outpatient Clinic at Sun Yat-sen university cancer centre is dedicated to the full-cycle symptom management of radiation therapy patients. To date, the clinic has treated 929 radiation dermatitis patients, accounting for 73.43% of the nursing outpatient volume, with NPC radiation dermatitis accounting for approximately 86.42%\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. There is a high demand from patients for nursing care related to radiation dermatitis. However, there are gaps between the management of radiation dermatitis in our hospital\u0026rsquo;s radiotherapy nursing outpatient clinic and the existing best evidence\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e, such as the lack of identification of high-risk factors and comprehensiveness and scientific basis in nursing measures for radiation dermatitis, resulting in an absence of homogeneity in the health education and poor outcomes in the treatment of grade Ⅱ~Ⅲ radiation dermatitis wounds. A system-wide standardized approach to managing radiation dermatitis in NPC patients is urgent\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e, specifically a skin management protocol should be established that defines risk identification, type and frequency of skin assessments and incorporate best evidence recommends for prevention and management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims and objectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe aim of this project was form and conduct the structure prevention and management of radiation dermatitis based on the best evidence in the Department of Radiation Oncology in Sun Yat-sen university cancer centre. The specific objectives were as follows:\u003c/p\u003e\n\u003cp\u003e(1) To identify gaps between the current practice of radiation dermatitis management and the best evidence.\u003c/p\u003e\n\u003cp\u003e(2) To develop tailored strategies for addressing the low compliance with evidence-based audit criteria during the baseline audit.\u003c/p\u003e\n\u003cp\u003e(3) To implement strategies to enhance compliance with practices for assessment, prevention, and management of radiation dermatitis based on evidence.\u003c/p\u003e\n\u003cp\u003e(4) To evaluate the post-implementation impact by conducting a second audit involving patients, practitioners, and systems to enhance clinical practice.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe project was conducted in the Radiation Oncology Department of Sun Yat-sen university cancer centre, which admits over 18000 patients in last year and ranked first globally for four consecutive years. The centre serve with 17 accelerators, and include 2 outpatient treatment areas and 5 inpatient wards with 334 hospital beds. The area of implementation was oncology radiotherapy care clinic which targeted to manage radiation-induced toxicities and Radiotherapy Ward One primarily admits patients with NPC. 5 nurses take turns to work shifts on weekdays in oncology radiotherapy care clinic, and all of whom are specialty nurses with the range of oncology, nutrition and rehabilitation.\u003c/p\u003e\u003cp\u003eThe current evidence implementation initiative employed the JBI Practical Application of Clinical Evidence System (JBI PACES) \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003eand Getting Research into Practice (GRiP) audit and feedback tool\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. This framework aimed at advancing evidence-based healthcare, unfolds in three phases. Initially, the project team is formed, and the baseline survey conducted using a self-developed questionnaire on radiation dermatitis prevention and management knowledge (Supplementary File 1). In the second phase, the team reviews and reflects on the baseline audit results, then develops and executes strategies to address the identified practice gaps. The final phase involves a follow-up audit to evaluate the project's outcomes. Additionally, a post-implementation survey is conducted to assess the knowledge of nurses and patients on managing dermatitis, and data is collected on the severity of patients\u0026rsquo; dermatitis and subjective symptoms before and after the implementation, to inform future practice improvements.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSamples\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis is an evidence-based implementation project. From March to June 2024, we enrolled 22 nasopharyngeal carcinoma patients preparing for radiotherapy in the baseline audit and 22 patients during October to December in the post-implementation follow-up audit. Inclusion criteria were as follows: Initially diagnosed with nasopharyngeal carcinoma through pathology, with the disease staged at Ⅰ to Ⅲ; the treatment plan includes radiotherapy.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAnalysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCompliance data changes were analyzed using descriptive statistics in Microsoft Excel 2019, and displayed as percentage variations from the initial baseline.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEthical considerations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAccording to the notice issued by the National Health Commission of China\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e regarding the ethical review procedures for human life sciences and medical research, continuous quality improvement projects do not fall under the scope of ethical review. These projects do not involve new technologies or new diagnostic and treatment standards, but are intended to help institutions provide medical services based on the best evidence (evidence summaries). The risk involved is lower than minimal risk; therefore, ethics approval was waived by the Ethics Committee of Sun Yat-sen University Cancer Center. Although ethic approval was waived, we still obtained verbal informed consent from all patients and nurses involved, explaining the purpose and process of the project. Patients and nurses have the right to refuse participation. All collected data were anonymized to protect the privacy of participants. This investigation conforms with the Principles of the Declaration of Helsinki.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePhase 1: Team establishment and baseline audit\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll pertinent stakeholders, encompassing both patients and project team members, were actively involved in this project. The project team is composed of multiple disciplines and comprised of 14 members, including the team leader and an evidence-based nurse(EBN), department director, head nurse, radiation oncologists, radiation technicians, specialized nurses, and wound specialists. Team members involved in the project were clearly positioned to offer the necessary support and resources. Their respective positions and roles were detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1 \u0026nbsp;Team Establishment\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eTeam member\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003ePosition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 298px;\"\u003e\n \u003cp\u003eRole/Responsibility\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eMember 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eProject executive director\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 298px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eExamination of the most reliable evidence available\u003c/li\u003e\n \u003cli\u003eDeveloping the process for implementing project\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePerformed preaudit and postaudit\u003c/li\u003e\n \u003cli\u003eAnalyzing the results and outcomes\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eMember 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eEvidence-based nurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 298px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eMethodological guidance\u003c/li\u003e\n \u003cli\u003eDesigning strategies\u003c/li\u003e\n \u003cli\u003eGuiding the change according to the clinical audit in the project.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eMember 3, 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eDepartment director\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 298px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eSystem leader\u003c/li\u003e\n \u003cli\u003eFacilitating and driving progress toward change, providing human, physical and financial resources\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eMember 4, 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eHead nurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 298px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eOvercoming obstacles\u003c/li\u003e\n \u003cli\u003eOrganizing nurse education and training\u003c/li\u003e\n \u003cli\u003eOverall project management including planning, promotion, decision-making, and quality control\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eMember 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eRadiation oncologists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 298px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eCommunicating and coordinating with patients\u003c/li\u003e\n \u003cli\u003eOffering constructive feedback.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eMember 7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eradiation technicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 298px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eFacilitating and driving progress toward change\u003c/li\u003e\n \u003cli\u003eApplying evidence\u003c/li\u003e\n \u003cli\u003eProviding feedback\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eMember 9, 10, 11, 12, 13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003especialized nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 298px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eDay-to-day leadership\u003c/li\u003e\n \u003cli\u003eApplying evidence on radiation dermatitis management\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCollecting and analyzing data\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eMember 14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003ewound specialists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 298px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eResponsible for consultations on complex radiation dermatitis, especially Grade Ⅳ radiation dermatitis.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ePrior to performing the baseline audit, meetings and discussions took place to establish the criteria, sample size, and methods of data collection. In the baseline audit, sample selection was based on convenience, and methods for collecting data encompassed questioning patients, conducting interviews, and examining both electronic and paper documents. Table 2 outlines the criteria used in \u0026nbsp;the baseline and the second audits, including the sample size and the methodology applied to assess adherence to best practices for each criterion. The baseline audit was implemented from February 1 to March 18, 2024, with patients who had undergone radiotherapy between November 17, 2023 and January 26, 2024, and met the inclusion criteria. 22 patients were included to assess how well current clinical practices align with evidence-based best practices for evaluating and managing radiation dermatitis. We used a checklist to assess patients\u0026rsquo; and nurses\u0026rsquo; compliance with each audit criterion. The accuracy rate, evidence implementation compliance rate, and score distribution were calculated. And the incidence of gradeⅡor higher radiation dermatitis was also recorded. The ultimate compliance data were imported into Excel software to acquire the baseline audit outcomes for each criterion. The audit criterions were showed in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 Criteria for the audit, sample size, and method for the measurement of compliance with best practice\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003eAudit criterion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eSample\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 244px;\"\u003e\n \u003cp\u003eMethod used to measure the compliance with the best practice\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e1.Radiation dermatitis management protocol and \u0026nbsp;guidelines for nasopharynx cancer patient has been implemented\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eBaseline audit: 22 patients\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFollow-up audit: 22 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 244px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eMeasured by documentation reviewing\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eYes, if standardized radiation dermatitis programs had been documented in written format.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e2. A Multidisciplinary team comprising radiation oncologists, oncology nurses, radiation therapists, \u0026nbsp;wound care specialists were established\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eBaseline audit: 22 patients\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFollow-up audit: 22 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 244px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eMeasured by documentation reviewing \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eYes, if a multidisciplinary consultation protocol has been established for severe radiation dermatitis and documented in written form.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e3.The risk factors for radiation dermatitis of patient were correctly identified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eBaseline audit: 26 nurses\u003c/p\u003e\n \u003cp\u003eFollow-up audit: 26 nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 244px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eMeasured by reviewing the documentation\u003c/li\u003e\n \u003cli\u003eYes, if nurses assess patients for radiation dermatitis risk factors and classify them into different risk levels in nursing documentation.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e4.Radiation dermatitis assessment is undertaken using the RTOG scales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eBaseline audit: 26 nurses\u003c/p\u003e\n \u003cp\u003eFollow-up audit: 26 nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 244px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eMeasured by reviewing the documentation\u003c/li\u003e\n \u003cli\u003eYes, if nurses accurately grade radiation dermatitis severity in patients using RTOG criteria.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003col start=\"5\"\u003e\n \u003cli\u003eSubjective tools have been used to assess the effects of sever radiation dermatitis\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eBaseline audit: 26 nurses\u003c/p\u003e\n \u003cp\u003eFollow-up audit: 26 nurses\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 244px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eMeasured by reviewing the electronic nursing records\u003c/li\u003e\n \u003cli\u003eYes, if nurses use Skindex-16 tools to assess the subjective symptoms of patient who are in sever radiation dermatitis.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003col start=\"6\"\u003e\n \u003cli\u003eAssessment of patients with radiation dermatitis is undertaken on a regular basis, the frequency of which is determined based on individual patient condition.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eBaseline audit: 26 nurses\u003c/p\u003e\n \u003cp\u003eFollow-up audit: 26 nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 244px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eMeasured by reviewing the electronic nursing records and follow-up record\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eYes, if nurses assess inpatient who are in gradeⅡand above everyday . In addition, outpatient who are in gradeⅡand above should be assessed at least twice a week\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003col start=\"7\"\u003e\n \u003cli\u003ePatients perform daily photographic documentation of irradiated skin areas\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eBaseline audit: 22 patients\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFollow-up audit: 22 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 244px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eMeasured by interviewing patients.\u003c/li\u003e\n \u003cli\u003eYes, patients take daily photos for recording the change of radiation area\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e8.Patients or their caregivers received health education regarding radiation dermatitis and its management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eBaseline audit: 22 patients\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFollow-up audit: 22 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 244px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eMeasured by interviewing patients.\u003c/li\u003e\n \u003cli\u003eYes, if patient answer yes and correct response rate for health education content exceeds 90%\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e9.Patient or caregivers have received evidence based written information on radiation dermatitis and its management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eBaseline audit: 22 patients\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFollow-up audit: 22 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 244px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eMeasured by reviewing the documentation\u003c/li\u003e\n \u003cli\u003eYes, if patient get access to written information, such as patient education brochure, video etc.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e10.Nurses have been trained in radiation dermatitis education.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eBaseline audit: 26 nurses\u003c/p\u003e\n \u003cp\u003eFollow-up audit: 26 nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 244px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eMeasured by interviewing and assessing nurses.\u003c/li\u003e\n \u003cli\u003eYes, if nurses answer yes. In addition, the nurses\u0026rsquo; radiation dermatitis knowledge was evaluated in the form of a questionnaire.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e11.Patients know the daily care of radiation dermatitis, including skin hygiene, moisturization protocol, irritant avoidance, trauma prevention, avoidance of UV exposure, barrier product application\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eBaseline audit: 22 patients\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFollow-up audit: 22 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 244px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eMeasured by interviewing patient\u003c/li\u003e\n \u003cli\u003eask patients questions about the daily care of radiation dermatitis. Yes, if the patient correct response rate exceeds 90%\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e12.Patients have been provided with a special \u0026nbsp;individualized guide and supervision on radiation dermatitis management.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eBaseline audit: 26 nurse\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFollow-up audit: 26 nurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 244px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eMeasured by interviewing nurse\u003c/li\u003e\n \u003cli\u003eYes, if nurse are competent in providing level-specific care for patients with radiation dermatitis\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e13.For\u0026nbsp;\u0026ge;gradeⅡradiation dermatitis: application of soft silicone film dressings reduces wound healing time in nasopharynx cancer patient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eBaseline audit: 22 patients\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFollow-up audit: 22 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 244px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eMeasured by reviewing the documentation\u003c/li\u003e\n \u003cli\u003eYes, if nurses correctly apply dressings for patients with GradeⅡand above radiation dermatitis\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e14.Topical application of \u0026nbsp;skin protectants during radiotherapy.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eBaseline audit: 22 patients\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFollow-up audit: 22 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 244px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eMeasured by interviewing \u0026nbsp;the patient\u003c/li\u003e\n \u003cli\u003eYes, if the patient grasp the correct use of skin protectants\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e15.Wound infection control protocol for radiation dermatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eBaseline audit: 26 nurses\u003c/p\u003e\n \u003cp\u003eFollow-up audit: 26 nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 244px;\"\u003e\n \u003cul start=\"50\"\u003e\n \u003cli\u003eMeasured by interviewing nurse\u003c/li\u003e\n \u003cli\u003eYes, if nurses can accurately master the identification of infected wounds, wound assessment, wound swab collection, and the management protocol for infected wounds.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhase 2 design and implementation of strategies to improve practice (Getting Research into Practice)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter the baseline audit, the results were presented to both the project team members and the clinical staff. Based on the Knowledge-to-Action framework, the project team conducted a barrier analysis from three perspectives: the evidence itself, the practice environment, and potential adopters, then developed strategies to overcome these barriers. Through feedback from nurses, potential implementation barriers were identified. Subsequently, A structured action plan was developed, employing institutional resources to formulate barrier-mitigation strategies for facilitating evidence-based practice implementation. A GRiP report was then shared with the nursing staff, followed by a communication meeting to introduce the project objectives and clarify individual roles.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhase 3 follow up audit\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA second audit was conducted using the same criteria in the baseline audit. This audit spanned 3 weeks using the same number of patients and the same nurses from 10 November 2024 to 1 December 2024.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003ePhase 1: baseline audit\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe baseline results are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The results indicate 0% compliance for eight criteria (1,2, 3, 5, 7, 9, 12, and 15), namely, radiation dermatitis management protocol for nasopharyngeal ptient; a multidisciplinary team for severe radiation dermatitis; the risk identification for radiation dermatitis; assessment tool for radiation dermatitis effect; patients perform daily photographic documentation of irradiated skin areas; written information on radiation dermatitis and its management for patient; special individualized guidance and supervision of patients. The best performance was seen criteria 10 that 96.15% had been trained in radiation dermatitis patient education, and 65.38% nurses assess patient in regular. Criteria 8 showed that 86.36% patient had received health education before radiotherapy. However, the accuracy rate of criteria 4 (radiation dermatitis assessment using RTOG criteria) was only 42.31%. Besides, 4.54% of patients could fully grasp the daily skin care measures during radiotherapy. Compliance with Criteria 13 and 14 (i.e.application of soft silicone film dressings, Topical application of skin protectants) were 9.09\u0026ndash;18.18%. Among 22 patients after radiotherapy, there were reported a 9.09% incidence of Grade Ⅲ radiation dermatitis.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePhase 2: strategies for getting research into practice\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDuring this phase, six primary barriers were systematically identified. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e comprehensively outlines these barriers along with their corresponding resources, strategies, and outcomes. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e displayed strategies from the Getting Research into Practice matrix.\u003c/p\u003e\u003cp\u003e\u003cb\u003eBarrier1\u003c/b\u003e: Radiotherapy treatment involves complex workflows spanning multiple departments, creating significant coordination challenges due to the absence of structured multidisciplinary team support. To solve this problem, a multidisciplinary team were established consisting of the department head, clinical doctor, head nurses, radiation therapists, oncology specialist nurses, nutrition specialist nurses, wound and ostomy care nurses, and evidence-based nursing specialists. The team is responsible for the development, implementation, supervision, and quality control of the radiation dermatitis management protocol. And the contents of management included the prevention and management of radiation dermatitis throughout the radiotherapy cycle include risk assessment, health education, psychological support, wound cleansing, infection control, wound healing promotion, and nutritional assessment and intervention. Multidisciplinary meetings took place monthly, where team members engaged in thorough discussions and communications before offering appropriate guidance to patients. Patients with gradeⅠ~Ⅱradiation dermatitis were followed up by specialist nurses once a week and more than gradeⅡradiation dermatitis were followed up twice a week.\u003c/p\u003e\u003cp\u003e\u003cb\u003eBarrier 2\u003c/b\u003e: There is currently no standardized protocol for managing radiation dermatitis, leading to inconsistent clinical practices. The multidisciplinary project team developed radiation dermatitis management protocol. This protocol could be divided into four phases:(1) standardized assessment protocols, (2) structured patient education, (3) evidence-based interventions for grade \u0026ge;Ⅱcases, and (4) systematic follow-up monitoring. The established radiation dermatitis management protocol shall be incorporated into routine clinical workflows. Comprehensive training will be provided to all nursing staff, with compliance monitoring overseen by department head nurses, team leaders, and clinical nurse specialists to ensure proper protocol implementation.\u003c/p\u003e\u003cp\u003e\u003cb\u003eBarrier 3\u003c/b\u003e: Radiation dermatitis involves multiple risk factors, yet there is no standardized classification system for risk stratification. To address the absence of grading criteria, the team member developed a risk assessment tool based on the literature review, combined with the established Grade Ⅲradiation dermatitis risk prediction model and expert consultation. The Radiation Dermatitis Risk Assessment tool comprised 12 items, with evaluation results categorized into two levels: low risk and high risk(Supplementary File 2). Patients evaluated to be at high risk for radiation dermatitis are guided and supervised by the primary nurse to visit the radiotherapy specialist nursing clinic twice a week for assessment, while low-risk patients visited once a week.\u003c/p\u003e\u003cp\u003e\u003cb\u003eBarrier 4\u003c/b\u003e: Medical staff have not received the latest knowledge and skills training on the prevention and care of radiation dermatitis. To address this barrier, the team members developed a training plan for ward doctors, nurses, and outpatient specialist nurses. A total of six training sessions were conducted, two of which were online, each lasting one hour. The training content was based on the latest evidence summary and designed by the team leader. Electronic handouts were distributed to each participant. The training primarily covered the importance of radiation dermatitis management, clinical manifestations of radiation dermatitis, risk factors, assessment tools, prevention and treatment, daily care, medication precautions, health education, management principles for different levels of radiation dermatitis, the procedure for handling severe radiation dermatitis, follow-up monitoring, and the use of the electronic assessment system. After the training, knowledge acquisition was assessed through questions or electronic questionnaires.\u003c/p\u003e\u003cp\u003e\u003cb\u003eBarrier5\u003c/b\u003e: The patient and caregivers lack knowledge of health education and does not pay enough attention to daily nursing measures, resulting in low compliance rates. In response to this identified issue,, we adopted diverse and easy-to-understand approaches to health education. In addition to face-to-face health education, we produced educational videos on radiation dermatitis and played on a loop in patient wards, made and distributed health education materials to patients including handbooks and patient diary forms, and encouraged the involvement and supervision of caregivers. Furthermore, we developed an electronic comprehensive health management platform for the entire treatment cycle which enabled patients to report discomfort symptoms at any time and allowed for real-time communication between nurses and patients to address concerns. Once patients join, they can access to relevant health education materials. The platform is managed by dedicated personnel who was responsible for weekly collection of patients\u0026rsquo; subjective skin symptoms, photos of their neck skin, and the impact of skin conditions on their life, emotions, and social interactions. They also address patients\u0026rsquo; questions regarding radiation dermatitis care. Patients who do not fill out the information on time will receive a pop-up reminder message on their phones.\u003c/p\u003e\u003cp\u003e\u003cb\u003eBarrier6\u003c/b\u003e: The implementation of the current radiation dermatitis management protocol requires nurses to invest more time, increasing their workload. To improve efficiency and reduce the burden on nurses, by coordinating with the Nursing Department and Information Department, the risk assessment form and the radiation dermatitis observation record form have been integrated into the nursing system and the hospital information system, establishing an information platform. After the nurse completes the assessment, the electronic information system automatically calculates the results based on the content of the nurse\u0026rsquo;s assessment and improve the efficiency. The system was also connected to portable iPad equipped with camera functions. And the use of portable iPad allowed nurses to complete assessments, take photos of radiation site, and record information directly at the patient\u0026rsquo;s bedside, eliminating the need to first record on paper and then upload to the nursing system at the nurse\u0026rsquo;s station. This reduces repetitive tasks and the time spent traveling back and forth to patient beds.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eStrategies for Getting Research into Practice matrix\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBarriers\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStrategies\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eResources\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOutcomes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. The lack of a multidisciplinary team to manage patients with radiation dermatitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEstablish a multidisciplinary team.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1. Hospital supports multidisciplinary cooperation.\u003c/p\u003e\u003cp\u003e2. Support from the Nursing Department, Department Heads, Radiotherapy Center Technician Team, and Wound and Ostomy Specialists.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEstablish a multidisciplinary team consisting of the department head, clinical doctor, head nurses, radiation therapists, oncology specialist nurses, nutrition specialist nurses, wound and ostomy care nurses, and evidence-based nursing specialists.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2.The lack of standardized protocol for managing radiation dermatitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEstablish a standardized protocol based on the best evidence for managing radiation dermatitis.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1. Intervention team (doctor,and evidence-based nursing specialists, nurses).\u003c/p\u003e\u003cp\u003e2. Summary of the existing best evidence.\u003c/p\u003e\u003cp\u003e3. Evidence-based training in hospitals.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEstablish a standardized protocol based on the best evidence for assessing, grading, educating, managing and monitoring radiation dermatitis\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3.The lack of standardized classification system for risk stratification.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEstablish a standardized classification system for risk stratification.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.Previously published work,including a predict model for radiation dermatitis.\u003c/p\u003e\u003cp\u003e2.Clinical experience.\u003c/p\u003e\u003cp\u003e3.Available database resources\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEstablish a standardized classification system for risk stratification\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4.Medical staff lacked the latest knowledge and skills training on the prevention and care of dermatitis.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.Create a training plan for medical staff.\u003c/p\u003e\u003cp\u003e2.Provide each medical staff with a training manual.\u003c/p\u003e\u003cp\u003e3.Administer a knowledge quiz to assess their understanding following the training.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1. A training plan.\u003c/p\u003e\u003cp\u003e2. Learning manuals.\u003c/p\u003e\u003cp\u003e3. A knowledge questionnaire.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eKnowledge and ability on management of patients with radiation dermatitis were increased\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5.The patient and caregivers lack knowledge of health education and does not pay enough attention to daily nursing measures\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.Implement individual health education and guidance sessions.\u003c/p\u003e\u003cp\u003e2.Produce health education materials.\u003c/p\u003e\u003cp\u003e3.Make online videos of health education\u003c/p\u003e\u003cp\u003e3.Develop an electronic comprehensive health management platform for the entire treatment cycle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSupport from director and head nurse of department.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePatients received education and their knowledge on radiation dermatitis increased.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6.The implementation of the current radiation dermatitis management protocol increased workload.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEstablish an information platform.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.Support from the Nursing Department and Information\u003c/p\u003e\u003cp\u003eDepartment.\u003c/p\u003e\u003cp\u003e2.Funding support.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.The workload of nurses was reduced and efficiency improved\u003c/p\u003e\u003cp\u003e2.The nurse\u0026rsquo;s initiative in applying evidence was strengthened.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePhase 3: follow-up audit and postimplementation survey\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA follow-up audit was conducted 8 weeks after phase 2 was completed. 0 case of severe (Grade Ⅲ) radiation dermatitis were found after the implementation of management protocol. In terms of system changes, we developed a radiation dermatitis management protocol and formed a multidisciplinary team, achieving progress from scratch. And both audit criteria demonstrated clinically significant improvement (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Of note, criterion 1,2,5,9,12,and 15 saw a 100% improvement in the compliance as compared with the 0% compliance rate in the baseline audit. And the compliance with criterion 3 increased from 0% at baseline audit to 68.18% at follow-up audit, and the compliance with criterion 4 increased from 42.31 to 73.08%. For criterion 6, the assessment frequency was adjusted according to their specific conditions in 92.31% of patients with radiation dermatitis, compared with 65.38% of patients at baseline audit. For criterion 7, 59.09% of patients take daily self-photos of the radiation site, compared with 0% of patients at baseline audit. For criterion 8, all patients also reported more targeted health education from nurses. Other feedback included improved daily care knowledge on dermatitis self-management, as well as the accuracy of patients using skin protectants has significantly improved. More details showed in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAudit Criteria: 1. Radiation dermatitis management protocol and guidelines has been implemented. 2. A Multidisciplinary team were established. 3. The risk factors for radiation dermatitis of patient were correctly identified. 4.Radiation dermatitis assessment is undertaken using the RTOG scale correctly. 5. Subjective tools have been used to assess the effects of sever radiation dermatitis.6.Assessment of patients with radiation dermatitis is undertaken on a regular basis, the frequency of which is determined based on individual patient condition.7. Patients perform daily photographic documentation of irradiated skin areas.8.Patients or their caregivers received health education regarding radiation dermatitis and its management.9.Patient or caregivers have received evidence based written information on radiation dermatitis and its management.10.Nurses have been trained in radiation dermatitis education.11.Patients know the daily care of radiation dermatitis, including skin hygiene, moisturization protocol, irritant avoidance, trauma prevention, avoidance of UV exposure, barrier product application.12.Patients have been provided with a special individualized guide and supervision on radiation dermatitis management.13.For \u0026ge;\u0026thinsp;gradeⅡradiation dermatitis: application of soft silicone film dressings reduces wound healing time in nasopharynx cancer patient.14.Topical application of skin protectants during radiotherapy.15.Wound infection control protocol for radiation dermatitis\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cb\u003eInterpretation of data\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study aimed to promote evidence-based management of radiation dermatitis in NPC patients using the JBI audit and feedback method. Data were evaluated from 22 patients and 26 nurses. Overall, the post-implementation audit result showed a remarkable increase in the compliance rate for most of all criteria. The implementation of the radiation dermatitis management protocol successfully reduced the incidence of GradeⅢradiation dermatitis from 9.09\u0026ndash;0%. This demonstrates that evidence-based management strategies can effectively prevent severe radiation dermatitis and consequently improve patients\u0026rsquo; quality of life.\u003c/p\u003e\u003cp\u003eA management protocol for radiation dermatitis was developed based on the best evidence and implemented under the supervision of a multidisciplinary team. The multidisciplinary team includes doctors, nurses, radiation therapists, wound care specialists, oncology nurses, and nutrition specialists. The multidisciplinary team can better enhanced the management of dermatitis and provided solutions to problems encountered during the implementation, previous studies have also confirmed this result\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. This team forms an organic combination that is patient-centered and supported by a group of multidisciplinary experts, ensuring that patients receive standardized and individualized dermatitis prevention and management in inpatient, outpatient, and radiation therapy settings. Firstly, the best available evidence recommends obtaining detailed patient medical histories related to individual risk factors for risk identification\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e, although there are no validated assessment tools. We have developed a risk assessment tool to address this clinical need and collaborated with the hospital\u0026rsquo;s IT department to integrate it into the nursing system, which achieved a significant increase in evaluation rates, rising from 0\u0026ndash;68.18%. This is likely related to the application of electronic information systems, which can reduce documentation time, improve work efficiency, and increase motivation\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eSecondly, assessing the grade of radiation dermatitis correctly is the first step in providing targeted care. However, since the department has not specified which dermatitis grading tool to use, nurses choose between the two common grading tools, CTCAE or RTOG, based on their preference, resulting inconsistency assessments in health care record. Therefore, it was difficult to compare the changes of skin conditions and evaluate effects of skin management. In the first audit, the correct rate of nurses use the RTOG grading system was 42.31%, The reason may be that the differences between the two assessment tools, leading to confusion in the content of the assessments. RTOG has been shown to have high rates of inter-observer variability when compared with other established systems\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. After the intervention, nurses were required to use the RTOG as the skin grading tool and provided targeted training to improve the accuracy of assessments. Although the accuracy of assessments improved, it still did not reach the target value of 100%, further training will enhanced. In addition, nurses will use electronic follow-up platform assess the patient\u0026rsquo;s skin-related subjective symptoms and their severity(criterion 5), as well as evaluate the impact of radiation dermatitis on daily life, social interactions, and emotional well-being. If the patient\u0026rsquo;s symptoms are moderate or severe, nurses will conduct online inquiries to help patients cope with their symptoms and distress, which exemplifies holistic nursing care. Electronic platform may provide an effective strategy for improving symptom distress, self-efficacy, and fatigue among patients with cancer\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAll nurses received training on radiation dermatitis and required to provided personalized guidance and supervision based on the patient\u0026rsquo;s dermatitis grade according recommendations\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. For GradeⅠor lower, the focus is primarily on prevention, including daily care measures. For GradeⅡor higher, in addition to daily care measures, the approach includes the use of skin protectants and dressings, wound management, measures to promote wound healing, and procedures for handling infectious wounds. The criterion on the patient include daily self-observation of the radiation site by photo documentation(criteria 7), health education acceptance rate(criteria 8), possession of a written educational manual(criteria 9), mastery of daily care measures(criteria 11), usage rate of wound dressings for GradeⅡradiation dermatitis(criteria 13), and correct use of skin protectant(criteria 14). Compliance rates reached 90.91%~100% for all criteria except numbers 7 and 11.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrategies to overcome barriers\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSeveral barriers hindered the implementation of management protocol of dermatitis, including the patient\u0026rsquo;s adherence to regular assessments, lack of time, other professionals\u0026rsquo; knowledge, and communication between nurses and patients\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. Strategies to overcome these barriers included measures to remind patients, knowledge reinforcement to nurses, the application of the digital assessment and follow-up platform, improving the accessibility of educational materials (educational manuals and videos) and targeted reinforcements.\u003c/p\u003e\u003cp\u003e\u003cb\u003eChallenge faced in this project\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAlthough the overall outcome of this implementation was positive, we encountered challenges at various stages of the project. One challenge we faced was that, despite implementing a stamp on the radiotherapy process sheet to remind patients to visit the radiotherapy nursing clinic for radiation dermatitis risk assessment and health education, a small number of patients still did not comply. This may have been because the stamp was not noticeable or the patients did not take it seriously. To address this, we created a reminder slip that included the time, location, and a QR code for appointments, which the radiotherapy reception staff distributed along with the radiotherapy process sheet. This significantly improved the rates of risk assessment and health education acceptance.\u003c/p\u003e\u003cp\u003eAnother challenge we faced was that, for outpatients with severe radiation dermatitis, nurses use wound swabs to determine if the wound is infectious. However, nurses do not have the authority to prescribe this test, requiring patients to see a doctor again to have it prescribed. This results in longer waiting times, and complicated procedures, which limit both nurses\u0026rsquo; and patients\u0026rsquo; adherence to managing infectious wounds. Therefore, collaboration between medical staff is one of the challenges we face. As with any change in practice, it understandably took a period of time for medical staff to fully accept the change.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitation of this project\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe limitations of this evidence-based project include the lack of baseline data on the proportion of GradeⅠandⅡradiation dermatitis and the timing of its onset, resulting in insufficient data for comparison. Additionally, our training methods for healthcare professionals were relatively limited. We should adopt diverse training approaches to enhance engagement and learning motivation.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSustainment of practice\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe project achieved 100% compliance with eight best practice criteria, and significantly reducing the incidence of serious dermatitis (Grade Ⅲ) to 0%. At the hospital level, our evidence-based nursing practice plan for radiation dermatitis has been incorporated into the hospital\u0026rsquo;s nursing guidelines. At the departmental level, we have now included radiation dermatitis management protocol into our annual teaching plan to facilitate its implementation throughout the department and continue to use electronic system for assessment, observation and followup. Lastly, we will conduct an audit of criteria compliance half- year to ensure sustainability.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe implementation of this project promotes compliance with evidence-based criteria among NPC patients for radiation dermatitis management and successfully accomplished most of all predefined objectives, which demonstrated how EBP improves clinical practice behavior. Notably from the audit results, there was a 0 case of Grade Ⅲ radiation dermatitis in the NPC patients undergoing radiotherapy, accompanied by substantially improved patient compliance with radiation dermatitis management protocols.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eNPC\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNasopharyngeal carcinoma\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eJBI PACES\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eJBI Practical Application of Clinical Evidence System\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eGRiP\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGetting Research into Practice\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eRTOG\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRadiation Therapy Oncology Group\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll methodologies employed in this program were rigorously conducted in accordance with the Principles of the Declaration of Helsinki. According to the notice issued by the National Health Commission of China regarding the ethical review procedures for human life sciences and medical research\u003csup\u003e[15]\u003c/sup\u003e, continuous quality improvement projects do not fall under the scope of ethical review. These projects do not involve new technologies or new diagnostic and treatment standards, but are intended to help institutions provide medical services based on the best evidence (evidence summaries). The risk involved is lower than minimal risk; therefore, ethics approval was waived by the Ethics Committee of Sun Yat-sen University Cancer Center. Although ethic approval was waived, we still obtained verbal informed consent from all patients and nurses involved, explaining the purpose and process of the project. Patients and nurses have the right to refuse participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data generated in this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe project was supported by the Natural Science Foundation of Guangzhou (NO. 2023A04J1775). The funders had no role in considering the project design or in the collection, analysis, interpretation of data, writing of the report, or decision to submit the article for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMin Hou contributed to the Conceptualization and methodology of the project, and writing-original draft. Wenhuan Zhong and Kefu Shi undertook investigation, data curation and project administration. Duoduo Pei, Liping Qi and Binbin Hou contributed to investigation, data curation. Huixia Feng and Jiali Liu provide resource support and writing-review and editing. All authors reviewed and endorsed the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely thank Professor Jun Ma and Yupei Chen for providing general support. Additional thanks to Dequan Kong who served in IT department for technical assistance with development of nursing system.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries[J]. CA Cancer J Clin. 2024;74(3):229\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen YP, Chan A, Le QT, et al. Nasopharyng carcinoma[J] Lancet. 2019;394(10192):64\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWei J, Meng L, Hou X, et al. Radiation-induced skin reactions: mechanism and treatment[J]. Cancer Manag Res. 2019;11:167\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYang X, Ren H, Guo X, et al. Radiation-induced skin injury: pathogenesis, treatment, and management[J]. Aging. 2020;12(22):23379\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRosenthal A, Israilevich R, Moy R. Management of acute radiation dermatitis: A review of the literature and proposal for treatment algorithm[J]. J Am Acad Dermatol. 2019;81(2):558\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHymes SR, Strom EA, Fife C. Radiation dermatitis: clinical presentation, pathophysiology, and treatment 2006[J]. J Am Acad Dermatol. 2006;54(1):28\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYao Z, Cheng B. Morbidity in Patients with Nasopharyngeal Carcinoma and Radiation-Induced Skin Lesions: Cause, Risk Factors, and Dermatitis Evolution and Severity[J]. Adv Skin Wound Care. 2021;34(12):1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrook I. Early side effects of radiation treatment for head and neck cancer[J]. Cancer Radiother. 2021;25(5):507\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFeight D, Baney T, Bruce S, et al. Putting evidence into practice[J]. Clin J Oncol Nurs. 2011;15(5):481\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMin Hou, W Z L Q. Establishment and practice of nurse specialist-led radiotherapy nursing clinic[J]. J Nursing(China). 2024;31(21):27\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYuanyuan Wang FJSY. Summary of the best evidence for the prevention and management of radiation dermatitis in patients with head and neck cancer[J]. J Nurses Train. 2024;39(04):401\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOddie K, Pinto M, Jollie S, et al. Identification of need for an evidence-based nurse-led assessment and management protocol for radiation dermatitis[J]. Cancer Nurs. 2014;37(2):E37\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJordan Z, Lockwood C, Munn Z, et al. The updated Joanna Briggs Institute Model of Evidence-Based Healthcare[J]. Int J Evid Based Healthc. 2019;17(1):58\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMunn ZM, A P. K. Evidence implementation projects using an evidence-based audit and feedback approach: the JBI Implementation Framework. In: Porritt K, McArthur A, Lockwood C, Munn Z, editors. JBI Handbook for Evidence Implementation. JBI, 2020. [M]. 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThe National Health Commission T M O E. Notice on Issuing Ethical Review Measures for Human Life Sciences and Medical Research_State Council Departmental. Document_Chinese Government Website[EB/OL]. [2025-07-09]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.gov.cn/zhengce/zhengceku/2023-02/28/content_5743658.htm\u003c/span\u003e\u003cspan address=\"https://www.gov.cn/zhengce/zhengceku/2023-02/28/content_5743658.htm\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYeh PH, Hung SK, Lee MS, et al. Implementing web-based ping-pong-type e-communication to enhance staff satisfaction, multidisciplinary cooperation, and clinical effectiveness: A SQUIRE-compliant quality-improving study[J]. Med (Baltim). 2016;95(44):e5236.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eForde E, Van den Berghe L, Buijs M, et al. Practical recommendations for the management of radiodermatitis: on behalf of the ESTRO RTT committee[J]. Radiat Oncol. 2025;20(1):46.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLindsay MR, Lytle K. Implementing Best Practices to Redesign Workflow and Optimize Nursing Documentation in the Electronic Health Record[J]. Appl Clin Inf. 2022;13(3):711\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSingleton AC, Raeside R, Hyun KK, et al. Electronic Health Interventions for Patients With Breast Cancer: Systematic Review and Meta-Analyses[J]. J Clin Oncol. 2022;40(20):2257\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBehroozian T, Bonomo P, Patel P, et al. Multinational Association of Supportive Care in Cancer (MASCC) clinical practice guidelines for the prevention and management of acute radiation dermatitis: international Delphi consensus-based recommendations[J]. Lancet Oncol. 2023;24(4):e172\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eClarke V, Lehane E, Mulcahy H, et al. Nurse Practitioners' Implementation of Evidence-Based Practice Into Routine Care: A Scoping Review[J]. Worldviews Evid Based Nurs. 2021;18(3):180\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Radiation dermatitis, Implementation science, Nasopharyngeal carcinoma, quality improvement","lastPublishedDoi":"10.21203/rs.3.rs-6925142/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6925142/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eRadiation dermatitis are one of the most common complications during radiation therapy, which affects 85% and 95% of patients. Severe radiation dermatitis can not only reduce the quality of life but also affect the continuity of treatment, significantly diminishing the effectiveness of radiotherapy. Although there were guidelines regarding the management of dermatitis, dermatitis among patients remain suboptimal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim:\u003c/strong\u003e This best practice implementation project aimed to implement an evidence-based practice in preventing and managing patients with radiation dermatitis, thereby improving the compliance of clinical practice with the best evidence and reducing serious dermatitis in NPC\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This was an evidence-based audit and feedback project that used a three-phase approach at a tumor specialized hospital in China. Phase 1 included the development of seven evidence-based audit criteria and carrying out baseline audit on 22 patients using the JBI’s Practical Application of Clinical Evidence System in the Department of Radiation Oncology of Sun Yat-sen universiy cancer centre. Phase 2 utilized the Getting Research into Practice component of the Practical Application of Clinical Evidence System to identify barriers to compliance with best practice principles and developed strategies and resources to improve compliance. Phase 3 involved conducting a follow-up audit using the same audit criteria to assess the results of interventions implemented to improve practice and identify issues that would be addressed in future audit.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eAfter implementing the evidence, the incidence rate of severe radiation dermatitis(≥Grade Ⅲ) decreased from 9.09%(2/22 cases) to 0% (0/22 cases). A comparison between the pre-implementation and post-implementation findings showed significant improvements for all audit criteria, and patients’ compliance with the radiation dermatitis management protocol increased to between 59.09% and 100%. Notably, the compliance rate increased from 0 to 100% for audit criterion 1,2,5,9,12,and 15.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThe implementation of this project improved patients’ compliance on dermatitis management among NPC patients and reduced the incidence rate of severe dermatitis.\u003c/p\u003e","manuscriptTitle":"Prevention and management of radiation dermatitis for patients with Nasopharyngeal carcinoma: a best practice implementation project","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-09 11:30:42","doi":"10.21203/rs.3.rs-6925142/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-16T13:30:20+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-09T06:25:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"210905626045668061400089611183012686419","date":"2025-12-08T15:40:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-07T11:40:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82323959797094762705421763866926285266","date":"2025-12-07T10:25:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116157425773013820117236654264839579529","date":"2025-12-06T04:46:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"120089294855456504231402986807607377725","date":"2025-08-31T14:39:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-29T10:52:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-09T19:07:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-09T15:12:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-07-09T15:08:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ab244e2a-fa81-47ee-87ff-3aa5e7e5e4da","owner":[],"postedDate":"September 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T16:11:30+00:00","versionOfRecord":{"articleIdentity":"rs-6925142","link":"https://doi.org/10.1186/s12912-026-04548-5","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2026-03-17 15:58:47","publishedOnDateReadable":"March 17th, 2026"},"versionCreatedAt":"2025-09-09 11:30:42","video":"","vorDoi":"10.1186/s12912-026-04548-5","vorDoiUrl":"https://doi.org/10.1186/s12912-026-04548-5","workflowStages":[]},"version":"v1","identity":"rs-6925142","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6925142","identity":"rs-6925142","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}