International Journal of Nursing Studies 47 (2010) 531533

Contents lists available at ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Editorial

Is pressure sore prevention a sensitive indicator of the quality of nursing

care? A cautionary note
Prevention of pressure ulcers is seen to be a key quality
indicator of nursing care and pressure ulcers are widely
supported as a nursing sensitive outcome (Van den Heede et
al., 2007). It has been suggested as a goal for nationwide
quality improvement (McGlynn et al., 2003), and is proposed
as an indicator in acute care by the US-based Hospital Quality
Alliance from 2010 and in Englands NHS (Grifths et al.,
2008) as well as in nursing homes (Nakrem et al., 2009).
Underpinning the belief that prevention of pressure ulcers is
a quality indicator is the belief that health providers have the
means and the tools to take effective action. Underlying this
is the assumption that risk assessment tools accurately
predict risk, that risk assessment is effective at reducing
pressure ulcer incidence and that strategies to escalate
management through increasingly complex pressure reduction devices will reduce risk. These processes are often
audited in order to determine the quality of care. Yet care
processes have not been found to discriminate between
institutions with high and low pressure ulcer prevalence
(Bates-Jensen et al., 2003). Examination of the evidence
reveals how precarious these assumptions are, starting with
the assumption that risk assessment tools are accurate.
1. Do risk assessment tools accurately predict risk?
Risk assessment tools are used to stratify patients likely
to develop pressure ulcers. However, pressure ulcer guidelines recommend risk assessment tools be used as an
adjunct to rather than a replacement of clinical judgement
(Royal College of Nursing, 2001), principally because the
tools cannot accurately and reliably predict patients at risk.
The chief factor underlying this performance failure is likely
to be that the tools are too simplistic (Papnikolaou et al.,
2007), although this simplicity is likely a reason for their
popularity in practice. The widely used Braden, Waterlow
and Norton scales are all tools that weight scoring
components equally, rather than weight the components
by the degree to which it contributes risk (Papnikolaou et al.,
2007). In addition, components of the scales are often
ambiguous, which impacts on the reliability and accuracy of
scores (Kottner et al., 2009a,b). Furthermore, some components require information, such as prior knowledge of the
0020-7489/$ see front matter 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2009.12.019

patients nutritional intake, that may not be available to the

assessor at the patients admission (Cook et al., 1999).
Consequently, predictive validity varies wildly. The Braden
scale the best researched tool has a positive predictive
validity of 2177% (Deoor and Grypdonck, 2004), while the
Norton scale varies from 9 to 83% (Deoor and Grypdonck,
2004) and the relatively untested Waterlow scale varies
from scale 5 to 7% (Rycroft-Malone and McInnes, 2000).
Admittedly, predictive validity may not be the best way
to evaluate the effectiveness of risk assessment tools
(Deoor and Grypdonck, 2004), as the patients in validity
studies are usually subject to pressure prevention strategies and so intrinsic risk is not being assessed. Predictive
validity cannot be properly determined when the probability of the outcome reduces as a result of the prediction.
This situation would be the case if risk assessment led to
effective preventative actions that reduce pressure ulcer
incidence, but is that really the case?
2. Does risk assessment using risk assessment tools
prevent pressure ulcer development?
Randomised trials of pressure prevention strategies are
the most reliable means of assessing their effectiveness, but a
Cochrane review found no randomised trials comparing a
risk assessment tool to no formal risk assessment or
comparing the performance of two tools (Moore and
Cowman, 2008). One trial not included by Moore and
Cowman did provide some tempting evidence that suggested
using a risk assessment tool does not reduce pressure ulcer
incidence (Vanderwee et al., 2007). Vanderwee and colleagues randomised 1617 participants in six hospitals in
Belgium covering 14 wards (surgery, general medicine and
geriatric wards) to a standard prevention strategy (Braden
score <17 or presence of non-blanching erythema (NBE)) or
to a more declarative strategy of awaiting the presence of NBE
alone. If patients scored <17 on the Braden scale or developed
NBE they were also randomly assigned to one of two types of
pressure reduction devices (alternating pressure mattress or
high specication foam constant pressure mattress) in
addition to a standardised pressure management protocol.
This approach meant that half the patients within each arm of

532

Editorial / International Journal of Nursing Studies 47 (2010) 531533

the trial were assigned to each mattress, thus ensuring no

difference in the proportions in each arm treated with each
mattress. Vanderwee et al. (2007) found no signicant
difference in the incidence of pressure ulcers (European
Pressure Ulcer Advisory Panel EPUAP grades 24) 53
participants (6.7%) in the standard strategy group and 56
participants (6.8%) in the NBE only group developed pressure
ulcers (absolute risk reduction 0.1%, 95%CI 2.5 to 2.4%).
The investigators did nd that the NBE-only approach was
associated with signicantly greater conversion to EPUAP
grade 3 or 4 ulcers, which does suggest a possible benet from
the use of risk assessment tools. However, the nding was
derived from a subgroup analysis. Such analyses can lead to
spurious inferences because of multiple signicance testing
and the implicit choices made as to which differences to test
(Oxman and Guyatt, 2002). Vanderwee and colleagues
reported 18 tests of signicance on their dataset. With a
1:20 chance of nding a signicant difference from chance
alone in each independent analysis there is no way of
properly determining from this study whether the signicant
result is a true result or a chance result. The probability of
nding a positive result by chance from 18 independent
analyses where there is no real difference is 60%. So what we
have is at best some suggestive evidence that is worthy of
further investigation in a properly designed trial. Unfortunately, it does not constitute denitive evidence.
Vanderwee and colleagues also found that the use of
pressure reduction devices in the standard approach was
double that of the NBE only strategy (31.9% vs. 15.5%,
absolute risk increase 16.2%, 95%CI 12.3 to 20.4%, number
needed to treat 6, 95%CI 5 to 8). These ndings suggest that
not only do risk assessment tools over-estimate risk, but also
they lead to much greater resource use no doubt at
considerable expense to health provider organisations,
given the substantial potential for overtreatment. A large
longitudinal study of ve acute care hospitals in the United
Kingdom followed 2507 patients in general medicine,
general surgery, orthopaedics, urology, coronary care, acute
care of the elderly, rehabilitation, and gynaecology for
29,611 patient-days between 1996 and 1998 (Clark et al.,
2002). Clark and colleagues found that overall 71% of the
patients were considered at some degree of risk using the
Waterlow scale; 29% were classied as at risk, 23% were
at high risk and 19% were at very high risk. These data
suggest that approximately three out of every four patients
admitted to a general hospital would need pressure ulcer
prevention strategies if just driven by scores from this risk
assessment tool, even though only 20% were dependent or
immobile. Assuming that the risk strata exist (even if the
numbers allocated to the strata are not accurate), the
challenge is how to best manage different levels of risk?
3. Do escalation strategies prevent pressure damage?
Escalation strategies increase the frequency, intensity or
complexity of interventions with increased levels of risk. For
example, a clinical guideline might advocate moving at risk
patients off standard mattresses and putting very high risk
patients on alternating pressure mattresses (Royal College of
Nursing, 2001). Moving patients off standard hospital
mattresses onto high specication foam mattresses may

reduce the relative risk of developing a pressure ulcer by

about 60% (RR 0.40, 95%CI 0.21 to 0.74) and similarly, moving
patients from standard mattresses to alternating pressure
mattresses may decrease the relative risk by about 70% (RR
0.31, 95%CI 0.17 to 0.58) (McInnes et al., 2008). However, in
the light of these small differences in estimates of effect it is
less clear whether alternating pressure mattresses are
superior to high specication foam mattresses. Alternating
pressure devices have been directly compared to foam
overlays, with no signicant difference between the two
types of device (McInnes et al., 2008), but the trials were small
and of poor quality. A large trial compared an alternating
pressure mattress with a high specication foam mattress
(Vanderwee et al., 2005) found no signicant difference in
incidence of EPUAP grade 2 or greater pressure ulcers (15.3%
vs. 15.6%, absolute risk increase 0.3%, 95%CI 6.5% to 6.9%).
Unfortunately the lack of a standard turning regimen on both
mattresses means the effect of the different mattresses
cannot be isolated and the equivalence in incidence rates may
be because of an interaction with turning regimen. However,
the trial probably modelled clinical practice, which is to
maintain a turning regimen on foam mattresses but not on
alternating pressure mattresses. In areas where this difference in regimens is practiced, it may not be necessary to use
alternating pressure mattresses where turning and high
specication foam mattresses can be used.
Like Vanderwee et al. (2007), the trial by Vanderwee et al.
(2005) is also suggestive. Health providers may be wasting
resource on the more expensive forms of pressure ulcer
prevention, especially considering that the cost of alternating pressure mattresses is far higher than high specication
foam mattresses or overlays (Nixon et al., 2006). However,
once again there is an absence of denitive evidence, and a
high quality trial is needed to address this gap in escalation
strategies. An effective and apparently simple alternative
escalation strategy is to increase the frequency of turning,
which is effective in reducing pressure ulcer incidence
(Deoor et al., 2005). However, the resource associated with
turning may pose a barrier to its effective use. On a 25 bed
general hospital ward, 18 patients would likely be at risk,
high risk or very high risk using the Waterlow score (Clark
et al., 2002), which would result in 216 turns per day on a two
hourly turning regimen. Data is very limited, but assuming a
range of 1015 min per turn (Hibbert et al., 1999; Jaichandar
et al., 2007), turning could require 3654 nursing hours per
day per ward if the Waterlow score was used to trigger
escalation. The resource required to maintain such regimens
may well be beyond the stafng capacity of wards.
4. Where to from here?
This brief overview of the evidence base makes it clear
that nursing should not uncritically assume that pressure
ulcer prevention is a measure of the quality of care or that
nursing quality can be easily determined by examining the
specic preventative care used. Although there is probably
sufcient evidence to give some condence that actions and
decisions typically within nurses sphere of responsibility
are likely to make a difference, there is not enough evidence
to be prescriptive about what precisely should be done
under what circumstances.

Editorial / International Journal of Nursing Studies 47 (2010) 531533

Firstly there is a paucity of cost effectiveness information,

which would help to determine the best way to deploy
limited nancial and human resources to maximise effect.
Secondly, there is a clear need for better assessment tools
that accurately predict risk in order to prevent overtreatment
since none of the existing ones seem adequate. Ideally, data
from an inception cohort without risk reduction strategies is
required to avoid the confounding effect of such strategies on
predictive accuracy. Use of these tools then need to be
evaluated in randomised trials against more declarative
strategies, such as awaiting the development of NBE before
initiating prevention strategies. However, the drive for
quality measurement may diminish the likelihood that
accurate tools can be developed, unless thoughtful research
designs that strategically address the broad evidence gaps
are funded. For instance, future trials testing existing risk
assessment tools against a declarative strategy could also use
the declarative arm as a validation cohort to develop better
risk assessment tools. Thirdly, there is an urgent need to
address the effectiveness of high specication foam mattresses in comparison to alternating pressure mattresses. If
the cheaper alternative is as effective, such evidence could
deliver welcome cost relief for health providers.
In our view, the incidence of pressure ulcers may well
be a valid nurse sensitive outcome, albeit one where the
amount of variation attributable to nursing is unclear.
There is potential to use it as a quality indicator but work
still needs to be done. Simple reporting of rates against a
denominator will not allow meaningful comparison or
benchmarking. Priorities for further research here include
the development of a parsimonious risk adjustment model
that will allow the comparison of different provider units
with different patient case mix (Grifths et al., 2008).
However, there is no clear basis for identifying any
particular care processes, for example the use of risk
assessment tools, as indicators of quality. Certainly it would
be wrong to effectively impose particular processes and
judge the quality of nursing care through nationally
collected and reported process indicators. Assessment in
itself does not result in better outcomes and there is scant
evidence that outcomes are improved by the use of a tool
even when risk as assessed by a tool is linked to intervention.
Further, the specic interventions that should result from an
assessment of risk (with or without the use of a tool) are
unclear. While there is some evidence to guide practice it
would be wrong to imply certainty of outcomes by selecting
care processes as indicators of quality. There is much work
still to be done.
Conict of interest
None.
References
Bates-Jensen, B.M., Cadogan, M., Osterweil, D., Levy-Storms, L., Jorge, J., AlSamarrai, N., Grbic, V., Schnelle, J.F., 2003. The minimum data set
pressure ulcer indicator: does it reect differences in care processes
related to pressure ulcer prevention and treatment in nursing homes?
Journal of the American Geriatrics Society 51, 12031212.
Clark, M., Benbow, M., Butcher, M., Gebhardt, K., Teasley, G., Zoller, J.,
2002. Collecting pressure ulcer prevention and management outcomes I. British Journal of Nursing 11 (4), 230238.

533

Cook, M., Hale, C., Watson, B., 1999. Interrater reliability and the assessment of pressure-sore risk using an adapted Waterlow Scale. Clinical
Effectiveness in Nursing 3, 6674.
Deoor, T., De Bacquer, D., Grypdonck, M., 2005. The effect of various
combinations of turning and pressure reducing devices on the incidence
of pressure ulcers. International Journal of Nursing Studies 42, 3746.
Deoor, T., Grypdonck, M.F.H., 2004. Validation of pressure ulcer risk assessment scales: a critique. Journal of Advanced Nursing 48 (6), 613621.
Grifths, P., Jones, S., Maben, J., Murrells, T., 2008. State of the Art Metrics
for Nursing: A Rapid Appraisal. Kings College London, London.
Hibbert, C.L., Edbrooke, D.L., Corcoran, M., Bright, N.N., Kingsley, J.N., 1999.
Cost considerations for the use of low-air-loss bed therapy in adult
intensive care. Intensive and Critical Care Nursing 15, 154162.
Jaichandar, K.S., Elara, M.R., Kumar, S., Chua, A., 2007. A semi autonomous
control and monitoring system for bed sores prevention. In: Proceedings of the 1st International Convention on Rehabilitation Engineering & Assistive Technology. ACM, Singapore, pp. 245248.
Kottner, J., Dassen, T., Tannen, A., 2009a. Inter- and intrarater reliability of
the Waterlow pressure sore risk scale: a systematic review. International Journal of Nursing Studies 46, 369379.
Kottner, J., Halfens, R., Dassen, T., 2009b. An interrater reliability study of
the assessment of pressure ulcer risk using the Braden scale and the
classication of pressure ulcers in a home care setting. International
Journal of Nursing Studies 46, 13071312.
McGlynn, E.A., Cassel, C.K., Leatherman, S.T., DeChristofaro, A., Smits, H.L.,
2003. Establishing national goals for quality improvement. Medical
Care 41 (Suppl. 1), I16I29.
McInnes, E., Cullum, N.A., Bell-Syer, S.E.M., Dumville, J.C., 2008. Support
surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews 2008 (4) (doi:001710.001002/14651858, Art. No.:
CD001735. CD14001735. pub14651853).
Moore, Z.E.H., Cowman, S., 2008. Risk assessment tools for the prevention
of pressure ulcers. Cochrane Database of Systematic Reviews 2008 (3)
(doi:006410.001002/14651858, Art. No.: CD006471. CD14006471.
pub14651852).
Nakrem, S., Vinsnes, A.G., Harkless, G.E., Paulsen, B., Seim, A., 2009.
Nursing sensitive quality indicators for nursing home care: international review of literature, policy and practice. International Journal
of Nursing Studies 46 (6), 848857.
Nixon, J., Cranny, G., Iglesias, C., Nelson, E.A., Hawkins, K., Phillips, A.,
Torgerson, D., Mason, S., Cullum, N., on behalf of PRESSURE Trial
Group, 2006. Randomised, controlled trial of alternating pressure
mattresses compared with alternating pressure overlays for the prevention of pressure ulcers: PRESSURE (pressure relieving support
surfaces) trial. BMJ 332, 14131416.
Oxman, A., Guyatt, G., 2002. When to believe a subgroup analysis. In:
Guyatt, G., Rennie, D. (Eds.), Users Guides to the Medical Literature.
AMA Press, USA.
Papnikolaou, P., Lyne, P., Anthony, D., 2007. Risk assessment scales for
pressure ulcers: a methodological review. International Journal of
Nursing Studies 44, 285296.
Royal College of Nursing, 2001. Pressure Ulcer Risk Assessment and
Prevention. Royal College of Nursing, London.
Rycroft-Malone, J., McInnes, E., 2000. Pressure Ulcer Risk Assessment and
Prevention. Technical Report. Royal College of Nursing, London.
Van den Heede, K., Clarke, S.P., Sermeus, W., Vleugels, A., Aiken, L.H., 2007.
International experts perspectives on the state of the nurse stafng
and patient outcomes literature. Journal of Nursing Scholarship 39
(4), 290297.
Vanderwee, K., Grypdonck, M., Deoor, T., 2005. Effectiveness of alternating pressure air mattress for prevention of pressure ulcers. Age &
Ageing 34, 261267.
Vanderwee, K., Grypdonck, M., Deoor, T., 2007. Non-blanchable erythema
as an indicator for the need for pressure ulcer prevention: a randomized-controlled trial. Journal of Clinical Nursing 16, 325335.

Andrew Jull*
School of Nursing, University of Auckland, New Zealand
Peter Grifths
National Nursing Research Unit, United Kingdom
*Corresponding author
E-mail address: [email protected]

23 December 2009