Outline and powerpoint 4 slides
Develop a content outline. Each topical entry should be a complete sentence and not just words or short phrases.
• Identifies any conflicts, gaps, and over conclusions from the findings (create outline sub headings etc)
• Discusses legal and ethical issues relevant to the articles (pressure ulcer) (create outline sub headings etc)
Then create a total of 4 slides based on outline.
• 2 slides with speaker notes for Identifies any conflicts, gaps, and over conclusions from the findings • 2 slides with speaker notes for Discusses legal and ethical issues relevant to the articles or research topic (pressure ulcer)
Articles are attached (6) which are to be utilized to complete the questions being asked above.
Include in text citations in speaker notes
Nurses’ attitudes, behaviours and perceived barriers towards pressure
Zena Moore MSc, RGN, FFNMRCSI
Lecturer, Faculty of Nursing and Midwifery, Royal College of Surgeons, Dublin, Ireland
Patricia Price BA, PhD, AFBPsS, CHPsychol
Director, Wound Healing Research Unit, UWCM, Cardiff Medicentre, Heath Park, Cardiff, UK
Submitted for publication: 13 June 2003
Accepted for publication: 26 March 2004
Faculty of Nursing
Royal College of Surgeons in Ireland
123 St Stephens Green
MOORE Z & PRICE P (2004) Journal of Clinical Nursing 13, 942–951
Nurses’ attitudes, behaviours and perceived barriers towards pressure ulcer
Background. Pressure ulcers are not a plague of modern man; they have been known
to exist since ancient Egyptian times. However, despite the increasing expenditure
on pressure ulcer prevention, pressure ulcers remain a major health care problem.
Although nurses do not have the sole responsibility for pressure ulcer prevention,
nurses have a unique opportunity to have a significant impact on this problem.
Aims and objectives. The specific aims of the study were to identify:
• Staff nurses’ attitudes towards pressure ulcer prevention.
• The behaviour of staff nurses’ in relation to pressure ulcer prevention.
• Staff nurses’ perceived barriers towards pressure ulcer prevention.
Design. A cross-sectional survey method was used.
Methods. A randomly selected sample of staff nurses (n ¼ 300) working in an acute
care setting in an urban location was invited to participate. Data were collected
using a prepiloted questionnaire. Data analysis was carried out using SPSS version
10 and SPSS Text Smart version 1.1.
Results. The nurses surveyed demonstrated a positive attitude towards pressure
ulcer prevention. However, prevention practices were demonstrated to be haphazard
and erratic and were negatively affected by lack of time and staff. These barriers
prevented the nurses’ positive attitude from being reflected into effective clinical
practice. Education, although poorly accessed, or made available, was rarely cited as
impeding practice in this area.
Conclusion. This study suggests that positive attitudes are not enough to ensure that
practice change takes place, reinforcing the complex nature of behavioural change.
Implementation strategies should introduce ways in which key staff can be
empowered to overcome barriers to change.
Relevance to clinical practice. This study provides a unique exploration of Irish
nurses’ attitudes, behaviours and perceived barriers towards pressure ulcer prevention,
thereby contributing to the body of knowledge on this subject. As tissue
viability is a new and emerging speciality, this information will contribute to
evidence based practice in this area of patient care and will form the basis for the
942 2004 Blackwell Publishing Ltd
development of an educational strategy for pressure ulcer prevention and
Key words: attitudes, barriers, behaviours, change, nurses, pressure ulcers
Introduction and background
Despite advances in modern technology and the array of
preventative equipment available, pressure ulcers are not on
the decline (Clark & Cullum, 1992; Clark, 1998; Whitfield
et al., 2000; Kaltenthaler et al., 2001). From a service
planning perspective, pressure ulcers are a significant financial
burden to any health care system and have an adverse
effect on achieving overall goals of care (Clark, 1994).
Changing population demographics mean that the increasing
age of mortality will result in a greater number of older
patients (Haalboom, 2000) and, although pressure ulcers do
not only afflict this group, increasing age heightens the risk of
pressure ulcer damage. Pressure ulcers occur as a result of a
combination of both intrinsic and extrinsic factors and one
important extrinsic factor is poor management of sick
patients (Bliss, 1990).
Tissue viability is a relatively new and developing speciality
in Ireland. Indeed, the first clinical nurse specialist post in
tissue viability was approved in 2001 (National Council for
the Professional Development of Nursing and Midwifery,
2002) and today there are approximately 22 specialists
working in this area of patient care (Moore & Cowman,
2003). The development of this area of specialism is welcome
when one considers that the pressure ulcer prevalence in
Europe is estimated to be approximately 18% [European
Pressure Advisory Panel (EPUAP), 2002] and in Ireland the
prevalence ranges from 12.5 to 21% in the acute care setting
(Moore & Pitman, 2000; Jordan O’Brien, 2002).
Although no national strategy for pressure ulcer prevention
and management currently exists in Ireland, two important
government documents place pressure ulcer prevention and
management high on the national agenda. The Health
Strategy has the tenets of quality, fairness, equity and people
centeredness as its core components [Department of Health
and Children (DoHC), 2001]. Implicit in this document is
that the provision of care should be timely, appropriate and
evidence based. The driving force should ultimately be to
improve the health and quality of life of the users of the Irish
health care system. Therefore, as a service provider, it is
essential that pressure ulcer prevention and management are
core components of the strategic planning of health care
services. Indeed, the report of The Working Group on Elder
Abuse (2002) puts the onus for the provision of adequate
prevention measures firmly in the hands of care providers.
The failure to provide such care is a form of abuse of the
individual and, as such, is intolerable.
Pressure ulcer prevention is a multi-faceted problem, where
attitudes may be important in influencing behaviour (Petty &
Cacioppo, 1996). If an individual has a very negative attitude
towards a given topic, then it is unlikely that the individual
will perform positive or supportive behaviours in relation to
that topic. For example, the more pressure ulcer prevention is
valued the greater the likelihood of preventative practices
being carried out (Maylor & Torrance, 1999a).
Ajzen and Madden (1986) suggest there are two independent
influences determining an individual’s intention to
perform a particular behaviour. These influences are personal
(the attitude towards the behaviour) and social (the social
pressure to perform the behaviour). The social pressure to
perform encompasses the concept that ‘important others’
influence the likelihood of an action being carried out (Ajzen
& Madden, 1986).
Perceived control is also considered an important variable in
the prediction of behavioural intention. Perceived control is
influenced by factors such as knowledge, skill, time, opportunity,
autonomy and resources, all of which warrant serious
consideration in planning services (Nash et al., 1993). Maylor
and Torrance (1999a) suggest there is a correlation between
perceptions of control and pressure ulcer prevalence rates. In
a department or unit where pressure ulcer prevention is
considered not to be controlled by powerful others, a higher
value is placed on pressure ulcer prevention. In this situation
pressure ulcer prevention is more likely to be carried out on a
regular basis. This comes about because the staff feel that they
control pressure ulcer prevention and can directly influence
the outcome, which is to prevent pressure ulcers.
Loss of control over behaviour can also be influenced by
internal and external factors (Ajzen & Madden, 1986). In the
case of pressure ulcer prevention, important influencing
internal factors may be skills and knowledge. Without
adequate instruction, a tendency to adhere to ritualistic
practices may prevail (Hicks, 1996). Prochaska and
Di Clemente (1984) have described the process of change in
Pressure ulcers Pressure ulcer prevention in clinical practice: the reality
2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 942–951 943
different stages, one of which is called self-liberation when an
individual has the ability to choose between alternatives. An
important aspect in choice is the subsequent anxiety felt in
taking responsibility for that choice. Choosing is made
significantly more difficult when there is an insufficient
amount of information available about a situation (Prochaska
& Di Clemente, 1984). A tendency to cling to ritualistic
practice may stem from a fear of change due to lack of
knowledge rather than an unwillingness to change.
Tissue viability is often perceived as a nurse-based problem
and the development of pressure ulcers may be linked to
nurse attitudes, education and competence in the area of
pressure ulcer prevention and management (Benbow, 1992;
Beitz et al., 1998; Culley, 1998). Pressure ulcer prevention is
the responsibility of all health care professionals involved in
patient care, and knowledge and skills are necessary to carry
this out effectively (Culley, 1998). Not only does education
heighten an awareness of the problem of pressure ulcers,
education also provides the basis for informed decisionmaking
and the framework to develop and maintain competence
(Benbow, 1992). Whilst education alone can have
limited value (Maylor & Torrance, 1999b), an important
component of this process is that nurses demonstrate a desire
to implement new knowledge in clinical practice (Benbow,
1992; Culley, 1998). Indeed, Bero et al. (1998) have shown
that, whilst there are many different types of intervention that
can be used to promote behavioural change, passive dissemination
of information is generally ineffective.
Pressure ulcer prevention and management involves not
only emphasizing educational strategies but also promoting a
positive attitude towards this aspect of patient care. Therefore,
the aim of this study was to identify nurses’ attitudes,
behaviours and perceived barriers towards pressure ulcer
prevention and management.
Aims and objectives
The specific aims of this study were to identify:
• Staff nurses’ attitudes towards pressure ulcer prevention.
• The behaviour of staff nurses’ in relation to pressure ulcer
• Staff nurses’ perceived barriers towards pressure ulcer
This study was undertaken in 2001 in the Republic of
Ireland. A cross-sectional survey was used to collect data
from staff nurses working in the area of pressure ulcer
The survey method is used to gather data from a large
sample and identify the views of a group rather than the
views of an individual (Parahoo, 1997). Use of a questionnaire
eliminates the effect of a researcher over the subject.
Remaining distant from the study participants allows them
more freedom to answer the questions honestly and openly.
Using structured questions further reduces the risk of bias
(Sajiwandani, 1996). Questionnaires have their limitations,
including uncertainty of who completes the form, social
desirability responses and lack of researcher presence to
explain areas of uncertainty or concern. However, limitations
of time and resources prevented a detailed qualitative
approach being used; the inclusion of an open-ended question
section in the data collection tool afforded a compromise
between these two approaches.
There are both advantages and disadvantages of the use of
postal questionnaires. One of the major advantages of postal
questionnaires is the low cost and the ability to reach large
numbers of subjects who may be geographically disparate
apart (Oppenheim, 1992a). A major disadvantage of postal
questionnaires is the poor response rate and thus the risk of
bias (Oppenheim, 1992a).
The study was carried out in a sample of six teaching hospitals
in an urban setting. The hospitals were chosen using
simple random sampling.
For the purposes of the study a staff nurse was defined as any
nurse registered to practice under the general division of the
live register of nurses as provided for in section 27 of the Irish
nurses act 1985 (An Bord Altranais, 2000a).
All staff nurses working full time on the permanent staff of
the hospitals in either medical, surgical, burns or plastics,
orthopaedic or care of older people wards were invited to
participate. Intensive care and coronary care units were also
included. These staff nurses were selected because pressure
ulcer prevention and management should form a routine part
of their daily nursing activities.
Staff nurses working in any area of the hospital where direct
inpatient assessment, pressure ulcer prevention care planning
Z Moore and P Price
944 2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 942–951
and delivery are not a routine part of the nurses’ daily
working life, were excluded from the study.
A list of potential subjects in each of the hospitals was
obtained from the Directors of Nursing at the study sites and
the sample was selected using a random numbering table
(Polit & Hungler, 1999). From a population of 1300 nurses,
300 participants were selected. This was based on requiring a
final return rate equivalent to 10% of the population
(n ¼ 130); 300 participants were selected to allow for the
high non-response rates that are a feature of this type of
research (McColl & Thomas, 2000).
A questionnaire was used to collect the data. Following a
detailed review of the literature (e.g. Hullund, 1985; Bostrom
et al., 1989; Bostrom & Kenneth, 1992; Halfens & Eggink,
1995; Maylor, 1997; Maylor & Torrance, 1999a,b), central
themes emerged as key topics to be covered in the
• What are staff nurses’ attitudes towards pressure ulcer
• Do staff nurses’ carry out, document and read pressure
ulcer prevention strategies?
• What are staff nurses’ perceived barriers towards pressure
• Do staff nurses routinely use pressure ulcer risk assessment
and pressure ulcer grading tools in clinical practice?
• What is the status of education in pressure ulcer prevention
among staff nurses?
• What is the nature of education on pressure ulcer prevention
among staff nurses?
A pool of questions was generated which were evaluated
using an iterative process by the researcher and expert
colleagues to ensure clarity, avoidance of ambiguity and
content validity (Oppenheim, 1992a; Parahoo, 1997). This
involved the circulation of the draft items until there was
consensus on content, order and wording.
To explore staff nurses’ attitudes towards pressure ulcer
prevention the survey included a section on attitudes where
the response-option utilized a 5-point Likert scale
(Oppenheim, 1992b). This type of response option was
chosen because it allows scaling of an individual’s attitude to
an issue and is more sensitive to the full range of possible
attitudes than a simple dichotomous agree/disagree option
The questionnaire also elicited information regarding
self-reported clinical behaviour using closed questions. The
third part of the questionnaire used open-ended questions
to allow respondents to identify perceived barriers towards
pressure ulcer prevention. This free text section of the
questionnaire allowed for detailed responses to key issues.
The final part of the questionnaire focused on demographic
Ethical approval was sought and granted by the Local
Research Ethics Committee. The researcher guaranteed
anonymity of the study participants and the participating
institutions (Mc Haffie, 1996) and the data were treated as
confidential at all times.
Access to staff nurses to carry out a pilot study was sought
from the Director of Nursing. A list of staff nurses working
on a medical ward in one of the teaching hospitals was
received from the ward sister in charge of the ward. The
questionnaires were circulated to 20 staff nurses. Sixteen
completed questionnaires were received.
As part of the reduction process an item analysis was
carried out on the attitude section. An item analysis is a
measure of the reliability of an instrument, measuring how
consistently each individual item performs in relation to the
total instrument. The questionnaire used for the pilot study
had 30 questions. Two questions were eliminated as
they were considered leading questions. Some questions
were re-worded to add more clarity to the questions.
In general the subjects did not have any problems with
the wording, length and format of the questionnaire.
The data collected during the pilot were not included as
part of the main study. The final questionnaire had 28
The questionnaires were all hand delivered to the study
sites for distribution through the internal mail system. In
two of the study sites a collection box was placed in each
clinical area where the completed questionnaires were
placed and collected by hand. In one of the study sites,
stamped self-addressed envelopes were enclosed and the
participants were requested to return the completed questionnaires
by mail. Non-responders were followed-up with
a further letter (and questionnaire) explaining the nature of
the study and requesting once again completion of the
Pressure ulcers Pressure ulcer prevention in clinical practice: the reality
2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 942–951 945
Data analysis was carried out using the statistical package for
social sciences (SPSS) base version 10 and SPSS Text Smart
version 1.1. SPSS allowed quantitative analysis of the
closed-ended questions. Text Smart allowed analysis of the
text based questions.
A total of 300 questionnaires was circulated and 121
completed questionnaires were returned (response rate ¼
40.3%). The nurses were working in a wide range of clinical
areas, with the highest percentage of nurses (24%) working
in a surgical ward.
Training in pressure ulcer prevention and management
Of the nurses who completed the questionnaire, 76% were
qualified between 2 and 10 years and 67% had not received
any formal training in pressure ulcer prevention and
management since qualifying as a nurse. The type of
training received is outlined in Table 1, with most of the
education in the form of in-service study days on wound
care, pressure ulcer prevention and manual handling. A
small number had received education at a higher level, such
as during a tissue viability course or a higher diploma in
Attitudes to pressure ulcer prevention
The lowest possible score (negative attitude) in the attitude
section was 11 with a highest possible score of 55. The staff
nurses demonstrated a positive attitude towards pressure
ulcer prevention (median ¼ 40, range 28–50).
There were interesting points to note with regard to
individual items within the attitude scale (Table 2).
Seventy-five per cent of staff nurses felt that all patients are
at risk of developing a pressure ulcer, that most pressure
ulcers can be avoided (76%) and nurses should concern
themselves with pressure ulcer prevention (99%). Pressure
ulcer prevention was seen as more important than pressure
ulcer treatment (92%) and regular (84%) and continuous
assessment (94%) was considered an accurate method for
obtaining a picture of patients’ risk status.
There was a broader range of responses related to other
factors. For example, 40% of the staff nurses felt that
prevalence rates are decreasing whilst only 30% felt that they
were increasing. Forty-one per cent of staff nurses felt that
pressure ulcer prevention is time consuming to carry out while
51% felt that pressure ulcer prevention is a low priority.
Twenty-eight percent admitted to being less interested in
pressure ulcer prevention than in other aspects of nursing care.
Thirty-two per cent of the staff nurses felt that their clinical
judgement is better than any available pressure ulcer risk
Potential barriers to carrying out pressure ulcer risk assessment
and pressure ulcer prevention are presented in Tables 3
and 4. ‘The patient’ was the most frequently cited barrier to
carrying out pressure ulcer risk assessment (60%). For
example, the patient may be too ill to assess or may be
uncooperative, making assessment difficult. Lack of time
(60%) and lack of staff (36%) were also perceived as
important barriers. Lack of training, resources and guidelines
and problems with the risk assessment tool in use were
rarely considered to be important (9%). Only four respondents
mentioned that lack of education was an issue of
concern. The barriers to carrying out pressure ulcer prevention
are similar to those affecting pressure ulcer risk assessment
(staff ¼ 57%, time ¼ 42%, patient ¼ 35%). However,
lack of education and training were not mentioned as
barriers to carrying out pressure ulcer prevention in this
Pressure ulcer prevention practices
A pressure ulcer risk assessment tool was in use in 95% of
practices. The most commonly cited risk assessment tools
were Maelor (40%) (Williams, 1991), Waterlow (22%)
(Waterlow, 1985) and Norton (13%) (Norton et al., 1962).
Seventy per cent of the staff nurses indicated that there was a
pressure ulcer-grading tool in use in their practice. However,
most of the staff nurses (78%) were unable to name correctly
the pressure ulcer-grading tool in use.
Table 1 Training in pressure ulcer prevention and management
Type of training received Number (%)
In-service on wound care, lifting and handling 20 (16)
Training on risk assessment tool or equipment 8 (6)
Talk from commercial company 5 (3)
Course, diploma, conference 6 (4)
Not stated 7 (5)
No training received 77 (66)
Total responses categorized 115 (100)
Z Moore and P Price
946 2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 942–951
The majority of staff nurses (93%) indicated that they
carried out pressure ulcer prevention practices. Eighty-nine per
cent carry out these practices because they consider it to be an
essential part of nursing practice, whilst 11% were influenced
by the practices or expectations of other staff. Only 19% of
staff nurses agreed that they carry out pressure ulcer prevention
because the hospital policy states that they should.
Table 2 Staff Nurses’ attitudes towards pressure ulcer prevention
agree (%) Agree (%)
nor disagree (%) Disagree (%)
All patients are at potential risk
of developing pressure ulcers
40 (33.1) 53 (43.8) 6 (5.0) 20 (16.5) 2 (1.7)
Pressure ulcer prevention is time
consuming for me to carry out
35 (28.9) 15 (12.5) 15 (12.5) 55 (45.5) 1 (0.8)
In my opinion patients tend not to
get as many pressure ulcers
12 (9.9) 44 (36.4) 26 (21.5) 37 (30.6) 0 (0)
I do not need to concern myself
with pressure ulcer prevention in my
0 (0) 0 (0) 1 (0.8) 18 (14.9) 102 (84.3)
Pressure ulcer treatment is a
greater priority than pressure ulcer
3 (1.7) 3 (2.5) 4 (3.3) 32 (26.4) 80 (66.1)
Continuous nursing assessment of
patients will give an accurate
account of their pressure ulcer risk
64 (52.9) 50 (41.3) 2 (1.7) 1 (0.8) 3 (2.5)
Most pressure ulcers can be
32 (26.4) 60 (49.6) 13 (10.7) 13 (10.7) 3 (2.5)
I am less interested in pressure
ulcer prevention than other aspects
of nursing care
30 (24.8) 4 (3.3) 23 (19.0) 62 (51.2) 2 (1.7)
My clinical judgement is better
than any pressure ulcer risk
assessment tool available to me
20 (16.5) 19 (15.7) 38 (31.4) 42 (34.7) 1 (0.8)
In comparison with other areas of
nursing care, pressure ulcer
prevention is a low priority for me
45 (49.6) 2 (1.7) 4 (3.3) 68 (56.2) 2 (1.7)
Pressure ulcer risk assessment should
be regularly carried out on all
patients during their stay in hospital
60 (49.6) 41 (33.9) 6 (5.0) 14 (11.6) 0 (0)
Table 3 Barriers to carrying out pressure ulcer risk assessment
Barriers to carrying out pressure
ulcer risk assessment Number (%)
Total number of respondents 99 (74)
Patient un-cooperative/too ill 75 (75)
Lack of time 73 (73)
Short staffed 44 (44)
Lack of training, resources, equipment, guidelines 12 (12)
Problems with assessment tool 11 (11)
Other aspects of care more important/lack of continuity 8 (8)
Forget 5 (5)
Lack of knowledge 4 (4)
Unable to assess 3 (3)
Respondents were asked to identify three barriers to carrying out risk
Table 4 Barriers to carrying out pressure ulcer prevention
Barriers to carrying out pressure
Total number of respondents 121 (100)
Lack of staff 69 (57)
Lack of time 51 (42)
Patient specific problems 43 (35)
Lack of aids 14 (11)
Lack of equipment 13 (10)
Unstable patient 13 (10)
Uncategorized 9 (7)
Respondents were asked to identify three barriers to carrying out
pressure ulcer prevention.
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2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 942–951 947
All nurses who both wrote and carried out pressure ulcer
preventative strategies indicated that not all patients at risk of
pressure ulcer development would have an individual pressure
ulcer prevention care plan written. Twenty-one per cent
of the nurses reported that they updated the care plans only
when they remembered to, whilst others (4%) indicated that
they never updated the care plans.
This paper set out to explore the following aims, what are
staff nurses’ attitudes towards pressure ulcer prevention?
What is the behaviour of staff nurses’ in relation to pressure
ulcer prevention? And what are staff nurses’ perceived
barriers towards pressure ulcer prevention? The findings of
the study demonstrate that the staff nurses displayed a
positive attitude towards pressure ulcer prevention and
management. However, barriers such as lack of time and
staff prevent this positive attitude being reflected into clinical
practice. This is borne out by the inconsistent behaviour of
the nurses in relation to pressure ulcer prevention.
The staff nurses who completed the questionnaires were
mostly qualified for between 2 and 10 years, therefore, it
could be assumed these nurses were probably in their 20s
or early 30s. These nurses were young compared with the
age profile of registered nurses in general in Ireland (An
Bord Altranais, 1999). However, as the study was carried
out in an urban setting, where the age profile of nurses is
younger than in a rural setting, this was to be expected
In this study, the staff nurses demonstrated a positive
attitude towards pressure ulcer prevention. This attitude did
not appear to be influenced by either the length of time the
nurses were qualified, the clinical area the nurses practised in
or whether they had received any formal training in pressure
ulcer prevention and management. Attitudes are considered
important because they give an indication of what to expect
from others (Petty & Cacioppo, 1996). A positive attitude
towards an issue is an important influencing factor that
determines an individual’s likelihood of carrying out the
behaviour in question (Fishbein & Ajzen, 1975). Indeed
Champion and Leach (1989) and Hicks (1996) have shown
how a positive attitude towards research increases its use in
nursing practice. In this study, lack of time and staff were
commonly cited as barriers towards carrying out pressure
ulcer prevention, whilst lack of training and education was
rarely mentioned. Pressure ulcer prevention is a multi
disciplinary problem. Therein lies a primary problem; if all
members of the team do not contribute fully, the efforts of the
other members may be fruitless. A second problem is the
whole area of staff shortages, which results in the overstretching
of staff at a clinical level. Certain aspects of
pressure ulcer prevention, such as repositioning, are difficult
to carry out unaided. If staff shortages continue, and given
the pressure on staff to prioritize tasks it will be of no surprise
if pressure ulcer prevention becomes less of a priority.
The staff nurses surveyed were unclear about prevalence
rates. Understanding pressure ulcer prevalence rates is an
important starting point in planning pressure ulcer prevention
strategies (Dealey, 1991). Awareness of prevalence rates
will not only increase the understanding of the problem of
pressure ulcers but will also enhance the likelihood that staff
will think that pressure ulcer prevention is an important
concept of nursing care (Anthony, 1996). To plan an effective
pressure ulcer prevention and management policy it is
important to know whether current practice is achieving
expected goals, i.e. a decreasing prevalence rate [Department
of Health UK (DoH UK), 1993]. Within the Irish health care
setting there is a clear lack of information relating to pressure
ulcer prevalence and prevention practices (Moore & Pitman,
2000). If prevalence studies are not carried out, staff may not
be alerted to the importance of this aspect of patient care.
A significant number of the staff nurses surveyed had
received no formal training in pressure ulcer prevention and
management since qualifying as a nurse. The importance of
education in pressure ulcer prevention and management is
well documented in the literature (Gould, 1986; Benbow,
1992; Maylor, 1997; Arblaster, 1998; Culley, 1998). Education
is a means by which nurses develop and maintain their
clinical competency thus providing the information needed to
make well-informed clinical decisions (An Bord Altranais,
2000b). Ajzen and Madden (1986) and Nash et al. (1993)
argue that perceived control is an important determinant of
an individual’s behavioural intent and this control is influenced
by exposure to education. Therefore, the lack of
education received by the nurses surveyed is a cause of
concern. Indeed Lamond and Farnell (1998) identified that
nurses with a sounder knowledge base made better clinical
decisions than those with a poorer knowledge base, thus
reiterating the importance of education.
Pressure ulcer risk assessment
Staff nurses were clear that pressure ulcer risk assessment is
important in that regular and continuous risk assessment
provides essential information regarding a patient’s risk
status. However, a number of the nurses admitted to being
less interested in pressure ulcer prevention than other aspects
of nursing care, and that pressure ulcer prevention is not a
high priority. This point is supported by an earlier study by
Z Moore and P Price
948 2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 942–951
Bostrom and Kenneth (1992) who identified that pressure
ulcer prevention was not always considered to be as
important as other nursing duties. Indeed, that nurses
suggested that the patient was often a barrier to carrying
out pressure ulcer risk assessment (the patient may be too ill
to assess or may be uncooperative), suggests that this is an
issue that needs further exploration. When faced with all
aspects of patient care, if pressure ulcer prevention is placed
as a low priority, irreversible damage may occur and indeed
go unnoticed for some time. Increasing the value placed on
pressure ulcer prevention can lead to an increase in preventative
strategies being carried out (Maylor & Torrance,
The documentation practices of the staff nurses surveyed
demonstrates an inconsistent approach to this aspect of
nursing practice. Some of the nurses indicated that they did
not carry out pressure ulcer prevention yet wrote pressure
ulcer prevention care plans. Other nurses suggested that not
all patients at risk would have a written prevention care plan.
Updating of care plans was also irregular and sometimes only
carried out when remembered. It is incumbent on all nurses
to document care, planned and delivered, in a logical and
meaningful way, bearing in mind that nursing care plans are
legal documents (Anthony, 1996).
The response rate of 40% warrants comment. This response
rate was realized despite careful attention to follow-up
strategies and reminders (Oppenheim, 1992c). The rapid
turn over of staff at each of the study sites compounded the
problem of identifying key staff. Sampling was carried out
immediately on receipt of the lists of staff nurses. However,
on delivery of the questionnaires a sizable proportion of the
staff (12%) was no longer in employment in the study sites. A
response rate of 40% indicates that caution must be exercised
when interpreting the data. The concern is that those who did
not reply to the questionnaire may be those with different
views on the topic. Further development of the data collection
tool may have resulted in a higher response rate as well
as improving the type of data collected.
An assessment of knowledge levels would have been a
useful additional variable to measure, although the length of
the questionnaire was considered an important factor in
terms of respondent burden. In addition, qualitative interviews
may have allowed respondents to highlight concerns
about the implementation practices in their clinical arena in a
way that is not possible with a questionnaire. Despite these
limitations, this study represents a useful addition to our
understanding of the attitudes and behaviours as reported by
the nurses surveyed, and will form the basis for evaluating
educational interventions in this area.
Pressure ulcer prevention and management is of major
importance in today’s health care environment. An extensive
amount of time and energy is spent on the planning of
pressure ulcer prevention strategies. However, despite the
increasing expenditure on pressure ulcer prevention, neither
the incidence nor prevalence of pressure ulcers is reducing,
whilst the increasing proportion of older people is likely to
exacerbate the situation.
The guidelines from An Bord Altranais (2000b) indicate
that nurses have a responsibility to ensure that they are
competent to deliver nursing care, including pressure ulcer
prevention and management. Nurses must actively seek
required education with a duty to maintain competency in
this aspect of clinical practice (An Bord Altranais, 2000b).
Management also has a responsibility to ensure that the
resources necessary to provide effective pressure ulcer
prevention are available, including providing education
and helping to foster an environment that encourages
This study suggests that behaviours related to pressure
ulcer prevention can be erratic, despite positive attitudes
towards pressure ulcer prevention. This is very important and
provides a sound stepping stone for advancing practice in
pressure ulcer prevention. Factors identified as barriers
include lack of staff, insufficient time and a lack of information
and education, which may be factors outside the control
of individual staff nurses – and therefore, non-volitional. In
addition, the influence of peer pressure (social norms) was
highlighted by some respondents. This research has highlighted
that positive attitudes are not enough to ensure that
practice change takes place, reinforcing the complex nature
of behavioural change. Implementation strategies to introduce
change must acknowledge this complexity and introduce
ways in which key staff can be empowered to manage
barriers to change.
Further research to investigate the relationship between the
level of knowledge of staff nurses and their attitudes to
pressure ulcer care and prevention should be encouraged. The
role of education in this important area cannot be underestimated
but expenditure on this topic needs to be targeted
appropriately. Therefore, it would be of value to examine the
level of knowledge of staff nurses to assess whether this
Pressure ulcers Pressure ulcer prevention in clinical practice: the reality
2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 942–951 949
influences attitudes or indeed pressure ulcer prevention
Within the Irish healthcare setting there is a dearth of
information relating to pressure ulcer prevention and management.
The politicization of pressure ulcers within the UK
has certainly heightened the awareness of the problem of
pressure ulcers and has provided much needed guidelines for
care. Bearing in mind the different budgeting structures and
indeed health care settings in Ireland, pressure ulcer prevention
and management practices within the Irish context, need
to be explored. This information could then form the basis
for planning a national pressure ulcer prevention and
This study was supported in part by a grant from The Eileen
Mansfield Research Scholarship and an educational grant
from the European Wound Management Association. The
authors wish to thank the following: Professor Seamus
Cowman, Ms Vanessa Jones, Ms Mary Mc Carthy, Ms
Antoinette Redmond, Ms Ann Woods, Ms Sibeal Carolan,
Ms Helen Strapp, Ms Mary O Keeffe and Mr Geoff Keye for
their support and encouragement, thanks to Mr Steve Pitman
and Ms Carmel Grogan for their advice and guidance, a
special thanks to Bud, David, Barry and Deirdre for their
patience, and finally, thanks to the study participants for
giving so generously of their time.
Study design: ZM, PP; data collection: ZM, data analysis: ZM,
PP; manuscript preparation: ZM, PP.
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Pressure ulcers Pressure ulcer prevention in clinical practice: the reality
2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 942–951 951
Copyright March/April 2015
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J Wound Ostomy Continence Nurs. 2015;42(2):138-144.
Published by Lippincott Williams & Wilkins
Incidence and Risk Factors for
Surgically Acquired Pressure Ulcers
A Prospective Cohort Study Investigators
Joan Webster Carolyn Lister Jean Corry Michelle Holland Kerrie Coleman
PURPOSE: To assess the incidence of hospital-acquired,
surgery-related pressure injury (ulcers) and identify risk
factors for these injuries.
DESIGN: We used a prospective cohort study to investigate
the research question.
SUBJECTS AND SETTINGS: The study was conducted at a
major metropolitan hospital in Brisbane, Australia. Five
hundred thirty-four adult patients booked for any surgical
procedure expected to last more than 30 minutes
were eligible for inclusion.
METHODS: Patients who provided informed consent for
study participation were assessed for pressure ulcers,
using the European Pressure Ulcer Advisory Panel and
National Pressure Ulcer Advisory Panel Guidelines,
before entering the operating room and again in the
post-anesthetic care unit (PACU). Research nurses and all
PACU nurses were trained in skin assessment and in pressure
ulcer staging. Patients were not assessed again after
their discharge from the PACU.
RESULTS: Seven patients (1.3%) had existing pressure
injuries (ulcers) and a further 6 (1.3%) developed a
surgery-related pressure ulcer. Risk factors associated
with surgery-related pressure injuries were similar to
non–surgically related risks and included older age,
skin condition, and being admitted from a location
other than one’s own home. Length of surgery was
not associated with pressure ulcer development in this
CONCLUSION: Perioperative nurses play an important role
in identifying existing or new pressure injuries. However,
many of these nurses are unfamiliar with pressure
ulcer classification, so education in this area is essential.
Although the incidence of surgically acquired pressure
ulcers was low in this cohort, careful skin inspection before
and after surgery provides an opportunity for early
treatment and may prevent existing lesions progressing
to higher stages.
KEY WORDS: cohort study, hospital-acquired, pressure
ulcer, pressure injury, surgical patients
Hospital-acquired pressure ulcers are a difficult and unresolved
problem facing health care facilities. According to
a recent database review of almost 52,000 hospitalized individuals,
approximately 4.5% of all admitted patients
developed a new pressure injury/ulcer during their hospital
stay.1 In this review, patients developing a pressure
ulcer were more than twice as likely to die in hospital and
30% were more likely to be readmitted within 30 days of
hospital discharge, compared with patients who did not
develop a pressure ulcer. In addition, length of stay was
double for those with a hospital-acquired pressure ulcer.
Although theoretically preventable, efforts to attain a
zero pressure ulcer incidence remains difficult, despite financial
penalties for hospital-acquired conditions in the
United States2 and more recently in Queensland, Australia.3
Such penalties have focused attention on quality activities
that may help drive improved health outcomes4 but results
from such activities have been mixed and have rarely
been evaluated using randomized controlled trials.5-7 Nor
Joan Webster, RN, BA, Nursing Director, Research, RBWH,
Herston, Queensland; Griffith Health Institute, Griffith University,
Kessles Rd, Nathan, QLD; and School of Nursing & Midwifery,
University of Queensland, Herston, Queensland, Australia.
Carolyn Lister, B App Sci (Nurs), Research Nurse, Perioperative
Services, RBWH, Herston, Queensland, Australia.
Jean Corry, EN (Advanced Practice), Research Nurse,
Perioperative Services, RBWH, Herston, Queensland, Australia.
Michelle Holland, RN, B.Bus., Risk Management Coordinator,
Safety and Quality Unit, RBWH, Herston, Queensland, Australia.
Kerrie Coleman, Dip ApSc, BNSc, MNclinical (Wound Management),
M Nurs (Chronic Disease), Nurse Practitioner, Complex Wound
Management, RBWH, Herston, Queensland, Australia.
Louise Marquart, BSc, BEcon, BAppSc (Hons), B Biostat, Statistics
Unit, Queensland Institute of Medical Research, Queensland, Australia.
There are no conflicts of interest to declare for any of the authors.
Correspondence: Joan Webster, RN, BA, Level 2, Building 34, Royal
Brisbane and Women’s Hospital Herston, 4029 Queensland,
JWOCN-D-13-00082.indd 138 24/02/15 12:47 AM
Webster etal March/April 2015
J WOCN ■ Volume 42/Number 2 Webster etal 139
Copyright © 2015 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
about surgery-related pressure ulcers. Specific aims of the
study were (1) to assess the incidence of hospital-acquired,
surgery-related pressure injuries (ulcers) and (2) to establish
risk factors for hospital-acquired, surgery-related pressure
We used a prospective cohort study design to investigate
research aims. Patients were eligible for inclusion if they
were at least 18 years of age and scheduled for a surgical
procedure expected to last more than 30 minutes.
Participants may have been day only cases or have a
planned postsurgery admission. All patients provided
written consent to participate and the institution’s human
research ethics committee reviewed and approved study
procedures. Patients who declined study participation or
were unable to provide informed consent were excluded.
Approximately 1236 patients undergo elective surgery
in the hospital’s perioperative services each month; of
these, 841 are elective and last longer than 30 minutes. We
assumed a recruitment rate of approximately 10 participants
per day, on weekdays, over an 8-week period. We
believed that this number would be sufficient to meet the
study objectives and to assess the feasibility of future, interventional
Study participants were assessed for pressure ulcers using
the definitions provided by the European Pressure Ulcer
Advisory Panel and National Pressure Ulcer Advisory
Panel.26 Table 1 summarizes pressure ulcer categories/
Patients meeting inclusion criteria were recruited, preoperatively,
on the day of surgery. Baseline demographic
data, including the presence of relevant comorbidities and
have other pressure ulcer prevention interventions, which
have been assessed more rigorously for effectiveness, such
as pressure redistribution surfaces, heel wedges, turning
regimes, use of risk assessment tools, and nutritional enhancements,
provided definitive answers to the question
of how pressure ulcers may be prevented.8–14
One approach to the problem has been to look at potentially
modifiable risk factors, and to focus interventions
around these risks.15 An impediment to this approach
is the vast literature around risks associated with pressure
ulcers. Scores of risks have been identified, dependent on
the type of patient and location of care. However, a recent,
comprehensive systematic review of patient risk factors
provides useful guidance for health care providers in this
area. The most frequent, independent risk factors associated
with pressure ulcers identified in the review were (1)
mobility, (2) skin condition/pressure ulcer status, and (3)
perfusion-related variables, such as diabetes mellitus, vascular
disease, and blood pressure.16 It is unclear from the
review though, how potentially modifiable intraoperative
risk factors contribute to overall risk.
Factors associated with pressure ulcer development in
the operating room environment include length of surgery,17-20
low body mass index,8,14 use of vasopressors,18
older age,14,20,21 diabetes mellitus,14,19,21-23 cardiac conditions,19
prone positioning,24 vascular disease,25 risk of mortality,18
and multiple comorbidities.23,25 However, apart
from one retrospective review of data associated with 3225
surgical patients18 and 1 randomized controlled trial of
337 patients undergoing cardiac surgery,14 most studies of
intraoperative risk factors have employed small sizes (29-
136), and they have included pressure ulcers developing at
any time during the hospital admission. In addition, only
2 have reported an immediate preoperative and postoperative
skin assessment.19,21 Consequently, the aim of the
current study was to provide more specific information
Europ ean Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel Classification System26
Category/Stage I: Nonblanchable erythema Intact skin with nonblanchable redness of a localized area usually over a bony
Category/Stage II: Partial thickness Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound
bed, without slough. Intact or open/ruptured serum filled blister
Category/Stage III: Full-thickness skin loss Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is
not exposed. Slough may be present but does not obscure the depth of tissue loss
Category/Stage IV: Full-thickness tissue loss Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be
present on some parts of the wound bed
Unstageable : Depth unknown Full-thickness tissue loss in which the base of the pressure ulcer is covered by slough
(yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the pressure
Suspected deep tissue injury: depth unknown Purple or maroon localized area or discolored, intact skin or blood-filled blister due to
damage of underlying soft tissue from pressure and/or shear
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140 Webster etal J WOCN ■ March/April 2015
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known risk factors, were collected at this time. In addition,
a skin assessment of patients was conducted by 1 of 2 research
nurses while the patient was in his or her home
ward, the surgical day care unit, or the holding bay. To
ensure consistency of reporting, both research nurses and
all postoperative anesthetic care unit (PACU) nurses were
trained in skin assessment and in pressure ulcer staging.
Any ambiguities in diagnosis were referred to a nurse practitioner
with experience in complex wound management
for arbitration. Following surgery, patients were reassessed
for presence and stage of any pressure injury while they
were cared for in our PACU. We planned for this to occur
within 1 hour of admission to the PACU. A reporting protocol
was instigated for any patient found to have a pressure
ulcer, either before surgery, or any that were found to
be surgery-related; that is, not present on admission but
identified in the PACU unit. Information about the surgical
procedure, such as length of surgery and position on the
operating room table, was obtained from the operating
room information system. Patients transferred directly to
the intensive care unit were not assessed postoperatively
because these patients were not admitted to our PACU. As
a result, research nurses conduct a skin inspection; we did
not follow patients after they had left the operating room.
Data were entered and analyzed using Statistical Package
for Social Sciences, version 21 (SPSS, Chicago, Illinois).
Baseline demographic and risk factor characteristics were
reported as frequencies and percentages for categorical
variables or means and standard deviations (SDs) for continuous
variables. We calculated the odds ratios (ORs) and
their 95% confidence intervals for the proportion of patients
with pressure injuries/ulcers and for the individual
risk factors for which we screened. Mean difference and
their 95% confidence intervals were calculated for continuous
variable risk factors. We report results as crude
ORs; that is, results were not adjusted for any potential
Between March and May 2013, 534 patients were recruited
and enrolled. The mean age of the sample was 54.1 ± 17.9
years (mean ± SD), and their mean weight was 84.0 ± 22.2
kg, with an average body mass index of 29.0 ± 7.0. Three
hundred six participants (57.3%) were male and the majority
(n = 393; 73.6%) were admitted from home. The
remaining participants were either inpatients (n = 132;
24.7%) or admitted from residential care (n = 9; 1.7%).
Many patients had 1 or more underlying medical conditions;
for example, 240 (44.9%) had a cardiac complication
(including elevated blood pressure), 130 (24.3%) had
a respiratory disorder, and 120 (22.5%) had a gastroenterological
condition. One hundred fifty-five patients (29.0%)
reported more than 1 comorbid condition. When skin
condition was evaluated, 445 (83.3%) had healthy skin
with the remainder having poor tissue turgor or edema.
Recent weight loss was reported by 67 (12.5%) participants.
Only 11 (2.1%) were incontinent and 7 (1.3%)
unable to move independently.
Participants underwent multiple surgical procedures,
the most frequent were general surgical procedures (n =
128; 24.0%) or orthopedic surgeries (109; 20.5%). Position
during surgery was available for 494 patients; 361 (73.1%)
were operated on in the supine position. A full-length gel
pressure redistributing mattress was used for most patients
(392/483; 81.2%). The majority 451/496 (90.9%)
had surgery under a general anesthetic; 21 (4.2%) underwent
epidural and 24 (4.8%) received local anesthesia
with sedation. The mean length of surgery was 167 ± 114
Follow-up data were unavailable for 60 (11.2%) of the
recruited patients (missed postoperatively, n = 30; surgical
procedure cancelled, n = 19; patient condition prohibited
skin inspection, n = 10; and surgery < 30 minutes, n = 1), leaving 474 patients for analysis. These patients did not differ from the total sample on any pressure ulcer risk characteristic. Pressure Ulcer Incidence Seven (1.3%) of the 534 patients originally recruited were found to have a pressure ulcer before surgery (3 were category/stage 1, 2 were stage 2, and 2 were unstageable). The stage 4 pressure ulcers present when surgery was undertaken were not documented in the patient’s medical record. Six (1.3%) new pressure ulcers developed among the 474 patients who were available for the postoperative examination; 4 were category/stage 1, and 2 were category 2). None of those who developed a new pressure ulcer had a pressure ulcer before surgery. Risk-Associated Factors Risks associated with pressure ulcer development were having a comorbid condition such as cardiac disease or peripheral vascular disease (PVD); poor skin condition; being admitted from hospital or residential care; having recent weight loss; incontinence; being unable to move independently prior to surgery; and having a pillow placed under the knees during surgery. Crude ORs for risk factors associated with the occurrence any pressure ulcer and those associated specifically with postoperative pressure ulcers are shown in Tables 2 and 3. ■ Discussion The purpose of this study was to enhance existing knowledge about the incidence and predictors of surgery-related pressure ulcers and, to date; our study is the largest, prospective investigation to do so. The incidence of hospitalacquired, surgery-related pressure ulcers identified in the immediate postoperative period was 1.3%. Our pressure JWOCN-D-13-00082.indd 140 24/02/15 12:47 AM J WOCN ■ Volume 42/Number 2 Webster etal 141 Copyright © 2015 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. TABLE 2. Factors Associated With Any Pressure Ulcer Among a Cohort of Surgical Patients in an Acute Hospital Setting Univariate Analysis Risk Factors Yes, n (%) No, n (%) Crude OR 95% CI Pa Comorbid conditions Cardiac 10/213 (4.7) 3/261 (1.1) 4.24 1.15-15.60 .030b Diabetes 5/82 (6.1) 8/392 (2.0) 3.12 0.99-9.78 .051b Renal 5/45 (11.1) 8/429 (1.9) 6.58 2.06-21.06 .002b Peripheral vascular disease 4/25 (16.0) 9/449 (2.0) 9.31 2.65-32.72 .001b Skin condition healthy 2/397 (0.5) 11/77 (14.3) 0.03 0.01-0.14 <.001b Patient admitted from home 4/353 (1.1) 9/121 (7.4) 0.14 0.04-0.47 .001b Weight loss 3/60 (5.0) 10/414 (2.4) 2.13 0.57-7.96 .026b Continent 10/465 (2.2) 3/9 (33.3) 0.04 0.01-0.20 <.001b Moves independently 11/469 (2.3) 2/5 (40.0) 0.04 0.01-0.24 .001b Pillow under knees in surgery 4/40 (10.0) 9/434 (2.1) 5.25 1.54-17.88 .008b More than 1 comorbidity 8/131 (6.1) 5/343 (1.5) 4.40 1.41-13.70 .011 Pressure Ulcer No Pressure Ulcer MD Older age (mean and SD in years) 73.46 (11.35) 52.72 (17.83) 20.74 10.96-30.52 <.001 Number of other comorbidities (mean and SD| ) 1.08 (1.19) 0.33 (0.64) 0.74 0.38-1.11 <.001 Abbreviations: CI, confidence interval; MD, mean difference; OR, odds ratio. a Level of significance. b Statistical significance. TABLE 3. Factors Associated With Any New Pressure Ulcer Among a Cohort of Surgical Patients in an Acute Hospital Setting Univariate Analysis Risk Factors Yes, n (%) No, n (%) Crude OR 95% CI Pa Skin condition healthy 1/397 (0.3) 5/77 (6.5) 0.04 0.00-0.32 .003b Patient admitted from home 2/353 (0.6) 4/121 (3.3) 0.17 0.03-0.92 .040b Cardiac condition 5/213 (2.3) 1/261 (0.4) 6.13 0.72-52.04 .068 Pillow under knees 2/40 (5.0) 4/434 (0.9) 5.43 1.03-28.71 .084 Epidural 2/41 (4.9) 4/433 (0.9) 5.50 0.98-30.99 .088 Peripheral vascular disease 1/25 (4.0) 5/449 (1.1) 3.59 0.44-29.59 .279 Diabetes 2/82 (2.4) 4/392 (1.0) 2.39 0.44-12.83 .278 Any comorbidities 3/131 (2.3) 3/343 (0.9) 2.66 0.53-13.33 .240 Pressure Ulcer No Pressure Ulcer MD Older age (mean and SD∙ in years) 75.17 (10.0) 53.01 (17.9) 22.16 7.75-36.57 <.003b Abbreviations: CI, confidence interval; MD, mean difference; OR, odds ratio. a Level of significance. b Statistical significance. ulcer rate was comparable to one other study, in which the incidence of immediate postoperative pressure ulcers was zero.23 In contrast, our rate was much lower than those reported in multiple other prospective studies, which ranged from 12% to 27%.14,17–19,21,25 The disparity in rates may be attributable to 2 important differences between those studies and ours. The first difference was an absence, in most studies, of information about immediate postoperative pressure ulcer rates. These studies reported the cumulative occurrence JWOCN-D-13-00082.indd 141 24/02/15 12:47 AM 142 Webster etal J WOCN ■ March/April 2015 Copyright © 2015 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. other studies in this field where skin condition was included as an independent risk factor. Nevertheless, the role of healthy skin in pressure ulcer prevention is well established, so our findings were not unexpected. The next factor we found to be associated with a surgically acquired pressure ulcer was admission from a destination other than their own home. We also found this to be the case in our other pressure ulcer, risk-factor studies.27,28 This relationship may be attributable to a reduced level of mobility and poorer overall health among patients admitted from residential care or among those who are acute inpatients. These patients are likely to be subject to a longer hospital stay that is known to be associated with pressure ulcer development.1,29 The final risk factor was older age; this finding is consistent with other studies.14,20,21 Although other risk factors shown in Table 2, such as “having a cardiac condition” or a “peripheral vascular disease” failed to reach statistical significance in this study, they were included because the odds of these conditions resulting in a pressure ulcer were high. Failure to achieve statistical significance for these risk factors may be attributable to sample size or to the low number of pressure ulcers observed during data collection. ■ Limitations Although the number of patients who participated in this study was robust (N = 534), the low incidence of identified pressure ulcers led to wide confidence intervals for most risk factors, indicating a high degree of imprecision in our results. For example, calculation of a crude OR indicated that participants with PVD were more than 9 times more likely to develop a pressure ulcer compared to those without PVD. However, the confidence intervals suggest that the true effect of having PVD on pressure ulcer development may be as low as 2 1∙2 times more likely, indicating a real difference as high as 36 times more likely (Table 1). Wide confidence intervals have been evident in other studies in this area, suggesting that larger samples are needed to more precisely determine the magnitude of various risk factors on pressure ulcer incidence.21–23 A second limitation was that the study was conducted at a single site. Nevertheless, our results are comparable to those studies conducted elsewhere, so findings are likely to be valid in other like organizations. In addition, only 202 of the participants in our study underwent surgery lasting more than 2 hours. Although not a limitation in itself, we found that 16 of these patients, most of whom had particularly long surgery, did not have a follow-up skin inspection. This was primarily because the research nurses worked only until 3:30 pm and PACU staff frequently found themselves unable to conduct the skin inspection. There was also some evidence that very sick patients were not checked by PACU staff for pressure ulcers postoperatively, including 4 who were transferred to the intensive care unit following their surgery. rates of pressure ulcers occurring at any time during the postoperative period, which may have resulted in higher reported rates. The exception was 1 study that reported an immediate, surgery-related postoperative rate of 12.7%. The immediate postoperative period was defined as “at operating theat
re discharge.” However, participants in that study were included only if surgery exceeded 2 hours, whereas we included patients with shorter surgeries, which may have led to our lower rate.19 The second difference between our study and others was our inclusion criteria. We enrolled patients whose surgery was expected to last more than 30 minutes, whereas many other studies recruited patients only if their surgery lasted more than 120 minutes.14,17–19,21,25 Our decision to include patients with shorter surgeries was made on theoretical grounds. We believed it possible to develop a pressure ulcer in under 2 hours, provided the patient was compromised by 1 or more pressure ulcer risk factors. We also were aware that no previous studies had investigated this time frame. In our study, all surgery-related pressure ulcers occurred in patients whose surgery exceeded 2 hours. Nevertheless, we support this decision because it adds to our understanding of the risks associated with a greater variety of surgical procedures, including those lasting less than 2 hours. Risk Factors for Any Pressure Ulcer Consistent with other studies of surgical patients, we found an association between older age,14,20,21 diabetes mellitus,14,19,21–23 cardiac conditions,19 vascular disease,25 and having multiple comorbid conditions23,25 and the development of any pressure ulcer. Although we failed to discover a relationship between low body mass index and the development of a pressure ulcer, we did find an increased incidence of pressure ulcers among those with recent weight loss. Other studies have also found that length of surgery contributed to the incidence of pressure ulcers.17–19 In contrast to studies that focused on surgeries persisting more than 2 hours, we found no statistical relationship between length of surgery and the development of a new pressure ulcer. We also found a higher rate of pressure ulcers among those with a renal condition and in patients who had a pillow under their knees during surgery. We were unable to identify other studies reporting these relationships. Protective factors included having healthy skin, being continent, being able to move independently, and being admitted from home. Risk Factors for Surgically Related Pressure Ulcer Six pressure ulcers occurred during the surgery and were statistically associated with 3 risk factors. The first of these was the state of patient’s skin (healthy with good turgor vs poor tissue turgor or edema). In other studies of surgically acquired pressure ulcers, this variable has been included in an overall risk assessment score, using the Braden Scale.14,17,18,23 Consequently, it was not possible to find JWOCN-D-13-00082.indd 142 24/02/15 12:47 AM J WOCN ■ Volume 42/Number 2 Webster etal 143 Copyright © 2015 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. ■ ACKNOWLEDGMENT We thank the RBWH Research Foundation for support. ■ References 1. Lyder CH, Wang Y, Metersky M, et al. Hospital-acquired pressure ulcers: results from the national Medicare Patient Safety Monitoring System study. J Am Geriatr Soc. 2012;60(9):1603-1608. 2. Centers for Medicare and Medicaid Services. Medicaid program; payment adjustment for provider-preventable conditions including health care–acquired conditions. Final rule. Fed Regist. 2011;76(108):32816-32838. 3. Healthcare Purchasing Framework. 2013-14. Adverse events: Hospital acquired pressure injuries. http://qheps.health. qld.gov.au/hpfp/docs/spec-pressinj.pdf. Accessed June 14, 2013. 4. Wald H, Richard A, Dickson VV, Capezuti E. Chief nursing officers’ perspectives on Medicare’s hospital-acquired conditions non-payment policy: implications for policy design and implementation. Implement Sci. 2012;7:78. 5. Niederhauser A, VanDeusen LC, Parker V, et al. Comprehensive programs for preventing pressure ulcers: a review of the literature. Adv Skin Wound Care. 2012;25(4):167-188; quiz 89-90. 6. Berthe JV, Bustillo A, Melot C, de Fontaine S. Does a foamyblock mattress system prevent pressure sores? A prospective randomised clinical trial in 1729 patients. Acta Chir Belg. 2007;107(2):155-161. 7. Unbeck M, Sterner E, Elg M, Fossum B, Thor J, Pukk Harenstam K. Design, application and impact of quality improvement ‘theme months’ in orthopaedic nursing: a mixed method case study on pressure ulcer prevention. Int J Nurs Stud. 2013;50(4): 527-535. 8. McGinnis E, Stubbs N. Pressure-relieving devices for treating heel pressure ulcers. Cochrane Database Syst Rev. 2011;9: CD005485. 9. Moore ZE, Cowman S. Repositioning for treating pressure ulcers. Cochrane Database Syst Rev. 2012;9:CD006898. 10. Moore ZE, Cowman S. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database Syst Rev. 2008;3:CD006471. 11. McInnes E, Jammali-Blasi A, Cullum N, Bell-Syer S, Dumville J. Support surfaces for treating pressure injury: a Cochrane systematic review. Int J Nurs Stud. 2011;50(3):419-430. 12. Langer G, Schloemer G, Knerr A, Kuss O, Behrens J. Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database Syst Rev. 2003;4:CD003216. 13. Conley D, Schultz AA, Selvin R. The challenge of predicting patients at risk for falling: development of the Conley Scale. Medsurg Nurs. 1999;8(6):348-354. 14. Schultz A, Bien M, Dumond K, Brown K, Myers A. Etiology and incidence of pressure ulcers in surgical patients. AORN J. 1999;70(3):434, 437-440, 443-449. 15. Guihan M, Bombardier CH. Potentially modifiable risk factors among veterans with spinal cord injury hospitalized for severe pressure ulcers: a descriptive study. J Spinal Cord Med. 2012;35(4):240-250. 16. Coleman S, Gorecki C, Nelson EA, et al. Patient risk factors for pressure ulcer development: systematic review. Int J Nurs Stud. 2013;50(7):974-1003. 17. Kemp MG, Keithley JK, Smith DW, Morreale B. Factors that contribute to pressure sores in surgical patients. Res Nurs Health. 1990;13(5):293-301. 18. Tschannen D, Bates O, Talsma A, Guo Y. Patient-specific and surgical characteristics in the development of pressure ulcers. Am J Crit Care. 2013;21(2):116-125. Consequently, our rate of new pressure ulcers may have been underestimated. Finally, limited funding prevented us from following up patients after discharge from the PACU. Blanchable erythema was frequently seen by the research nurses among patients with risks for pressure ulcers, so it would have been useful to continue to follow these patients, to observe any pressure ulcer development. The literature suggests that pressure ulcers may occur in the early postoperative period23 but, whether these are directly attributable to the intraoperative period or subsequent care is unclear. ■ Implications for Practice and Research Careful skin assessment in days following surgery is extremely important, especially among patients who are at risk for pressure ulcer development. It is also important to document any changes in skin condition. A recent statewide audit in Queensland found that only 43% of pressure injuries/ulcers identified across the state had current documentation in the patient’s notes.30 This lack of documentation suggests that full skin inspection may sometimes not occur or that results are not recorded and, as the research nurses noted, patients themselves are a poor source of information regarding their skin condition, particularly on the lower limbs. We are also aware, from the education training with recovery room staff, of a lack of knowledge about pressure ulcers and their staging. Comprehensive education about pressure ulcers may not be included in nursing programs, so it is important that such education is provided in the workplace. Especially where the incidence of pressure ulcers is low, any future cohort studies will require large sample sizes to confirm predictors of pressure ulcers. Interventions, to reduce the rate of hospital-acquired pressure ulcers, need to be based on the predictive risk factors that are able to be modified using well-conducted randomized controlled trials. However, as findings from this study and others show, very few of the risks associ
ated with pressure ulcer development are modifiable. Consequently, careful daily assessment and use of interventions that have demonstrated efficacy may be the best way forward. ■ Conclusions Perioperative nurses play an important role in identifying existing or new pressure ulcers. However, many are unfamiliar with pressure ulcer classification, so education in this area is essential. Although the incidence of surgically acquired pressure ulcers was low in this cohort that included all surgeries lasting 30 or more minutes, careful skin inspection before and after surgery provides an opportunity for early treatment and may prevent existing lesions progressing to higher stages. JWOCN-D-13-00082.indd 143 24/02/15 12:47 AM 144 Webster etal J WOCN ■ March/April 2015 Copyright © 2015 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. 19. Bulfone G, Marzoli I, Quattrin R, Fabbro C, Palese A. A longitudinal study of the incidence of pressure sores and the associated risks and strategies adopted in Italian operating theatres. J Perioper Pract. 2012;22(2):50-56. 20. Houwing R, Rozendaal M, Wouters-Wesseling W, Buskens E, Keller P, Haalboom J. Pressure ulcer risk in hip fracture patients. Acta Orthop Scand. 2004;75(4):390-393. 21. Papantonio CT, Wallop JM, Kolodner KB. Sacral ulcers following cardiac surgery: incidence and risks. Adv Wound Care. 1994;7(2):24-36. 22. Liu P, He W, Chen HL. Diabetes mellitus as a risk factor for surgery-related pressure ulcers: a meta-analysis. J Wound Ostomy Continence Nurs. 2012;39(5):495-499. 23. Lewicki LJ, Mion L, Splane KG, Samstag D, Secic M. Patient risk factors for pressure ulcers during cardiac surgery. AORN J. 1997; 65(5):933-942. 24. Lee WY, Lin PC, Weng CH, Lin YL, Tsai WL. A project to reduce the incidence of facial pressure ulcers caused by prolonged surgery with prone positioning. Hu Li Za Zhi. 2012;59(3): 70-78. 25. Loorham-Battersby CM, McGuiness W. Heel damage and epidural analgesia: is there a connection? J Wound Care. 2011;20(1): 28, 30, 2-4. 26. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Washington, DC: National Pressure Ulcer Advisory Panel; 2009: 8-9. 27. Webster J, Coleman K, Mudge A, et al. Pressure ulcers: effectiveness of risk-assessment tools. A randomised controlled trial (the ULCER trial). BMJ Qual Saf. 2011;20(4):297-306. 28. Webster J, Gavin N, Nicholas C, Coleman K, Gardner G. Validity of the Waterlow Scale and risk of pressure injury in acute care. Br J Nurs. 2010;19(6):S14, S6, S8 passim. 29. Hauck K, Zhao X. How dangerous is a day in hospital? A model of adverse events and length of stay for medical inpatients. Med Care. 2011;49(12):1068-1075. 30. Hill J, Vanderkwast C. Queensland Health Pressure Ulcer Prevalence Audit 2008. Brisbane, Queensland, Australia: Queensland Health; 2012:23. http://qheps.health.qld.gov.au/psq/pip/ docs/pup_report2008.pdf. Call for Authors: Wound Care • Continuous Quality Improvement projects, research reports, or institutional case studies focusing on innovative approaches to reduction of facility acquired pressure ulcers. • Original research or literature review on causes and management of refractory wounds. • Case studies, case series, review articles, or research reports on management of wound-related pain. • Case studies, case series, review articles, or research reports on matrix dressings, human skin substitutes, growth factors, or other advanced wound therapies. • Research reports or literature review on pathology, prevention, and management of biofilms. • Literature review and current guidelines on skin and wound care in neonates and infants. JWOCN-D-13-00082.indd 144 24/02/15 12:47 AM s 3 6 9 research j o u r n a l o f wo u n d c a r e vo l 2 3 , n o 7 , J U LY 2 0 1 4 © 2 0 1 4 M A H e a l t h c a r e l t d Pressure ulcer risk assessment and prevention: What difference does a risk scale make? A comparison between Norway and Ireland l Objective: To explore similarities and differences in nurses’ views on risk assessment practices and preventive care activities in a context where patients’ risk of developing pressure ulcers is assessed using clinical judgment (Norway) and a context where patients’ risk of developing pressure ulcers is assessed using a formal structured risk assessment combined with clinical judgement (Ireland). l Method: A descriptive, qualitative design was employed across two different care settings with a total of 14 health care workers, nine from Norway and five from Ireland. l Results: Regardless of whether risk assessment was undertaken using clinical judgment or formal structured risk assessment, identified risk factors, at risk patients and appropriate preventive initiatives discussed by participant were similar across care settings. Furthermore, risk assessment did not necessarily result in the planning and implementation of appropriate pressure ulcer prevention initiatives. Thus, in this instance, use of a formal risk assessment tool does not seem to make any difference to the planning, initiation and evaluation of pressure ulcer prevention strategies. l Conclusion: Regardless of the method of risk assessment, patients at risk of developing pressure ulcers are detected, suggesting that the practice of risk assessment should be re-evaluated. Moreover, appropriate preventive interventions were described. However, the missing link between risk assessment and documented care planning is of concern and barriers to appropriate pressure ulcer documentation should be explored further. l Declaration of interest: This work is partly funded by a research grant from the Norwegian Nurses Organisation (NNO) (Norsk Sykepleierforbund NSF) in 2012. The authors have no conflict of interest to declare. pressure ulcer; risk assessment; prevention; focus group; Norway; Ireland Within healthcare practice today, regardless of the clinical setting, the prevalence and incidence of pressure ulcers is considered to be a key quality indicator.1 Indeed, a recent publication from the European Parliament focusing on patient safety calls on the Member States to encourage healthcare providers to focus on pressure ulcers, which they highlight are a major but often hidden problem.2 Pressure ulcers pose a significant problem for individuals, with all components of the activity of daily living adversely affected.3 Worryingly, pain is one of the most common complaints, which is often suggested to be intractable and exacerbated by treatment and prevention strategies employed.3 For health services, pressure ulcers are expensive, occupying up to 4% of health budgets, with nursing time accounting for up to more than 90% of costs.4,5 Bearing in mind the significance of pressure ulcers for the individual3 and society as a whole,4 coupled with the knowledge that most pressure ulcers can be prevented6 establishment of focused prevention strategies is suggested to be the key to success.7 The focus for pressure ulcer prevention has been primarily on identifying those at risk of pressure ulcer development and following this up with implementation of appropriate pressure ulcer prevention strategies.8 For those settings using formal risk assessment, the mean percentage of patients assessed is 57.25%, varying from 24% to 100%.9 One of the concerns here is that there are a plethora of risk assessment tools in current use, yet none has been demonstrated to be 100% reliable and valid.10–12 In general, each tool is developed for certain patients, or as a result of a search of the literature. As patients vary considerably regarding age, health status and pressure ulcer risk, in addition to the fact that institutions can choose which scale to use, there is a possibility that risk tools are not always uniquely developed for those specific patients cared for within each clinical setting. This compounds the challenges for healthcare providers in being able to correctly identify those at risk. Potentially, this could mean that clinical staff do not trust the current formal structured ris
k assessment tools and therefore, consider use of alternate methods of assessment.9 Thus, arguments abound in the literaE. Johansen,1 assistant professor, Bsc, Msc, RN; Z. Moore,2 professor and head of the school of nursing and midwifery, PhD, MSc, FFNMRCSI, PG Dip, RGN; M. van Etten3 ; physiotherapist, seating & mobility consultant, H. Strapp,4 tissue viability clinical nurse specialist, RGN, RSCN, RNP, MSc, PG Dip; 1 Faculty of Health Sciences Buskerud and Vestfold University College Drammen, Norway; 2 Royal College of Surgeons in Ireland, Ireland; 3 Halden, Norway; 4 AMNCH, Dublin 25, Ireland Email: Edda.Johansen@ hbv.no 3 7 0 j o u r n a l o f wo u n d c a r e vo l 2 3 , n o 7 , J U LY 2 0 1 4 research © 2 0 1 4 M A H e a l t h c a r e l t d ture pertaining to whether clinical judgment is as effective as formal structured risk assessment, yet just two studies have explored this from a randomised controlled trial perspective.13,14 Neither study found any difference in pressure ulcer incidence whether patients were assessed using formal structured risk assessment or whether assessed using clinical judgment alone. However, in interpreting these studies, one needs to question the concept of “clinical judgment” and how it is developed. Clinical judgment is considered to be an outcome and is arrived at following the process of critical thinking and critical reasoning.15 In this context it is taken to mean the judgment by the healthcare professional of the patient’s risk status following assessment of the patient and the perception of the healthcare professional of the risk factors that the individual patient presents with. Prior knowledge and experience of use of formal, structured risk assessment tools will inevitably influence clinical judgment, as it is impossible to unlearn what has been learned during clinical use of such risk assessment tools.12 Thus, to determine clearly if clinical judgment alone is as good as, or better than, formal structured risk assessment, it is important that confounding variables, such as prior use of the risk assessment tool, are eliminated.16 This was not the case in the studies of Saleh et al.13 and Webster et al.14 Conversely, in Norway, the use of formal structured risk assessment as a component of pressure ulcer risk assessment has yet to be established.17 Thus, in general, staff has no experience and little knowledge of instruments such as Waterlow, Norton, Modified Norton or Braden. This means that in Norway, clinical judgment alone is being used as a means of assessing patients’ risk of pressure ulcer development. Further, this clinical judgment is, in most circumstances, not influenced by prior experience of risk assessment tools.17 Such a clinical setting provides an ideal medium to explore clinical risk assessment and prevention practices and compare these with a setting where formal structured risk assessment is commonplace. In terms of pressure ulcer prevention, an issue of concern is that, despite considerable investment in education and training, research has identified significant deficits in patients receiving fully appropriate interventions to combat risk.18–20 Indeed, an integrative review by Moore et al.9 found that the mean use of pressure redistribution devices was 60%, varying from 28% to 97.3%. Furthermore, the mean use of repositioning for pressure ulcer prevention was 19%, varying from 0% to 37%.9 Overall the mean recording of pressure ulcer presence or prevention strategies within the nursing notes was 46.4%, varying from 9% to 70%.9 It is clear, therefore, that there are significant challenges in achieving the goals of pressure ulcer prevention as outlined in best practice guidelines,8 and this has significant implications for patients themselves and for achievement of quality and safety standards.2 Questions are raised pertaining to the value of formal, structured risk assessment as compared to clinical judgment alone, in addition to how either of these risk assessment methods act as a precursor to risk intervention. Norway and Ireland were chosen as the settings for this current study as Ireland uses formal structured risk assessment and Norway does not. This provides an ideal opportunity to explore how nurses describe their risk assessments and preventive practices in the two care settings. Thus, the aim of this study was to compare pressure ulcer risk assessment practices and preventive care activities between Ireland and Norway as perceived and experienced by nurses in either country. Methods Study design A descriptive, qualitative design was employed to explore nurses’ views on pressure ulcer risk assessment and preventive practices across two different care settings within Norway and Ireland. A qualitative research approach was chosen as it is considered an appropriate design where limited knowledge exists on a phenomenon,21 as was the situation for this study. Setting and participants This study was carried out in Norway and Ireland with a total of 14 healthcare workers, nine from Norway and five from Ireland. In Norway, participants were recruited from a cohort of 19 wound care students, nurses and social educators working with patients in different healthcare sectors in different parts of Norway. As the first author (EJ) was closely connected to the course and the students informing the study, the recruitment of participants was handled by a department secretary through email correspondence. Seven nurses and two social educators working in hospitals, home care and nursing homes, aged 28–51 years, with 4 to 9 years of clinical experience volunteered and subsequently participated in the study. In Ireland, nurses from 7 clinical sites within an acute care hospital setting received an invitation to participate in the study. As only 3 staff nurses and 2 clinical nurse managers volunteered, they were all invited to participate in the study. The participants from Ireland were working in a variety of clinical settings, including surgery, acute medicine, orthopedics and acute care of the older person. These participants were aged between 25–54 years, with 2 to 30 years of service. All participants (Norway and Ireland) were female. 3 7 2 j o u r n a l o f wo u n d c a r e vo l 2 3 , n o 7 , J U LY 2 0 1 4 research © 2 0 1 4 M A H e a l t h c a r e l t d Data collection A semi-structured interview design was chosen as it ensured that specific topics were covered while also being open to any spontaneous information proffered by respondents.22 Two focus group interviews were carried out, one in November 2012 (Norway) and a second interview in April 2013 (Ireland). A focus group is a method of systematic questioning used for obtaining qualitative data from many people.23 Interaction between group members can contribute to rich information and conflicting viewpoints can further enhance the overall knowledge about a topic.24 Focus group interviewing was therefore chosen for this study as it had the potential to expose similarities and disparities in clinical practice, both within and across countries. The questions used to guide the interview process included: 1. Can you tell us your experiences with pressure ulcers?; 2. Can you tell us how you risk assess patients for pressure ulcer?; 3. Tell us what makes patients at risk of developing a pressure ulcer; 4. Tell us how you prevent pressure ulcers; 5. Tell us what you know about risk assessment scales; and 6. Are there any other issues regarding pressure ulcers you would like to tell us about? Because rich information can be gathered when informants describe their experiences through concrete stories, respondents were encouraged to give examples from clinical practice.24 In the focus group interviews, one researcher was leading the interview while others kept field notes. The researchers’ roles were clarified for the participants at the onset of the interviews. In Norway, the first author (EJ) conducted the interview while in Ireland HS conducted the interview with ZM clarifying questions and taking notes. The third author (MvE) participated in both interviews as an observer, making field notes on nonverbal cu
es, agreements or disagreements, interest or disinterest of the participants and group dynamics. As data analysis began when field notes were made, having the same observer in both settings increased the immediate opportunity to reflect on similarities and differences in practices within and across countries. At the beginning of the focus groups the participants were thanked for their participation and a meal was provided. The study purpose was reiterated and it was emphasised that all participants’ experiences and opinions were valuable and that no right or wrong answers existed. Written consent was received from the participants. The focus groups were audio taped and transcribed verbatim by EJ (Norwegian interview) and ZM (Irish interview). Data analysis The analysis of the interviews began in the focus group settings and continued while the researchers transcribed and became familiar with the material. In qualitative studies, researchers’ different viewpoints on the same findings might increase the understanding of complex phenomena.25 To enhance the study trustworthiness, the Irish transcript was analysed independently by three Englishspeaking researchers (EJ, MvE, ZM) and the Norwegian transcripts independently by the bilingual speakers (EJ and MvE). The individual interpretations and conclusions for each interview were discussed until consensus was reached. Field notes and the third author’s experiences (MvE) from the observer role were integrated in the analysis. The interpretations and conclusions made by the three English-speaking researchers on the English interview were verified by the fourth author (HS), whereas the bilingual researchers were responsible for analysis of the Norwegian interview. The overarching themes from the Norwegian interview were translated into English. This study followed the inductive content analyses process described by King and Horrocks.26 The analysis involved reading and re-reading of the transcripts and highlighting with a marker those sections of the transcripts that provided an understanding of pressure ulcer risk assessment and preventive care. The highlighted phrases were tabulated and what was of interest within the extracted transcripts was noted in the table. The next step involved the formulation of descriptive codes from the interview extracts without any interpretation or ideas on what lay behind. The table now had three sections; interview extracts, comments of what was of interest and descriptive codes. The next step of the analysis was to interpret the meaning of the descriptive codes, and group the codes that seemed to share some common meaning, thereby reducing the material further. The interview extracts were then viewed together with the descriptive codes resulting in a third step involving the development of the interpretative codes. This way of registering data made it possible to view the stages of the analysis while keeping the research questions in the forefront. The final step was to develop the overarching themes26 which involved looking across both sets of interviews to elicit similarities and differences across countries. Ethics The study was approved by the Norwegian Social Science Data Services and the Research Ethics Committee of the participating hospital in Ireland. Participation was voluntary and participants were guaranteed anonymity, and signed informed consent was collected in the interview settings. Written s j o u r n a l o f wo u n d c a r e vo l 2 3 , n o 7 , J U LY 2 0 1 4 3 7 3 research © 2 0 1 4 M A H e a l t h c a r e l t d information, outlining the study and its aim, was sent by e-mail before to the interview to allow time to ask questions about the study and assess whether to participate or not. Results Risk assessment practice The focus groups confirmed that risk assessment practices varied across the two countries. Norwegian participants were generally unfamiliar with formal, structured risk assessment scales, leaving pressure ulcer risk assessment based solely on clinical judgment. However, one Norwegian participant mentioned that risk assessment scales had been discussed at her workplace: “Starting now to discuss one such risk assessment tool, the Braden scale, to assess patients who get to us from hospitals or home. We are at bit at the starting line yet but what we have thought about (pause), that’s what we have thought about (Braden scale)”. [Norway] Nurses in Ireland, on the other hand, routinely used a numeric risk assessment tool in combination with clinical judgment: “I don’t know what they do in other wards but I know in our ward, no matter what, we have to have a skin care plan on everybody so we assess their skin and Maelor score”. [Ireland] “I think everybody has a Maelor score when they are admitted, you know, or when they come to the ward, It’s part of the admission”. [Ireland] Overall, the Maelor score was undertaken in patients primarily on admission, after which the nurses relied on their clinical assessment of the patient and existing care plans for further monitoring of the patients risk status. However, one respondent suggested that accurate care planning was dependent on staffing levels, competence and time. Due to staff shortages, care plans were not always updated, leaving some nurses continuing to use the Maelor score to determine the patients risk status. Conversely, another participant suggested that they would never go back to reassess the patient’s Maelor score; furthermore, this participant felt that although the risk assessment highlighted the patient’s risk, it would have to be followed by a full patient assessment: “It just highlights it, then you go and assess the patient physically”. [Ireland] From the Irish data, it emerged that there was an expectation by others that risk assessment using the established formal risk assessment tool would be conducted on all patients. As such, nurses were asked to provide evidence of the risk assessment undertaken: “Over the last few months the XX consultants are asking how the patients’ skin is, we are not used to that”. [Ireland] The nurses expressed that being “checked” undermined their scope of practice: “Recently the XX consultant is giving step-bystep instructions on pressure ulcer prevention and it is demeaning to nursing”. [Ireland] Pressure ulcer risk In both countries, the main risk factors described for pressure ulcer development were immobility, poor skin, incontinence and nutritional state. Immobility was identified as being particularly important in both countries: “It has to be the mobilisation, how mobile is the patient”? [Ireland] “If you have a patient that is mobile which you come across, then you do not have to think so much about pressure ulcers”. [Norway] It became clear from the data that the risk factors considered important and the types of patients deemed to be at risk, as outlined by the participants, concurred across both countries. However, because some nurses in Ireland worked in orthopaedic wards, they also described post-operative immobilisation as a significant pressure ulcer risk factor. Further, the presence of comorbidities and diabetes were also considered important in Ireland. In Norway, a lack of pressure ulcer knowledge among patients was considered to place the individual at risk; however, this was not mentioned by the nurses in Ireland: “I think the knowledge patients themselves hold is too limited. They haven’t been told they mustn’t lie on the side where they have an ulcer”. [Norway] Overall, participants in both focus groups discussed risk factors for pressure ulcer development, freely. There was general consensus among the groups of the most pertinent factors to consider and 3 7 4 j o u r n a l o f wo u n d c a r e vo l 2 3 , n o 7 , J U LY 2 0 1 4 research © 2 0 1 4 M A H e a l t h c a r e l t d the interactions between the focus group members indicated that they were comfortable with this concept. Not surprisingly, the importance of overall risk scores being an indication of risk status emerged only in the data from Ireland. Pressure ulcer prevention The focus groups r
evealed that, independent of risk assessment practices across countries, skin assessment and care, pressure relief, turning, nutrition care and access to necessary equipment were important for preventive strategies. However, access to appropriate mattresses seemed to be easier in Ireland than in Norway. In Ireland, unlike Norway, the Maelor scoring and care planning was regarded as important for pressure ulcer prevention. In Ireland for instance, results of the risk assessment was used to request other interventions for the patient such as nutritional assessment: “Order [sic] a dietician if necessary – useful in this way”. [Ireland] The importance of involving other professions to get the necessary equipment was only mentioned in Norway: “Pressure relief, turning schedules and then get the physiotherapist on board to get necessary equipment”. [Norway] The data revealed that the participants discussed preventive strategies at the same time as they described risk and risk assessment, making assessments and planning of interventions into integrated activities. For instance, in the Irish transcript the importance of care plans was described concurrently while describing risk assessments and risk factors: “We skin assess/risk score and develop a care plan on everyone …everyone has a care plan”. [Ireland] This means that risk assessment was not seen as a separate entity to planning prevention strategies, thus, nurses may in fact be integrating both risk assessment and prevention planning into a single activity. Care planning In Ireland, standardised care plans were used, however, these were often referred to as a “tick-the-box” exercise: “But a lot of the time, the care plans are a ticking exercise for nurses to kind of cover themselves. I’m not convinced that it’s (the prevention) done as well as the care plan”. [Ireland] In Norway, respondents suggested that care plans for prevention were rare, however, care plans were developed when wounds were formed: “We are not so clever at prevention, but we are very good at treating wounds when they have originated”. [Norway] Interestingly the participants in Ireland also suggested that care planning differed, becoming more focused if the patient had an existing pressure ulcer: “The care plans are all right when they are done …we can’t 100% depend on the care plan. But the skin ones are done well, if someone has a dressing, the care plan is good”. [Ireland] Participants in Ireland indicated that they would be reminded by consultants if care plans were missing and that this made them very “care-plan oriented”. This also influenced the updating of care plans: “But we update them every week because it’s something we are supposed to do”. [Ireland] “The consultants would pick it up if they find that something is wrong, they will ask – show me where it is documented – so, you know, we are very care-plan orientated”. [Ireland] Despite this, the importance of care plans for practice was unclear in both countries: “We don’t use them for reports (handing over information to other staff members) as such”. [Ireland] “We do not manage to keep them alive [the care plans]”. [Norway] Thus, the focus group interviews revealed that care plans may be missing and furthermore, existing care plans might not be used, leading to a disparity between care planning and the care actually provided. Indeed, staff, time and competence were considered to be important for accurate care plan development and implementation: “We can’t 100% depend on the care plan, they are as good as our staff is” “…because it’s a time management issue”. [Ireland] s j o u r n a l o f wo u n d c a r e vo l 2 3 , n o 7 , J U LY 2 0 1 4 3 7 5 research © 2 0 1 4 M A H e a l t h c a r e l t d Barriers to pressure ulcer prevention In both Norway and Ireland, the interview identified factors having a negative impact on pressure ulcer prevention, for instance a lack of staff: “When you need to reposition and in a way is relied on available staff to help, they are not always available”. [Norway] “If you are down carers or staff you don’t have the physical power to do it, because you have no one to help you, you are not getting as much emphasis on turning, it could be delayed”. [Ireland] In both countries, participants suggested that students and some staff lacked the necessary competence to prevent pressure ulcers. This was explained, in part, by a lack of focus on pressure ulcer prevention by educational institutions: “I know there was only one kind of lecture on skin care that was about it”. [Norway] “It tends to be the older nurses on the wards that focus on pressure area care because that was so drummed into us , it will always be a part of the way we nurse, but for the student nurse, it doesn’t seem to sort of focus really”. [Ireland] Thus, for some, their pressure ulcer competence was solely based on experiences from clinical practice and not from theoretical teaching around the topics. Equipment for pressure ulcer prevention The Norwegian participants described how pressure redistribution high-specification mattresses were not always available and that some of the base equipment for the beds was old and worn, lacking pressure redistribution properties. Conversely, the Irish respondents suggested that they had ready access to equipment, high specification mattresses and tissue viability services: “In the older days there were more pressure ulcers coming in because we hadn’t got the equipment like the special mattress and speciality like tissue viability”. [Ireland] In Ireland, participants suggested that results from the Maelor score justified the supply of additional high specification pressure redistribution mattresses. However, they felt that use of a high specification mattress could detract staff from considering other important aspects of pressure ulcer prevention: “When a mattress is ordered, then less focus is paid because staff says that the patient is ok now”. [Ireland] Or, on considering the suitability of the already existing equipment: “Overlays are ordered and people don’t know that the base mattress is very good and no additional equipment may be needed”. [Ireland] Overall, it is evident from the analysis of the data from the focus groups that there are differences in the approach to pressure ulcer prevention between countries. In Norway, risk assessment is undertaken using clinical judgement, whereas in Ireland formal risk assessment involves the combination of a specific risk assessment tool with clinical judgement. Despite this, risk factors for the development of pressure ulcers identified by both groups were similar, including the most appropriate interventions needed to reduce or eliminate this risk. Differences emerged pertaining to the use of documented care plans for pressure ulcer prevention, with those in Norway tending to focus less on preventive care planning. Discussion This study revealed that whether participants used a numeric risk assessment scale in combination with clinical assessments, or not, had little impact on what clinicians regarded to be risk factors, risk patients or relevant preventive initiatives. Identifying at-risk patients Participants from both countries identified patients at risk of pressure ulcer development to be those who were immobile, incontinent, with poor nutritional and skin status. Furthermore, across both countries, immobility was highlighted as the key risk factor. A recent systematic review by Coleman et al.27 and an integrative review by Moore et al.17 both note that activity and mobility were key risk factors for pressure ulcer development. Activity and mobility are included in many numeric risk assessment scales together with several other risk factors such as skin condition, nutritional status, level of consciousness, pain and incontinence.27 As risk scales are routinely used in Ireland, it is not surprising to find that at-risk patients fit the risk factors found in those scales. However, to find that Norwegian healthcare workers, who base their assessment on clinical as
sessments solely, correspond with the Irish respondents and also highlight 3 7 6 j o u r n a l o f wo u n d c a r e vo l 2 3 , n o 7 , J U LY 2 0 1 4 research © 2 0 1 4 M A H e a l t h c a r e l t d immobility as being important is noteworthy. Interestingly, in some of the risk assessment scales, age, nutrition and incontinence for instance, are weighed equally as important for pressure ulcer development as are mobility and activity.28 As pressure and shear most likely occur in immobilised or inactive patients, it is argued here that immobility is a key risk factor where other factors only become important if they lead to immobility, or in the presence of immobility, where they reduce the individuals’ tolerance to pressure and shear.29 It is therefore questioned how age, incontinence and nutritional status predisposes patients to pressure ulcers if they are not always primarily related to immobility and thus to exposure to unrelieved pressure and shear forces. Indeed, Moore et al.29 argue that there is a hierarchy of pressure ulcer risk, with pressure and shear being the causative factors and activity and mobility the key factors that expose the individual to pressure and shearing forces. This opinion was also found among respondents in this study where they argued that they were not concerned about pressure ulcers in mobile patients. In the presence of activity and mobility problems other risk factors might, however, play a role in how well the individual can tolerate immobility and as such decreases the time it takes for the person to develop a pressure ulcer. Interestingly, these additional risk factors, for instance incontinence, poor nutritional and skin status, were identified by healthcare workers regardless of whether risk scales were in use or not, indicating that clinical judgment is an important precursor to risk assessment. Immobility as a key risk factor is supported by Webster et al.14 who contend that risk scales should be replaced by an assessment of patients’ own ability to reposition and if they cannot reposition, then pressure ulcer prevention interventions should be provided immediately. This approach is supported by earlier work of Sharp and McLaws30 who argue that risk assessment should be simple and focus primarily on mobility as other risk factors included in numeric scales might not be accurately predictive of pressure ulcer risk. In a study by Sving et al.,31 a Modified Norton Score (MNS) was used together with clinical assessments to identify patients at risk. Nurses suggested that immobile patients were at risk and preventive initiatives were offered to patients who were clinically assessed to be immobile rather than through assessments made by the MNS.31 If a simple assessment based on patients’ mobility is sensitive enough to identify patients at risk and those not at risk, the use of extensive numeric scales could be replaced by the combination of clinical assessments and a simple non-numeric risk scale based on mobility. Such practice might avoid nurses’ restricted time being used inappropriately on timeconsuming scales.9 Indeed, assessment based on mobility could contribute to improved patient care by making sure that preventive initiatives are effectively offered to those actually at risk. However, it remains important to validate the precise role of immobility in a prospective manner, in order to place the role of immobility into an evidencebased context. Indeed, Webster et al.14 found no difference in pressure ulcer incidence among those assessed using Waterlow, Ramstadius or clinical judgment, meaning that none of the risk assessment practices seemed to specifically influence care delivery. It is important to note, that due to the risk of bias inherent in many of the current risk assessment validation studies as identified by Balzer and colleagues32 it is, as yet, unknown whether initial risk assessment based on immobility is accurate and reliable. However, as this current study found that even across care settings and countries, risk factors and patients at risk as cited by participants were similar, with mobility considered to be the key factor, it is suggested that the use of scale or no scale seemed to have little impact on who were regarded being atrisk patients. Therefore, it is argued that risk assessment could begin with an assessment of mobility and activity and proceed to more complete assessments if impairments are identified.9 Care plans – the missing link In this study, participants discussed that risk assessment did not necessary lead to care planning and provision of appropriate preventive interventions. A lack of connection between risk assessment, care plans and care provided was found in both countries, even though the participants were more careplan oriented in Ireland. Healthcare workers are legally required to register care plans relevant to patients’ needs and implementation of appropriate care plans are necessary to provide safe and consistent care.33,34 However, in this study, in Norway, care plans were more likely to be prepared when patients had developed a wound, possibly leaving preventive care to be reliant on individual staffs’ knowledge and interest. According to the participants a lack of time, staff competence and access to equipment hindered optimal documentation and care, a finding that is consistent with earlier studies.35 Indeed, the caring culture in individual wards has also been found to negatively affect preventive care.31 This finding is supported by earlier work of Moore and Price36 who found that over half of nurses surveyed felt that pressure ulcer prevention was a low priority within the clinical practice setting. Further, the barriers to carrying out pressure ulcer prevention cited are similar to those affecting pressure ulcer risk assessment.36 s j o u r n a l o f wo u n d c a r e vo l 2 3 , n o 7 , J U LY 2 0 1 4 3 7 7 research © 2 0 1 4 M A H e a l t h c a r e l t d This study found that in Ireland, care plans were sometimes reported as a “tick-the-box” exercise partly carried out because the documentation was monitored and staff reminded if care plans were not in place. This lack of connection between risk assessment and documented care is evident across the literature where nurses’ documentation of pressure ulcer prevention was found to be erratic, lacking consistency and standardisation.9 In addition, participants in this study admitted that what was registered in the care plans did not necessary reflect the care provided, leaving a gap between actual practices and nursing documentation. It is important to note that as long as care plans for prevention are not recorded it is difficult to prove that care has ever been offered. The documentation practices reported by participants in this study make it impossible to conclude that appropriate preventative care is actually provided to at-risk patients. Thus, more attention is needed on documentation practice to ensure that it reflects the care provided9 and not least, that care plans for prevention rather than for treatment are recorded. From this study it is evident that regardless of risk assessment practices, patients are not necessary provided with appropriate care plans which are subsequently implemented and evaluated. A further investigation into how risk assessment can provide a precursor to structured preventive care is paramount as care planning and care provided are not necessarily influenced by risk assessment. Rather than continuously re-developing existing risk scales to improve practice and reduce pressure ulcer prevalence, it seems timely to investigate those obstacles that lead to the creation of a missing link between risk assessment and the care planned and provided. Preventive practice From this study it became clear that regardless of risk assessment practice, nurses knew which patients’ were at risk, however, several barriers hindered them from offering evidence-based care. Access to equipment was only a Norwegian issue. In Ireland, base hospital mattresses were of a good quality and risk scores were used to justify the requirement for additional pressure re
distribution devices with staff reporting ready access to equipment. Conversely, in Norway, equipment was described as being old and worn and additional pressure redistribution devices were not always accessible when needed. The systematic review of McInnes et al.37 concludes that individuals at high risk of developing pressure ulcers should be nursed on higher-specification foam mattresses rather than standard hospital foam mattresses. It is clear from this study that within the Norwegian healthcare system, this evidence has yet to be integrated into clinical practice. If risk assessment is to lead to optimal preventive care, it is crucial that healthcare workers have access to appropriate equipment and other preventative strategies. Indeed, it is of limited value to have structured risk assessments and theoretically appropriate care plans in place if the necessary tools or staff competence and time for pressure ulcer prevention are not available. Therefore, it is argued that pressure ulcer prevention must become a key quality issue for clinical care leaders35 as the procurement of necessary equipment, competence and time may rely on these leaders’ priorities. Limitations As only two focus group interviews, with nine and five respondents respectively, were undertaken for this study, the findings should be interpreted with care. It is worthy of consideration also, that the findings may have been influenced by the wide range of care settings in which respondents were employed. Nonetheless, it is clear that additional research on the role of risk scales and clinical assessments in identifying patients at risk is needed, in addition to how risk assessment might successfully lead to preventive care planning and care delivery. Conclusion Regardless of whether clinical risk assessment was combined with a formal structured risk assessment tool or not, identified risk factors, at-risk patients and appropriate preventive initiatives discussed by participant were similar across care settings. Furthermore, risk assessment did not necessarily result in the planning and implementation of appropriate pressure ulcer prevention initiatives. It is clear from this study therefore, that use of a formal risk assessment tool does not necessarily make any difference to the identification of at-risk patients, planning, initiation and evaluation of pressure ulcer prevention strategies. This finding is not unique to the current study, rather has been borne out in a number of RCTs exploring this subject.13,14 A risk assessment tool is supposed to help clinicians to focus on particular areas of practice, in this instance pressure ulcer risk. However, as long as there is no evidence to prove that the extensive number of available numeric risk scales add valuable information to clinical risk assessments, it is argued that risk assessment possibly should focus on mobility and activity.9,30 For those patients found to have impaired activity or mobility, a thorough clinical assessment should be offered to make sure that appropriate preventive care plans and initiatives are supplied. With a missing link between risk assessment, care planning and preventive care provision, neither risk scales nor clinical risk assessment will necessarily lead to a reduction in pressure ulcer prevalence. 3 7 8 j o u r n a l o f wo u n d c a r e vo l 2 3 , n o 7 , J U LY 2 0 1 4 research © 2 0 1 4 M A H e a l t h c a r e l t d Relevance to clinical practice It is evident from this study that the use of numeric risk assessment scales and their implications for clinical practice should be further assessed because clinical judgment has an important part in pressure ulcer prevention. Regardless of whether clinical assessment is used alone or in combination with risk scales, patients at risk are detected. However, the missing link between risk assessment and documented care planning should be of concern to clinical practice and barriers to appropriate pressure ulcer documentation should be explored further. Likewise, the missing connection between developed care plans and the actual care delivered is particularly important to understand, as care plans seem to act as inactive records made for procedural confirmation rather than patient care. Therefore, clinical preventive practice might rely on nurses’ individual competence, consequently leading to irregular practice. Consequently, it might threaten patient safety both while being hospitalised and on discharge as insufficient documentation might lead to unsatisfactory follow up at the next care level. n References 1 Department of Health and Children. Building a culture of patient safety, report of the comission on patient safety and quality assurance Dublin: Stationary Office; 2008. Available from: http://www.dohc.ie/ publications/pdf/en_patientsafety. pdf [Accessed July 2014]. 2 Rossi, O. REPORT on the report from the Commission to the Council on the basis of Member States’ reports on the implementation of the Council Recommendation (2009/C 151/01) on patient safety, including the prevention and control of healthcare-associated infections (2013/2022(INI)) In: Committee on the Environment PHaFS (ed). Brussels: European Parliament 2013. 3 Gorecki, C., Brown, J.M., Nelson, E.A., et al. Impact of pressure ulcers on quality of life in older patients: a systematic review. J Am Geriatr Soc 2009; 57: 7, 1175–1183. doi: 10.1111/j.1532- 5415.2009.02307.x. 4 Posnett, J., Gottrup, F., Lundgren, H., Saal, G. The resource impact of wounds on health-care providers in Europe. J Wound Care 2009; 18: 4, 154–161. 5 Dealey, C., Posnett, J., Walker, A. The cost of pressure ulcers in the United Kingdom. J Wound Care 2012; 21: 6, 261–266. 6 Institute for Healthcare Improvement. Pressure Ulcers. Cambridge, MA: Institute for Healthcare Improvement, 2014. 7 NHS UK 1000 Lives Plus: Preventing Hospital Acquired Pressure Ulcers. Cardiff, Wales: NHS Wales; 2013. 8 European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel, 2009. 9 Moore, Z., Johansen, E., van Etten, M. A review of PU risk assessment and prevention in Scandinavia, Iceland and Ireland (part II). J Wound care 2013; 22: 8, 423–431. 10 Anthony, D., Parboteeah, S., Saleh, M., et al. Waterlow and Braden scores: a review of the literature and a comparison between the scores and clinical judgement. J Clin Nurs 2008; 17: 5, 646–653. doi: 10.1111/j.1365- 2702.2007.02029.x. 11 Pancorbo-Hidalgo, P.L., Garcia-Fernandez, F.P., Lopez-Medina, I.M., AlvarezNieto, C. Risk assessment scales for pressure ulcer prevention: a systematic review. J Adv Nurs 2006; 54: 1, 94–100. 12 Moore, Z.E.H., Cowman, S. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database Syst Rev 2008; 3: CD006471. 13. Saleh, M., Anthony, D., Parboteeah, S. The impact of pressure ulcer risk assessment on patient outcomes among hospitalised patients. J Clin Nurs 2009; 18: 13, 1923–1929. 14 Webster, J., Coleman, K., Mudge, A., et al. Pressure ulcers: effectiveness of risk-assessment tools. A randomised controlled trial (the ULCER trial). BMJ 2011; 20: 4, 297–306. 15 Alfaro-LeFevre, R. What is Critical Thinking, Clinical Reasoning? Critical Thinking, Clinical Reasoning and Clinical Judgment – A Practical Approach (5th ed). Elsevier Health Sciences, 2013. 16 Hazard Munro, B. Statistical Methods for Health Care Research (5th ed). Lippincott Williams & Wilkins; 2005. 17 Moore, Z., Johanssen, E., van Etten, M. A review of PU prevalence and incidence across Scandinavia, Iceland and Ireland (Part I). J Wound Care 2013; 22: 7, 1–7. 18 Paquay, L., Wouters, R., Defloor, T., et al. Adherence to pressure ulcer prevention guidelines in home care: a survey of current practice. J Clin Nurs 2008; 17: 5, 627–636. 19 O’Brien, J.J., Cowman, S. An exploration of nursing documentation of pressure ulcer care in an acute setting in Ireland. J Wound Care 2011; 20: 5, 197–203. 20 Moore, Z., Cowman, S. Pressure ulcer prevalence and prevention practices in care of the older person in the
Republic of Ireland. J Clin Nurs 2012; 21: 3–4, 362–371. 21 Gill, P., Stewart, K., Treasure, E., Chadwick, B. Methods of data collection in qualitative research: interviews and focus groups. British Dental Journal. 2008;204(6):291-5. 22 Sandelowski, M. Focus on Research Methods Whatever Happened to Qualitative Description? Res Nurs Health 2000; 23: 4, 334–340. 23 Lawal, M. Reconciling methodological approaches of survey and focus group. Nurse Res 2009; 17: 1, 54–61. 24 Lambert, S., Loiselle, C. Combining individual interviews and focus groups to enhance data richness. J Adv Nurs 2008; 62: 2, 228–237. 25 Malterud, K. Qualitative research: standards, challenges, and guidelines. Lancet 2001; 358: 9280, 483–488. 26 King, N., Horrocks, C. Interviews in Qualitative Research. Sage, 2010. 27 Coleman, S., Gorecki, C., Nelson, E.A., et al. Patient risk factors for pressure ulcer development: Systematic review. Int J Nurs Stud 2013; 50: 7, 974–1003. 28 Clark, M., Cullum, N. Matching patient need for pressure sore prevention with the supply of pressure redistributing mattresses. J Adv Nurs 1992; 17: 3, 310–316. 29 Moore, Z., Cowman, S., Conroy, R.M. A randomised controlled clinical trial of repositioning, using the 30° tilt, for the prevention of pressure ulcers. J Clin Nurs 2011; 20: 17–18, 2633–2644. 30 Sharp, C.A., McLaws, M.L. Estimating the risk of pressure ulcer development: is it truly evidence based? Int Wound J 2006; 3: 4, 344–353. 31 Sving, E., Gunningberg, L., Högman, M., Mamhidir, A.G. Registered nurses’ attention to and perceptions of pressure ulcer prevention in hospital settings. J Clin Nurs 2012; 21: 9–10, 1293–1303. 32 Balzer, K., Köpke, S., Lühmann, D., et al. Designing trials for pressure ulcer risk assessment research: methodological challenges. Int J Nurs Stud 2013; 50: 8, 1136–1150. 31 Helse- og omsorgsdepartementet. Lov om helsepersonell m.v. (helsepersonelloven). Helse-og omsorgsdepartementet, 1999. 34 The code of professional conduct for each nurse and midwife, 2000. Available from: http://www.nursingboard.ie/en/ policies-guidelines.aspx?page=2 [Accessed July 2014]. 35 Strand, T., Lindgren, M. Knowledge, attitudes and barriers towards prevention of pressure ulcers in intensive care units: a descriptive crosssectional study. Intensive Crit Care Nurs 2010; 26: 6, 335–342. 36 Moore, Z., Price, P.E. Nurses’ attitudes, behaviours and perceived barriers towards pressure ulcer prevention. J Clin Nurs 2004; 13: 8, 942–951. 37 McInnes, E., Jammali-Blasi, A., Bell-Syer, S.E.M., et al. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Reviews 2011; 4, CD001735. doi: 10.1002/14651858. CD001735.pub4. Copyright of Journal of Wound Care is the property of Mark Allen Publishing Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use. J Wound Ostomy Continence Nurs. 2014;41(6):528-534. Published by Lippincott Williams & Wilkins WOUND CARE 528 J WOCN ■ November/December 2014 Copyright © 2014 by the Wound, Ostomy and Continence Nurses Society™ Patient Perceptions of the Role of Nutrition for Pressure Ulcer Prevention in Hospital An Interpretive Study Shelley Roberts ■ Ben Desbrow ■ Wendy Chaboyer ■ ABSTRACT PURPOSE: The aims of this study were to explore (a) patients’ perceptions of the role of nutrition in pressure ulcer prevention; and (b) patients’ experiences with dieticians in the hospital setting. DESIGN: Interpretive qualitative study. SUBJECTS AND SETTING: The sample comprised 13 females and 7 males. Their mean age was 61.3 ± 12.6 years (mean ± SD), and their average hospital length of stay was 7.4 ± 13.0 days. The research setting was a public health hospital in Australia. METHODS: In this interpretive study, adult medical patients at risk of pressure ulcers due to restricted mobility participated in a 20 to 30 minute interview using a semi-structured interview guide. Interview questions were grouped into 2 domains; perceptions on the role of nutrition for pressure ulcer prevention; and experiences with dieticians. Recorded interviews were transcribed and analyzed using content analysis. RESULTS: Within the fi rst domain, ‘patient knowledge of nutrition in pressure ulcer prevention,’ there were varying patient understandings of the role of nutrition for prevention of pressure ulcers. This is refl ected in 5 themes: (1) recognizing the role of diet in pressure ulcer prevention; (2) promoting skin health with good nutrition; (3) understanding the relationship between nutrition and health; (4) lacking insight into the role of nutrition in pressure ulcer prevention; and (5) acknowledging other risk factors for pressure ulcers. Within the second domain, patients described their experiences with and perceptions on dieticians. Two themes emerged, which expressed differing opinions around the role and reputation of dieticians; they were receptive of dietician input; and displaying ambivalence towards dieticians’ advice. CONCLUSIONS: Hospital patients at risk for pressure ulcer development have variable knowledge of the preventive role of nutrition. Patients had differing perceptions ■ Introduction Pressure ulcers (PUs) are associated with signifi cant costs to both patients and the health care system. 1,2 Issues such as pain, discomfort, decreased mobility and independence, wound exudate, odor, social isolation, and poor body image have been described by individuals who have experienced PUs. 3 In the hospital setting, PUs are associated with an increased risk of complications and lengthy healing times, resulting in longer length of stay (LOS) and higher hospital costs. 1-7 In the Australian public hospital setting, PUs increase LOS of acute admissions by a median of 4.3 days, 8 and a recent study estimated the total cost of PU in Australian public and private hospitals in 2010–11 was US$1.64 billion ( ±US$1.05 billion). 9 In the United Kingdom, the estimated annual cost of treating PU to healing time in hospital and long-term care settings was £1.4 billion to 2.1 billion in 1999 to 2000. 10 Clearly, the Shelley Roberts, MNutrDiet, PhD candidate, Centre for Health Practice Innovation, and School of Public Health, Griffi th University, Gold Coast, Queensland, Australia. Ben Desbrow, PhD, Associate Professor, Centre for Health Practice Innovation, Griffi th Health Institute, and School of Public Health, Griffi th University, Gold Coast, Queensland, Australia. Wendy Chaboyer, PhD, Director, NHMRC Centre for Research Excellence in Nursing, Griffi th Health Institute and Centre for Health Practice Innovation, Griffi th University, Gold Coast, Queensland, Australia. The authors declare no confl icts of interest. Correspondence: Shelley Roberts, MNutrDiet, School of Public Health, Gold Coast Campus, Griffi th University, QLD 4222, Australia ( s.roberts@griffi th.edu.au ). DOI: 10.1097/WON.0000000000000072 of the importance and value of information provided by dieticians. KEY WORDS: nutrition , patient knowledge , pressure ulcer , prevention Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. JWOCN-D-13-00098_LR 528 WOCN-D-13-00098_LR 528 10/31/14 12:29 AM 0/31/14 12:29 AM J WOCN ■ Volume 41/Number 6 Roberts et al 529 strong predictor of PU in the clinical setting. 4,6,20 Participants were eligible for inclusion if they could provide consent (aged ≥ 18 years, cognitively intact), had a hospital LOS of 3 or more days, and met the criteria for reduced mobility. The study sample was selected using a maximum variation purposive sampling technique (ie, a mix of men and women, younger and older patients, patients with and without experience with PU). 21 Data Collection Individual patient interviews were conducted on the ward, in a quiet area, and at a time convenient for the patient. The interviews lasted 15 to 30 minutes. Using a semistructured interview guide, patients were asked about their perceptions of the role nutrit
ion played in PUP and their experiences with and opinions about the role of dieticians. Three nutrition-related questions were asked. They were based on literature review and current clinical practice guidelines, which suggest that nutritional intervention and education are important components of PUP. Prompts were used to gain additional information as required. Individual interviews were conducted by a research assistant with experience in qualitative data collection. Interviews were recorded with a handheld digital recording device and transcribed for analysis. Data Analysis Interview transcripts were analyzed using inductive content analysis, which provides a systematic and objective means to make valid inferences from verbal data to describe and quantify phenomena. 22-24 This technique takes into account meanings, intentions, consequences, and the context in which data were collected. 20 Because the interview questions encompassed 2 domains (knowledge of nutrition in PUP and experience with dieticians), data from each interview were analyzed in relation to these domains. To become familiar with the data, transcripts were read and reread, and notes were taken by 2 of the authors. For each domain, codes were developed from the verbatim statements of participants, which were then grouped into subthemes identifi ed from the data. Subthemes were then classifi ed into themes within each domain. Frequent discussion among the research team was undertaken to ensure that the codes accurately refl ected the data, and that the themes and subthemes adequately encompassed the data. Trustworthiness of fi ndings in qualitative data analysis is often considered in relation to credibility, dependability, and transferability. 25 We used purposive sampling which ensured a broad representation of patients, and regular meetings with the research team ensured codes, subthemes and themes accurately refl ected the data for transferability and credibility. A code book and memos were written to document the analytic process, including decisions about emerging subthemes and themes, providing an audit trail of the analysis. patient burden and hospital costs associated with PU in the clinical setting are signifi cant, and preferably avoided through effective pressure ulcer prevention (PUP). Historically, risk factors such as pressure, moisture, shearing forces, and friction have been a primary focus for PUP. 11-13 In addition, research suggests that malnutrition is an important risk factor for PU development. Malnutrition is associated with an odds ratio of 2.6 (95% confi dence interval: 1.8-3.5; P < .001) of developing a PU in the public hospital setting in Australia. 14 Current evidence suggests that oral nutrition support for patients at risk of PU is effective in reducing the incidence of PU development by approximately 26%, resulting in substantial cost savings. 15 However, there is no evidence to date that a dietician consultation is associated with a reduction in PU risk. Hospitalized patients often fail to eat enough to meet their estimated energy and protein requirements. 16-18 It is crucial, therefore, to improve the nutritional intake of patients at risk for PU, in order to reduce their risk of PU development. Patients may play a more active role in their nutritional care in hospitals if they understand the link between nutrition and PUP. Evidence suggests that patient education around PUP is lacking. A study of patients in 89 institutions in the Netherlands reported that only 14.7% of high-risk patients were educated about PU causes and prevention strategies. 19 To our knowledge, research focusing on patients’ understandings around nutrition of PUP or their experiences with and opinions of dieticians is lacking. Therefore, the aims of this study were to explore (1) patients’ perceptions on the role of nutrition in PUP and (2) patients’ experiences with dieticians. Understanding patients’ perceptions around nutrition for PUP and dietician input in the clinical setting may provide a foundation for targeted interventions to promote good nutrition and prevent PUs. ■ Methods This interpretive qualitative interview study is part of a larger, multisite, mixed-methods study conducted across 4 medical wards in 2 metropolitan hospitals in Southeast Queensland, Australia. Both hospitals have established PUP programs, and preventive strategies have been implemented into regular clinical practice. Ethical approval for study procedures was obtained through Queensland Health (reference number HREC/11/QTHS/111) and Griffi th University (reference number NRS/40/11/HREC). All participants signed a consent form prior to data collection. The sample comprised adult medical patients who received care in 4 inpatient medical units who had reduced mobility (ie, bed-bound, wheelchair-bound, or requiring a mobility aid or physical assistance) and were therefore deemed at risk for PU development. Reduced mobility was chosen as an inclusion criterion to identify patients at risk of PU because it is a widely recognized risk factor and Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. JWOCN-D-13-00098_LR 529 WOCN-D-13-00098_LR 529 10/31/14 12:29 AM 0/31/14 12:29 AM 530 Roberts et al J WOCN ■ November/December 2014 ■ Results The sample comprised 13 women and 7 men. Participants mean age was 61.3 ± 12.6 years (mean ± SD, range 24-80 years), and their mean hospital LOS was 7.4 ± 13.0 days (range 3-62 days). After 16 interviews, no new information was emerging; however, 4 more interviews were completed to ensure data saturation. Within each domain, a number of themes emerged. A summary of the domains, themes, and subthemes is provided in Table 1 . Domain 1: Patient Knowledge of Nutrition in PUP The fi rst domain had 5 themes that expressed respondents’ perceptions of the role of nutrition for preventing PUs. Consistent with inductive approaches to qualitative analysis, we did not identify an overarching theme, nor was any theme prioritized over the others as each provided a unique perspective. In addition, we refrained from counting frequencies of emerging themes. The fi rst theme was “recognizing the role of diet for PUP.” Participants acknowledged that nutrition as important for prevention of PUs. Nevertheless, while most patients thought that nutrition played a role in prevention, they were unsure exactly what that role was. As respondent 1 stated, “I’m not a dietician and I’m not a medical expert, but I would suggest that nutrition is very, very important.” Some patients stated that consuming a poor diet will result in a higher likelihood of developing a PU. Other patients described a good diet as being a protective factor for PU, and weight loss (in the buttocks area) was described as a factor that may increase the risk of PU. “The good food is building you up all the time, and you may even be putting on weight. And it’s usually when someone loses a lot of weight in their bottom area that these things happen quicker. The skin comes apart quicker. Whereas with well-padded bottoms, it takes a while to happen.” Losing weight if overweight or obese was also described as a measure for PUP and healing. One participant postulated that consuming “heavy foods” in hospital would lead to patients feeling full and heavy, encouraging them to stay in bed rather than resuming mobility. Another participant, unsure of the role that nutrition played in PUP, supposed that nutrition affects your blood, and if your “blood’s out” (ie, blood test results abnormal), you may be more likely to develop PU. On the whole, this theme refl ects patients’ recognition that nutrition plays a role in PUP, but the description of that role was ambiguous. The second theme, “promoting skin health with good nutrition,” portrays how patients linked skin health and nutrition, even if they did not fully understand the mechanisms behind this relationship. Some participants made general statements that nutrition was related to skin health, while others said that poor nutrition would cause skin t
o break down more easily. Several participants mentioned dietary protein as an important factor for skin integrity. Protein was also mentioned as important for wound healing and prevention of infection. One patient thought that fl uid intake would play a role in PUP; however, they were unsure of its exact role. Although respondents did not articulate the exact relationship between nutrition and skin health, they appeared to have a broad understanding of this notion. One respondent noted, “I should assume that if you weren’t eating properly, and aren’t getting the right nutrition, of course your skin’s going to break down twice as much.” Another observed, “You need vitamins and minerals and proteins in the right ratio so that your skin, your body tissue maintain its intactness, because if it doesn’t maintain intactness, then you’re prone to infection.” The third theme, “understanding the relationship between nutrition and health” describes the perception that nutrition was important for health in general and would be expected to play a role in PUP. As one respondent articulated, “I know nutrition is important for all areas of health, and so it would have a part to play with pressure sore prevention.” The fourth theme “lacking insight into the role of nutrition and PUP” depicts the lack of understanding or knowledge of a relationship between nutrition and PUP expressed by some participants. Some respondents stated that they had “no idea” how nutrition and PUP may be related, and others reported that they had not given this potential connection much thought before. One respondent related, “I’ve got no idea, really. No, none whatsoever.” Another observed, “I don’t think nutrition plays a role in bed sores…. I don’t think it’s to do with nutrition. I wouldn’t have thought so anyway.” The fi nal theme in the knowledge of nutrition and PUP domain was “acknowledging other risk factors for PU.” Within this theme, patients described other risk factors they considered to be of importance for PUP; they were skin health, age, pressure, shear and friction, and comorbid conditions. Skin health and integrity were mentioned most frequently, but no link was made between skin health and nutrition. Keeping skin healthy was described as an important way to prevent PUs, and patients mentioned delicate or thin skin as being associated with vulnerability to PU development. Age was identifi ed as a factor affecting skin health and integrity. Participants noted that aging is linked to more fragile skin that is prone to skin tears. The combination of older age and medications such as warfarin was linked to fi ne skin that bruises, tears, and bleeds easily. Participants also acknowledged that older patients should be monitored for PU because they are at high risk. Pressure on the body associated with lying/sleeping positions and prolonged time spent in bed were described as factors involved in the development of PU. Several participants stated that “…heels rubbing on the bed” acted as a risk factor for PU development. Finally, patients expressed the belief that various illnesses were Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. JWOCN-D-13-00098_LR 530 WOCN-D-13-00098_LR 530 10/31/14 12:29 AM 0/31/14 12:29 AM J WOCN ■ Volume 41/Number 6 Roberts et al 531 TABLE 1. Description of Domains, Themes, and Subthemes Domain Theme Subtheme Patient knowledge of nutrition in PUP Recognizing the role of diet in PUP • Nutrition probably plays a role in PUP • Poor diet/weight loss (especially in the buttocks) is a risk factor for PU • Good diet/weight gain (when underweight) is a protective factor for PU • “Heavy food” may reduce mobility • If overweight, losing weight is important for PUP and healing Promoting skin health with good nutrition • Nutrition plays a role as it is related to skin health • Poor nutrition would cause skin to break down more easily • Protein, vitamins, and minerals maintain skin/tissue integrity and prevent infection • High protein diet for skin integrity and healing • Fluid intake may play a role (unsure what) Understanding the relationship between nutrition and health • Nutrition is important for all areas of health, so it would have a role in PUP • Nutrition plays a role as it is the well-being of the body • Better nutrition results in better health and circulation • If you have a healthy body, you won’t get PU as bad Lacking insight into the role of nutrition in PUP • Unsure how nutrition and PUP may be related • Has not thought about nutrition as a factor in PUP • Doesn’t think nutrition has a role Acknowledging other risk factors for PU • Main issue is skin integrity • Pressure, positioning, and medical conditions are important risk factors for PU • Friction/shear as a risk factor • Skin health is important • Age and medications affect skin health • Older patients are at risk Patient feedback on dieticians Receptive of dietician input • Feels lucky to be seen by the dietician • Appreciates nutritional information provided • Dieticians are happy and bright Displaying ambivalence toward dieticians’ advice • Patients do not think they need to see a dietician • Already knows how to eat • Dietician appointment did not meet expectations • Patient felt disempowered • Confl icting advice from dietician and specialist • Did not gain any new knowledge from dietician • Did not like prescribed diet Abbreviations: PU, pressure ulcer; PUP, pressure ulcer prevention. important in PU development. As one participant noted, “I think it’s to do with the patient, what’s wrong with them, and the way they lie.” Another stated, “Well the main reason [for developing a PU] is pressure on the body from the bed and the angles you sleep.” A third respondent observed, “I tend to think it’s more if the skin’s thinish and delicate.” Domain 2: Patient Feedback on Dieticians The second domain “patient feedback on dieticians” comprised 2 themes, describing patients’ experiences with and perceptions of dieticians. These included (1) receptive of dietician input and (2) displaying ambivalence toward dieticians’ advice. The theme “receptive of dietician input” describes positive experiences during interactions with dieticians. These participants expressed willingness to participate in nutritional education and gratitude toward dietetic input. They tended to describe dieticians as happy and bright and felt appreciative of the information and services they provided. As one respondent noted, “I’m lucky enough to have been referred, to a dietician.” Similarly, another stated, “It had just so much information; leafl ets and talking to the nutritionist, it was lovely.” In contrast to theme 1, the theme “displaying ambivalence towards dieticians’ advice” refl ects confl icting views of the value of dietetic advice. Some participants expressed the opinion that they did not need to see a dietician, Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. JWOCN-D-13-00098_LR 531 WOCN-D-13-00098_LR 531 10/31/14 12:29 AM 0/31/14 12:29 AM 532 Roberts et al J WOCN ■ November/December 2014 defi ned as an individual’s capacity to obtain, process, and understand information and services needed to make appropriate health decisions. 26 Health literacy in the hospital setting is especially important since education must be delivered in a setting of an acute illness. A study based in the United States found that 81% of English-speaking patients over 60 years of age lacked adequate health literacy to make informed decisions about their health care. 27 Researchers have also reported that patient education materials and consent forms in hospital are often above patients’ reading levels, rendering their comprehension even more challenging. 28-31 We recommend consideration of patients’ education, literacy levels, and prior knowledge of nutrition when planning education for
acutely ill persons at risk for PU development. Participants in this study expressed differing perceptions of the importance and value of information provided by dieticians. Some patients expressed their gratitude toward dietetic input in the hospital setting, but others deemed it unnecessary. These fi ndings suggest that the role and importance of dieticians are unclear to patients in the hospital setting, and this lack of knowledge may affect patients’ responsiveness to PUP programs that include nutrition education. Interventions such as educational interventions related to nutrition and PUP must be compatible with individuals’ values, beliefs, and current needs, and they must be perceived as feasible and benefi cial. 32 This observation is refl ected in previous studies exploring staff perceptions on the role of clinical dieticians. 33,34 A study conducted at a public hospital in Queensland, Australia, used thematic analysis to explore staff perceptions around nutrition care. 33 They found that the role of the dietician was unclear to nursing and allied health staff such as pharmacists, speech pathologists, physiotherapists, and occupational therapists. The health care providers also expressed mixed views on whose responsibility it was to identify and provide nutritional care to malnourished patients. 33 Similarly, a cross-sectional survey of 237 internal medicine physicians and clinical dieticians in Michigan found that most responses to questions around the role and responsibilities of dieticians differed between professions. 34 If the role of dieticians is unclear among clinicians involved in PUP and wound care, it is not surprising that patients lack an adequate understanding of how consultation with a dietician may provide benefi t for prevention of PU development. Even though evidence supporting the effectiveness of dietary counseling in PUP or management of malnutrition in hospitals is lacking, 35 nutrition education may be an important component of PUP programs. This is refl ected in international PUP guidelines, which suggest that patient education is an important aspect of PUP. 36,37 Additional research is needed to determine the effectiveness of patient and nutritional education on PUP. Some participants displayed a lack of confi dence in dieticians, and they suggested they did not learn anything new from the dietician, disliked the prescribed dietary primarily because they already knew how and what to eat to keep healthy. Some stated that the need to consult with a dietician never crossed their minds, while others stated that meeting with a dietician was necessary only if diagnosed with a disease that required a special diet. One respondent described the need for a dietician, “…only if I needed it. Well, if I had any sort of diseases or sicknesses that needed, um, to be on certain diets, I’d be interested then. But for, like, everyday life I’ve got a fair idea what’s good for me and what isn’t, you know. So not really, no.” Another patient reported that an appointment with a dietician did not meet her expectations; she further stated that she left this appointment feeling disempowered. This participant also discussed receiving confl icting advice between the dietician and her diabetes specialist. “She (dietician) was telling me things that were in opposition to what my specialists were telling me. (Specialist): ‘You need to lose weight’. (Dietician): ‘No, you won’t be losing weight. When you’re diabetic you put weight on’.” Other participants thought that they did not learn anything new from their dietician as compared to nutritional information gained from everyday life. As one participant opined, “Well, she [dietician] didn’t provide me with anything I didn’t already know. I was quite bored.” Some stated they did not like the diet they were prescribed, or disliked restrictions on certain foods, resulting in discontinuation of their prescribed diet. ■ Discussion This study is the fi rst to our knowledge to explore awareness of the role of nutrition for PUP among patients at risk for PU development. Participants were patients at 2 Australian hospitals where both PUP and patient education were important parts of clinical practice, and it was initially postulated that their knowledge of the importance of nutrition in PUP would be adequate. Instead, we found variable levels of understanding of the role of nutrition in PUP. Some respondents had a personal history of PU or had experience through family members. These experiences may have infl uenced their perceptions around nutrition for PUP and the importance of dieticians. Nevertheless, study fi ndings suggest that patients had inadequate knowledge of nutrition and PUP despite welldeveloped programs that include consultation with a dietician and appropriate counseling. We, therefore, recommend additional education focusing on PUP that includes the role of nutrition for all patients deemed at risk for PU development. Based on the variable levels of knowledge expressed by study respondents, we also recommend individual assessment to determine patients’ level of knowledge and motivation to be involved in their care. Research suggests that basic literacy levels in adults may not be suffi cient to understand oral or written information regarding their medical condition and health care. 25 Health literacy is Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. JWOCN-D-13-00098_LR 532 WOCN-D-13-00098_LR 532 10/31/14 12:29 AM 0/31/14 12:29 AM J WOCN ■ Volume 41/Number 6 Roberts et al 533 Owing to the compromised nutrition seen in many persons at risk for PU development, we believe that selected patients will benefi t from nutritional education aimed at PUP that is tailored to suit their literacy levels. A better understanding of the role of dieticians within the clinical setting may improve patient participation in their nutritional care and associated outcomes. ■ ACKNOWLEDGMENT This research received funding from the Area of Strategic Investment Health and Chronic Diseases, Griffith University. Author contributions: Shelley Roberts: Conception and design of the study; collection, analysis, and interpretation of data; drafting and revision of manuscript; and approval of fi nal version of manuscript. Wendy Chaboyer and Ben Desbrow: Conception and design of the study; analysis and interpretation of data; drafting and revision of manuscript; and approval of the fi nal version of the manuscript. ■ References 1. Allman RM . Current concepts—geriatrics—pressure ulcers among the elderly . N Engl J Med. 1989 ; 320 ( 13 ): 850-853 . 2. Allman RM . Outcomes in prospective studies and clinical trials . Adv Wound Care. 1995 ; 8 : 61 . 3. Fox C . Living with a pressure ulcer: a descriptive study of patients’ experiences . British Journal of Community Nursing. 2002 ; 10 : 12-14 . 4. Allman RM . Pressure ulcer prevalence, incidence, risk factors, and impact . Clin Geriatr Med. 1997 ; 13 ( 3 ): 421-436 . 5. Allman RM , Laprade CA , Noel LB , et al. Pressure sores among hospitalized patients . Ann Int Med. 1986 ; 105 ( 3 ): 337-342 . 6. Grey JE , Enoch S , Harding KG . ABC of wound healing—pressure ulcers . Br Med J. 2006 ; 332 ( 7539 ): 472-475 . 7. Stratton RJ , Green CJ , Elia M . Disease-Related Malnutrition: An Evidence-Based Approach to Treatment. Wallingford, UK : CAB International ; 2003 . 8. Graves N , Birrell FA , Whitby M . Modeling the economic losses from pressure ulcers among hospitalized patients in Australia . Wound Repair Regen. 2005 ; 13 ( 5 ): 462-467 . 9. Graves N , Zheng H . Modelling the direct health care costs of chronic wounds in Australia . Wound Practice and Research. 2014 ; 22 ( 1 ): 20-33 . 10. Bennett G , Dealey C , Posnett J . The cost of pressure ulcers in the UK . Age Ageing. 2004 ; 33 ( 3 ): 230-235 . 11. Crowe T , Brockbank C . Nutrition therapy in the prevention and treatment of pressure ulcers . Wound Pract Res. 2009 ; 17 ( 2 ): 90-99 . 12. Lahmann NA , Tannen A , Dassen T , Kottner J . Friction and shear highly associated with pressu
re ulcers of residents in long-term care—Classifi cation Tree Analysis (CHAID) of Braden items . J Eval Clin Pract. 2011 ; 17 ( 1 ): 168-173 . 13. Mathus-Vliegen EMH . Nutritional status, nutrition, and pressure ulcers . Nutr Clin Pract. 2001 ; 16 : 286-291 . 14. Banks M , Bauer J , Graves N , Ash S . Malnutrition and pressure ulcer risk in adults in Australian health care facilities . Nutrition. 2010 ; 26 ( 9 ): 896-901 . 15. Banks MD , Graves N , Bauer JD , Ash S . Cost effectiveness of nutrition support in the prevention of pressure ulcer in hospitals . Eur J Clin Nutr. 2013 ; 67 ( 1 ): 42-46 . plan, or thought advice from their dietician contrasted to information given by their other providers. While dieticians are experts in nutritional care, recent research suggests that general practitioners are the most recognized health care professional providing nutritional care to patients with chronic disease in Australia, followed by dieticians. 34 Although this study was based in the primary care setting, it highlights the importance of a consistent approach to the information provided by all health care professionals providing care for an individual patient. Clinical Implications Three main recommendations arise from this study. We found that patients at risk of PU development expressed varying levels of knowledge of the role of nutrition in PUP, and require tailored education in this area, taking into account their health literacy. We hypothesize that tailored education may raise patients’ knowledge of nutrition and PU development and increase their participation in their nutritional care. We also recommend clarifi cation of the role of dieticians in the clinical setting, as patients appear to lack an understanding of the potential health gains to be made from dietetic input and nutritional care in hospital. A better understanding of this role and its importance in PUP may increase patients’ responsiveness to dietetic input and participation in their nutritional care. ■ Limitations Interview questions were asked after each patient had participated in an observational study targeting the patients’ role in PUP. As patients knew their oral intake was being monitored, their awareness of a potential role of nutrition in PUP may have been increased, infl uencing results of this study. Participant’s clinical conditions may have in- fl uenced their responses. We sought to minimize this potentially confounding influence by ensuring that interviews were conducted when patients felt well enough to participate, ensuring that patients remained comfortable during the interview, and informing participants that the interview may be ceased at any time if they felt tired or distressed. Another potential limitation is that analysis occurred several months after data collection; therefore, member checking was not possible as patients had been discharged from hospital. Selection bias is a consideration in any research. In qualitative research, purposive sampling is used to achieve variation in the experiences being explored and in this study, recruitment occurred until data saturation was reached. 21 It is always possible that some views were not represented in our sample. ■ Conclusions Findings from this study suggest that patients at risk of PUs have confl icting views on the role of nutrition in PUP. Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. JWOCN-D-13-00098_LR 533 WOCN-D-13-00098_LR 533 10/31/14 12:29 AM 0/31/14 12:29 AM 534 Roberts et al J WOCN ■ November/December 2014 27. Williams MV , Parker RM , Baker DW , et al. Inadequate functional health literacy among patients at two public hospitals . JAMA. 1995 ; 274 ( 21 ): 1677-1682 . 28. Baker D , Parker R , William MV , Pitkins K . The health care experience of patients with low literacy . Clin Res. 1993 ; 41 : 584A . 29. Davis TC , Crouch MA , Wills G , Miller S , Abdehou DM . The gap between patient reading comprehension and the readability of patient education materials . J Fam Pract. 1990 ; 31 ( 5 ): 533-538 . 30. Grundner TM . On the readability of surgical consent forms . N Engl J Med. 1980 ; 302 ( 16 ): 900-902 . 31. Parikh NS , Parker RM , Nurss JR , Baker DW , Williams MV . Shame and health literacy: the unspoken connection . Patient Educ Couns. 1996 ; 27 ( 1 ): 33-39 . 32. Berwick DM . Disseminating innovations in health care . JAMA. 2003 ; 289 ( 15 ): 1969-1975 . 33. Ross LJ , Mudge AM , Young AM , Banks M . Everyone’s problem but nobody’s job: staff perceptions and explanations for poor nutritional intake in older medical patients . Nutr Diet. 2011 ; 68 ( 1 ): 41-46 . 34. Boyhtari ME , Cardinal BJ . The role of clinical dietitians as perceived by dietitians and physicians . J Am Diet Assoc. 1997 ; 97 ( 8 ): 851 +. 35. Baldwin C , Parsons T , Logan S . Dietary advice for illness-related malnutrition in adults . Cochrane Database Syst Rev. 2007 ;( 1 ): CD002008 . 36. Australian Wound Management Association . Pan Pacifi c Clinical Practice Guideline for the Prevention and Management of Pressure Injury. Osborne Park, WA : Cambridge Media ; 2012 . 37. European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel . Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Washington, DC : European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel ; 2009 . 16. Dupertuis YM , Kossovsky MP , Kyle UG , Raguso CA , Genton L , Pichard C . Food intake in 1707 hospitalised patients: a prospective comprehensive hospital survey . Clin Nutr. 2003 ; 22 ( 2 ): 115-123 . 17. Mudge AM , Ross LJ , Young AM , Isenring EA , Banks MD . Helping understand nutritional gaps in the elderly (HUNGER): A prospective study of patient factors associated with inadequate nutritional intake in older medical inpatients . Clin Nutr. 2011 ; 30 ( 3 ): 320-325 . 18. Thibault R , Chikhi M , Clerc A , et al. Assessment of food intake in hospitalised patients: a 10-year comparative study of a prospective hospital survey . Clin Nutr. 2011 ; 30 ( 3 ): 289-296 . 19. Bours GJ , Halfens RJ , Abu-Saad HH , Grol RT . Prevalence, prevention, and treatment of pressure ulcers: descriptive study in 89 institutions in the Netherlands . Res Nurs Health. 2002 ; 25 ( 2 ): 99-110 . 20. Lindgren M , Unosson M , Fredrikson M , Ek A . Immobility—a major risk factor for development of pressure ulcers among adult hospitalized patients: a prospective study . Scand J Caring Sci. 2004 ; 18 ( 1 ): 57-64 . 21. Sandelowski M . Sample size in qualitative research . Res Nurs Health. 1995 ; 18 ( 2 ): 179-183 . 22. Downe-Wamboldt B . Content analysis: method, applications, and issues . Health Care Women Int. 1992 ; 13 ( 3 ): 313-321 . 23. Elo S , Kyngas H . The qualitative content analysis process . J Adv Nurs. 2008 ; 62 ( 1 ): 107-115 . 24. Graneheim UH , Lundman B . Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness . Nurs Educ Today. 2004 ; 24 ( 2 ): 105-112 . 25. Parker R , Baker D , Williams M , Nurss J . The test of functional health literacy in adults . J Gen Int Med. 1995 ; 10 ( 10 ): 537-541 . 26. Institute of Medicine . Health Literacy: A Prescription to End Confusion. 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DOI: 10.1097/WON.0000000000000100 Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. JWOCN-D-13-00098_LR 534 WOCN-D-13-00098_LR 534 10/31/14 12:29 AM 0/31/14 12:29 AM International Journal of Nursing Studies 44 (2007) 1109–1119 Nurses’ reasoning process during care planning taking pressure ulcer prevention as an example. A think-aloud study Kajsa Helena Funkessona,, Els-Marie Anba¨ckena , Anna-Christina Ekb a Department of Social and Welfare Studies, Linko¨ping University, Sweden b Department of Medicine and Care division of Nursing Science, Faculty of Health Sciences, Linko¨ping University, Sweden Received 16 September 2005; received in revised form 21 February 2006; accepted 27 April 2006 Abstract Background: Nurses’ clinical reasoning is of great importance for the delivery of safe and efficient care. Pressure ulcer prevention allows a variety of aspects within nursing to be viewed. Objective: The aim of this study was to describe both the process and the content of nurses’ reasoning during care planning at different nursing homes, using pressure ulcer prevention as an example. Design: A qualitative research design was chosen. Settings: Seven different nursing homes within one community were included. Participants: Eleven registered nurses were interviewed. Method: The methods used were think-aloud technique, protocol analysis and qualitative content analysis. Client simulation illustrating transition was used. The case used for care planning was in three parts covering the transition from hospital until 3 weeks in the nursing home. Result: Most nurses in this study conducted direct and indirect reasoning in a wide range of areas in connection with pressure ulcer prevention. The reasoning focused different parts of the nursing process depending on part of the case. Complex assertations as well as strategies aiming to reduce cognitive strain were rare. Nurses involved in direct nursing care held a broader reasoning than consultant nurses. Both explanations and actions based on older ideas and traditions occurred. Conclusions: Reasoning concerning pressure ulcer prevention while care planning was dominated by routine thinking. Knowing the person over a period of time made a more complex reasoning possible. The nurses’ experience, knowledge together with how close to the elderly the nurses work seem to be important factors that affect the content of reasoning. r 2006 Elsevier Ltd. All rights reserved. Keywords: Clinical reasoning; Elderly care; Nursing homes; Patient care planning; Protocol analysis What is already known about the topic? Nurses use different types of cognitive operators and strategies when they reason. The context is of importance for the reasoning process A variety of aspects differ between novices and experts in their reasoning process What this paper adds Reasoning concerning pressure ulcer prevention while care planning seems to be dominated by routine thinking. ARTICLE IN PRESS www.elsevier.com/locate/ijnurstu 0020-7489/$ – see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2006.04.016 Corresponding author. Tel.: +46 11 363511; fax: +46 11 125448. E-mail address: firstname.lastname@example.org (Kajsa H. Funkesson). Knowing the person over a period of time seems to make a more complex reasoning possible. The content of reasoning seems to be affected by how close to the person the RNs work. 1. Introduction Elderly people in Sweden moving to community care residences and in particular those of the nursing home kind, most often have a complex medical history with several diagnoses, which creates a great need of nursing care (The Swedish Board of Health and Welfare, 2001). The role among registered nurses working in nursing homes in Sweden varies. On an organisational level, most registered nurses at community care residences have two roles, one with the main responsibility for the nursing care and care planning for a limited number of residents and one with a consultative role for the care of a larger number of residents. The way the nurses perform the roles differs, at some community care residences nurses hardly ever participate in the care of the persons for whom they are principally responsible, at others they do. In both cases, they are the only staff with medical competence assessing the needs of the person. Considering this, the ability to reason and to use science and reliable experience in the reasoning process is of utmost importance, especially in connection with care planning and the delivery of safe and efficient care when acute problems occur for the client (Higgs and Jones, 2000; Higgs et al., 2001). So far not much is known about the reasoning process in relation to care planning for elderly persons living in community care residences The aim of this study was to describe nurses’ reasoning process during care planning for an elderly person who has just moved to a nursing home, as well as the content of the reasoning in relation to pressure ulcer prevention during different phases of care planning. 2. The reasoning process The reasoning process that takes place while making judgments about a person’s situation can be viewed from many different perspectives. Having to do with context and aim, it can be named critical thinking, reflective reasoning, diagnostic reasoning, decisionmaking, etc. In medicine and related areas, it is often called clinical reasoning. Fowler (1997) describes clinical reasoning as a process where multiple possibilities are processed while making judgments about a client’s situation, with the purpose of achieving a desired outcome. Simmons et al. (2003) characterise this process as recursive, where both inductive and deductive cognitive skills are used. Clinical reasoning can also be described simply as a process where knowledge and experience are applied to clinical situations, in order to develop a solution (Noll et al., 2001). Nurses’ reasoning is, to a great extent, dependant on the context in which it takes place (Crow et al., 1995; Thompson, 1999), which makes every situation unique. It is mainly about judging a person’s situation, seeing the needs and problems, making priorities and decisions about patient care (Junnola et al., 2002). In this paper, clinical reasoning is see
n as a cognitive process, where both theoretical knowledge and personal experience are used in a unique care situation aiming to achieve a desired outcome for the person in focus. Greenwood (1998) differentiates between reasoning terminating in conclusions and in actions. The first is called theoretical reasoning, the second practical. When nurses lack clinical experience to handle a situation they need to reason theoretically. It is also important that the theory used is evidence based and contextually relevant (Higgs et al., 2001). In a study by Fowler (1997), six cognitive operators were found in the nurses’ reasoning; describing, explaining, evaluating, connecting, planning and judging. The purpose of these operators was to understand the situation and to produce judgements about incoming cues. Fowler (1997) also found six strategies in the reasoning; cue logic, framing, hypothesising, testing, reflective comparison and prototypical case reasoning. These were used to reduce cognitive strain, helping the nurse to manage the situation. Evidence from this study suggests that the context in which the reasoning takes place influences the use of cognitive operators and strategies. Within the last 25 years, several studies have been conducted with the aim of exploring the reasoning process in nursing. For example, Benner (1984, 1996), and Greenwood and King (1995) studied this process within expert and novice nurses and Simmons et al. (2003) within experienced nurses. It has also been explored in different contexts (Carr, 2004; McCarthy, 2003) and areas in nursing, of which one is care planning (Fowler, 1997; Grobe et al., 1991). However, studies have stated the importance of context and experience on the reasoning process but not on the way nurses perform their work. The way nurses reason and make decisions has been explored, either by the use of simulated cases, such as written scenarios (Fonteyn et al., 1993; Ritter, 2003) and computer simulations (Junnola et al., 2002), or by studies within real practise situations (Fonteyn and Fisher, 1995; Greenwood et al., 2000). 3. The study 3.1. Participants and contexts This study was conducted in one community in Sweden. To enable differences in the way registered ARTICLE IN PRESS 1110 Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 nurses (RNs) perform their role to be represented in the study, all community care residences of the nursing home model, a total of eight, were included. Participating RNs should have more than 1 year of experience from working at the nursing home in question. All RNs who fulfilled the inclusion criteria were invited to participate but a maximum of two RNs from the same nursing home were allowed to be included. The invitation along with written information in which they were told that the study was about a care planning situation, was presented to the RNs by the head of the nursing home. A total of 11 female RNs from seven nursing homes gave their written informed consent. All were included. Six of the participating RNs, who came from four nursing homes, hardly ever participated in the nursing care (‘‘consultant nurses’’). Five of the participating RNs, coming from three nursing homes, worked closer to the residents and the nursing staff. These RNs participated in the care of those they were primarily responsible for on a regular basis (‘‘care nurses’’). The participants’ experience from working at nursing homes ranged from one and a half years to 15 years. Five had a nursing qualification older than 15 years. Three had a degree at bachelor level and one at master. Both groups, ‘‘consultant nurses’’ and ‘‘care nurses’’, had approximately the same distribution of personal data, such as age, nursing experience and level of nursing education. 3.2. Method The methods chosen were verbal protocol (VP) and protocol analysis (PA) also called think-aloud (TA) technique (Ericsson and Simon, 1984, 1993). This technique views the flow of information in our mind while reasoning and seeks to reveal the mental processes which take place during a problem solving task and has been well described by Ericsson and Simon (1984, 1993). Since the beginning of the 1980s, the think aloud technique has been used by nursing researchers to reveal nurses’ reasoning process (Benner, 1984; Greenwood and King, 1995; Simmons et al., 2003). Protocol analyses in four steps were chosen to analyse the incoming data (Ericsson and Simon,1993; Fonteyn and Fisher,1995). Investigation of the content of the reasoning was conducted by means of a qualitative content analysis (Mayring, 2000; Morgan, 1993). 3.3. Procedure Client simulation in terms of a written case was used as a mean for reasoning. This enabled a standardisation of the case and reasoning situation, which was considered important due to the aim and because of the different working situations at the nursing homes. The simulated case was based upon an authentic case about an 85-year-old woman who suffered a stroke resulting in severe problems within the physiological, psychological, social and spiritual areas. The simulation enabled the reasoning to be followed over a period of time. The presentation was structured according to a model called VIPS (Ehrenberg et al., 1996) well known to the participants. The VIPS model used in this study is a model for documentation of nursing care based upon the nursing process which has been adapted to documentation in nursing homes (Ehrenberg and Ehnfors, 1999a). It includes nursing history, status, diagnoses, goals, outcome and a nursing discharge note (Ehrenberg et al., 1996). The presentation given to the participants included nursing history together with a nursing discharge note plus two nursing statuses. All TA interviews were performed individually at the nursing home, in a secluded room without any disturbance. After permission from the participants, the interviews were audiotaped. Information was given about the TA technique as well as the difference between thinking aloud and talking aloud. This was followed by a short practise session. The participants were informed that the task was about care planning for a person who was moving into ‘‘their’’ nursing home after a period of hospital care and that they had the role of nurse responsible for the person. They were also told that the case was to be presented in three parts, starting 1 day before arrival and ending 3 weeks later. Preceding each part, the investigator made a short introduction. Just before starting, they were reminded to think aloud and express everything that passed through their minds while care planning. If more than a moment of silence occurred during the interview, the investigator reminded them again. This was to assure that all thoughts were verbalized and that a minimum of time was left for reconstructions. The actual TA interviews varied between 60 and 90 min in time. The study was approved by the Research Ethics Committee of the Faculty of Health Sciences, Linko¨ping University (Registration number: 02-385). 3.4. Data analyses The interviews were transcribed verbatim into VPs. The first step of the PA, general analysis, focused on getting a broad sense of meaning and to capture that of interest for the aim of this study. Pressure ulcer prevention was chosen as an example because in this context this is of special importance, since hospitalised immobile persons in general (Lindgren et al., 2004) and the elderly in particular runs an increased risk of developing pressure ulcers (Margolis et al., 2002). Pressure ulcer prevention also serves as an indicator of the quality of care provided (Stephan-Haynes, 2004; Wipke-Tevis et al., 2004) and it allows a variety of important aspects within nursing to be viewed such as ARTICLE IN PRESS Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 1111 nutrition, activity, wellbeing, etc. Parts that directly, or indirectly, referred to pressure ulcer prevention or the treatment of first degree of pressure ulcers were marked. Indirect parts were those of importance for th
e prevention of pressure ulcers but not spoken of as such, as in this example ‘‘ydry skin is easily rectified with a softening cream.’’ The procedure capturing parts of interest for the study were repeated twice on two different occasions. Marked parts were coded as directly or indirectly connected to the topic. The second step, referred phrase analysis, aimed to identify what the participants concentrated on during the interviews. Nouns and noun phrases used while reasoning were marked and coded as a concept. Each concept was given a preliminary definition which was refined as the analyses proceeded. Finally, they were sorted with help of the nursing process. To give a picture of the flow of the reasoning process in relation to the nursing process, each phrase was numbered in order of appearance. The numbered phrases were plotted on a graph, one for each participant. At the third step, assertional analysis, the VPs were further examined to establish the aim or purpose of each phrase in the reasoning process. In focus for the analysis were the different types of relationship formed between concepts found in the referred phrase analysis. With this in mind, each phrase in the VPs was coded. The assertions found in this process were gradually refined throughout the analysis. To enhance the validity of coding the phrases, this part of the procedure was repeated with some time in between. In cases where codes did not match, a re-examination of the phrase was performed. The fourth step of PA, script analysis, aimed to make conclusions concerning the respondents’ reasoning process. The coded VPs were now seen as a whole. The texts were coded once again this time using the cognitive operators and strategies found by Fowler (1997) as a reference frame. This procedure was repeated in the same way as in the last phase. It was intended that data not fitting into this frame would be analysed separately but no such data were found. The content analysis started with a reduction of text. In order to get a general view of what was said about pressure ulcer prevention the reduced VPs were read through again. To get a picture of how and when the nurses reasoned about pressure ulcer prevention, the indirect and direct reasoning were analysed. This was followed by making notes in the margin, underlining significant concepts, sorting text units into different content areas. As a starting point for these areas, the keywords from the VIPS model in the case were used. Text that did not fit into these areas was analysed separately. This resulted in one additional content area named ‘‘nursing care management.’’ Finally the whole text was read through again to make sure that the text units were well connected to their context. In order to visualise the content, for the two groups in the three parts of the case, the occurrence of direct and indirect reasoning within the different content areas was put together. A second researcher studied the content of the verbal protocols and followed the different steps of the analyses thoroughly. Differences of opinion were discussed, enabling codes etc to be refined continuously. The results of the analyses were carefully discussed throughout the whole process. On the whole however there was a high correspondence between the two researchers. 4. Findings The general analyses of the PA showed that most nurses in this study had an extensive reasoning as a whole, of which the main part directly or indirectly connected to prevention of pressure ulcer. The ‘‘referred phrase analyses’’ showed that all participants reasoned within assessing, planning, implementation and evaluation of the nursing process. Within these phases 16 different concepts, were found (Table 1). The six most frequently used where sign, valuation, general action, nursing action, paramedic action and goal. On an individual level, the reasoning differed greatly but looking at the participants as a whole and to the three parts of the case, the reasoning showed certain patterns, (Table 2). Planning was a phase focused on most throughout all three parts of the care planning but before arrival this was the main focus. The day after arrival, the reasoning focused on assessing almost as much as planning and the different actions were more often a result of the assessment, with nursing ethics as an important component in the reasoning. By now, all 11 participants had some reasoning connected to pressure ulcer prevention. The reasoning 3 weeks after arrival was the most comprehensive. In addition to assessing and planning, all participants, in one way or other, reasoned about how to follow up the results. As shown in Table 2, the analysis reveals some differences between ‘‘care nurses’’ and ‘‘consultant nurses’’ in their average use of concepts within the ‘‘implementation phase’’ and ‘‘evaluation phase’’. Focusing on the flow of reasoning, it was found that reasoning leading to an action was most often preceded by reasoning that went back and forth between different phases. Another finding was that abnormal cues led to a greater focus on the assessing phase. At the ‘‘assertional analysis’’ three different kinds of assertions were found in the reasoning. These were ‘‘implicational’’, tending to suggest or imply something, ‘‘significative’’, having a special meaning and ‘‘causal’’ focusing on cause and effect. The two most frequently used were implicational and significative. Causal assertions were rare. The ARTICLE IN PRESS 1112 Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 ‘‘script analysis’’ where the use of cognitive operators and strategies in the nurses reasoning were analysed showed that cognitive strategies were infrequently used. Instead, the reasoning was dominated by the use of operators. However the operator ‘‘connecting’’, where the RNs consider possible relationships among cues, was rare. The findings of these two last steps of the PA analysis were true for both ‘‘consultant’’ and ‘‘care nurses’’. Looking at the content of the reasoning, the result shows certain differences between the participants on a group level (Table 3). On the whole, the ‘‘care nurses’’ held a broader reasoning. ‘‘Activity’’ was the only content area within which the ‘‘consultant nurses’’ reasoned the most. The content area elimination showed the biggest difference. Most of the ‘‘consultant nurses’’ did not focus on this aspect at all, or said that this aspect was taken care of by the nursing assistants. All ‘‘care nurses’’, on the other hand, reasoned about avoiding incontinence in a way that could, indirectly, help to prevent pressure ulcers. The importance of good hygiene was highlighted by several nurses in this group but only ARTICLE IN PRESS Table 1 Concepts derived from the referred phrase analyses Concept Definition Examples from the VPs Time (occurs in all phases) Chronological reference ‘‘yheavily overweight before she became ill’’ ‘‘ybut only three weeks have passed’’ Assessment phase Sign Identification of objective information about health status ‘‘ydry skin that easily becomes bruised’’ ‘‘ysleeps a lot even during the day’’ Valuation Identifying the value of something ‘‘Dry skin is easily rectified with the help of some moisturising cream and it is very important to rub it in after washing’’ Nursing ethics A guideline for the nursing care given at the nursing home, or for the nurse in particular ‘‘Turning the patient repeatedly at night time interrupts sleep and a good night’s sleep is valuable’’ Prerequisite Identifying circumstances needed for the trustworthiness of the reasoning ‘‘It might not be totally wrong to lose a few kilos but she must not do it too quickly either’’ Assumption A starting point for reasoning that is not taken for granted. ‘‘It takes time for older people to recover’’ Conclusion A judgement reached from evaluating signs and/or facts ‘‘y 1000 ml glucose is not at all enough to p
rovide nourishment’’ Planning phase General action An action that is indirectly tied to the person in focus for the nursing given, for example making phone calls, taking contacts, reporting, documenting ‘‘ I ought to speak to the doctor about this’’ ‘‘I can contact the hospital and discuss it with the nurse’’ Routine An action taken on regular basis or as a rule ‘‘In cases like this the person gets an anti-decubitus mattress as a rule’’ Nursing action An action nurses decide about and have the responsibility for. It can be specific or general. ‘‘ywe have nutritious drinks and nutritional supplements here, so we can offer these to her’’ Paramedic action An action decided upon by an occupational therapist or a physiotherapist ‘‘ywe have to ask an occupational therapist about one of those fancy mattresses’’ Treatment Medical prescription ‘‘yI suppose we must have a discussion with the doctor about inserting a feeding tubey’’ Goal Description of an endpoint, which one aims to reach ‘‘We have to be careful when we turn her over and hold her so we do not harm the skin’’ Implementation phase Procedure Description of how to do or perform a task ‘‘We shall look at different criteria, inspect the skin, how they eat, if they are heavy or thin, how they can move about y’’ Making priorities Pointing out the importance of a task ‘‘At first we have to relieve the pressure from the skin’’ Evaluation phase Following-up Description of how to evaluate the result or what to evaluate ‘‘y in this case I would weigh the lady once a weeky’’ The part of the citation written in italics is the part in focus for the specific concept. Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 1113 one respondent associated this directly to an increased risk of developing pressure ulcersy Urine and faeces incontinence, the use of a diaperythen it is about preserving her skin and preventing pressure ulcers and such. Another difference between the two groups was that none of the ‘‘consultant nurses’’ connected nutrition directly to pressure ulcer prevention. The indirect reasoning was mainly about keeping the person well nourished to promote well-being and rehabilitation but the fact that she was overweight also led to reasoningy She weighed far too much before she got illy now she has probably lost a few pounds as she has only had some nourishment intravenously y I have to take a closer look into this when I see hery it’s not about putting an old person on a diet, on the contrary she has to be well nourished to recover. In a few cases, the participants connected her overweight to an increased risk of pressure ulcer development and later when the person had lost 7 kg the views about this differed, was it good or bad? she has lost seven kilosy but maybe it’s okay. Earlier she was really big, immobile and heavy so it might not be all bad. It’s easier for her and for us when she weighs less. A majority of the participants made a direct connection between the person’s immobility and the risk of pressure ulcers in their reasoning implementing a special mattress. A few participants made this connection already before they had ‘‘met’’ her, one expressed it like this. There is a big risk of pressure ulcers here, her fragile skin, she’s incontinent and she is mostly in bed y.maybe she will need an antidecubitus mattress immediately. On the whole this was the most common preventive action taken. Among those who did not reason directly about the risk of pressure ulcer in connection to ‘‘activity’’, most reasoned in a general way about how to mobilise and the need for a repositioning schedule during the day, as well as at nighty We will have to assess how often we need to turn her at night, maybe not so often if it’s possible. She needs to sleep at night. ARTICLE IN PRESS Table 2 Occurrence of reasoning in connection with derived concepts and the different phases in the nursing process Concept Before arrival (n ¼ 10) The day after (n ¼ 11) Three weeks later (n ¼ 11) Time 3 5 4 Assessment phase 54a (52b ,56c )% 64a (58b ,70c )% 76a (75b ,76c )% Sign 10 11 11 Valuation 7 10 11 Nursing ethics 1 7 7 Prerequisite 6 1 3 Assumption 6 8 8 Conclusion 6 5 10 Planning phase 62a (58b ,66c )% 65a (63b ,66c )% 69a (66b ,73c )% General action 10 11 9 Routine 3 2 1 Nursing action 10 11 11 Paramedic action 8 6 9 Treatment 3 6 6 Goal 7 7 10 Implementation phase 55a (50b ,60c )% 55a (50b ,60c )% 59a (50b ,70c )% Procedure 5 7 6 Making priorities 7 5 7 Evaluation phase 9a (16b , 0c )% 45a (66b ,20c )% 100a (100b ,100c )% Following-up 1 5 11 a The average use of the concepts belonging to the specific phase based on all the 11 VPs. b The ‘‘consultant nurses’’ average use of the concepts belonging to the specific phase. c The ‘‘care nurses’’ average use of the concepts belonging to the specific phase. 1114 Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 The significance of a comfortable wheelchair was also something many respondents highlighted from the very start but first when persistent discolouration of the skin over the sacrum occurred, began reasoning about the use of a pressure ulcer prevention cushion. Consulting an occupational therapist was part of many participants reasoning. In connection with the content area ‘‘skin’’, all respondents identified the risk of pressure ulcer development though four respondents did not make any direct reasoning until persistent discolouration was a fact. yoh I seey her bottom has become red. Then we can’t have her on her back at all, only turn her from side to sidey Early in the care-planning process, before or just after the person’s arrival, many participants focused on the need for skin care in their reasoning. Preparing the bed with extra pillows, rotation device etc was part of the reasoning, as was having a moisturising cream for her dry skin at hand in the room but also how to instruct the staff about the care needed. The RN, at the only nursing homes where they performed a structured pressure ulcer risk assessment on arrival, reasoned like thisy We check different criteria, such as skin, how they eat if they are heavy or skinny, how mobile they are. In my opinion Ebba runs a severe risk of developing pressure ulcers and that we have to prevent. When persistent discolouration had occurred, many of the participants reasoned that an explanation could be her malnutrition. Other explanations were also given, such as insufficient peripheral circulation and lack of turning routines. Most of the participants stressed the importance of regular turning from side to side but the view on massaging the discoloured part of the body differed from being totally avoided to being one of the most important actions to take. How the participants interpreted the discolouration also differed, some looked at it as first grade pressure ulcer and others as an increased risk of skin damage. The reasoning in connection with the person’s wellbeing and ability to communicate was not very extensive and only indirect reasoning in connection to pressure ulcer prevention was found. The importance of communicating with the person in the process of care planning was highlighted by some, as well as the importance of listening to what she has to say during their everyday worky She has slurred speech, so we will have to let her finish what she has to say and show her that we understand, that we have the time to stay and listenythis aspect is important for me to emphasise when I meet the staff. The fact that the person easily cried, that she was tired and apathetic led some participants to reason about the importance of well-being for her recovery and rehabilitation. Several interpreted her status as probable depression, important to deal with. Some stressed the importance of keeping her free from pain. The reasoning around well-being was also about how things link to each othery ythe tiredness probably arises from her not getting enough nourishment. We will have to
see that she sleeps properly gradually activating her more and more but her tiredness is also due to her illnessy The content area of ‘‘nursing care management’’ concerning information, supervising and care planning ARTICLE IN PRESS Table 3 Number of respondents that directly (D) or indirectly (I) focused on the prevention of pressure ulcers in the three different parts of the case, seen in each group Content area Consultant nurses (n ¼ 6) Care nurses (n ¼ 5) Part 1a D/I Part 2b D/I Part 3c D/I Part 1a D/I Part 2b D/I Part 3c D/I Communication —/2 —/3 —/2 —/3 —/4 —/4 Breathing/circulation — 2/— — — 2/1 2/1 Nutrition —/3 —/3 —/5 1/3 1/3 —/5 Elimination —/1 —/2 —/1 1/2 1/3 —/2 Skin 1/1 2/2 6/— 2/2 2/3 5/— Activity 2/2 3/3 4/1 1/3 1/3 2/3 Wellbeing — —/1 —/2 —/1 —/1 —/2 Nursing care management 1/2 3/— —/1 2/2 —/2 3/— a Before arrival. b The day after arrival. c Three weeks after arrival. Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 1115 emerged in several participants’ reasoning. In this case, both direct and indirect reasoning in connection with pressure ulcer prevention was found. One participant not only involved the staff in this but also the person herself and her daughter. Some reasoned about the importance of documentation in a way that can, indirectly, prevent pressure ulcer developmenty We usually document important things like this in her nursing journal such as the regular use of moisturising cream to keep her skin smooth. Then everyone knows. 5. Discussion 5.1. Method As the purpose of this study was to reveal both the thinking process and to reach an understanding of the content, TA together with PA and qualitative content analyses was chosen. Methods like grounded theory (Edwards et al., 2004) and phenomenography (Baker, 1997) as well as quantitative methods (Brynes and West, 2000), also used to explore clinical reasoning, were not seen as alternatives since none of these methods capture the flow of thinking. The data collected in this study by the use of TA during the simulated care-planning situation was very rich. In order to minimise the risk of influencing the thinking process and its content, the nurses were unaware of the focus on pressure ulcer prevention during the TA interview. None of the participants had any major problem with thinking aloud and talking aloud was rare. As the participants had very little problem with the flow of information and thought process the interviewer only rarely had to remind them to go on thinking aloud. In no other way did the interviewer prompt the participants. All this considered the risk for reconstruction was minimal. Almost all participants said that this was a very typical case, making it easy for them to imagine the person, which strengthens the trustworthiness of the study. Due to this, together with the fact that the case is authentic and standardised, comparisons between nurses and groups of nurses is made possible. Still there are limitations that must be considered to using a simulated case, such as reduction of task complexity due to the lack of influence of the senses, time and context. The standardisation itself also limits the cue seeking process. However, real practise situations cannot be standardized and are ethically more complex which can make it impossible to think aloud during the nursing task. In such cases, ‘‘think afters’’ or retrospective interviews have to be used, imposing a greater risk for reconstruction of the reasoning (Fonteyn et al., 1993; Greenwood, 1998). In order to obtain a description of nurses’ reasoning process during care planning, PA was chosen. A lot of time was spent in finding the deeper meaning of each step of the PA in order to avoid the unintentional influence of earlier studies’ findings enabling comparisons. The hardest step to get a grip on was the third, assertional analysis. The different kinds of assertions found however correspond well with assertions found by Fonteyn et al. (1993) and to some extent with Simmons et al. (2003). The causal assertion was the easiest to discover despite the fact that it was rare and it is the only one identified in this study as well as in the other two. As the purpose of the content analysis was to obtain a more detailed description of the content (Morgan, 1993) the analysis was not further abstracted into themes and categories. The result shows that taking pressure ulcer prevention as an example when analysing the interviews, enabled a variety of content areas to be viewed as intended. 5.2. Findings As clinical reasoning is about applying knowledge and experiences to solve a clinical situation, it is hardly surprising that the results of this study show that both process and content of the clinical reasoning during care planning are, to a great extent, individual. Besides personal qualities and characteristics, many factors differ between the individual participants, such as previous working experiences, content of education, academic level, etc. On a group level the reasoning did not differ much between RNs who work close to the elderly at the nursing homes, ‘‘care nurses’’ or more as consultants, ‘‘consultant nurses’’. The only differences shown were in the use of concepts. This study however is too small to say whether these differences are due to coincidence or to the way they perform their work. However seen as a whole there are certain patterns to be found. One general finding was that there were no clear limits between the different phases of the nursing process and neither did the reasoning keep to one phase at a time, instead it had a tendency to go back and forth. This result corresponds well with earlier studies (Fowler, 1997; Grobe et al., 1991; McCarthy, 2003) and might to some extent explain the problems in nursing documentation such as concordance between nursing records in nursing homes and actual nursing care shown in the study by Ehrenberg and Ehnfors (2001). This study, as well as that of McCarthy (2003) and Ehrenberg and Ehnfors (1999b), also indicates that nurses seldom use reasoning in order to achieve nursing diagnoses. Routine thinking among the RNs in this study is indicated by the rare use of the most complex assertion, the causal, as well as by the lack of strategies aiming to reduce cognitive strain. On the other hand, the fact that the reasoning increased over time, especially in ARTICLE IN PRESS 1116 Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 connection with assessing and evaluation of the person’s needs, points towards an increasing complexity of the reasoning, the better the nurses know the person. This study also indicates that the content of reasoning is affected by how close to the elderly the RNs work. Nurses who, as part of their work, participated in the nursing care, ‘‘care nurses’’ reasoned to a greater extent in a holistic way focusing on more perspectives than consultant nurses did. The ‘‘consultant nurses’’ mostly have a larger number of residents to pay attention to, often without deeper knowledge about the person. It has been found in studies performed both in the community and in hospital settings that knowing the person is especially important for determining nursing care both ethically and technically. Furthermore, the continuity of care is of special importance in order to provide more than just physical aspects (Luker et al., 2000; Takamura and Kanada, 2003). Without personal knowledge about the person, the ‘‘consultant nurses’’ depend a lot on the information given through documentation and the nursing assistant calling for help. The fact that there are normally considerable shortcomings in the documentation in nursing homes (Ehrenberg and Ehnfors, 2001; Voutilainen et al., 2004) makes nursing documentation doubtful as a data source for pressure ulcer prevention and care planning. The documentation given in the simulated case to the participating RNs was richer and more complete than is normally the case, which was something most
participants commented upon. Still the ‘‘consultant nurses’’ had a more limited reasoning, overlooking problems such as incontinence. This however correlates well with Gunningberg et al. (2001) who found that RNs seldom relate incontinence to the prevention of pressure ulcers. As RNs in Swedish nursing homes work more and more as consultants, this can affect the nursing care, endangering a holistic view of the residents, putting the residents at unnecessary risk. Though the correlation between nutritional status and pressure ulcer development is well documented (Christensson et al., 1999; Ek et al., 1991), only two nurses in this study made this correlation. This unawareness correlates well with findings made by Gunningberg et al. (2001). On a group level the ‘‘care nurses’’ had a greater focus on the person’s nutritional problems than the other group. The only area where the ‘‘consultant nurses’’ as a group had the most extensive reasoning and reasoned more often directly about pressure ulcer prevention was around the person’s activity. As immobility is shown to be the most important risk factor for pressure ulcer development (Lindgren et al., 2004), this awareness among RNs and all nursing staff is of great importance. The consciousness of the importance of skin care in relation to pressure ulcer prevention was high among most RNs in this study. However all except one lacked routines for identifying those at risk on admission or made a formal pressure ulcer risk assessment. In addition, the need for continuous skin inspections were recognised by very few. There was also some reasoning made and actions taken based on old ideas and tradition that were more or less in contradiction to evidence based practise and current guidelines, for example massaging discoloured skin, a result that correlates quite well with other studies (Buss et al., 2004; Gunningberg et al., 2001 Sharp et al., 2000;). This, together with the RNs’ tendency to think routinely with regard to pressure ulcer prevention, indicates a need for continuous further education in this area for RNs working at community care residences, such as nursing homes. The positive effect of staff education in reducing skin damage and pressure ulcers has been shown by Hunter et al.(2003) in a clinical trial at two nursing homes. On the whole, the focus on physical aspects was overwhelming in the RNs’ reasoning, even though quite a lot of information was given about other dimensions of the person’s well-being and ability to communicate. This, however, reflects quite well the current evidence-based guidelines concerning pressure ulcer prevention, where the importance of informing and educating the patient and involving the patient in the actions taken, are the only things highlighted, besides physical and technical aspects (Rycroft-Malone, 2001; Infomedica, 2004). 6. Conclusions and implications Reasoning concerning pressure ulcer prevention among the RNs in this study was dominated by routine thinking. However, getting to know the person over a period of time made a more complex reasoning possible. The RNs’ experiences, knowledge, together with how close to the elderly the RNs work, seem to be important factors that affect the content of reasoning. RNs who did not participate in the nursing care had a tendency to overlook certain areas of nursing in their reasoning when care planning, such as incontinence care. Reasoning based on old ideas and traditions, rather than on evidence where pressure ulcer prevention is concerned, reveals a need for continuous further education for RNs in this area. The way in which RNs perform their work at Swedish community care residences is changing, towards them only rarely participating directly in the nursing care. Thus, further studies in real practise situations, with the aim of exploring how this change affects the reasoning in care planning, the content of documentation and the care performed by the nursing staff would be of great interest. Acknowledgements We greatly acknowledge the support from Linko¨ping University as well as participating nurses. ARTICLE IN PRESS Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 1117 References Baker, J.D., 1997. Phenomenography: an alternative approach to researching the clinical decision-making of nurses. Nursing Inquiry 4 (1), 41–47. Benner, P., 1984. 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Nursing home quality and pressure ulcer prevention and management practices. Journal of American Geriatric Society 52 (4), 583–588. ARTICLE IN PRESS Kajsa H. Funkesson et al. / International Journal of Nursing Studies 44 (2007) 1109–1119 1119 Pressure ulcers: Development and psychometric evaluation of the Attitude towards Pressure ulcer Prevention instrument (APuP) D. Beeckman a,b, *, T. Defloor a , L. Demarre´ a , A. Van Hecke a , K. Vanderwee a aNursing Science, Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium bDepartment of Bachelor in Nursing, University College Arteveldehogeschool Ghent, Ghent, Belgium What is already known about the topic? Pressure ulcer prevalence has not declined in recent years despite the availability of internationally accepted evidence-based prevention guidelines. A negative attitude towards pressure ulcer prevention is expected to be a barrier to using pressure ulcer prevention guidelines. International Journal of Nursing Studies 47 (2010) 1432–1441 ARTICLE INFO Article history: Received 16 March 2010 Received in revised form 16 April 2010 Accepted 16 April 2010 Keywords: Nursing Pressure ulcers Prevention Psychometric Validity Reliability Attitude Instrument ABSTRACT Background: Pressure ulcers continue to be a significant problem in hospitals, nursing homes and community care settings. Pressure ulcer incidence is widely accepted as an indicator for the quality of care. Negative attitudes towards pressure ulcer prevention may result in suboptimal preventive care. A reliable and valid instrument to assess attitudes towards pressure ulcer prevention is lacking. Aims and objectives: Development and psychometric evaluation of the Attitude towards Pressure ulcer Prevention instrument (APuP). Design: Prospective psychometric instrument validation study. Methods: A literature review was performed to design the instrument. Content validity was evaluated by nine European pressure ulcer experts and five experts in psychometric instrument validation in a double Delphi procedure. A convenience sample of 258 nurses and 291 nursing students from Belgium and The Netherlands participated in order to evaluate construct validity and stability reliability of the instrument. The data were collected between February and May 2008. Results: A factor analysis indicated the construct of a 13 item instrument in a five factor solution: (1) attitude towards personal competency to prevent pressure ulcers (three items); (2) attitude towards the priority of pressure ulcer prevention (three items); (3) attitude towards the impact of pressure ulcers (three items); (4) attitude towards personal responsibility in pressure ulcer prevention (two items); and (5) attitude towards confidence in the effectiveness of prevention (two items). This five factor solution accounted for 61.4% of the variance in responses related to attitudes towards pressure ulcer prevention. All items demonstrated factor loadings over 0.60. The instrument produced similar results during stability testing [ICC = 0.88 (95% CI = 0.84–0.91, P < 0.001)]. For the total instrument, the internal consistency (Cronbachs a) was 0.79. Conclusion: The APuP is a psychometrically sound instrument that can be used to effectively assess attitudes towards pressure ulcer prevention in patient care, education, and research. In further research, the association between attitude, knowledge and clinical performance should be explored. 2010 Elsevier Ltd. All rights reserved. * Corresponding author at: Nursing Science, Ghent University, U.Z. Block A 2nd floor, De Pintelaan 185, B-9000 Ghent, Belgium. Tel.: +32 9 332 36 19; fax: +32 9 332 50 02. E-mail address: Dimitri.Beeckman@UGent.be (D. Beeckman). Contents lists available at ScienceDirect International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns 0020-7489/$ – see front matter 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2010.04.004 Psychometric aspects of instruments to assess attitudes towards pressure ulcer prevention are not evaluated. What this paper adds The Attitude towards Pressure ulcer Prevention instrument (APuP) can be considered as a brief, conceptual
ly sound, rigorously developed instrument with evidence supporting its psychometric properties. The APuP can be used in education, research and clinical practice to assess attitudes towards pressure ulcer prevention. Further research should focus on the predictive validity of the instrument and on the exploration of the relation between attitude, knowledge, and clinical performance. 1. Introduction A pressure ulcer is a localised injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated (European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel, 2009). The ulcers are most often observed in geriatric patients and patients dealing with physical disabilities caused by inactivity, immobility and deprived health status (Schoonhoven et al., 2007; Vanderwee et al., 2007a) Pressure ulcers are recognised as an international patient safety problem and are associated with quality of care (Gunningberg and Stotts, 2008; Baharestani et al., 2009). The lesions are considered as adverse outcomes with a significant impact on patients, their family, caregivers and healthcare organisations (Lardenoye et al., 2009; Gorecki et al., 2009). Recent studies indicate that pain, infectious complications, prolonged and expensive hospitalisations, persistent open ulcers, increased risk of death and reduced health-related quality of life are associated with the development of pressure ulcers (Hopkins et al., 2006; Essex et al., 2009). Appropriate prevention should be considered early in all patients at risk and whenever early signs of pressure ulcer development are observed (nonblanchable erythema) (Schoonhoven et al., 2007; Vanderwee et al., 2007b, 2009). Prevention should focus on the reduction of the amount and/or duration of pressure and shear (European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel, 2009). Despite the availability and accessibility of internationally accepted evidence-based prevention guidelines, pressure ulcer prevalence has not declined in recent years (Gunningberg, 2006; Schoonhoven et al., 2007, Vanderwee et al., 2007a; Hurd and Posnett, 2009; Shahin et al., 2009). The rationale for this is unclear. The identification of factors contributing to compliance and non-compliance for pressure ulcer prevention guidelines is expected to be important to be able to implement new insights effectively (van Gaal et al., 2010). A negative attitude towards pressure ulcer prevention may be one of those factors (Grol and Wensing, 2004). Nevertheless, attitudes are frequently overlooked when planning guideline dissemination and implementation (Moulding et al., 1999). An attitude can be defined as a relatively enduring organisation of interrelated beliefs (Rockeach, 1966) and may indicate what can be expected from others (Petty and Cacioppo, 1996). An individual who believes that performing a given behaviour will lead to mostly positive outcomes, will probably hold a more favourable attitude towards performing the behaviour and vice versa (Ajzen and Madden, 1986). An accurate assessment method for attitudes may be useful in predicting clinical performance. 2. Literature overview This literature overview focuses on research describing the development and psychometric validation of instruments and methods to assess attitudes towards pressure ulcer prevention. The databases PubMed, The Cochrane Library Central Register of Controlled Trials (CENTRAL) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for research published in English, Dutch, French and German. The keywords ‘attitude’; ‘attitude to health’; ‘pressure ulcer’; ‘instrument’; ‘scale’; ‘psychometric properties’; and ‘psychometric validation’ were combined to conduct the search. The literature search was completed in January 2010 and revealed five publications in English and one publication in German. Kimura and Pacala (1997) developed an instrument to study the attitudes of family physicians towards the Agency Health Care Policy and Research (AHCPR) guideline on pressure ulcer prevention. The questionnaire consisted of four items to be rated on a four-point Likert scale: (1) adequacy of the training to manage pressure ulcers, (2) perceived effectiveness in treating pressure ulcers, (3) importance of pressure ulcers in primary care practice, and (4) the role of family physicians in pressure ulcer management. No information on psychometric validation of the instrument was reported. Moore and Price (2004) conducted a literature review to develop an instrument to assess the attitudes of staff nurses towards pressure ulcer prevention. The instrument included 11 items to be rated on a five-point Likert scale. The instrument was pilottested in a small sample of 16 nurses from teaching hospitals to assess internal consistency. No further validation was performed. Krause et al. (2004) developed a semi-standardised questionnaire to assess the attitudes of nurses and physicians towards pressure ulcers. No information about the design and validation of the instrument was described. Ka¨llman and Suserud (2009) developed a Swedish version of the instrument developed by Moore and Price (2004) to assess the attitudes of registered nurses and nursing assistants towards pressure ulcer prevention in Sweden. The layout and content of the questionnaire were reviewed by three pressure experts. The questionnaire was pilot-tested in a small sample of four registered nurses and four nursing assistants. The final instrument consisted of 11 items to be rated on a five-point Likert scale. In two studies, qualitative methods were used to describe the views and beliefs about pressure ulcer D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441 1433 prevention of nurses and nursing aides in nursing homes (Buss et al., 2004; Goldsworthy, 2008). This literature overview reveals that various researchers studied attitudes towards the prevention of pressure ulcers. The limited evaluation of the psychometric aspects of the instruments is a major problem to be able to evaluate and compare these findings. Both quantitative (questionnaires) and qualitative research designs have been used. Construct validity and stability of the instruments were never evaluated. Internal consistency was evaluated in only one study. The development and psychometric evaluation of an instrument to assess attitudes regarding pressure ulcer prevention is necessary. 3. Aims and objectives The aim of this study was to develop and to evaluate the psychometric characteristics of the Attitude towards Pressure ulcer Prevention instrument (APuP). 4. Methods 4.1. Design A two-phase prospective psychometric instrument validation study was conducted. Phase 1 included the design of the instrument and phase 2 included the psychometric evaluation. 4.1.1. Phase 1: Design of the instrument A literature review was performed in order to define eight attitude subscales: 1. Attitude towards the impact of pressure ulcers on patients. 2. Attitude towards the financial impact of pressure ulcers on society. 3. Attitude towards the support by management. 4. Attitude towards the priority of pressure ulcer prevention. 5. Attitude towards personal responsibility in pressure ulcer prevention. 6. Attitude towards the importance of a sound knowledge base. 7. Attitude towards confidence in personal skills. 8. Attitude towards confidence in the effectiveness of prevention. A range of items was formulated to be covered by the subscales. All items were derived from literature, clinical experience and deductive reasoning by the developers. As recommended by Clark and Watson (2005), the number of items was chosen so as to sample systematically all content that potentially could be relevant to the target construct. Because the subsequent psychometric analyses could potentially identify weak, unrelated items, the item pool was se
lected broader than initially was derived from the literature review. This allowed to drop out some items from the emerging instrument. Half of the items was worded negatively and half was worded positively. All items were developed to be rated on a four-point Likert rating scale (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree). The relevance of each item was evaluated in a double Delphi procedure by two expert panels (McKenna, 1994; Thomas et al., 1992; Polit and Beck, 2007). The first panel consisted of nine trustees of the European Pressure Ulcer Advisory Panel (EPUAP) who each had an extensive experience in pressure ulcer care and research (PhD level). The second panel consisted of five experts (geriatrician, dermatologist, nursing researcher, psychologist, sociologist). The experts independently reviewed each item for appropriateness and relevance in assessing attitudes towards pressure ulcer prevention. A five-point Likert scale was used to indicate the relevance of the items under study (from 1 = irrelevant to 5 = highly relevant). The content validity index (CVI) was computed using the proportion of experts wh agreed about item relevance. The CVI was between 0.87 and 1.00, indicating adequate content validity (Polit and Beck, 2007). Twelve items were re-worded to improve item relevance. After this item modification, the instrument was pilot-tested in a sample of five nurses and five nursing students. The aim was (1) to evaluate the clarity of the items and report any ambiguous items and items difficult to interpret, (2) to receive feedback about the format/layout of the instrument, and (3) to get insight into the time needed to complete the instrument. In general the participants did not have any problems with the wording, length and format of the instrument. An overview of the instrument design process is provided in Fig. 1. 4.1.2. Phase 2: Psychometric evaluation of the instrument The psychometric evaluation included the evaluation of the construct validity (factor analysis, discriminating power and internal consistency) and stability reliability testing of the instrument. 4.2. Sample The initial 32-item APuP instrument was administered to a convenience sample of qualified nurses (n = 258) and nursing students (n = 291) in Belgium and The Netherlands. The sample size determination was based on Polit and Beck (2007) who states that 10 respondents per item is mostly recommended as a minimum to support the factor analysis. In Belgium, 210 qualified nurses from two general hospitals (n = 172) and one psychiatric hospital (n = 38) were included. In this group of qualified nurses, 67 of them attended a Master of Sciences in Nursing (MScN) educational programme. Besides, nursing students from two schools with an undergraduate nursing education (n = 77) and two nursing colleges (n = 214) were included. All nursing students were at the second semester of their particular year of basic nursing education. In the Netherlands, 48 pressure ulcer nurses were asked to participate because of their specific specialty in the prevention and treatment of pressure ulcers. To allow the evaluation of the discriminating power of the APuP instrument, eight subgroups were pre-defined based on a theoretically expected difference in attitudes towards pressure ulcer prevention. An overview of these pre-defined groups is provided in Table 1. 1434 D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441 4.3. Ethical approval Ethical approval was provided by the ethics review committee of Ghent University Hospital (B/67020072806). The questionnaire included a cover letter addressing the purpose of the study. Anonymity and confidentiality were assured. All data were treated as confidential at all times. The return of a completed instrument was considered as the consent to participate. 4.4. Procedure The study was performed in Belgium and The Netherlands between February and May 2008. To be able to study the stability of the instrument over a time period, data were collected at two different points in time (a 1-week interval). The 1-week period between the test and the retest was used to reduce confounding factors during the intervening time interval as much as possible (Polit and Beck, 2007). These confounding factors included: (1) the possibility that the attitudes changed over time (independently of the measure’s stability), and (2) the possibility that the respondents were influenced by their memory of initial responses. The participants were not informed in advance of the test–retest procedure. The same conditions were ensured at both data collecting time points. The time to complete the instrument was 10 min. 4.5. Data analysis Construct validity and stability reliability of the instrument were assessed. Construct validity was assessed by (1) factor analysis using principal component analysis, (2) discriminating power (known-groups technique), and (3) internal consistency analysis. In the factor analysis, the varimax rotation with Kaiser normalisation was used. The numbers of factors were determined by eigenvalues (1). The Kaiser–Meyer–Olkin (KMO) Measure of Sampling Adequacy over 0.50, Bartlett’s test of sphericity, scree plot, factor loadings of over 0.40, and explainable percentages of variance (minimum of 5% reported variance per factor) were evaluated. Item reduction and attitude subscale modification were performed based on this factor analysis. Analysis on discriminating power, internal consistency, and stability reliability were executed on the modified model. Sum scores were calculated to obtain the total attitude score. Scores on the negatively worded items were reversed to obtain a total score. The independent sample Fig. 1. Phase 1: Design of the instrument. Table 1 Pre-defined groups based on the theoretically expected attitude levels. Pre-defined groups Theoretically expected more positive attitude Theoretically expected more negative attitude 1 Pressure ulcer nursesa vs. Bedside nursesb 2 Pressure ulcer nurses vs. First year nursing students 3 Infection control nursesc vs. MScN studentsd 4 Third year nursing students vs. First year nursing students 5 Third year nursing students vs. Second year nursing students 6 Second year nursing students vs. First year nursing students 7 General nurses vs. Mental health nurses 8 Bachelor degree vs. Undergraduate degree a Pressure ulcer nurse, qualified nurse in The Netherlands, specialised in the prevention and treatment of pressure ulcers. b Bedside nurse, qualified nurse working on a hospital ward c Infection control nurse, qualified nurse in Belgium with the specific task to identify and control infections that occur in the community or in a hospital setting d MScN, qualified bachelor nurse studying to obtain a Master of Sciences in Nursing. D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441 1435 t-test was used to signify differences between the attitude scores of the pre-defined groups (discriminating power). The internal consistency was studied by calculating interitem correlations Cronbachs a (Polit and Beck, 2007). The criteria for Cronbachs a as described by Streiner and Norman (2003) were used for the interpretation of the results: 0.70 < Cronbachs a < 0.90. To assess the reliability of the instrument, the intraclass correlation coefficient was calculated for each theme and for the overall instrument. Reliability coefficients 0.70 were considered as satisfactory (Polit and Beck, 2007). All statistical analyses were performed using SPSS1 15.0 (SPSS1 Inc., Chicago, IL, USA). An a level of 0.05 was applied for all statistical tests. An overview of the psychometric evaluation of the instrument is provided in Fig. 2. 5. Results 5.1. Basic characteristics of the participants A total of 258 nurses and 291 nursing students participated. About 70% of the nurses were between the age of 25 and 50. More than half of the nurses (54.2%) stated to have more than 10 years experience in nursing care. Approximately 65% of the nurses worked in a hospital and 17.1% worked in mental healthcare. Almost 75% of the nursing
students were bachelor students and 79.4% of them were specialising in general nursing. Half of the students were first year nursing students. An overview of the demographic data is provided in Table 2. 5.2. Psychometric evaluation of the instrument 5.2.1. Construct validity 220.127.116.11. Factor analysis. Several exploratory analyses were conducted on the 32-item instrument. The model chosen included five factors, covering 13 items, and had the most meaningful content. The KMO for this model indicated sampling adequacy (KMO = 0.72). Bartlett’s test of sphericity was statistically significant (x2 = 1062.6, df = 78, P < 0.001). Following factors were defined: Factor 1: Attitude towards personal competency to prevent pressure ulcers. Factor 2: Attitude towards the priority of pressure ulcer prevention. Factor 3: Attitude towards the impact of pressure ulcers. Factor 4: Attitude towards responsibility in pressure ulcer prevention. Factor 5: Attitude towards confidence in the effectiveness of prevention. The five factors accounted for 61.4% of the variance in responses related to attitudes towards pressure ulcer Fig. 2. Phase 2: Psychometric evaluation of the instrument. 1436 D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441 prevention. Factor 1 consisted of 2 positively and 1 negatively worded items, explaining 14.6% of the variance. Factor 2 included 1 positively and 2 negatively worded items, explaining 14.0% of the variance. Factor 3 included 1 positively and 2 negatively worded items, explaining 11.5% of the variance. Factor 4 included 1 positively and 1 negatively worded items, explaining 10.8% of the variance. Factor 5 included 1 positively and 1 negatively worded items, explaining 10.5% of the variance. All items demonstrated strong factor loadings (>0.60; See Table 3).
18.104.22.168. Discriminating power. Group scores of participants
having a theoretically expected more positive attitude
were found to be statistically significantly higher than
those of participants with theoretically expected more
negative attitudes. Expert nurses proved to have more
positive attitudes than non-expert nurses (resp. 30.6/52 vs.
27.4/52, t = 4.61, df = 139, P < 0.001) (See Table 4). There was no difference between the group scores of second year nursing students (26.3/52, SD = 3.1) and first year nursing students (26.4/52, SD = 3.0) (t = 0.3, df = 194, P = 0.74) (See Table 4). In general, nurses proved to have more positive attitudes towards pressure ulcers than nursing students (resp. 28.0/52 vs. 26.9/52, t = 3.55, df = 547, P < 0.001) for the total APuP instrument. Nurses proved to have more positive attitudes for ‘competence’ (5.6/12 vs. 4.9/12, t = 5.50, df = 547, P < 0.001) and ‘impact’ (7.9/12 vs. 6.3/12, t = 2.41, df = 547, P = 0.016) than nursing students. No significant differences were found between nurses and nursing students in the other subscales. 22.214.171.124. Internal consistency. Cronbachs a was 0.79 for the total APuP instrument, 0.81 for ‘competence’, 0.75 for ‘priority’, 0.79 for ‘impact’, 0.82 for ‘responsibility’, and 0.76 for ‘effectiveness of prevention’. 5.2.2. Stability reliability (intraclass correlation) The overall intraclass correlation coefficient was 0.88 (95% CI = 0.84–0.91, P < 0.001). The intraclass correlation coefficient for the subscales ranged between 0.77 (95% CI = 0.70–0.83, P < 0.001) and 0.85 (95% CI = 0.80–0.89, P < 0.001). The final version of the APuP is presented in Table 5. 6. Discussion An accurate assessment of attitudes towards pressure ulcer prevention is an important step in identifying interventions to improve pressure ulcer prevention. As evidenced by the literature overview, none of the actual instruments exhibits fully satisfactory psychometric characteristics. The results from the psychometric evaluation of the APuP indicated that the instrument and the subscales Table 2 Demographic data. Nurses (n = 258) % (n) Student nurses (n = 291) % (n) Gender Male 20.5% (53) 14.8% (43) Female 79.5% (205) 85.2% (248) Education Undergraduate degree 28.3% (73) 26.5% (77) Bachelor degree (BA) 65.5% (169) 73.5% (214) MScN degree (MScN) 6.2% (16) N/Aa Age category <25 years 18.2% (47) 85.2% (248) 25–34 years 31.4% (81) 8.2% (24) 35–50 years 37.6% (97) 5.8% (17) >50 years 12.8% (33) 0.7% (2)
No experience 7.4% (19) N/Aa
<5 years 20.9% (54) N/Aa 5–10 years 17.4% (45) N/Aa 10–20 years 24.0% (62) N/Aa >20 years 30.2% (78) N/Aa
Year of education
1st year N/Aa 46.6% (138)
2nd year N/Aa 19.9% (58)
3rd year N/Aa 32.6% (95)
General nursing 73.6% (190) 79.4% (231)
Geriatrics 3.5% (9) 7.2% (21)
Pediatrics 1.9% (5) 1.7% (5)
Mental health 17.8% (46) 7.6% (22)
Community nursing 3.1% (8) 4.1% (12)
a Not applicable.
Factor analysis using principal component analysis.
Item Factor 1
1. I feel confident in my ability to prevent pressure ulcers. 0.83 0.07 0.05 0.06 0.01
2. I am well trained to prevent pressure ulcers. 0.75 0.15 0.02 0.04 0.03
3. Pressure ulcer prevention is too difficult. Others are better than I am. 0.75 0.00 0.11 0.09 0.13
4. Too much attention goes to the prevention of pressure ulcers. 0.09 0.75 0.01 0.00 0.21
5. Pressure ulcer prevention is not that important. 0.01 0.72 0.33 0.01 0.03
6. Pressure ulcer prevention should be a priority. 0.21 0.63 0.02 0.29 0.20
7. A pressure ulcer almost never causes discomfort for a patient. 0.02 0.15 0.69 0.17 0.08
8. The impact of pressure ulcers on a patient should not be exaggerated. 0.01 0.23 0.65 0.02 0.19
9. The financial impact of pressure ulcers on society should not be exaggerated. 0.06 0.16 0.64 0.01 0.01
10. I personally feel not responsible if a pressure ulcer develops in my patient. 0.09 0.05 0.03 0.86 0.08
11. I personally have an important task in pressure ulcer prevention. 0.18 0.29 0.11 0.69 0.11
12. Pressure ulcers are preventable in high risk patients. 0.03 0.05 0.01 0.08 0.78
13. Pressure ulcers are never preventable. 0.11 0.03 0.04 0.06 0.74
D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441 1437
are reliable and construct valid to be used to assess
attitudes towards pressure ulcer prevention.
The subscales and the items in the initial version of the
instrument were developed based on important issues
within pressure ulcer preventive care. All subscales
together represented what in this study was postulated
as attitudes towards pressure ulcer preventive care.
Content validity was achieved through literature review
Group N Mean score (max = 52) (SD) Significance
more positive attitude
more negative attitude
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Pressure ulcer nursesa (A) 48 30.6 (3.8) 27.4 (3.9) 4.6 139 <0.001 vs. bedside nursesb (B) 93 Pressure ulcer nursesa (A) 48 30.6 (3.8) 26.4 (3.0) 7.7 184 <0.001 vs. first year nursing students (B) 138 Infection control nursesc (A) 5 31.0 (4.1) 26.8 (4.1) 2.2 70 0.03 vs. MScN studentsd (B) 67 Third year nursing students (A) 95 27.8 (3.4) 26.4 (3.0) 3.3 231 0.001 vs. first year nursing students (B) 138 Third year nursing students (A) 95 27.8 (3.4) 26.3 (3.1) 2.8 151 0.005 vs. second year nursing students (B) 58 Second year nursing students (A) 58 26.3 (3.1) 26.4 (3.0) 0.3 194 0.74 vs. first year nursing students (B) 138 General nurses (A) 172 28.6 (4.0) 25.9 (3.9) 4.1 216 <0.001 vs. mental health nurses (B) 46 Bachelor degree (A) 383 28.3 (3.6) 26.9 (3.5) 4.1 531 <0.001 vs. undergraduate degree (B) 150 o Value independent sample t-test. oo Degrees of freedom. ooo P-value. a Pressure ulcer nurse, qualified nurse in The Netherlands, specialised in the prevention and treatment of pressure ulcers. b Bedside nurse, qualified nurse working on a hospital ward. c Infection control nurse, qualified nurse in Belgium with the specific task to identify and control infections that occur in the community or in a hospital setting. d MScN, qualified bachelor nurse studying to obtain a Master of Sciences in Nursing. Table 5 Final version of the Attitude towards Pressure ulcer Prevention instrument (APuP) (maximum score = 52). Strongly agree Agree Disagree Strongly disagree F1. Personal competency to prevent pressure ulcers (three items) (maximum score = 12) F1.1. (+)a I feel confident in my ability to prevent pressure ulcers. o oo o F1.2. (+)a I am well trained to prevent pressure ulcers. o oo o F1.3. () b Pressure ulcer prevention is too difficult. Others are better than I am. o oo o F2. Priority of pressure ulcer prevention (three items) (maximum score = 12) F2.1. () b Too much attention goes to the prevention of pressure ulcers. o oo o F2.2. () b Pressure ulcer prevention is not that important. o oo o F2.3. (+)a Pressure ulcer prevention should be a priority. o oo o F3. Impact of pressure ulcers (three items) (maximum score = 12) F3.1. () b A pressure ulcer almost never causes discomfort for a patient. o oo o F3.2. () b The financial impact of pressure ulcers on a patient should not be exaggerated. o oo o F3.3. (+)a The financial impact of pressure ulcers on society is high. o oo o F4. Responsibility in pressure ulcer prevention (two items) (maximum score = 8) F4.1. () b I am not responsible if a pressure ulcer develops in my patients. o oo o F4.2. (+)a I have an important task in pressure ulcer prevention. o oo o F5. Confidence in the effectiveness of prevention (two items) (maximum score = 8) F5.1. (+)a Pressure ulcers are preventable in high risk patients. o oo o F5.2. () b Pressure ulcers are almost never preventable. o oo o a Positively worded item. b Negatively worded item. 1438 D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441 and consultation with experienced pressure ulcer and psychometric validation experts. The content validity index fully achieved Lynn’s (1986) criterion for content validity. Additionally, based on the pilot study in five experts and five non-experts, the instrument was found to have an established content validity. Construct validity of the APuP was assessed in a factor analysis by using a principal component analysis. A principal component analysis was used because it is considered to be a well-suited approach to combine a large number of items into a few principal factors. In a factor analysis, principal component analysis is an easily understood and commonly used extraction technique. The Bartlett test of sphericity indicated that the correlations did not happen by chance and there was justification for the factor analysis. There was also an adequate sample for the factor analysis based on calculated KMO. After testing the instrument in a factor analysis, the number of subscales and items was reduced and the proportions of items within the subscales were changed. While modifying the instrument, attention was paid to the meaningfulness of the content of the total instrument and the subscales, as this also has an effect on instrument reliability. The five underlying factors showed a logical connection to the theoretical framework used during the design of the instrument. The range of items as defined in during the creation of the instrument allowed to test a diversity of models and to remove items if they were found to be weak and/or unrelated after factor analysis. All kinds of models, with different compositions/numbers of items, were tested. The composition of these models was primarily based on a meaningful content and theoretical sense. In the final model chosen, all included items (n = 13) possessed factor loadings over 0.6 and the five factors accounted for 61.4% of the variance in responses related to attitudes towards pressure ulcer prevention. The final model made good theoretical sense and contained fewer similar items than in the initial version. The ‘‘competence’’ subscale reflects the attitude towards the perceived own ability to provide adequate pressure ulcer preventive care. A competence is defined as the ability to perform a specific task, action or function successfully and is closely related to knowledge. In a recent study by Athlin et al. (2009), competences among healthcare personnel was described as an important factor to prevent pressure ulcers. The second subscale, ‘‘priority’’, deals with the importance given to pressure ulcer prevention in daily care. The importance to assess the priority of pressure ulcer prevention in care is supported in research by Gunningberg et al. (2001) and Moore and Price (2004). These authors stated that a majority of the nurses consider pressure ulcer prevention as being of low priority in their daily work. Also in a study by Buss et al. (2004), pressure ulcer prevention was found not to be a great issue in the daily work of nurses. If low priority is given to the prevention of pressure ulcers, it will be unlikely to expect good preventive care. The ‘‘impact’’ subscale reflects the perceived consequences of pressure ulcers on patients (discomfort and financial impact) and on society (financial impact). Evidence concerning the important impact of pressure ulcers on patients and society is provided by multiple researchers (Hopkins et al., 2006; Essex et al., 2009; Lardenoye et al., 2009; Gorecki et al., 2009). If pressure ulcers are considered as being of low impact, it will be unlikely to expect good preventive care. In the initial version of the instrument, the impact of pressure ulcers on patients and the impact on society were defined in two separate subscales. The factor analyses provided evidence that one subscale was able to explain this attitude. The ‘responsibility’ subscale is defined as the perception about who is responsible for pressure ulcer prevention. The nurse responsibility was stressed as an important factor in pressure ulcer preventive care by Athlin et al. (2009). The researchers claim that, although pressure ulcer care is often seen as a task of licensed practical nurses, the registered nurses should have the superior responsibility due to their higher level of education. This responsibility should concern prevention, risk assessment and the supervision of licensed practical nurses. Confidence in the effectiveness of prevention was defined as the final subscale. The attitude that pressure ulcer prevention is not effective might probably have an impact on the application of prevention. Buss et al. (2004) state that the use of preventive interventions in daily practice depends very much on the nurses’ conviction about the effectiveness of the intervention. This statement was supported in research by Halfens and Eggink, 1995. The more pressure ulcer prevention is valued, the greater the likelihood of preventative practices being carried out (Maylor and Torrance, 1999). The evidence to support construct validity, using the known-groups technique, was strong. The known-groups
method is a typical method to support construct validity and is provided when the instrument is able to discriminate between a group of individuals expected to have a particular trait and a group who do not have the trait. According to Polit and Beck (2007), this technique gives a good indication of what construct an instrument actually measures. In this study, data collection procedure was rigorously set up in different types of clinical and educational settings. Eight groups having a different expertise in pressure ulcer care were pre-defined and group scores were compared. The discriminant validity of the APuP was strongly supported by statistically signifi- cant mean differences among pressure ulcer experts and non-experts, suggesting its potential usefulness to track changes in attitudes across different clinical and educational settings in intervention outcome studies.Cronbachs a coefficients were calculated to assess the internal consistency of the instrument and its subscales. The study demonstrated acceptable to excellent internal consistency for both the total instrument and its subscales, with Cronbachs a ranging from 0.75 to 0.82. The intraclass correlation of the APuP reached the established recommendations, indicating that the scale can provide a reliable assessment for both group and individual measurements, comparisons, or both. The strength of the APuP to yield consistent responses on different rating moments, effectively demonstrates the ease of use and clinical usefulness of the instrument. D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441 1439 In contrast to the actual instruments, the APuP is able to offer a more comprehensive picture of the attitude towards pressure ulcer prevention. The instrument has several potential applications. This study attempted to construct a short instrument for use in clinical practice, education and research. Along with the ease of administration and scoring, the APuP can be included in any rapid survey for assessing attitudes towards pressure ulcer prevention and for evaluating efficacy of intervention programmes. The evaluation of interventions to improve attitudes is possible using this instrument in pretest–posttest setting or in randomised-controlled trials. The instrument can help to develop strategies for improving quality of pressure ulcer prevention by identifying priorities based on lowscoring subscales. Alternatively, this instrument can be used for individuals to determine an objective measure of personal attitude. Further research should include testing the instrument in different healthcare settings with varying characteristics in order to study predictive validity of the instrument and to explore the possible link between attitude, knowledge, and clinical performance. 6.1. Limitations A first limitation reflects on the use of a convenience sample. Besides, data on non-response were not collected. It is possible that potential participants who declined participation may be different from the study participants. This might limit the generalisability of the findings. Secondly, the fact that no more than three items were included in each subscale should be a point of special interest. Ideally more items should be added, especially to the subscales on ‘personal responsibility’, and ‘confidence in the effectiveness of prevention’. On the other hand, the development of a short instrument facilitates the ease of administration and contributes to the application in practice. 7. Conclusion The results of this study indicate that the Attitude towards Pressure ulcer Prevention instrument (APuP), as well as each subscale, can be considered a brief, conceptually sound, rigorously developed instrument with evidence supporting the psychometric properties. Conflicts of interest: None declared. Funding: None. 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