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Tidskrift: International Journal of Nursing Studies
Running title
Factors contributing to evidence-based pressure ulcer prevention. A crosssectional study in two hospitals
Eva Sving RN1,2,3, Ewa Idvall, Professor, PhD4 , Hans Högberg, Statistician, PhD2,5, Lena
Gunningberg, Associate Professor, PhD3,6
Clinical Training Centre, County Council of Gävleborg, Sweden
1.Centre for Research & Development, Uppsala University/County Council of Gävleborg
2.Department of Public Health and Caring Sciences, Caring Sciences, Uppsala University,
Sweden
3.Faculty of Health and Society, Malmö University and Skåne University Hospital,
Malmö, Sweden
4.Department of Public Health Medicine, County Council of Gävleborg, Gävle, Sweden
5.School of Nursing, University of California San Francisco, US
Abstract
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Background: There is a need for more knowledge about what contributes to evidence-based
pressure ulcer prevention care.
Objectives: To investigate whether patient characteristics, hospital context, nurse staffing
and workload could predict whether patients received risk assessment, skin assessment and
pressure ulcer prevention in two Swedish hospitals.
Design: A cross-sectional study.
Settings: One university hospital and one general hospital.
Participants: Geriatric (n=8), medical (n=24) and surgical (n=19) units. Intensive care units
(n=6) were excluded. All adult patients (> 17 years), in total 825, were included.
Methods: A one-day prevalence study was conducted using the methodology outlined by the
European Pressure Ulcer Advisory Panel, together with the methodology outlined by the
Collaborative Alliance for Nursing Outcomes. Outcome variables were risk and skin
assessment within 24 hours of admission, pressure-reducing mattresses and planned
repositioning. Predictor variables were patient characteristics, hospital context, nurse staffing
and workload. The data were analysed using binary logistic regression modelling.
Results: The outcome variables risk and skin assessment were more likely to be performed on
older patients (p = 0.006, p < 0.001), at the university hospital (p ? ) and at medical units (p =
0.006). Risk assessments were more likely to be performed on units with lower workloads (p
< 0.001). The outcome variable pressure-reducing mattresses was more likely to be used for
patients with more days of hospitalization (p < 0.001), patients with a higher risk for
developing pressure ulcers (p = 0.008), at the university hospital (p?) and geriatric units (p =
0.014), and on units with lower total hours of care (p 0.003). The outcome variable planned
repositioning was more likely to be performed for patients at risk for developing pressure
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ulcers (p < 0.001), at the general hospital (p = 0.005), at medical units (p = 0.007) and on
units with higher total hours of care (p = 0.024).
Conclusion: The preformed pressure ulcer prevention was not evidence based. Quality
improvement work at the university hospital might have contributed to the higher degree of
evidence-based care there. Surprisingly, nurse staffing and workload played a minor role.
Keywords
Pressure ulcer prevention, nurse staffing, workload, hospital context, patient characteristic,
predictors.
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Running title
Factors contributing to evidence-based pressure ulcer prevention. A crosssectional study in two hospitals
Background
Pressure ulcers are related to reduced quality of life for the patient [1] and high costs for the
healthcare system [2]. Evidenced-based international guidelines built on current research are
available to health care professionals. However, studies show that pressure ulcer prevention is
lacking [3, 4]. Although pressure ulcers are considered adverse events in healthcare, the
problem remains. In European studies, the reported prevalence of pressure ulcers varies
between 9 and 18 % [5-7].
The main patient-related risk factors are activity and mobility problems due to the risk of
pressure and/or shear on the skin. Early risk assessment including use of a combination of a
validated risk assessment instrument, skin assessment and clinical judgment is crucial [8].
When a patient is at risk for developing pressure ulcers, the multidisciplinary team should
establish goals and a prevention plan together with the patient, and evaluate these regularly.
Higher specification foam mattresses are recommended for all risk patients, according to a
Cochrane review [9]. There is insufficient evidence for determining the frequency with which
patients should be repositioned [8]. Defloor et al. [10] reported that patients on pressurereducing mattresses need less repositioning compared to patients on standard mattress.
Studies have also revealed that when guidelines are implemented, the prevalence of pressure
ulcers decreases [11, 12].
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Different factors in the healthcare organization have been examined in an attempt to
understand how they affect pressure ulcer prevention. Examples are hospital organization,
nurse staffing, workload and factors in direct patient care. The results are not clearcut.
Hospital context has been examined by Estabrook [13], who reported that the only significant
factor for higher levels of application of research findings in clinical practice was hospital size
(a proxy for university hospital). On the other hand, Brown et al. [14] concluded that hospital
size did not matter when nurse-sensitive care outcomes were studied. Nurse staffing is another
aspect that can affect patient safety and pressure ulcer prevention. In some studies, a lower
number of registered nurses has been associated with poorer patient outcomes [15, 16]. A
high number of patients assigned to a nurse was correlated with more perceived pressure ulcer
events [17], but no such relationship was found in another study [18]. When workload was
higher and registered nurses felt pressed for time, the prevalence of pressure ulcers increased
[19].
The Collaborative Alliance for Nursing Outcomes (CALNOC) is a nursing-sensitive
benchmarking registry, including five states in the United States (U.S.) [20]. CALNOC
combines nurse staffing and workload with patient outcomes, e.g. pressure ulcers. A
benchmarking research project related to pressure ulcer prevention was initiated in 2009 by
CALNOC and two hospitals in Sweden. The findings revealed a higher prevalence of
hospital-acquired pressure ulcer prevalence (Category 1-4) in the two Swedish hospitals (7 14 %) than in the U.S. hospitals (2.0%). Risk and skin assessment were part of routine care in
the U.S. The university hospital in Sweden performed more risk assessment (60 %) compared
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to the general hospital (6 %). Furthermore, the total number of nursing hours per patient day
was higher in the U.S. hospitals, which also had a higher proportion of registered nurses [21].
The healthcare system is a complex organization, which needs to cooperate on different levels
to prevent adverse events, such as pressure ulcers. There are many factors that contribute to
the development of pressure ulcers, e.g. patient-related risk factors, performed prevention care
and factors in the health care organization. In previous studies, these factors have primarily
been investigated separately. Simultaneous testing of the effects of variables could be
explained in light of their relationships to each other. Therefore, we wished to analyse the
combined effect of different factors using data from the two Swedish hospitals [21, 22]. The
aim of the study was to investigate whether patient characteristics, hospital context, nurse
staffing and workload could predict whether patients received risk assessment, skin
assessment and pressure ulcer prevention in two Swedish hospitals.
Method
Design
A cross-sectional study design was used. Clinical data (pressure ulcer prevention and
pressure ulcer prevalence) were collected during one day, September 30, 2009, and data on
nurse staffing and workload were collected for one month, September 2009 [22].
Settings
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The study was conducted in one university hospital (1100 beds) and one general hospital (350
beds) in two County Councils in Sweden. The university hospital had developed a hospitalwide quality improvement plan related to pressure ulcers consisting of education,
development of clinical guidelines, documentation and pressure ulcers as a quality indicator.
For example, an education programme, seminars for registered nurses and assistant nurses,
and a network for pressure ulcer nurses were established. Multidisciplinary clinical guidelines
were developed. Templates for risk assessment, pressure ulcer classification and standard care
plans were integrated into the Electronic Health Record. Prevalence surveys were conducted
regularly and repeated with fast feedback of results to the units [23]. Finally, pressure ulcer
prevalence was established as a quality indicator at the hospital level.
The general hospital had not worked systematically at the hospital level with quality
improvement related to pressure ulcers and conducted its first pressure ulcer prevalence
survey in 2009.
Participants
The study included participants from 44 units in the two hospitals: geriatric (n=8), medical
(n=24) and surgical (n=19). All adult patients (> 17 years), in total 825, admitted to those
units before midnight the day of the study were included. Intensive care units (n=6) were
excluded due to the different nursing care needs and nurse staffing levels.
Variables
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Outcome variables were documentation of 1) risk assessment and 2) skin assessment within
24 hours of admission, the use of 3) pressure-reducing mattresses, and 4) planned
repositioning in bed.
Predictor variables were age, gender, days of hospitalization, risk score (Braden <17) on the
day of survey, hospital type (university and general hospital), unit type (geriatric, medical and
surgical), nurse staffing (total hours of care per patient day, percent of care provided by
registered nurses) and percent patient turnover per patient day. Patients’ pressure ulcer risk on
the day of survey was assessed using the Braden scale, which consists of six subscales, i.e.
sensory perception, activity, nutrition, moisture, shear and friction, and has demonstrated
well-established validity and reliability [24]. Data collection sources, variables, and
definitions are presented in Table 1.
Pressure ulcer status was classified using four categories, where Category 1 is intact skin with
non-blanchable redness and Category 4 is full thickness tissue loss with exposed bone, tendon
or muscle [8]. If there was no documentation of an existing pressure ulcer in the patient’s
records within 24 hours of admission, the ulcer was identified as a hospital-acquired pressure
ulcer [25].
Data collection
Procedure
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The procedure followed the methodology outlined by the European Pressure Ulcer Advisory
Panel [26] and the Collaborative Alliance for Nursing Outcomes [25].
Prior to the study, the data collectors (registered nurses) participated in a half-day seminar;
they were presented information on study procedures and data collection with a specific focus
on the clinical assessment of patients. The registered nurses also completed a 1-hour elearning session that included training of classification of pressure ulcers and differentiation
from moisture lesions [22]. The feasibility of identifying variables from the Electronic Health
Record was pilot tested, and it was confirmed that accurate data could be obtained.
On the day of data collection, a team consisting of two registered nurses (one staff nurse and
one nurse from a different unit) visited each patient and gathered the clinical data. Afterwards,
a retrospective audit of the electronic health records was conducted.
Nurse staffing and workload variables were gathered on the unit level and were extracted
from the computerized patient and staff administration system for September 2009 (Table 1).
Data analysis
For descriptive purposes, frequency, mean, standard deviation (SD), median, interquartile
range (IQR) and percentage data were used. Binary logistic regression modelling was
conducted to examine the relation between outcome and predictor variables. To investigate
the simultaneous effect of the included predictor variables, multiple logistic regression models
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were used with all the predictor variables included simultaneously for each of the four
outcome variables. The results of the multiple logistic regressions were presented as odds
ratios (OR), 95% confidence intervals (CI) and p-values of the Wald tests of the null
hypothesis of odds ratios equal to one. Odds ratios should be interpreted as the change in the
ratio of getting preventive care to not getting preventive care, comparing two patients with a
one-unit change in a predictor variable, keeping the other predictor variables constant. Model
adequacy was tested using the likelihood ratio test (LR-test), comparing the specific model to
a null model, i.e. testing the simultaneous significance of the coefficients. Moreover, the
Hosmer-Lemeshow test (H-L test) was used to test the goodness-of-fit of the models. Results
were considered statistically significant when the p-value was less than 0.05. All tests were
two-tailed. Data were analysed using the statistical software package SPSS 19.0.
Ethical considerations
The study was approved by the hospital directors. It followed the principles of the Declaration
of Helsinki and the national and local ethical guidelines for research [27]. The patients
received verbal and written information about the study and gave their verbal consent; if
necessary relatives were consulted. The patients were informed that they were free to
withdraw at any time. All data were treated confidentially.
Results
The total sample consisted of 825 patients with a mean age of 68.4 years and a mean length of
stay prior to the survey day of 14.7 days. The gender distribution was almost equal. Seventeen
percent of patients were assessed as being at risk for developing pressure ulcers (Braden
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score<17). The prevalence of hospital-acquired pressure ulcers was 12.6 % (Category 1-4)
and 4.7 % when Category 1 was excluded. The median value of total hours of care at the two
hospitals was 8.0, and the median value of percent of total hours of care by registered nurses
was 56.3. Percept patient turnover per patient day had a median value of 40.3. Almost 75 %
of patients were admitted to the university hospital. Surgical and medical units had 40 % of
the patients each (Table 2).
Pressure ulcer prevention was performed for 44.1-58.7 % of the patients at risk for developing
a pressure ulcer (Braden score <17). Planned repositioning was the outcome variable
performed least often. Data on risk and skin assessment and pressure ulcer prevention are
presented in Table 3. The results from the multivariate binary logistic regression models are
presented in Table 4 and below.
Risk assessment
Patient age, hospital context and workload were statistically significant predictors of risk
assessment. Older patients were more likely to be risk assessed. Moreover, patients at the
university hospital and patients on medical units had higher odds of being risk assessed. When
the workload was lower, it was more likely for patients to be risk assessed.
Skin assessment
Patient age, patients’ risk scores (Braden <17), and hospital context were significant
predictors of performed skin assessment. Skin assessment was more likely to be performed on
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older patients and patients scoring Braden <17. Patients at the university hospital had higher
odds and were thus more likely to be risk assessed than those at the general hospital. It was
more likely for the patients at a medical unit to be risk assessed than those at geriatric and
surgical units.
Pressure-Reducing mattresses
Significant predictors for pressure-reducing mattresses were days of hospitalization, patients’
risk scores (Braden <17), hospital context and total hours of care per patient day. Patients
with more days of hospitalization prior to the day of survey and patients at risk for developing
pressure ulcers (Braden score < 17) were more likely to have pressure-reducing mattresses.
Patients at the university hospital and patients at geriatric units were more likely to have a
pressure-reducing mattress. When total hours of care were lower, it was more likely that
pressure-reducing mattresses were used.
Planned repositioning in bed
Significant predictors of planned repositioning were patients’ risk scores (Braden <17),
hospital context and total hours of care per patient day. Patients with assessed risk for
developing pressure ulcers had the highest odds ratio of receiving planned prepositioning
relative to patients with no risk for developing pressure ulcers. Patients at the general hospital
were more likely to have planned repositioning than those at the university hospital. This
result was in contrast to results for the other outcome variables. Patients at medical units were
more likely to have planned repositioning. Patients at a unit with higher total hours of care
were also more likely to have planned repositioning.
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For all four models, the LR-test indicates that the specified models were significant, i.e. the
models with at least one of the included variables were significantly better than models with
only a constant term. Considering the outcome of the Hosmer-Lemeshow test, the first model
showed a significant lack of fit, while the other three models seemed to fit well (p-values <
0.05).
Discussion
The present study combined patient characteristics, hospital context, nurse staffing and
workload in regression models to identify predictors of risk and skin assessment, use of
pressure-reducing mattresses and planned repositioning. The results show that the statistically
significant predictors varied between the four outcomes variables.
Predictors of prevention care related to patient characteristics were high age and risk score
(Braden < 17). However, only 44-47% of patients at risk for developing pressure ulcers
received pressure-reducing mattresses and planned repositioning. Insufficient pressure ulcer
prevention has also been shown in other studies [4, 11]. It is possible that registered nurses
use their own clinical judgment when deciding on prevention care. Fossum et al. [28] found
that registered nurses bypass data collection, i.e. going immediately to planning care without
analysing assessment data. A routine for structured risk and skin assessment is important, as
prevention should be based on each patient’s individual needs. The staff (physicians, nurses,
physical therapists and occupational therapists) need to know what, when and how pressure
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ulcer prevention should be performed, both in general on the units but also to address each
patient’s needs.
Hospital context was a predictor for all four outcome variables. Patients at the large university
hospital were more likely to be risk and skin assessed and to have pressure-reducing
mattresses. This finding confirms results reported by Estabrooks et al. [13], who found that
the only significant hospital characteristics associated with higher levels of application of
research findings in clinical practice was hospital size. The quality improvement work
performed in the large university hospital for several years, including prevalence surveys,
could be one explanation for the differences [23]. Lahmann et al. [11] showed that repeated
participation in pressure ulcer surveys reduced pressure ulcer prevalence and increased use of
guidelines, including preventive measures and devices. Furthermore, in the present study,
patients admitted to medical units were more likely to have planned repositioning. Differences
between units in the performance of pressure ulcer prevention were also found in a study in
Belgium [4]. Patients at risk for pressure ulcers are admitted to all kinds of units. Therefore,
staff in all units must have knowledge and skills, as well as routines for pressure ulcer
prevention. Today in Sweden, there is a national focus on patient safety and quality
improvements regarding pressure ulcer prevention. The first national pressure ulcer
prevalence survey was conducted in 2011, and more than 35,000 persons participated
(Gunningberg et al. 2012, in press).
Nurse staffing did not prove to be as important as hospital context in predicting prevention
care. Total hours of care were also not a significant predictor of risk and skin assessment.
Furthermore, percent of care provided by registered nurses was not a significant predictor in
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any of the four outcome variables. These findings were surprising, as registered nurses often
argue that low staffing levels are an explanation for insufficient nursing care. Registered
nurses should assume responsibility for risk and skin assessment, establishment of patient care
plans, interventions, nursing documentation and evaluation of the nursing care provided. A
study performed in Sweden shows the opposite, i.e., that registered nurses trusted and
delegated tasks to assistant nurses [29]. Bååth et al. (2012 in press) stated that both registered
nurses and assistant nurses perform skin assessment, and that there seems to be no established
boundaries as to who performs the assessment or in what way it is performed. Several studies
have shown that registered nurses in Sweden do not prioritize pressure ulcer prevention [2931], and Athlin et al. [30] pointed out the need to increase the perceived value of such
prevention. Positive attitudes towards pressure ulcer prevention have been shown to be more
important than knowledge of performed prevention [6]. In the benchmarking research project
carried out collaboratively in Sweden and the U.S., almost 100 % of U.S. patients were risk
assessed within 24 hours of admission [21] and care plans were in place for risk patients,
illustrating that it is possible to achieve such goals. Furthermore, it is important to have the
optimal total hours of care and percent of care provided by registered nurses. The present
results show that with a higher total number of hours of care, planned repositioning was more
likely to be performed. Planned repositioning is time-consuming compared to the use of
pressure-reducing mattresses, thus the result may indicate lack of time. It is important to
understand that immobilized patients at risk for developing pressure ulcers need both
pressure-reducing mattresses and planned repositioning. Twiggs et al. [32] examined a nurse
staffing method based on individual assessment of each unit to determine staffing
requirements, rather than a “one-size-fits-all” approach, and found that it significantly
decreased pressure ulcer prevalence at the hospital level. However, a study performed by
Aiken et al. [33] revealed that lowering the patient-to-nurse ratio markedly improves patient
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outcomes in hospitals with good work environments, slightly improves outcomes in hospitals
with average environments, and has no effect in hospitals with poor environments.
In our study, patient turnover was the definition of workload and a significant predictor of
one of the outcome variables: risk assessments. Units with high patient turnover can be
expected to be characterized by lack of time and patients less likely to be risk assessed.
Registered nurses’ time for pressure ulcer prevention may be lower on units with a high
turnover, as other problems and patient needs are prioritized. Even if the patient is on the unit
only a short time, risk assessment has to be performed. Development of a pressure ulcer can
occur quickly and an early risk assessment is recommended within 24 hours of admission [8].
The other three outcome variables were not predictors of workload. Perhaps these variables
are more sensitive to other factors contributing to workload, such as organizational factors,
availability or leadership [34].
In the present study, we have tested factors from three different levels in the healthcare
organization simultaneously, as it is important to understand how the parts of this complex
system are linked together. These levels must be organized in ways that support patients’
journey through the system [35]. If such an organization can be achieved, evidence-based
pressure ulcer prevention will be possible.
Method discussion
The present study employed a cross-sectional design, which is appropriate for describing the
status of phenomena and for describing relationships among phenomena [36]. A cross-
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sectional design provides a “snapshot" of the prevalence of a phenomenon at a particular point
in time and can be used to describe characteristics that exist in a population.
To succeed in benchmarking quality indicators in different countries, it is crucial that the
same methodology be used. The pressure ulcer prevalence methodology employed here is
used in many countries in Europe and similar methodologies are used around the globe [26].
The data on clinical observations were based on examination of patients by two registered
nurses on each ward, who were trained specifically for this task, which increased the
reliability of the observations.
Nurse staffing and workload were defined according to the Collaborative Alliance for Nursing
Outcomes. The Swedish investigators worked closely with CALNOC leaders to adhere to the
methodology as closely as possible.
The logic underlying logistic regression models intended to evaluate predictors of outcomes is
that the event used for prediction must precede the outcome, which was the case for all
variables except risk assessment with the Braden scale and the outcomes risk and skin
assessment within 24 hours of admission. However, in our judgment, this has only had a
minor impact on our results.
For the regression model for risk assessment showed a significant the Hosmer-Lemeshow test
showed a significant lack of fit. That means that there were significant differences between
individual observed and predicted outcomes according to the model. In the present study, we
used predictors previously found to have an effect on the care provided. The aim was to test
whether these predictors were useful in predicting whether patients received risk and skin
assessment, as well as pressure ulcer prevention. One reason for the lack of fit could be that
the set of predictors was not optimal, i.e. that some of the predictors should be removed or
some other unknown predictors should enter the model. Another reason could be that some of
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the included patients had extreme response patterns that had a considerable impact on the lack
of fit. It was not, however, within the scope of the present study to identify the best model.
Thus, the result of the model for risk assessment must be regarded with some caution.
Conclusion
Statistically significant predictors were patients’ age and risk score, but pressure ulcer
prevention was lacking, thus the care was not evidence-based. Hospital context was
statistically significant in relation to all four outcome variables. Quality improvement work in
the university hospital might have contributed to the higher degree of evidence-based care
there. Surprisingly, nurse staffing and workload played a minor role. One explanation could
be insufficient routines on the units. Leaders in the healthcare organization should be
accountable for establishing routines that support evidence-based care, while registered nurses
should be accountable for the organization of bedside care.
What we already know

Pressure ulcer prevention remains a problem in health care.

Pressure ulcer prevention is lacking for patients with a high risk for developing
pressure ulcers.
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What is new

Factors on different levels in the healthcare organization were examined to
determine which of them contribute to evidence-based pressure ulcer prevention in
hospital settings.

Quality improvement work and routines in the healthcare organization seem to be
more important factors than nurse staffing and workload.
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