Running head: PRESSURE INJURY PREVENTION

Pressure Injury Prevention in the Inpatient Setting
Jonathan Holloway, BSN, RN
Mentor: Judith Ochieng, PhD, DNP, MSN-ED, RN, FNP-BC
Arizona State University

1

PRESSURE INJURY PREVENTION

2
Abstract

Background: Pressure injuries inflict a major, preventable burden onto hospital systems,
healthcare providers, and patients. The purpose of this evidence based project was to evaluate the
impact of a pressure injury prevention education program on nursing staff knowledge and
pressure injury rates in an Arizona post-cardiac care unit.
Method: A single group pre-test post-test design was utilized to evaluate nursing staff knowledge
before and after an education program on pressure injury prevention. Staff knowledge was
evaluated using a modified version of the Pressure Ulcer Knowledge Assessment Tool 2.0.
Participants completed pre- and post-education surveys. Rates of hospital acquired pressure
injuries were obtained via chart review.
Results: Pre- and post-education scores were analyzed in participants who completed both
surveys using a paired t-test. Post-education scores (M = 0.73, SD = 0.07) were significantly
higher than pre-education scores (M = 0.59, SD = 0.09); t(7) = -5.39, p = .001. Pre- and posteducation median scores of all participants were analyzed using two-tailed Mann-Whitney U
test. Post-education scores (Mdn = 0.71) were significantly higher compared to pre-education
scores (Mdn = 0.56); U = 102.5, z = -4.05, p = .001. Monthly incidence of pressure injuries on
the unit increased following education.
Discussion: Increase in scores from pre- to post-education surveys indicate staff knowledge
improved. The increased incidence of pressure injuries is thought to be secondary to staff’s
increased ability to detect pressure injuries. Staff education is recommended, but more research
is needed regarding the impact on pressure injury rates.
Keywords: Pressure injury, pressure injury prevention, pressure injury education,
pressure injury prevention program, nursing knowledge.

PRESSURE INJURY PREVENTION

3

Pressure Injury Prevention Programs in the Inpatient Setting
The Problem
Hospital Acquired Pressure Injuries (HAPI)s are a major burden for nurses, hospitals,
insurance agencies, and patients alike. Since the development of the Center for Medicare and
Medicaid’s (CMS) hospital-acquired conditions policy in 2008, CMS no longer reimburses
hospitals for most pressure injuries not documented at the time of admission (Center for
Medicare and Medicaid Services [CMS], 2018). The purpose of this policy was to push hospital
systems to develop new ways to prevent these kinds of injuries (CMS, 2018). Pressure injuries
(PI) occur in the hospital setting as a result of intense, prolonged pressure which is sometimes in
combination with shear forces. The pressure tolerance of soft tissue is affected by multiple
factors including microclimate, nutrition, perfusion, and patient comorbidities. This tissue
damage can appear as many different stages of tissue injury ranging from erythematous nonblanchable skin to open wounds with exposed bone (NPUAP, 2016).
In 2016, the National Pressure Ulcer Advisory Panel (NPUAP) held a consensus
conference where the term “pressure ulcer” was replaced with “pressure injury” in an attempt to
help healthcare workers more clearly understand this type of wound. The NPUAP went on
further to define a PI as, “localized damage to the skin and underlying soft tissue usually over a
bony prominence or related to a medical or other device” with or without shear (NPUAP, 2016).
Most research shows that the true cost of HAPI is not clear. This is due to variances in
how prior studies, as well as hospital systems, looked at bill and coding. These differences make
for poor comparisons when trying to analyze the real cost of these injuries (Chan et al., 2017;
Padula & Delarmente, 2019). Though the data is not clear, it is projected that PIs cost are much
higher than previously expressed in data (Chan et al., 2017).

PRESSURE INJURY PREVENTION
HAPIs have a significant impact on the health and wellbeing of patients. HAPIs lead to
both physical and emotional distress for patients while also increasing patient’s length of stay,
cost of care, and readmission rates (Dreyfus, Gayle, Trueman, Delhougne, & Siddiqui, 2018).
Nursing staff’s knowledge is an important aspect in both the prevention of HAPIs and in
ensuring appropriate care of patients (Barakat-Johnson, Lai, Wand, & White, 2018). Research
has shown that, nursing knowledge is often limited regarding HAPIs (Dalvand, Ebadi, &
Gheshlagh, 2018).
Purpose and Rationale
Starting with the decision by the Center for Medicare and Medicaid Services in 2008 to
stop payment for hospital acquired pressure injuries (CMS, 2018), there has been a push to
decrease the number of HAPIs in the United States. With this change, hospitals and other health
care organizations have had more incentive to develop programs and implement preventive
measures to stop the formation of HAPIs in their patients. Healthy people 2020 is one such
organization. Healthy people 2020 has set a goal to lower PI related hospitalizations among the
elderly by 10% or more by the end of 2020 (U.S. Department of Health and Human Services,
Office of Disease Prevention and Health Promotion, 2020). Achieving this goal not only serves
to decrease unnecessary costs and expenses for each hospital system, but also improves patient
safety and satisfaction. Patients who are PI free spend less time in the hospital and suffer from
less pain, injury, and death than those who develop HAPIs during their hospital stay (Bauer,
Rock, Nazzal, Jones, & Qu, 2016).
The purpose of this evidence based project is to address barriers to prevention,
management, and care related to the development of HAPIs. This will be accomplished by
evaluation of staff knowledge and its impact on these barriers. This project will also explore the

4

PRESSURE INJURY PREVENTION

5

known evidence-based practice options to decrease pressure injuries in the inpatient hospital
setting as they relate to staff knowledge.
Epidemiological Significance
In 2014, PI wounds in the Medicare population was around 2.5% with an assumed
Medicare cost per wound between $3,696 to $21,060 US dollars (Nussbaum et al., 2018). These
wounds have the potential to become non-healing chronic wounds that can lead to the
amputation of limbs or even death (Nussbaum et al., 2018). Research supports the fact the most
PIs are preventable with one such recent Swedish study determining that about 91% of PIs in the
hospital setting are likely preventable (Gunningberg, et al., 2019). The impact of these wounds
and their general preventability have been a significant oversight in the health care system today.
The real cost of PIs is unclear. Most modern research shows a limited understanding of
the total cost of HAPIs in the United States (Chan et al., 2017; Padula & Delarmente, 2019).
Systematic reviews have found that the cost of a PI is often skewed due to much of the research
on the subject not clearly outlining coding standards. This leads to poor comparison of studies
and unclear final costs of these injuries. Regardless, the cost of these chronic ulcers are likely
substantial (Chan et al., 2017). This unknown cost has been found throughout other research
studies (Padula, & Delarmente, 2019). Medicare costs due to wound care are likely far greater
than what was thought in the past, given that most studies previously done have failed to
evaluate the impact that loss of work or other social dynamics had on patients (Padula, &
Delarmente, 2019). Cost simulations suggest that the cost of PIs in the United States exceeds
26.8 billion dollars per year (Padula & Delarmente, 2019). This equates to a 10 billion dollar
increase in the total cost of PI over the last ten years (Padula & Delarmente, 2019).

PRESSURE INJURY PREVENTION

6

HAPIs result in longer healing times, extended hospital stays, loss of limbs, and increased
risk of death. All of this has an impact. The impact on patients, families, hospitals, staff
members, taxpayers, and insurers leads to unnecessary stress for all parties involved (Bauer et
al., 2016). Mortality rates for hospitalized patients with pressure injuries are 9.1% compared to
1.8% for patients without pressure injuries (Bauer et al., 2016). The patient’s quality of life is
drastically impacted when they have a chronic PI. The patient’s physical, mental and social
wellbeing are often times negatively affected (Jackson, et al., 2018).
There are multiple modalities that can be implemented to prevent HAPIs from developing
or worsening. One international systemic review and meta-analysis covering eight different
countries evaluated the knowledge level of nurses, nursing students, and nursing assistants on
care measures to prevent the formation of HAPIs (Dalvand et al., 2018). A knowledge deficit
was identified in all three groups regarding pressure injury prevention. The study found that
pressure injury prevention knowledge was below the recommended 60% acceptable cut off score
for all three groups (Dalvand et al., 2018). Moreover, knowledge regarding preventative
measures for pressure injuries was the lowest score for all three groups (Dalvand et al., 2018).
Multiple sources report that since the CMS change in insurance reimbursement, many
hospitals have sought to implement changes to decrease HAPIs with variable success in their
long-term sustainability (Padula et al., 2016; Dreyfus, et al., 2018). Pressure Injury prevention
programs (PIPP) have been a fundamental tool in the prevention of HAPIs in these systems (Lin,
Wu, Song, Coyer, & Chaboyer, 2019). PIPP can have several different educational and
knowledge improvement components to include e-learning modules, booklets, videos,
conferences or meetings, and posters (Lin, et al., 2019; Cowan, et al., 2018). All of these
educational modalities seek to improve nursing staff knowledge. another technique for

PRESSURE INJURY PREVENTION

7

prevention programs includes consult driven huddles as a popular choice of hospital quality
improvement project (Padula et al., 2015). These huddles have been found to be extremely
effective when utilizing wound care staff or management (Lin et al., 2019). One large scale study
involving nursing staff working in the Department of Veteran Affairs hospital system found that
education delivered in shorter segments over a larger period of time was superior compared to a
single longer education period (Cowan, et al., 2018). Literature supports different modalities of
education in the prevention of PI. PIPP that are tailored to the needs of hospital systems may be a
viable prevention and evidence-based improvement project.
Internal Evidence
Data gathered from a Southern Arizona non-profit government hospital system from 2017
to late 2018 regarding HAPIs showed a total decrease of HAPIs between the two years from 113
to 88. However, it is noted that several floors in the hospital had marked increases in their total
number, with an orthopedic floor having a 33% increase and a medical-surgical floor with a 600%
increase in HAPIs. Both floors have gone through major staff changes in leadership, nursing staff
turnover, and acquisition of new nurses. It is likely that these floors are suffering the same
difficulties as stated in the above background assessment. The Wound care team associated with
the hospital system is looking into an education system that is lightweight and possible transferable
to other sections of the hospital that may improve staff knowledge as a solution to the noted
increase in PI.
PICO Question
This clinical inquiry has led to the following PICO question: In the adult inpatient
nursing population (P), does providing knowledge based education on pressure injury
management and prevention, like a pressure injury prevention program (I), compared to current

PRESSURE INJURY PREVENTION

8

education (C) result in a decrease in pressure injuries and improved nursing staff knowledge of
wound management (O).
Search Strategies
An exhaustive electronic search of databases was performed between January 2019 to
March 2019. All aspects of the PICO question were evaluated. Three article databases were
searched to retrieve the studies used for this project. The databases searched include Cochrane
library, CINAHL Plus, and PubMed. After searching the databases using key terms such as
pressure ulcer, pressure injury, prevention, therapy, control education, training, inpatient,
hospital acquired, and nursing knowledge. The terms were searched via mesh and truncated
options when possible in the databases. Following this, ten papers were selected for their
appropriateness and inclusion in this search for information. The inclusion criteria consisted of
articles with strong scientific underpinnings, studies completed in the last five years, studies
done on humans, participants over 18 years old, studies publish in English, and studies with a
focus on pressure injury prevention or education. Searches with less than 200 results had their
titles and abstracts evaluated for further use.
The first database search was PubMed. PubMed is a United States government operated
database maintained by the National Center of Biotechnology Information and the United States
National Library of Medicine. Because of PubMed’s strong scientific and research-based
underpinnings, it was selected for use. The database search used the terms pressure ulcer,
nursing knowledge, and pressure injury with the mesh terms of therapy and control with the
truncated term education. This revealed 998 results. After application of the exclusion criteria to
include only data completed in the past five years, data done on humans, and adjusting for 19
years of age and above, the number of results was reduced from 998 to 102. Other terms with

PRESSURE INJURY PREVENTION

9

and without truncation like randomized control trial and systematic review were used to further
limit the number of data results found from the initial 102 down to four, so these terms were not
used.
CINAHL Plus is a research database for nursing and other health journals. The initial
search of the database included the bullion terms pressure ulcer and education. Both terms were
truncated to increase results. An initial search found 515 results. After applying limitations like
English language, and adjusting for research performed within the last five years, 150 results
were left for evaluation. A further reduction of results was found when the terms systematic
review and randomized control trial were used. Use of these terms resulted in a decrease of
search results from 150 down to one so these terms were not used.
The Cochrane Library was chosen as a database search because of its high quality
reviews. The search started with the mesh term pressure ulcer, which gave a total of 672 results.
After adding prevention or education, the search was narrowed to 357 total results. After
applying the filter of date ranges from 2014-2019, 27 Cochrane Reviews were found and 103
trials. There are no options available to filter for experiment type or participant age, so these
criteria were not applied in this database search. Data saturation was reached in all three
databases.
Critical Appraisal and Synthesis
Ten articles were retained from the literature search for this review and are presented in
the synthesis table (Appendix B). Only one study was done in the United States (US) with the
majority of other studies coming from Canada or Australia and the remaining studies coming
from other countries around the world (Appendix A). All ten articles evaluated were performed
within five years from the date of literature search. There was a moderate level of heterogeneity

PRESSURE INJURY PREVENTION

10

regarding study design. Study designs included one systematic review, one randomized control
trial, and one mixed method Study. Three studies were a form of quasi-experimental studies
using a pre- and post-test design. The remaining studies were either prospective, cross sectional,
or quantitative in nature and design (Appendix A & B). This provided a broad perspective of
information relating to the topic which was needed due to the limited amount of stringent
research that has been done on the topic.
All ten articles were evaluated using Joanna Briggs Institute’s critical appraisal tools
specific to the type of article used (Joanna Briggs Institute, 2017). The level of evidence for
most articles was a level III, or moderate level of evidence, with the systematic review and
randomized control trials being high with a I or II level due to their robust design. All studies
seemed to have some limitations to their stringencies but still provided a clear level of utility
regarding their data (Appendix A & B).
All studies evaluated were performed within the inpatient setting. Aside from the
systematic review, all studies provided demographic information regarding patient age.
Regarding age groups, most studies had a level of homogeneity with the majority of study
participants over the age of 50 years old. One study looked at the education scores and age of
medical staff and reported an age range between 26-55 years old (Appendix A & B).
There was a moderate level of homogeneity regarding measurement tools with the
patient’s chart, Braden scale, and some variant of the Pressure Ulcer Knowledge Assessment
Tool (PUKAT) being utilized in the studies. An intervention tool commonly utilized was some
form of a Pressure Injury Prevention Bundle which provided different forms of education
regarding PI prevention (Appendix B). There was a high level of homogeneity regarding the

PRESSURE INJURY PREVENTION

11

idea that education would improve outcomes. Seven of the ten studies found this to be true in
some way.
The timelines for the ten studies varied greatly with a moderate level of heterogeneity to
them. This was due to some of the studies looking at patient outcomes while other studies
evaluated staff knowledge. Because of this difference, timeline of interventions spanned
anywhere from months to years (Appendix B).
Conclusion from Evidence
This synthesis of evidence most predominantly suggests that there is a positive outcome
when some form of staff education is applied to PI prevention. The synthesis also supports that
data coming from a PIPP is a viable and common means to communicate educational
information in the inpatient setting. The limited amount of level I and II data suggest a need for
more development in this topic as there are limited high level research studies on the topic at this
time. The synthesis also strongly supports the use of standardized tools like the PUKAT, Braden
scores, and chart reviews as key components to evaluate success in the implementation of PIPP.
Conceptual Framework and EBP Model
The Knowledge to Action Framework is a conceptual framework that was proposed by
Graham, et al. (2006) (Appendix C). It was designed to help facilitate the use of developed
knowledge to the appropriate knowledge utilizers. It was chosen as the model guide for this
project due to its appropriateness regarding education development and implementation into
practice.
The knowledge to action framework starts with knowledge creation and then action.
These two processes are further broken down into separate phases.

PRESSURE INJURY PREVENTION

12

Knowledge creation involves knowledge inquiry, synthesis, and products. The design is
an upside-down triangle and highlights the refinement of knowledge to a usable product.
Knowledge action is then adapted to context, assessed for barrier and implemented. This
process is well suited for the development of a PIPP or education bundle (Appendix A & B). The
action goes on to describe how to implement this knowledge via monitored, evaluated, and
sustainment steps. All steps and phases can be dynamic, complex, and without boundaries to
highlight the author’s conceptualization that the components of the framework can move
between phases and steps fluidly if necessary (Graham et al., 2006). This framework’s fluid and
dynamic use will be useful in the implementation of an educational program for hospital staff to
help create a structure of implementation that can be easily followed.
The Conner’s Conceptual model of research utilization evaluation was developed by
Conner (1980) (Appendix D). It was chosen as a model for its simple four step process of
implementing new research knowledge and evaluating the utilization of that knowledge. It
emphasizes four key components: goals, inputs, processes, and outcomes (Conner, 1980).
The first component of the model is to set a goal to evaluate the success of the knowledge
utilization. Input is the knowledge findings to be evaluated via its quality and importance.
Process is the monitoring of knowledge utilization. Outcome of the knowledge utilization is the
last step of the model and looks at the outcome of the set goal (Conner, 1980). These steps are
simple and follow the goal of evaluating the knowledge gained by hospital staff after the
provided education.
Methods
A one group pre-test post-test design quality improvement project was conducted
between November 2019 and January 2020. The project received exemption from Arizona State

PRESSURE INJURY PREVENTION

13

University’s Institutional Review Board on September 13, 2019. Participation in the project was
not mandatory and a consent form was provided to all participants before taking part in either the
pre- or post-education survey. Consideration for the anonymity of participants in the project was
done via participants creating an anonymous personal identifier that would be used for both the
pre- and post-education survey. Participants were instructed to create unique personal identifiers
using any combination of numbers or letters. Participants were advised to create personal
identifiers that could be remembered by the participant in order to properly match pre- and posteducational surveys. Before the participants created the identifier, an example of how to create a
memorable anonymous identifier was provided. All data collected was saved on a password
protected laptop within an encrypted Excel file. The hospital system and employers had no
access to individual scores or data.
The population to be evaluated was the inpatient nursing staff working the post-cardiac
care unit in a Southern Arizona hospital system. Though float nurses were permitted to attend all
educational sessions and complete surveys, their responses were excluded from statistical
analysis given inability to attend educational sessions. In 2019, the unit had between an average
of 7.8 to 8.7 nurses per day staffing the unit with a patient to nurse ratio of 3 to 3.4 patients per
nurse. During that same year, HAPI rates for the unit ranged from zero to three instances per
month. There were a total of 10 pressure injuries documented in the post-cardiac care unit in
2019.
This project utilized a modified version of the Pressure Ulcer Knowledge Assessment
Tool 2.0 (PUKAT 2.0) developed in 2017. The tool is an updated version from 2010 (Manderlier
et al., 2017). Permission to utilize the tool was obtained via email communication with creators
of the tool.

PRESSURE INJURY PREVENTION

14

The PUKAT 2.0 has been found to have good psychometric properties and validity
(Manderlier et al., 2017). The survey was also chosen due to its simplicity compared to other
tools as it contained only 25 questions compared to other tools. The survey covered 6 themes:
etiology, classification and observation, risk assessment, nutrition, prevention, and special
patient groups.
Recruitment into the study began November 2019. Participants were provided
information regarding the project to include information on how to access the pre-education
survey online. Laptops and tablets were made available for staff interested in the survey. Staff
were also instructed on the importance of remembering their anonymous personal identifiers for
completion of the post-education survey. A drawing for participants who completed both the preeducation and post-education survey was established to both incentivize participants to
remember their anonymous personal identifier and to create a benefit for taking time to be a part
of the survey. The drawing consisted of four twenty-five-dollar gift cards to be provided at the
end of the project.
The education phase began December 2019 with a series of ten-minute-long education
sessions on PI prevention. These sessions focused on low scoring domains from the preeducation modified PUKAT 2.0 survey. Educational sessions were provided by the primary
investigator, who was a member of the wound ostomy care team. The investigator also posed
questions to nursing staff regarding prior subject areas covered to promote reinforcement and
retainment of information. Nursing staff was also was given the opportunity to ask questions at
the end of each educational session. Questions most often addressed general PI care. A small
board with focused education was displayed in the nursing charting area. The board was updated
weekly with new information for staff to evaluate.

PRESSURE INJURY PREVENTION

15

The post-survey phase began January 2020. The education board was removed, and
nursing staff was again given access to the online post-education modified PUKAT 2.0. This was
done about three times a week for both day and night staff. Laptops and tablets were again made
available to staff during these times to take the post-education survey.
A chart review began in February 2020 to evaluate pressure injury rates in order to
determine whether there was any immediate impact of education on PI rates. The chart review
data was provided by the IT department of the hospital system with data representing the number
of PI on the floor for the past year up until the end of February. Data analysis began in March
with the use of Intellectus Statistics software.
A budget was created that looked at direct cost such as office supplies and promotional
supplies. The budget also covered indirect costs to include employee time and hospital
equipment utilization. Savings and cost of individual patient care were also considered. A
projected $965 total cost was calculated with a total projected savings of $27,516 possible should
the project prevent one pressure injury (Appendix E). No direct funding was provided, and all
expenses were covered by the project investigator.
Results
A total of 42 participants took either the pre-education survey, post-education survey, or
both. 28 participants completed the pre-education survey. 22 participants completed the posteducation survey. Eight participants completed both surveys. All participants were post cardiac
care nursing staff. Gender reported showed 11 (26.2%) of the participants were male, 29 (69.1%)
were female and two (4.7%) preferred not to say. When asked “What is your education level?”,
24 (57.1%) participants reported having a bachelor’s degree in nursing. 12 (28.6%) reported an
associate degree in nursing, and six (14.3%) reported master’s degree in nursing.

PRESSURE INJURY PREVENTION

16

Age reports of participants showed five (11.9%) were under 25 years old. 20 (47.7%)
participants were between the age of 25 to 34. 10 (23.8%) participants were 25 to 44 years old.
Five (11.9%) participants were 45 to 54 years old. Two (4.7%) were over the age of 55.
Looking at years worked as a nurse, eight (19.0%) participants reported less than one
year of work. 11 (26.2%) reported one to two years of work. Six (14.3%) reported three to four
years of work. Three (7.2%) reported five to six years of work. 14 (33.3.8%) reported seven or
more years of work.
A two-tailed paired samples t-test was conducted to examine whether the mean difference
of the matched pre-education survey and post-education survey were significant. In order to meet
the assumptions of a two-tailed paired samples t-test, a Shapiro Wilk test and a Levene’s were
conducted.
The Shapiro-Wilk test was conducted to determine whether the differences in matched
pre-education surveys and post-education surveys could have been produced by a normal
distribution (Razali & Wah, 2011). The results of the Shapiro-Wilk test were not significant
based on an alpha value of 0.05, W = 0.91, p = .365. This result suggests the possibility that the
differences in matched pre-education surveys and post-education surveys were produced by a
normal distribution cannot be ruled out, indicating the normality assumption is met.
The Variance Levine’s test was conducted to assess whether the variances of matched
pre-education surveys and post-education surveys were significantly different. The result of
Levine’s test was not significant based on an alpha value of 0.05, F(1, 14) = 0.04, p = .848. This
result suggests it is possible that matched pre-education surveys and post-education surveys were
produced by distributions with equal variances, indicating the assumption of homogeneity of
variance was met.

PRESSURE INJURY PREVENTION

17

The result of the two-tailed paired samples t-test was significant based on an alpha value
of 0.05, t(7) = -5.39, p = .001, indicating the null hypothesis can be rejected. This finding
suggests the difference in the mean of matched pre-education survey data and the mean of
matched post-education survey data was significantly different from zero. The mean of matched
pre-education survey data was significantly lower than the mean of matched post-education
survey data (Appendix F).
Due to the limited number of matched samples for the two-tailed paired samples t-test, a
two-tailed Mann-Whitney U test was conducted to examine whether there was a significant
difference in scores between the levels of the pre-education survey and post-education survey
data. The two-tailed Mann-Whitney U test is an alternative to the independent samples t-test and
does not share the same distributional assumptions (Conover & Iman, 1981). There were twentyeight observations in the pre-education survey group and twenty-two observations in the posteducation survey group.
The result of the two-tailed Mann-Whitney U test was significant based on an alpha value
of 0.05, U = 102.5, z = -4.05, p < .001. The mean rank for the pre-education survey group was
18.1 and the mean rank for the post-education group was 34.84. This suggests the distribution of
scores for the pre-education survey group was significantly different from the distribution of
scores for the post-education survey group. The median for pre-education surveys (Mdn = 0.56)
was significantly lower than the median for post-education surveys (Mdn = 0.71) (Appendix G).
A chart review was also conducted to check the rates of HAPIs on the post cardiac care
unit floor. November and December rates were zero. January had one HAPI on the floor and
Decemeber there were three. March 2020 there were no HAPIs and has stayed since the time of
this works completion.

PRESSURE INJURY PREVENTION

18
Discussion

There was a noted statistical significance between the pre-education survey and posteducation scores. These results suggest an improvement in nursing staff knowledge regarding PI
prevention and management. This increase in staff knowledge should correlate with a decrease in
HAPI rates. However, after a chart review of PI rates in the post cardiac care unit, there was a
paradoxical increase in PI rates immediately after education. PI rates increased from one to three
in the two months following education completion but then dropped to zero and have stayed
since the time of this work. This is thought to be attributed to the nursing staff’s awareness and
ability to appropriately recognize newly developed HAPIs after receiving education. Staff's
increased ability to quickly identify HAPIs, although showing an increase in numbers following
education, will likely account for improved prevention and decreased harm as it has allowed for
identification at an earlier stage.
These findings correlate with other studies that showed the use of PIPPs improve staff
knowledge (Martin, et al., 2017; Baron, et al., 2016). Other studies support the use of tools like
the Pressure Ulcer Knowledge Assessment Tool as a means to measure knowledge (Dalvand,
Ebadi, & Gheshlagh, 2018).
The potential impact of the evidence-based project on staff includes an improved
workflow for nursing staff as a decreased stress and increased knowledge would likely improve
the staff’s ability to prevent and manage PIs. The impact on the wound care team would include
an improvement in resource allocation as the wound care team would be better equipped to
transition to an education and prevention focus due to a decrease in consults related to pressure
injury management and development. Regarding patient impact, there would be a reduced cost to
patients due to wound prevention. Adequate care to prevent the development of PI would result

PRESSURE INJURY PREVENTION

19

in the development of trust in nursing staff from both patients and family members. Patients
would also have potentially decreased lengths of stay due to complications associated with PIs as
well as increased quality of life being PI free. Patients would likely also have a decreased
hospital mortality rate as PI rates would decrease. The healthcare system itself would have
improved cost savings regarding Medicare and Medicaid reimbursement. There would also be a
decrease in burden and utilization within the healthcare system as rates of HAPIs decrease.
Sustainability of this evidence-based research project is expected as the program has
shown improvement in staff knowledge regarding pressure injury prevention. The project was
also undertaken as part of the wound care team’s goal to transition from a pressure injury
management perspective to a prevention focus. This internal organizational shift, project success
as well as framework design to be evolving supports the sustainability of the project as a whole.
Furthermore, education and investment in nurses promote a culture where staff are motivated to
implement actions of prevention. This change in culture is likely to assist in the continued
sustainability of the project.
Limitations of this evidence-based study include low numbers of matched data for a more
clear, statistical analysis. This was likely due to the extended timeline between staff education
and the need for an improved method to match pre- and post-education data. It was found upon
starting the post-education survey that multiple staff members reported they did not remember
their anonymous identifier thereby limiting the numbers of matched data available. Another
limitation was the lack of use of a control group to mitigate the impact of confounding variables.
This use of control groups was not used due to the increased number of staff that would be
necessary to incorporate a control group. In addition, the study’s goal of having minimal impact
on the workflow of staff thereby limiting the ability to have a large number of participants. There

PRESSURE INJURY PREVENTION

20

is also a potential for the Hawthorne effect on staff, causing staff to potentiality to find ways to
improve scores aside from educational sessions provided. To reduce the potential for this bias in
the study, the staff was educated multiple times to include in the consent that scores would have
no impact on their work status.
The need to limit the development of HAPIs is important not only to hospitals and staff
but also to the patients they care for. Proper staff education in prevention measures and practices
are important tools in this process. This evidence-based quality improvement project found that
the use of PIPP did improve staff knowledge but did not immediately improve PI rates. This
shows the need for more quality studies regarding the immediate change of PI rates after staff
education. Other recommendations for further research would include studies to further evaluate
the long-term impacts of education as well as the implementation of other education modality on
HAPI development.

PRESSURE INJURY PREVENTION

21
References

Anderson, M. L., Finch Guthrie, P., Kraft, W., Reicks, P., Skay, C., & Beal, A. (2015). Universal
pressure ulcer prevention bundle with WOC nurse support. Journal of Wound, Ostomy
and Continence Nursing, 42(3), 217-225.
Barakat-Johnson, M., Lai, M., Wand, T., & White, K. (2018). A qualitative study of the thoughts
and experiences of hospital nurses providing pressure injury prevention and
management. Collegian. doi:10.1016/j.colegn.2018.04.005
Baron, M., Reuter, C., Burgos, M., Cavalli, V., Brandenburg, C., & Krug, S. (2016).
Experimental study with nursing staff related to the knowledge about pressure ulcers.
Revista Latino-Americana De Enfermagem, 24(0), E2831.
Bauer, K., Rock, K., Nazzal, M., Jones, Q., & Qu, W. (2016). Pressure ulcers in the United
States’ inpatient population from 2008 to 2012: Results of a retrospective nationwide
study. Ostomy Wound Management, 62(11), 30-38.
Chan, B., Cadarette, S., Wodchis, W., Wong, J., Mittmann, N., & Krahn, M. (2017). Cost-ofillness studies in chronic ulcers: a systematic review. Journal of Wound Care, 26(4), 414. https://doi.org/10.12968/jowc.2017.26.Sup4.S3
Center for Medicare and Medicaid Services. (2018). Fiscal Year (FY) 2009 Inpatient Prospective
Payment System (IPPS), Long Term Care Hospital (LTCH) PPS, and Inpatient
Psychiatric Facility (IPF) PPS Changes [PDF file]. Retrieved from
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM6189.pdf
Centers for Medicare and Medicaid Services. (2016). Skilled nursing facility quality reporting
program-specifications for percent of residents or patients with pressure ulcers that are

PRESSURE INJURY PREVENTION

22

new or worsened [PDF file]. Retrieved from https://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/SNFQRP-Measure-Calculations-and-Reporting-Users-Manual-V20.pdf
Conner, R. F. (1980). The evaluation of research utilization. In M. W. Klein & K. S. Teilmann
(Eds.), Handbook of Criminal Justice Evaluation (pp. 629–653). Beverly Hills, CA:
Sage.
Conover, W. J., & Iman, R. L. (1981). Rank transformations as a bridge between parametric and
nonparametric statistics. The American Statistician, 35(3), 124-129.
Cowan, L., Garvan, C., Rugs, D., Barks, L., Chavez, M., & Orozco, T. (2018). Pressure Injury
Education in the Department of Veterans Affairs: Results of a National Wound Provider
Cross-sectional Survey. Journal of Wound, Ostomy and Continence Nursing, 45(5), 419424.
Coyer, F., Gardner, A., Doubrovsky, A., Cole, R., Ryan, F., Allen, C., & McNamara, G. (2015).
Reducing pressure injuries in critically ill patients by using a patient skin integrity care
bundle (InSPiRE). American Journal of Critical Care : An Official Publication,
American Association of Critical-Care Nurses, 24(3), 199-209.
Dalvand, S., Ebadi, A., & Gheshlagh, R. (2018). Nurses’ knowledge on pressure injury
prevention: A systematic review and meta-analysis based on the Pressure Ulcer
Knowledge Assessment Tool. Clinical, Cosmetic and Investigational Dermatology, 11,
613-620.
Dreyfus, J., Gayle, J., Trueman, P., Delhougne, G., & Siddiqui, A. (2018). Assessment of risk
factors associated with hospital-acquired pressure injuries and impact on health care

PRESSURE INJURY PREVENTION

23

utilization and cost outcomes in US hospitals. American Journal of Medical
Quality, 33(4), 348-358.
Field, B., Booth, A., Ilott, I., & Gerrish, K. (2014). Using the Knowledge to Action Framework
in practice: A citation analysis and systematic review. Implementation Science : IS, 9(1),
172.
Graham, I. D., Logan, J., Harrison, M. B., Straus, S. E., Tetroe, J., Caswell, W., et al. (2006).
Lost in knowledge translation: Time for a map? The Journal of Continuing Education in
the Health Professions, 26, 13–24.
Gunningberg, L., Sving, E., Hommel, A., Ålenius, C., Wiger, P., & Bååth, C. (2019). Tracking
pressure injuries as adverse events: National use of the Global Trigger Tool over a 4‐year
period. Journal of Evaluation in Clinical Practice, 25(1), 21–27. https://doiorg.ezproxy1.lib.asu.edu/10.1111/jep.12996.
Jackson, D., Durrant, L., Hutchinson, M., Ballard, C., Neville, S., & Usher, K. (2018). Living
with multiple losses: Insights from patients living with pressure injury. Collegian, 25(4),
409-414.
Joanna Brigges Institute. (2017). Critical appraisal tools. Retrieved April 20, 2019, from
http://joannabriggs.org/research/critical-appraisal-tools.html
Lin, F., Wu, Z., Song, B., Coyer, F., & Chaboyer, W. (2019). The effectiveness of
multicomponent pressure injury prevention programs in adult intensive care patients: A
systematic review. International Journal of Nursing Studies, 102, 103483.
Mahalingam, S., Gao, L., Nageshwaran, C., Vickers, T., Bottomley, P., & Grewal. (2014).
Improving pressure ulcer risk assessment and management using the Waterlow scale at a
London teaching hospital. Journal of Wound Care, 23(12), 613-622.

PRESSURE INJURY PREVENTION

24

Mallah, Nassar, & Kurdahi Badr. (2015). The effectiveness of a pressure ulcer intervention
program on the prevalence of hospital acquired pressure ulcers: Controlled before and
after study. Applied Nursing Research, 28(2), 106-113.
Manderlier, B., Van Damme, N., Vanderwee, K., Verhaeghe, S., Van Hecke, A., & Beeckman,
D. (2017). Development and psychometric validation of PUKAT 2·0, a knowledge
assessment tool for pressure ulcer prevention. International Wound Journal, 14(6), 10411051.
Martin, D., Albensi, L., Haute, S., Froese, M., Montgomery, M., Lam, M., … Basova, N. (2017).
Healthy Skin Wins: A glowing pressure ulcer prevention program that can guide
evidence-based practice. Worldviews on Evidence-Based Nursing, 14(6), 473–483.
https://doi-org.ezproxy1.lib.asu.edu/10.1111/wvn.12242
National Pressure Ulcer Advisory Panel. (2016). NPUAP pressure injury stages. Retrieved April
20, 2019, from http://www.npuap.org/resources/educational-and-clinicalresources/npuap-pressure-injury-stages/
Nussbaum, S., Carter, M., Fife, C., Davanzo, J., Haught, R., Nusgart, M., & Cartwright, D.
(2018). An Economic Evaluation of the Impact, Cost, and Medicare Policy Implications
of Chronic Nonhealing Wounds. Value in Health, 21(1), 27-32.
Padula, W., & Delarmente, B. (2019). The national cost of hospital‐acquired pressure injuries in
the United States. International Wound Journal, 16(3), 634-640.
Padula, V., Gibbons, R., Valuck, R., Makic, M., Mishra, M., Pronovost, P., & Meltzer, D.
(2016). Are evidence-based practices associated with effective prevention of hospitalacquired pressure ulcers in US Academic Medical Centers? Medical Care, 54(5), 512518.

PRESSURE INJURY PREVENTION

25

Padula, W., Mishra, M., Makic, M., Wald, H., Campbell, J., Nair, K., & Valuck, R. (2015).
Increased adoption of quality improvement interventions to implement evidence‐based
practices for pressure ulcer prevention in U.S. academic medical centers. Worldviews on
Evidence Based Nursing, 12(6), 328-336.
Razali, N. M., & Wah, Y. B. (2011). Power comparisons of Shapiro-Wilk, KolmogorovSmirnov, Lilliefors and Anderson-Darling tests. Journal of Statistical Modeling and
Analytics, 2(1), 21-33.
Smith, S., Ashby, S., Thomas, L., & Williams, F. (2018). Evaluation of a multifactorial approach
to reduce the prevalence of pressure injuries in regional Australian acute inpatient care
settings. International Wound Journal, 15(1), 95-105.
Suva, G., Sharma, T., Campbell, K., Sibbald, R., An, D., & Woo, K. (2018). Strategies to support
pressure injury best practices by the inter‐professional team: A systematic review.
International Wound Journal, 15(4), 580-589
Sving, E., Högman, M., Mamhidir, A., & Gunningberg, L. (2016). Getting evidence‐based
pressure ulcer prevention into practice: A multi‐faceted unit‐tailored intervention in a
hospital setting. International Wound Journal, 13(5), 645-654.
Tayyib, N., Coyer, F., & Lewis, P. (2015). A two‐arm cluster randomized control trial to
determine the effectiveness of a pressure ulcer prevention bundle for critically ill patients.
Journal of Nursing Scholarship, 47(3), 237-247.
U.S. Department of Health and Human Services, Office of Disease Prevention and Health
Promotion. (2020). Maternal, infant, and child health. Retrieved
from https://www.healthypeople.gov/node/3493/data-details

PRESSURE INJURY PREVENTION

26
Appendix A

Table 1
Evaluation Table
Citation

Conceptual
Framework

Design/Method

Sample/Setting

Major Variable
& Definitions

Measurement

Analysis

Findings

Suva et al., (2018).
Strategies to
support pressure
injury best
practices by the
inter-professional
team: a systematic
review

Via email
corresponde
nce with
author: none
used though
several were
reviewed.

Design: SR

(EDU) N:3728
(EDU) n:22
Systems N: 6347
Systems n: 12

IV- Edu and
Training,
systems,
experience,
team-based
approach,
organizations,
policy,
communication,
identification of
barriers and
enablers,
guidelines, staff.

Standardized
data extracting
form,
independent
review

Screening-, CA,
Critical Appraisal
Skills Program
(CASP),
Assessing the
Methodological
Quality of
Systematic
Review
(AMSTAR) tool.

Lack of PI
prevention
knowledge,

Funding:
Via email
correspondence:
Ministry of Health
and Long-Term
Care.
Bias: Self-reports
no search of grey
literature and only
English articles
searched.

Country: Canada.

Purpose:
Identify Edu
barriers, enablers,
and strategies for
supporting PI
care.
Assess
organizational
and system level
barriers, enablers,
support (PI) care.
Find future
research on the
subject.

DS: CINAHL,
Cochrane CT,
Cochrane SR,
DARE, Embase,
Eric, MEDLINE,
PsychINFO
IC: Published
between 06-14,
>18YO, English,
all study designs.
EC: Not English,
grey lit., outside
timeline, white
papers, case
studies,
guidelines,
without research
methodology,

DV- Impact on
PI rate,
management

Barriers to
change
Multiple Edu
strategies
improve
knowledge.
PI prevention
and
management
knowledge
improves
nurses’
confidence and
competence.
Multiple factors
impact PI best
practice

Decision for
use
LOE: 1
Strengths: Vast
discussion of
different factors
impacting PI
prevention
including Edu
Weaknesses:
Studies results
were
heterogeneous,
so no MA.
Conclusion:
Good evidence
supports
education as an
important
component to
improve PI
prevention.
Feasibility/Appl
icability to pt.

Key : BMI: Body Mass Index, CA- Content Analysis, CT- Clinical Trial, DI: Duration of Intervention DQ- Descriptive Qualitative, DS- Databases Searched, DV- Dependent
Variable, EC- Exclusion Criteria, Edu- Education, Freq: Frequency, HAPI: Hospital Acquired Pressure Injury, Hrs.: Hours, IC- Inclusion Criteria, , ICU: Intensive Care Unit,
IP: Inpatient IV- Independent Variable, LOE- Level Of Evidence, LOS: Length of Stay, LPN- Licensed Practical Nurse, MA- Meta Analysis, N: Sample Size (Studies), n:
Sample size (People), NRNCT- Non-randomized Non-Controlled Trial, PARIHS: Promoting Action on Research Implementation in Health Services, PI- Pressure Injury, PUPressure Ulcer, PIPP- Pressure Injury Prevention Program, PUKAT- Pressure Ulcer Knowledge Assessment Tool, Q: Question, QE: Quasi- experimental, RCS: Retrospective
Cross-sectional Study, RCT- Randomized control trial, RN- Registered Nurse, SD- Standard Deviation, SR- Systematic Review, SS: Sample Size, TMC- Tucson Medical Center,
USA: United States of America, WOC: Wound Ostomy Care, YO- Years Old,

PRESSURE INJURY PREVENTION

27
studies with
animals.

Unclear role of
clinical
experience
Importance of
communication
Barriers to PI
prevention
include time,
resources,
cooperation

population:
Education is a
feasible option to
implement at
TMC. Education
systems could be
introduced to any
population at the
hospital.

Enablers
include group,
leaders,
teamwork,
support,
networks.
Citation

Conceptual
Framework

Design/Method

Sample/Setting

Major Variable
& Definitions

Measurement

Martin et al.,
(2017). Healthy
Skin Wins: A
Glowing Pressure
Ulcer Prevention
Program That Can
Guide EvidenceBased Practice

Diffusion of
Innovation
model

Design:
Explanatory
sequential mixed
method NRNCT
(pre- & post-test)
& DQ (focus
groups) purposive
sampling

PU reduction n:
239

IV: PIPP
implementation,
use of hands on
and online
tutorials
regarding PIPP.

NRNCT: Preand posttesting, PU
knowledge
assessment
tool

DV: PU rates,
Post tutorial
knowledge score.

DQ: Focus
groups, voice
recordings,
narrative
screening tool,

Funding: None
listed.

Purpose:
Determine the
effectiveness of

Online Edu
n:80
Setting: 304 bed
community
hospital,
Winnipeg,
Canada.

Analysis
RNCT: Pre-test
and post-test Ttesting

Findings

Pre- and postPIPP
implementation
used chi-squared
testing

NRNCT:
Tutorial
knowledge pretests (M = 13.3,
SD = 1.98) and
post-tests (M =
14.3, SD = 2.00)
scores; t (79)= 4.80, p < .001

DQ: 12
transcripts

The initial
reduction in the

Decision for
use
LOE: 3
Strengths:
Better
perspective of
the whole
situation when
utilizing a
mixed method.
More
appropriate for
nursing.

Key : BMI: Body Mass Index, CA- Content Analysis, CT- Clinical Trial, DI: Duration of Intervention DQ- Descriptive Qualitative, DS- Databases Searched, DV- Dependent
Variable, EC- Exclusion Criteria, Edu- Education, Freq: Frequency, HAPI: Hospital Acquired Pressure Injury, Hrs.: Hours, IC- Inclusion Criteria, , ICU: Intensive Care Unit,
IP: Inpatient IV- Independent Variable, LOE- Level Of Evidence, LOS: Length of Stay, LPN- Licensed Practical Nurse, MA- Meta Analysis, N: Sample Size (Studies), n:
Sample size (People), NRNCT- Non-randomized Non-Controlled Trial, PARIHS: Promoting Action on Research Implementation in Health Services, PI- Pressure Injury, PUPressure Ulcer, PIPP- Pressure Injury Prevention Program, PUKAT- Pressure Ulcer Knowledge Assessment Tool, Q: Question, QE: Quasi- experimental, RCS: Retrospective
Cross-sectional Study, RCT- Randomized control trial, RN- Registered Nurse, SD- Standard Deviation, SR- Systematic Review, SS: Sample Size, TMC- Tucson Medical Center,
USA: United States of America, WOC: Wound Ostomy Care, YO- Years Old,

PRESSURE INJURY PREVENTION
Bias: None
recognized.
Country: Canada

the PIPP in
reducing PU
prevalence.
Determine
effectiveness of
online tutorials to
increase staff
knowledge about
PU prevention
and perspective of
PIPP.

28
Inpatient hospital
setting.
Sample
Demographics:
Male: 6, Female:
74, 18-25YO:
11, 25-35YO:
34, 36-45YO:
14, 45-55YO:
17, >56YO: 5,
Allied health: 29,
RN: 41, LPN: 7,
Health care aids:
3.
IC: All admitted
patients over 18
who provided
verbal consent,
nursing, and staff
who volunteered
for the study.
EC: Casual
employees.
Patients less than
18YO.
Attrition: None
listed

Q: From your
viewpoint, what
changes worked
best to prevent
PUs?
What other
strategies could
healthcare
providers use to
protect patients’
skin?

semistructured
interview
guide,
individual
interviews

recorded from
focused groups
and individual
interviews
resulted in two
major themes.

PU prevalence
post-PIPP was
X2(1)=51.9308,
p<.0001
PIPP
implementation
Reduction in PU
incidence 6-day
repeat was found
at X2(1) =
9.5798, p < .002

What physical
resources
(equipment,
supplies, staff)
could be made
available to you
to help your
team prevent
PUs?

DQ: Themes
from focus
groups found
“It’s definitely a
combination of
everything”
multifactorial
contributing to
PU prevention.

Please describe
the support that
you receive from
hospital
management to
prevent PUs.

“There’s a
disconnect
between what’s
needed and
what’s
available.”

Is there anything
else?

Provided data
on the
experience of
staff. Proper
population and
looks at the
education of
staff.
Weaknesses:
No data on how
themes are
developed. LOE
not as strong as
other studies
due to design.
Feasibility/App
licability to
patient
population:
The study's use
of a PIPP with
Edu to decrease
PU rates in a
community
base inpatient
setting makes
this an ideal
study to support
the PICO
question.

Key : BMI: Body Mass Index, CA- Content Analysis, CT- Clinical Trial, DI: Duration of Intervention DQ- Descriptive Qualitative, DS- Databases Searched, DV- Dependent
Variable, EC- Exclusion Criteria, Edu- Education, Freq: Frequency, HAPI: Hospital Acquired Pressure Injury, Hrs.: Hours, IC- Inclusion Criteria, , ICU: Intensive Care Unit,
IP: Inpatient IV- Independent Variable, LOE- Level Of Evidence, LOS: Length of Stay, LPN- Licensed Practical Nurse, MA- Meta Analysis, N: Sample Size (Studies), n:
Sample size (People), NRNCT- Non-randomized Non-Controlled Trial, PARIHS: Promoting Action on Research Implementation in Health Services, PI- Pressure Injury, PUPressure Ulcer, PIPP- Pressure Injury Prevention Program, PUKAT- Pressure Ulcer Knowledge Assessment Tool, Q: Question, QE: Quasi- experimental, RCS: Retrospective
Cross-sectional Study, RCT- Randomized control trial, RN- Registered Nurse, SD- Standard Deviation, SR- Systematic Review, SS: Sample Size, TMC- Tucson Medical Center,
USA: United States of America, WOC: Wound Ostomy Care, YO- Years Old,

PRESSURE INJURY PREVENTION

29

Citation

Conceptual
Framework

Design/Method

Sample/Setting

Major Variable &
Definitions

Measurement

Tayyib et al.,
(2015). A Two‐
Arm Cluster
Randomized
Control Trial to
Determine the
Effectiveness of a
Pressure Ulcer
Prevention
Bundle for
Critically Ill
Patients.

None listed.

Two-Armed
Clustered RCT

Total

IV: PU prevention
bundle

Braden scale,
survey of
demographics
and clinical data,
sequential organ
failure
assessment, skin
assessment tool,
PU staging.

Funding: None
listed.

Purpose: To test
the effectiveness
of a PU
prevention bundle
in reducing
incidence of PU
in critically ill
patients in a Saudi
hospital

N: 140
n:70
Group that
developed PU
N: 28
N control: 23
N intervention:
5
Setting: Two
Saudi Arabian
ICU’s

DV: Development of
PU.
Definitions PU
prevention bundle:
Bundle of best available
evidence based
international guidelines
for PU prevention from
the European pressure
ulcer advisory panel.
Checklist of task
completion for bundle.

Analysis

Findings

Decision for
use

Two-tail
statistical
analysis
used to
find
sample size
of 48 per
group.

PU incidence
different
between the
intervention
group
(7.14%, 5/70
patients) and
the control
group
(32.86%,
23/70
patients; X2
=14.46,
df=1, p<.001)

LOE: 2

Long-rank
and cox
proportion
al hazards
analyses
used to
compare
time and
determine

PU bundle 12
in
intervention.
37 control.

Strengths: Due
to the nature of
RCT’s the LOE
is high. This
study also
looked at more
than one
hospital.
Weaknesses:
PU prevention
bundle only
implemented in
ICU. Limited
discussion on

Key : BMI: Body Mass Index, CA- Content Analysis, CT- Clinical Trial, DI: Duration of Intervention DQ- Descriptive Qualitative, DS- Databases Searched, DV- Dependent
Variable, EC- Exclusion Criteria, Edu- Education, Freq: Frequency, HAPI: Hospital Acquired Pressure Injury, Hrs.: Hours, IC- Inclusion Criteria, , ICU: Intensive Care Unit,
IP: Inpatient IV- Independent Variable, LOE- Level Of Evidence, LOS: Length of Stay, LPN- Licensed Practical Nurse, MA- Meta Analysis, N: Sample Size (Studies), n:
Sample size (People), NRNCT- Non-randomized Non-Controlled Trial, PARIHS: Promoting Action on Research Implementation in Health Services, PI- Pressure Injury, PUPressure Ulcer, PIPP- Pressure Injury Prevention Program, PUKAT- Pressure Ulcer Knowledge Assessment Tool, Q: Question, QE: Quasi- experimental, RCS: Retrospective
Cross-sectional Study, RCT- Randomized control trial, RN- Registered Nurse, SD- Standard Deviation, SR- Systematic Review, SS: Sample Size, TMC- Tucson Medical Center,
USA: United States of America, WOC: Wound Ostomy Care, YO- Years Old,

PRESSURE INJURY PREVENTION

30

BIAS: None
recognized.

Sample
Demographics:

Country: Saudi
Arabia.

Total: Male: 98,
Female: 42,
Mean age of
control 52.
Mean age of
intervention: 50
Group that
developed PU
Total Male: 19,
Total Female: 9
Number of PU
control: 37
Number of PU
intervention: 12

hazard
ratio
between
groups.
Poisson
regression
used to
compare
the
incidence
ratio
between
groups.
Generalize
d linear
model
variance
estimator
was used
to account
for
repeated
measures.
PU staging
between
groups
used a chisquare test
of
independen
ce.

(Breslow’s
generalized
Wilcoxon=11
.130, df=1,
p<.001)
PU rates over
study period
intervention
(12/70) and
control
(37/70)
groups
(expβ=0.30,
95%CI,
0.158-0.588,
p<.001).

what was
implemented.
Conclusion:
PU prevention
bundles
significantly
decrease PU
outcomes when
utilized in the
ICU.
Feasibility/App
licability to Pt.
Population:
The study was
performed in
Saudi Arabia
but supports the
idea that a PU
prevention
bundle with RN
Edu helps
translate
knowledge to
practice which
could be
utilized at
TMC.

Key : BMI: Body Mass Index, CA- Content Analysis, CT- Clinical Trial, DI: Duration of Intervention DQ- Descriptive Qualitative, DS- Databases Searched, DV- Dependent
Variable, EC- Exclusion Criteria, Edu- Education, Freq: Frequency, HAPI: Hospital Acquired Pressure Injury, Hrs.: Hours, IC- Inclusion Criteria, , ICU: Intensive Care Unit,
IP: Inpatient IV- Independent Variable, LOE- Level Of Evidence, LOS: Length of Stay, LPN- Licensed Practical Nurse, MA- Meta Analysis, N: Sample Size (Studies), n:
Sample size (People), NRNCT- Non-randomized Non-Controlled Trial, PARIHS: Promoting Action on Research Implementation in Health Services, PI- Pressure Injury, PUPressure Ulcer, PIPP- Pressure Injury Prevention Program, PUKAT- Pressure Ulcer Knowledge Assessment Tool, Q: Question, QE: Quasi- experimental, RCS: Retrospective
Cross-sectional Study, RCT- Randomized control trial, RN- Registered Nurse, SD- Standard Deviation, SR- Systematic Review, SS: Sample Size, TMC- Tucson Medical Center,
USA: United States of America, WOC: Wound Ostomy Care, YO- Years Old,

PRESSURE INJURY PREVENTION
Citation

Conceptual
Framework

Anderson et al.,
(2015) Universal
Pressure Ulcer
Prevention Bundle
with WOC Nurse
Support.

Concept of
Core
Implementat
ion. and
Core
intervention
in
developing
the PIPP
bundle.

Funding: Grant
support via Sage
Products, Inc.,
Center for Clinical
investigation.
Bias: Possible
issues with funding
from Sage though
researchers state
this had no impact
on the study.
Country: USA

Design/Method
Design: QE preand postintervention
design.
Descriptive
Method for WOC
nurses.
Purpose:
Examine the
effectiveness of a
PUP applied to
ICU patients with
WOC nursing
rounds.
.

31
Sample/Setting

Major Variable
& Definitions

Measurement

Initial SS: n=
1017

IV: Study
phase- PIPP
bundle
intervention with
WOC nurse
rounding.

Admission/dis
charge skin
assessment,
chart reviews,
WOC nurse
rounding logs.

Exclusion: With
PU, age, prior
study, declined,
consent, no
English: n=: 505
ICU LOS <24:
174
Missing data:11
SS: n=327
Pre-intervention:
n=181
Postintervention: n=
146
IC: Over 18YO,
able to get
family and
Patient consent,
LOS >24 Hrs.
EC: Presence of
PU, under 18
YO, Previous
study enrollment,

DV: Incidence of
unit acquired PU

Analysis
Mean and
standard
deviation for
patient
characteristics.
Frequencies used
for ICU admin,
assignment, and
transfer stats.
T and X2 testing
for pre- and postpatient
characteristics.
Differences preand post-test used
t-test, multiple
logistic regression
Covariant
analyzed with
bivariate analyses
if P<.25.

Findings
Nagelkerke R
squared was .396
(P<.001) PIPP
bundle and WOC
rounds increased
Nagelkerke R
squared value by
0.099 (P<.001)
>0.297 when
only covariant in
model.
Intervention
effect
statistically
significant at
P<.001 (Wald x2
= 11.695, df =1)

Decision for
use
LOE: 3
Strengths:
Quantitative
data collected.
Multipole
Hospital ICUs
evaluated
Shows that
training via
WOC or
Education for
PUP bundle I
decreased PU
rates.
Large sample
size.
Data collected
over 6 months.
Weaknesses:
Benefit from
control group.
Unclear if the
outcome is due
to WOC
intervention or
Bundle

Key : BMI: Body Mass Index, CA- Content Analysis, CT- Clinical Trial, DI: Duration of Intervention DQ- Descriptive Qualitative, DS- Databases Searched, DV- Dependent
Variable, EC- Exclusion Criteria, Edu- Education, Freq: Frequency, HAPI: Hospital Acquired Pressure Injury, Hrs.: Hours, IC- Inclusion Criteria, , ICU: Intensive Care Unit,
IP: Inpatient IV- Independent Variable, LOE- Level Of Evidence, LOS: Length of Stay, LPN- Licensed Practical Nurse, MA- Meta Analysis, N: Sample Size (Studies), n:
Sample size (People), NRNCT- Non-randomized Non-Controlled Trial, PARIHS: Promoting Action on Research Implementation in Health Services, PI- Pressure Injury, PUPressure Ulcer, PIPP- Pressure Injury Prevention Program, PUKAT- Pressure Ulcer Knowledge Assessment Tool, Q: Question, QE: Quasi- experimental, RCS: Retrospective
Cross-sectional Study, RCT- Randomized control trial, RN- Registered Nurse, SD- Standard Deviation, SR- Systematic Review, SS: Sample Size, TMC- Tucson Medical Center,
USA: United States of America, WOC: Wound Ostomy Care, YO- Years Old,

PRESSURE INJURY PREVENTION

32
non-English
speaking

Conclusion:
PUP bundle and
WOC
intervention
decrease PU
rates.

Setting: 3 ICUs
North Memorial
Medical Center
Minneapolis,
Minnesota.

Feasibility/App
licability to Pt.
population:
It can be
applied to any
floor and easily
implemented.

DI: 6 months

Citation
Coyer et al.,
(2015) Reducing
Pressure Injuries
in Critically ill
Patients by Using
a Patient Skin
Integrity Ce
Bundle (inspire).
Funding: Grant
by Royal Brisbane
and Women’s
Hospital
Foundation and
the School of
Nursing,
Queensland

Conceptual
Framework
None listed.

Design/Method

Sample/Setting

Design: QE
before and after
design with
control group.

SS total: n= 207

Purpose: Test a
PUP bundle
(InSpire Protocol)
for reducing PI in
the critically ill
Adult ICU
population

Intervention
group: n= 105

Major Variable &
Definitions

IC: Admitted to
ICU, expected
LOS >24 Hrs.,
Age >18YO.
EC: Community
acquired loss of
skin integrity on
admission, PI
within 24 Hrs. of

KaplanMeier
survival
analysis to
compare

DV: Incidence of PI

Data collection
form, skin
assessment tool,
PI staging tools,
Digital images,

Analysis
SPSS,
Descriptive
statics for
means and
SD for
continuous
variables.
Freq and %
for
categorical
variables.

Control group: n
= 102

IV: Intervention with
PIPP bundle

Measurement

Findings
PI
cumulative
incidence
significant
difference
(x2=4.3,
P=.05).
Intervention
fewer PI
events over
time. (logrank [MantelCox] =
11.842, df=1,
P<.001)

Decision for
use
LOE: 3
Strengths:
Clear cause and
effect.
Well balanced
control and
intervention
groups.
Groups similar.
First study to
look at device
related PI

Key : BMI: Body Mass Index, CA- Content Analysis, CT- Clinical Trial, DI: Duration of Intervention DQ- Descriptive Qualitative, DS- Databases Searched, DV- Dependent
Variable, EC- Exclusion Criteria, Edu- Education, Freq: Frequency, HAPI: Hospital Acquired Pressure Injury, Hrs.: Hours, IC- Inclusion Criteria, , ICU: Intensive Care Unit,
IP: Inpatient IV- Independent Variable, LOE- Level Of Evidence, LOS: Length of Stay, LPN- Licensed Practical Nurse, MA- Meta Analysis, N: Sample Size (Studies), n:
Sample size (People), NRNCT- Non-randomized Non-Controlled Trial, PARIHS: Promoting Action on Research Implementation in Health Services, PI- Pressure Injury, PUPressure Ulcer, PIPP- Pressure Injury Prevention Program, PUKAT- Pressure Ulcer Knowledge Assessment Tool, Q: Question, QE: Quasi- experimental, RCS: Retrospective
Cross-sectional Study, RCT- Randomized control trial, RN- Registered Nurse, SD- Standard Deviation, SR- Systematic Review, SS: Sample Size, TMC- Tucson Medical Center,
USA: United States of America, WOC: Wound Ostomy Care, YO- Years Old,

PRESSURE INJURY PREVENTION

33

University of
Technology.
Purchase subsidy
provided by Sage
Products Global
and Mayo
Healthcare,
Australia.

ICU admission,
Medical orders
contraindicating
intervention.

time to
new PI
between
groups.

Heel PI more
common in
control
(P=.02)

SETTING: 36
bed general adult
ICU

Bias: None
recognized.

DI: Conducted
for 12 months.
Recruitment to
discharge.

X2 Test of
independen
ce used to
determine
differences
in PI stage
and
process of
care.
Logistic
analysis
used to
adjust
confounder
s

Mucous
injury less
often in
control
(P<.001)

Country:
Australia

Citation
Sving et al.,
(2016). Getting
evidence-based
pressure ulcer
prevention into
practice: a multifaceted unittailored

Conceptual
Framework

Design/Method

PARIHS
framework.

QE clustered pre
and Posttest.
Purpose:
Evaluate if multifaceted, unittailored EB
interventions
affect PI

Sample/Setting
Total Patient
n = 506.
Patient Pretest
n = 251.
Patient Posttest

Major Variable &
Definitions
IV: Intervention
with PIPP bundle
DV: Pressure
ulcer prevalence

Measurement

Data collection
prevalence,
observation,
review or
records.
Modified
northern scale
to assign at

Analysis

SPSS
Logistic
regression for
intervention
effect on
dichotomous
variables.

Weakness:
only QE.
Unclear what
initial
assessment of
eligibility
No mention of
patient consent.
Feasibility/App
licability to Pt.
population:
Utilizes a PUP
bundle that can
be implemented
in a hospital.

Findings
Post-test PUP
care increase
P=0.021
Increase in
offloading of
heals P=0.001

Decision for
use
LOE: 3
Strengths:
good use of
frameworks.

Key : BMI: Body Mass Index, CA- Content Analysis, CT- Clinical Trial, DI: Duration of Intervention DQ- Descriptive Qualitative, DS- Databases Searched, DV- Dependent
Variable, EC- Exclusion Criteria, Edu- Education, Freq: Frequency, HAPI: Hospital Acquired Pressure Injury, Hrs.: Hours, IC- Inclusion Criteria, , ICU: Intensive Care Unit,
IP: Inpatient IV- Independent Variable, LOE- Level Of Evidence, LOS: Length of Stay, LPN- Licensed Practical Nurse, MA- Meta Analysis, N: Sample Size (Studies), n:
Sample size (People), NRNCT- Non-randomized Non-Controlled Trial, PARIHS: Promoting Action on Research Implementation in Health Services, PI- Pressure Injury, PUPressure Ulcer, PIPP- Pressure Injury Prevention Program, PUKAT- Pressure Ulcer Knowledge Assessment Tool, Q: Question, QE: Quasi- experimental, RCS: Retrospective
Cross-sectional Study, RCT- Randomized control trial, RN- Registered Nurse, SD- Standard Deviation, SR- Systematic Review, SS: Sample Size, TMC- Tucson Medical Center,
USA: United States of America, WOC: Wound Ostomy Care, YO- Years Old,

PRESSURE INJURY PREVENTION
intervention in a
hospital setting.
Funding: Center
for Research &
Development,
Uppsala/County
Council.
Bias: None
recognized.
Country: Sweden.

prevention, PI
prevalence,
Knowledge and
attitudes of nurses
and staff.

34
n = 255.
Total nurses
n = 276
Nurse pretest
n=145.
Nurse Posttest
N= 130.
IC: Consenting
patients Over 18
YO admitted
before midnight
on day when PI
survey done
Nurses working
units.
EC: None listed.
Setting: 5
Swedish general
hospital units. 3
surgical 2
medical units.
DI: between 6-8
months per unit.

risk,
Questionnaire,
PUKAT,
APUP

Between group
differences tested
Student’s twotailed T-test
significance set to
.05.

Use of sliding
sheets increase
P=0.026

Units included
at different
points of time.

24 Hr.
assessment of PI
increased
P=0.008.

Multiple units
from different
parts of hospital
provided a more
diverse
population.

Nurse knowledge
increased P=.001
mean sore 63%.

Demographic
data the same
A good
description of
the intervention.
Weakness:
Likely to soon
to look at effect
as data for PI
showed no
change.

Feasibility/App
licability to Pt.
population:
Useful to see
data on nurse
knowledge and

Key : BMI: Body Mass Index, CA- Content Analysis, CT- Clinical Trial, DI: Duration of Intervention DQ- Descriptive Qualitative, DS- Databases Searched, DV- Dependent
Variable, EC- Exclusion Criteria, Edu- Education, Freq: Frequency, HAPI: Hospital Acquired Pressure Injury, Hrs.: Hours, IC- Inclusion Criteria, , ICU: Intensive Care Unit,
IP: Inpatient IV- Independent Variable, LOE- Level Of Evidence, LOS: Length of Stay, LPN- Licensed Practical Nurse, MA- Meta Analysis, N: Sample Size (Studies), n:
Sample size (People), NRNCT- Non-randomized Non-Controlled Trial, PARIHS: Promoting Action on Research Implementation in Health Services, PI- Pressure Injury, PUPressure Ulcer, PIPP- Pressure Injury Prevention Program, PUKAT- Pressure Ulcer Knowledge Assessment Tool, Q: Question, QE: Quasi- experimental, RCS: Retrospective
Cross-sectional Study, RCT- Randomized control trial, RN- Registered Nurse, SD- Standard Deviation, SR- Systematic Review, SS: Sample Size, TMC- Tucson Medical Center,
USA: United States of America, WOC: Wound Ostomy Care, YO- Years Old,

PRESSURE INJURY PREVENTION

35
change in
practice.
Multiple areas
of hospital
evaluated.
Usable
framework and
data collection
method.
Lessons learned
about the time
frame for data
collection.

Citation
Mallah et al,
(2015). The
Effectiveness of a
Pressure Ulcer
Intervention
Program on the
Prevalence of
Hospital Acquired
Pressure Ulcers:
Controlled Before
and After Study.
Funding: None
listed.

Conceptual
Framework
None listed.

Design/Method
Prospective
research design
with pre and postintervention data.
Purpose:
Determine
efficacy and asses
which component
of the intervention
was most
predictive of
decreasing HAPI.

Sample/Setting
SS: n= 486
patients.
IC: verbal
consent,
admitted to the
hospital.

Major Variable &
Definitions
IV1: LOS.
IV2: Braden Score.
IV3: Prevention
Strategies.

EC: None listed.

DV: Development of
HAPI.

Setting: 19
inpatient units in
a tertiary medical

Definition: HAPI- Any
ulcer noted 24 or more
Hrs. after admission.

Measurement
Survey, Braden
Scale, NPUAP PI
staging guideline.
Electronic PI
reporting.

Analysis
SPSS
Univariate
analysis to
describe
sample.
Percent for
categories.
Mean and
SD for
continuous
variables.
X2 testing
for before

Findings

Decision for
use

HA PI
reduced after
intervention
x2= 7.64,
P<0.01.

LOE: 3

Braden scale
sensitivity
=92.3%.

Broad-spectrum
across the
hospital.

Specificity =
60.4%.

Weaknesses:

Strengths:
Good sample
size.

LOS
significant PI

Key : BMI: Body Mass Index, CA- Content Analysis, CT- Clinical Trial, DI: Duration of Intervention DQ- Descriptive Qualitative, DS- Databases Searched, DV- Dependent
Variable, EC- Exclusion Criteria, Edu- Education, Freq: Frequency, HAPI: Hospital Acquired Pressure Injury, Hrs.: Hours, IC- Inclusion Criteria, , ICU: Intensive Care Unit,
IP: Inpatient IV- Independent Variable, LOE- Level Of Evidence, LOS: Length of Stay, LPN- Licensed Practical Nurse, MA- Meta Analysis, N: Sample Size (Studies), n:
Sample size (People), NRNCT- Non-randomized Non-Controlled Trial, PARIHS: Promoting Action on Research Implementation in Health Services, PI- Pressure Injury, PUPressure Ulcer, PIPP- Pressure Injury Prevention Program, PUKAT- Pressure Ulcer Knowledge Assessment Tool, Q: Question, QE: Quasi- experimental, RCS: Retrospective
Cross-sectional Study, RCT- Randomized control trial, RN- Registered Nurse, SD- Standard Deviation, SR- Systematic Review, SS: Sample Size, TMC- Tucson Medical Center,
USA: United States of America, WOC: Wound Ostomy Care, YO- Years Old,

PRESSURE INJURY PREVENTION

36

Bias: None
recognized.

center in
Lebanon.

and after
HAPI.

Country:
Lebanon.

DI: 6 months
pre-intervention
6 postintervention.

Sensitivity
and
specificity
analysis for
Braden
scale.
T-tests and
univariate
analysis
comparing
potential
risk for
with and
without
HAPI.
Multivariat
e logistic
regression
analysis for
impact of
the
potential
risk
Model
validation
with
Hosmer
and
Lemeshow

development
(t = 3.06,
P=0.032).

Value in
evaluating other
risk factors.

Braden scale
significant

Only looks at
rate of PI not
incidence.

(t= 4.55,
P=0.023).
Braden score
and skin care
significant
with multiple
logistic
regression
Braden score
OR1.187
(CL=1.0311.546, p
=0.03)
Skin care OR
= .058
(CL=.0360.092, p =
0.98)

Conclusions:
Skincare
management
and Braden
scores best
indicators for
the
development of
PI
Feasibility/App
licability to Pt.
population:
A similar
population
looks at
multiple areas
of hospital.
Disuses the use
of nursing
education as
part of
intervention.

Key : BMI: Body Mass Index, CA- Content Analysis, CT- Clinical Trial, DI: Duration of Intervention DQ- Descriptive Qualitative, DS- Databases Searched, DV- Dependent
Variable, EC- Exclusion Criteria, Edu- Education, Freq: Frequency, HAPI: Hospital Acquired Pressure Injury, Hrs.: Hours, IC- Inclusion Criteria, , ICU: Intensive Care Unit,
IP: Inpatient IV- Independent Variable, LOE- Level Of Evidence, LOS: Length of Stay, LPN- Licensed Practical Nurse, MA- Meta Analysis, N: Sample Size (Studies), n:
Sample size (People), NRNCT- Non-randomized Non-Controlled Trial, PARIHS: Promoting Action on Research Implementation in Health Services, PI- Pressure Injury, PUPressure Ulcer, PIPP- Pressure Injury Prevention Program, PUKAT- Pressure Ulcer Knowledge Assessment Tool, Q: Question, QE: Quasi- experimental, RCS: Retrospective
Cross-sectional Study, RCT- Randomized control trial, RN- Registered Nurse, SD- Standard Deviation, SR- Systematic Review, SS: Sample Size, TMC- Tucson Medical Center,
USA: United States of America, WOC: Wound Ostomy Care, YO- Years Old,

PRESSURE INJURY PREVENTION

37
goodnessof-fit
statistic
chisquared
test.

Citation
Baron et al.,
(2016).
Experimental
study with nursing
staff related to the
knowledge about
pressure ulcers.
Bias: None
recognized.
Funding: None
stated.
Country: Brazil.

Conceptual
Framework
None listed.

Design/Method
Quantitated QE
design with
control groups.

Sample/Setting

Analysis

Findings

SPSS,
Independe
nt double
typing
EpiInfo.

Similar
demographic
characteristic
s between
groups.

IC: Staff that
agreed to
participate with
informed
consent.

Distributio
n tested
with
Kolmogoro
v-Smirnov
test.

No difference
found
between pretest group
scores (P>
0.05).

EC: Staff not
available for
initial questioner.
Staff that score
over 90% on
questioner, staff
that scored under
75% on
questioner.

Nonnormal
distribution
data tested
with nonparametric
tests.

Post testing
found
significant
difference
(P= 0.001)
87.8%
correct.

Demograp
hic data

Post-test
control group

SS: total n=71
Nurses n = 12
Nurse
technicians n=74

Purpose:
Evaluate
knowledge of PI
interventions after
before and after
education.

Major Variable &
Definitions
IV: 10 weeks of PI
prevention education.
DV: Knowledge scores

Measurement
Socidemographic
questioner.
Adapted Piper
Knowledge test

Decision for
use
LOE: 3
Strengths:
multiple sights.
Clear
description of
testing
questions.
Good support
from other
studies on
results.
Also looks at
Nursing
technician
knowledge.
Weaknesses:
Did not make

Key : BMI: Body Mass Index, CA- Content Analysis, CT- Clinical Trial, DI: Duration of Intervention DQ- Descriptive Qualitative, DS- Databases Searched, DV- Dependent
Variable, EC- Exclusion Criteria, Edu- Education, Freq: Frequency, HAPI: Hospital Acquired Pressure Injury, Hrs.: Hours, IC- Inclusion Criteria, , ICU: Intensive Care Unit,
IP: Inpatient IV- Independent Variable, LOE- Level Of Evidence, LOS: Length of Stay, LPN- Licensed Practical Nurse, MA- Meta Analysis, N: Sample Size (Studies), n:
Sample size (People), NRNCT- Non-randomized Non-Controlled Trial, PARIHS: Promoting Action on Research Implementation in Health Services, PI- Pressure Injury, PUPressure Ulcer, PIPP- Pressure Injury Prevention Program, PUKAT- Pressure Ulcer Knowledge Assessment Tool, Q: Question, QE: Quasi- experimental, RCS: Retrospective
Cross-sectional Study, RCT- Randomized control trial, RN- Registered Nurse, SD- Standard Deviation, SR- Systematic Review, SS: Sample Size, TMC- Tucson Medical Center,
USA: United States of America, WOC: Wound Ostomy Care, YO- Years Old,

PRESSURE INJURY PREVENTION

38
Setting: 3 ICU’s
in general
hospitals in
Brazil. One large
hospital two
medium
hospitals.
DI: 4 months
total
Intervention
education once a
week for 10
weeks for one
Hr. each.

shows
distribution
and
frequency
as means
and SD.

no significant
difference in
scores
(P>0.05)
79.1%
correct.

Chi-square
test
assesses
relationshi
ps in
demograph
ic data and
knowledge.
used to
verify
association
of scores.

No
relationship
between
gender,
knowledge.
Age,
knowledge.
Training
time,
knowledge.

MannWhitney
test used to
verify
possible
differences
of correct
scores
between
groups.
Wilcoxon
test for
pre- and

90%
improvement.
Unclear number
of participants
from what
hospital.
Exclusion
inclusion
criteria weak.
Conclusions:
Education
improves
knowledge
scores.
Feasibility/App
licability to Pt.
population:
Would be worth
looking into
nursing
technicians as
part of the study
population as
they also are
part of care.
In-patient
population.

Key : BMI: Body Mass Index, CA- Content Analysis, CT- Clinical Trial, DI: Duration of Intervention DQ- Descriptive Qualitative, DS- Databases Searched, DV- Dependent
Variable, EC- Exclusion Criteria, Edu- Education, Freq: Frequency, HAPI: Hospital Acquired Pressure Injury, Hrs.: Hours, IC- Inclusion Criteria, , ICU: Intensive Care Unit,
IP: Inpatient IV- Independent Variable, LOE- Level Of Evidence, LOS: Length of Stay, LPN- Licensed Practical Nurse, MA- Meta Analysis, N: Sample Size (Studies), n:
Sample size (People), NRNCT- Non-randomized Non-Controlled Trial, PARIHS: Promoting Action on Research Implementation in Health Services, PI- Pressure Injury, PUPressure Ulcer, PIPP- Pressure Injury Prevention Program, PUKAT- Pressure Ulcer Knowledge Assessment Tool, Q: Question, QE: Quasi- experimental, RCS: Retrospective
Cross-sectional Study, RCT- Randomized control trial, RN- Registered Nurse, SD- Standard Deviation, SR- Systematic Review, SS: Sample Size, TMC- Tucson Medical Center,
USA: United States of America, WOC: Wound Ostomy Care, YO- Years Old,

PRESSURE INJURY PREVENTION

39
postperiods.
Significanc
e a<0.05.

Citation
Smith et al.,
(2018).
Evaluation of a
multifactorial
approach to
reduce the
prevalence of
pressure injuries
in regional
Australian acute
inpatient care
settings.
Bias: None
recognized.
Funding: None
listed.
Country:
Australia

Conceptual
Framework
Knowledge
translation
theory.
Modified
theory of
planned
behavior.
.

Design/Method

Sample/Setting

Quantitative
Retrospective
cross-sectional
study.

SS:

Purpose:
Compare changes
in PI prevalence
in relation to staff
behavior after
implementation of
the Crystal model.

2014 n = 1199.

2008 n= 1407.
2010 n= 1331.

IC: In hospital at
the time of
prevalence check
over 18 YO,
verbal consent,
EC: Pediatric
patients,
obstetrics
patients,
psychiatric
patients, OR
patients, same
day surgery
patients.
Setting: Public
health care with

Major Variable &
Definitions

Measurement

Analysis

Findings

IV: The change over
time in the PUP model to
reflect international
guidelines regarding
education, Best Practice
evidence and,
surveillance.

Point prevalence
survey tool.

Descriptive
statistics to
identify
changes
and
patterns in
data.

N for
pressure
injuries
decreased
from 414 in
2008 to 173
in 201 to 137
in 2014.

LOE: 3

Documented
repositioning
increased to
74% from
20.6%.

Weaknesses:

Documentati
on of PI risk
assessment
increased
from 78.9%
in 2008 to
84.3% in
2014.

Evaluation tool
changed with
time.

DV: Current PI rate at
time of prevalence
survey over 6 years.

PI risk tool.

Compared
means and
percent of
categorical
and
numerical
data.

Decision for
use

Strengths:
A retrospective
look at PI data
when
implementing a
PIPP.

Needs more
control for
outcomes.

PIPP changed
over time.
Conclusions:
There is some
supporting
evidence that a

Key : BMI: Body Mass Index, CA- Content Analysis, CT- Clinical Trial, DI: Duration of Intervention DQ- Descriptive Qualitative, DS- Databases Searched, DV- Dependent
Variable, EC- Exclusion Criteria, Edu- Education, Freq: Frequency, HAPI: Hospital Acquired Pressure Injury, Hrs.: Hours, IC- Inclusion Criteria, , ICU: Intensive Care Unit,
IP: Inpatient IV- Independent Variable, LOE- Level Of Evidence, LOS: Length of Stay, LPN- Licensed Practical Nurse, MA- Meta Analysis, N: Sample Size (Studies), n:
Sample size (People), NRNCT- Non-randomized Non-Controlled Trial, PARIHS: Promoting Action on Research Implementation in Health Services, PI- Pressure Injury, PUPressure Ulcer, PIPP- Pressure Injury Prevention Program, PUKAT- Pressure Ulcer Knowledge Assessment Tool, Q: Question, QE: Quasi- experimental, RCS: Retrospective
Cross-sectional Study, RCT- Randomized control trial, RN- Registered Nurse, SD- Standard Deviation, SR- Systematic Review, SS: Sample Size, TMC- Tucson Medical Center,
USA: United States of America, WOC: Wound Ostomy Care, YO- Years Old,

PRESSURE INJURY PREVENTION

40
4organization in
North Southwest
Wales Australia
with 41 inpatient
facilities.

PIPP with an elearning
component does
improve PI
rates over time.

DI: 2008-2014
prevalence
surveys.

Evaluation tool
changed over
time.
Feasibility/App
licability to Pt.
population:
Modality of
multiple
hospitals as
well as utilizes
a prevalence
survey gives
some idea of
long-term
impact of PIPP.

Citation
Dalvand, et al.,
(2018). Nurses’
knowledge on
pressure injury
prevention: A
systematic review
and meta-analysis
based on the

Conceptual
Framework
None Listed

Design/Method
SR and metaanalysis
Purpose: Assess
the overall
knowledge of
nurses on PI
prevention based
on their scores on

Sample/Setting
SS: 8 studies
11 groups
N=4766
IC: use PUKAT
reported required
data.

Major Variable &
Definitions
IV: The application of
the PUKAT to measure
staff knowledge.
DV: Nursing staffs
having appropriate
wound care knowledge

Measurement

Analysis

Findings

Pressure ulcer
knowledge
assessment tool
questionnaires

Statistical
analysis
done with
STATA
version 12
software

All Below
desired 60%.

STROBE

Knowledge
score all
commers
53.1% (95%

Decision for
use
LOE: 1
Strengths:
Easily
represented
data.

Binomial
distribution

Key : BMI: Body Mass Index, CA- Content Analysis, CT- Clinical Trial, DI: Duration of Intervention DQ- Descriptive Qualitative, DS- Databases Searched, DV- Dependent
Variable, EC- Exclusion Criteria, Edu- Education, Freq: Frequency, HAPI: Hospital Acquired Pressure Injury, Hrs.: Hours, IC- Inclusion Criteria, , ICU: Intensive Care Unit,
IP: Inpatient IV- Independent Variable, LOE- Level Of Evidence, LOS: Length of Stay, LPN- Licensed Practical Nurse, MA- Meta Analysis, N: Sample Size (Studies), n:
Sample size (People), NRNCT- Non-randomized Non-Controlled Trial, PARIHS: Promoting Action on Research Implementation in Health Services, PI- Pressure Injury, PUPressure Ulcer, PIPP- Pressure Injury Prevention Program, PUKAT- Pressure Ulcer Knowledge Assessment Tool, Q: Question, QE: Quasi- experimental, RCS: Retrospective
Cross-sectional Study, RCT- Randomized control trial, RN- Registered Nurse, SD- Standard Deviation, SR- Systematic Review, SS: Sample Size, TMC- Tucson Medical Center,
USA: United States of America, WOC: Wound Ostomy Care, YO- Years Old,

PRESSURE INJURY PREVENTION
Pressure Ulcer
Knowledge
Assessment Tool.
Funding: No
funding was
received for the
study.
Bias: tested for
publication bias
found not to be
significant.
Reported no
conflicts of
interest.
Country:
Iran

the Pressure Ulcer
Knowledge
Assessment Tool
and its subscales
in different
settings.

41
EC: lack of
access to
article’s full text
use of other tools
DS: PubMed,
Science Direct,
Scopus, Web of
Science

formula for
variance

CI: 47.558.8)

Good sample
size.

Weighted
mean for
percent of
each study.

Nursing
knowledge
(55.4% 95%
CI: 42.368.4)

Broader
population type
than most
available
studies
currently.

Random
effect
model to
combine
studies and
estimate
dimension
scores.

Lowest
scores on
prevention

Commonly
used tool with
good evidence
for use.
Weaknesses:
Limited depth
of use with
other tools.
DS several
outside normal.
Conclusion:
Evidence
supports that
nursing staff
knowledge is
limited
worldwide. The
use of PUKAT
useful in

Key : BMI: Body Mass Index, CA- Content Analysis, CT- Clinical Trial, DI: Duration of Intervention DQ- Descriptive Qualitative, DS- Databases Searched, DV- Dependent
Variable, EC- Exclusion Criteria, Edu- Education, Freq: Frequency, HAPI: Hospital Acquired Pressure Injury, Hrs.: Hours, IC- Inclusion Criteria, , ICU: Intensive Care Unit,
IP: Inpatient IV- Independent Variable, LOE- Level Of Evidence, LOS: Length of Stay, LPN- Licensed Practical Nurse, MA- Meta Analysis, N: Sample Size (Studies), n:
Sample size (People), NRNCT- Non-randomized Non-Controlled Trial, PARIHS: Promoting Action on Research Implementation in Health Services, PI- Pressure Injury, PUPressure Ulcer, PIPP- Pressure Injury Prevention Program, PUKAT- Pressure Ulcer Knowledge Assessment Tool, Q: Question, QE: Quasi- experimental, RCS: Retrospective
Cross-sectional Study, RCT- Randomized control trial, RN- Registered Nurse, SD- Standard Deviation, SR- Systematic Review, SS: Sample Size, TMC- Tucson Medical Center,
USA: United States of America, WOC: Wound Ostomy Care, YO- Years Old,

PRESSURE INJURY PREVENTION

42
determining
knowledge.
Feasibility/App
licability to Pt.
population:
analysis shows
target change to
be nursing staff
knowledge. Use
of evaluation
tool fit well
with situation at
projected sight.

Key : BMI: Body Mass Index, CA- Content Analysis, CT- Clinical Trial, DI: Duration of Intervention DQ- Descriptive Qualitative, DS- Databases Searched, DV- Dependent
Variable, EC- Exclusion Criteria, Edu- Education, Freq: Frequency, HAPI: Hospital Acquired Pressure Injury, Hrs.: Hours, IC- Inclusion Criteria, , ICU: Intensive Care Unit,
IP: Inpatient IV- Independent Variable, LOE- Level Of Evidence, LOS: Length of Stay, LPN- Licensed Practical Nurse, MA- Meta Analysis, N: Sample Size (Studies), n:
Sample size (People), NRNCT- Non-randomized Non-Controlled Trial, PARIHS: Promoting Action on Research Implementation in Health Services, PI- Pressure Injury, PUPressure Ulcer, PIPP- Pressure Injury Prevention Program, PUKAT- Pressure Ulcer Knowledge Assessment Tool, Q: Question, QE: Quasi- experimental, RCS: Retrospective
Cross-sectional Study, RCT- Randomized control trial, RN- Registered Nurse, SD- Standard Deviation, SR- Systematic Review, SS: Sample Size, TMC- Tucson Medical Center,
USA: United States of America, WOC: Wound Ostomy Care, YO- Years Old,

PRESSURE INJURY PREVENTION

43
Appendix B

Table 2
Syntheses Table
Author

Suva et
al.,

Design

LOE
Demographics
Age

Sample Size/ #
of Studies
Included

Martin et
al.,
20
17

1

2

3

N
/
A

52YO and
47.5YO

85%
between
26-55YO

X

X

2
0
1
7
S
R

Year

Setting:
In-patient

Tayyib et
al.,
2
0
1
5
R
C
T

N/A

1
7
p
a
p
e
r
s

140
patients

M
M
S

80 staff
tested

Anderson et
al.,
2015

Coyer et
Sving et
al.,
al.,
2
2
0
0
1
1
5
6
QE
Q
Q
PIPI
E
E
P
P
I
I
P
P
I
I
3
3
3
Study Characteristics

Mallah et
al.,
20
15

Baron et al.,

P
R
PI
PI

QS/
ED

3

3

Patient’s
mean age:
78

Mean age:
44.69

Intervention
group mean
age: 33.8

N
/
A

X

X

X

X

Pretest mean
age: 63.25
Posttest mean
age: 62.03

Mean
age: 55

X

327 PIPI total

X

207
patients

506
patients,
208
HCS staff

420
patients

Smith et
al.,

201
6

71 total staff
1/3 MA

2
0
1
7
C
S
R
Q
R

Mahalingam
et al.,
201
8

SR

3

3937
patient
charts

3

N/A

X

4,766

CSRQR- Cross-sectional retrospective quantitative research, HAPI- Hospital Acquired Pressure Injury, HCS - Health Care System, N/A- not applicable, MA- Medical assistants,
MMS- Mixed method study, NRNCT- Nonrandomized Noncontrolled Trial, PI- Pressure Injury, PIPI- Pre-intervention Post-intervention, PR- Prospective Research, PTPTPre-test Post-test, PU- Pressure ulcer, PUKAT- Pressure Ulcer Knowledge Assessment Tool, PIPP- Pressure Injury Prevention Program, QE: Quasi- experimental, QS/EDQuantitative study with experimental design, RCT- Randomized control trial, SR- Systematic Review, YO- Years old.

PRESSURE INJURY PREVENTION

44

Measurement
Tools

N/A

PU count

PUKAT
shortened

# of PI

Duration

N/A

784 days

15 min
online
tutorial and
roll out of
PIPP

Four months
preintervention
five months
postintervention
X

X

PIPP used

Education
Improved
Outcomes

X

X

X

X

# of PI

Staff
PUKAT
and
APUP.
Patient
modified
Norton
scale # PI
12 months 17 months
of data
collection,
one-month
training
X

Braden
scale, chart
review

Piper test

Survey
data

PUKAT

Six-month
pre, sixmonth post

Once a week
for ten weeks

Six years

N/A

X

X

X

X

N/A

X

N/A

CSRQR- Cross-sectional retrospective quantitative research, HAPI- Hospital Acquired Pressure Injury, HCS - Health Care System, N/A- not applicable, MA- Medical assistants,
MMS- Mixed method study, NRNCT- Nonrandomized Noncontrolled Trial, PI- Pressure Injury, PIPI- Pre-intervention Post-intervention, PR- Prospective Research, PTPTPre-test Post-test, PU- Pressure ulcer, PUKAT- Pressure Ulcer Knowledge Assessment Tool, PIPP- Pressure Injury Prevention Program, QE: Quasi- experimental, QS/EDQuantitative study with experimental design, RCT- Randomized control trial, SR- Systematic Review, YO- Years old.

PRESSURE INJURY PREVENTION

45
Appendix C

Figure 1
Diagram of Knowledge to action framework (Graham, et al., 2006).

PRESSURE INJURY PREVENTION

46
Appendix D

Figure 2
Diagram of Conner conceptual mode for research utilization evaluation (Conner, 1980).

PRESSURE INJURY PREVENTION

47
Appendix E

Table 3
Budget

Pressure Injury Education evaluation cost analysis table
Description
Cost
Direct Costs
Supplies and handouts $150.00
Promotional supplies
X4 $25.00 gift cards
Indirect Cost
Utilization of hospital
$100.00
equipment (Room with
computers)
Employee time $29 per $615.00 likely much
hr for 20 employees for less as a quiz can be
1 hr.
taken after work or on
break.
Funding
WOC Budget
$100.00
Unit Budget
Hospital Budget
Cost Savings
Savings
Development
$35.66 an hr for >200
$7,132.00 for 200 hr
hr
Cost of individual
$20,000.
$20,000
patient care for one
pressure Injury
Online evaluation tool
Self-developed google
$384.00
form
PUKAT
Permission to use free
unknown
Total cost
$965.00
Total saved
$27,516.00

PRESSURE INJURY PREVENTION

48
Appendix F

Table 4
Two-tailed Paired Samples t-Test

Two-Tailed Paired Samples t-Test for the Difference Between Pre_Education_Summary
and Post_education_Summary
Pre_Quiz_Summary
Post_Quiz_Summary
M
SD
M
SD
t
p
0.57
0.09
0.69
0.14
-3.46
.009
Note. N = 9. Degrees of Freedom for the t-statistic = 8. d represents Cohen's d.

Figure 3

d
1.15

PRESSURE INJURY PREVENTION

49
Appendix G

Table 5

Figure 4