Collegian 26 (2019) 95–102

Contents lists available at ScienceDirect

Collegian
journal homepage: www.elsevier.com/locate/coll

A qualitative study of the thoughts and experiences of hospital nurses

providing pressure injury prevention and management
Michelle Barakat-Johnson a,b,d,∗ , Michelle Lai a,c , Timothy Wand a,b,e , Kathryn White a,b,c
a
Faculty of Medicine and Health, The University of Sydney, Camperdown, Sydney, Australia
b
Sydney Local Health District, Sydney, Australia
c
The Cancer Nursing Research Unit, Level 6 North, Chris O’Brien Lifehouse, Missenden Road, Camperdown, Sydney, Australia
d
Patient Safety and Quality, Level 7, King George V Building, Royal Prince Alfred Hospital, Missenden Road, Camperdown, Sydney, Australia
e
Emergency Department, Royal Prince Alfred Hospital, Missenden Road, Camperdown, Sydney, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Hospital-acquired pressure injuries are a quality indicator in healthcare, including nursing
Received 7 December 2017 care. Successful implementation of interventions to prevent pressure injuries can be impeded by factors
Received in revised form 24 February 2018 beyond the control of nursing staff. Limited research exists on nurses’ experiences of providing pressure
Accepted 25 April 2018
injury prevention and management in a hospital setting.
Aim: To gain an in-depth understanding of nurses’ experiences concerning pressure injury prevention
Keywords:
and management in a hospital setting.
Barriers
Methods: A qualitative study design was employed. The purposive sample consisted of twenty nurses
Experiences
Hospital working in units with a high incidence of pressure injuries across a local health district in Sydney,
Nurses Australia. Participants were interviewed between May and September 2016, either individually or as
Perception a group using semi-structured interviews.
Pressure injury management Findings: Four themes were identified that captured the experiences of nurses providing pressure injury
Pressure injury prevention prevention and management in a hospital setting: “managing competing demands in complex clinical
Qualitative research settings”; “the importance of knowledge and skill”; “clarifying organisational expectations, purpose and
successes”; and “feeling ethically challenged when unable to provide quality patient care”.
Discussion: Participants were aware of the importance of pressure injury prevention and management
but found it difficult to provide quality care due to competing priorities and challenges faced at both an
organisational and patient level.
Conclusion: Pressure injury prevention and management is just one aspect of patient care and should not
be considered on its own to change existing practice. Participants wanted to implement preventative
strategies and provide optimal pressure injury care, however, complexities associated with a hospital
setting hindered this process. Hospitals need to put measures in place that support and enable nurses to
deliver the quality care required to prevent and manage pressure injuries.
© 2018 Australian College of Nursing Ltd. Published by Elsevier Ltd.

1. Introduction reported that PIs adversely affect their emotional, mental, physi-
cal, and social health (Essex, Clark, Sims, Warriner, & Cullum, 2009;
Pressure injuries (PIs) remain a significant clinical concern neg- Gorecki et al., 2012; Spilsbury et al., 2007). Furthermore, hospital-
atively impacting on the quality of life of patients (Bale, Dealey, acquired pressure injuries (HAPIs) also increase hospital length
Defloor, Hopkins, & Worboys, 2007; Chou et al., 2013; Gorecki, of stay and public health system costs which is estimated to be
Nixon, Madill, Firth, & Brown, 2012). For example, patients have over AU$900 million (Cooper, 2013; Nguyen, Chaboyer, & Whitty,
2015). Globally, PIs are the most common iatrogenic problem with
prevalence rates reported to range between 12% and 17% in Europe
∗ Corresponding author at: Sydney Local Health District and Faculty of Medicine (Gunningberg, Hommel, Baath, & Idvall, 2013; Moore & Cowman,
and Health, The University of Sydney, Camperdown, Sydney, Australia 2012); 12% and 19% in the US (Jenkins & O’Neal, 2010); an average
E-mail addresses: michelle.barakatjohnson@health.nsw.gov.au of 15% in the UK; and 2.5% to 17.6% in Australia (Clinical Excellence
(M. Barakat-Johnson), michelle.lai@sydney.edu.au (M. Lai) Commission, 2016; Miles, Fullbrook, Nowicki, 2013; Mulligan,
tim.wand@health.nsw.gov.au (T. Wand), kate.white@sydney.edu.au (K. White).
Prentice, Scott, 2011; Santamaria, McCann, O’Keefe, Rakis, Sage,
URLs: http://www.twitter.com/helle@barakm2016 (M. Barakat-Johnson).

https://doi.org/10.1016/j.colegn.2018.04.005
1322-7696/© 2018 Australian College of Nursing Ltd. Published by Elsevier Ltd.
96 M. Barakat-Johnson et al. / Collegian 26 (2019) 95–102

further research to gain a deeper understanding of factors that

Summary of relevance affect PIPM.
Problem or issue An insight into nurses’ experience of PIPM is therefore war-
The experiences of hospital nurses concerning pressure injury ranted to identify areas for practice improvement, education, and
care has received little qualitative exploration.
ultimately, better patient care and outcomes. Complexities encoun-
What is already known?
tered when providing PIPM, and successful strategies employed by
Hospital-acquired pressure injuries are perceived to be an
indicator of poor quality nursing care. Existing international nurses, were of key interest. To the best of our knowledge, this is the
research on the prevention and management of pressure first study to report qualitative data in Australia of hospital nurses’
injuries has focused on nurses’ knowledge, attitudes, and per- experiences of PIPM.
ceptions through quantitative studies. The aim of this study was to gain an in-depth understanding of
What this paper adds? the experiences of nurses concerning PIPM in a hospital setting.
Nurses deliver pressure injury prevention and management
under difficult circumstances at a clinical, educational, and
organisational level. Nurses are internally conflicted about the 2. Methods
quality of pressure injury care, which they perceived to be, in
part, determined by factors out of their control. 2.1. Design

A qualitative exploratory research design using semi-structured

interviews was employed (Sandelowski, 2000). The methods of this
Tudor, Wei Ng, Morrow, 2015). Recently, in Australia, PIs have been study were guided by the “consolidated criteria for reporting qual-
identified as the fifth most costly commonly occurring preventable itative research” (COREQ) (Tong, Sainsbury, & Craig, 2007). This
complication in hospitals and have subsequently been included as study was one element of a broader study in the LHD examining
one of the eight national standards to improve safety and qual- the substantial increase in HAPIs.
ity care nationally (Australian Commission on Safety & Quality in
Health Care, 2017). 2.2. Sampling and participants
Following an unexplained increase of reported incidents of
HAPIs (by 63% from 2010 to 2014) in a local health district (LHD) Purposive sampling was used to ensure that the cohort included
comprising of four hospitals in Sydney, Australia, an in-depth anal- both senior and junior nurses from orthopaedic, cardio-vascular,
ysis on all aspects of pressure injury prevention and management transplant, acute and medical aged care, neurosciences, rehabili-
(PIPM) was conducted as an overall study to understand reasons tation and intensive care units. These units were selected as they
for the increased HAPI rate. One component of the overall study had the highest incidence (just over 32%) of reported HAPIs over
sought to determine perceptions and attitudes of nurses to PIPM, a 12 month period compared to other units in this district. Addi-
which had provided insight into nurses’ perspective, but raised tionally, it has been consistently demonstrated that patients in
further questions for the research team. This article presents the these units are at high risk of developing PIs (National Pressure
findings of a qualitative study on the experiences of hospital nurses Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel &
in delivering PIPM. Pan Pacific Pressure Injury Alliance, 2014). The sample comprised
Research spanning three decades has highlighted that the of registered nurses, enrolled nurses, clinical nurse educators, clin-
majority of PIs could be avoided through interventions by clinicians, ical nurse specialists, and nurse unit managers in four hospitals
patients and carers. HAPIs are considered an indicator of poor qual- across the LHD.
ity care, particularly nursing care (Heslop & Lu, 2014; Jull & Griffiths, Participation was voluntary. Prospective participants returned
2010; Savitz, Jones, & Bernard, 2005). This is because nurses play an written or verbal expression of interest to the lead author subse-
integral role in preventing skin care complications (Lyder & Ayello, quent to the distribution of an information flyer. Also, a member
2008). At the frontline, nurses engage with skin care practices at of the research team invited nurses to participate at the nurses’
all stages, from prevention to treatment, and are thus the most afternoon handover at each of the clinical units identified as hav-
appropriate discipline to lead and implement initiatives for prac- ing a high incidence of PIs. To maintain anonymity, age was not
tice changes (Hiser et al., 2006; Yap & Kennerly, 2011). However, collected, however years of experience, and the participant’s role
despite best efforts to deliver effective care to patients, the daily were collected.
challenges faced by nurses with PIPM can be underestimated.
Few qualitative studies (Athlin, Idvall, Jernfalt, & Johansson,
2010; Samuriwo, 2010a; Samuriwo, 2010b; Sving, Gunningberg, 2.3. Data collection
Hogman, & Mamhidir, 2012) have considered nurses’ experiences
of PIPM in a hospital setting. Particularly their perceptions and A semi-structured interview guide comprising of demographic
values concerning PIPM, which affect care delivery and priorities. and open questions was developed by the authors to allow a more
Samuriwo (2010b) and Sving et al. (2012) showed that nurses’ in-depth exploration of nurses’ experiences (Table 1). The semi-
efforts at PIPM are challenged by organisational and environmental structured interview guide was reviewed by two expert wound
factors such as hospital flow, time constraints and the prioritisation nurses and two qualitative research experts, and piloted on five
of other nursing tasks. Even when processes to decrease PI rates senior and junior nurses. Data were collected between May and
are implemented, compliance with certain PI practices and policy September 2016. Interviews lasted between 20–40 minutes. Of
guidelines by nurses are low (Niederhauser et al., 2012; Sving et al., these, two group interviews were conducted and the remaining
2012). were held individually (Table 2). All interviews were conducted in
Similarly, Athlin et al. (2010) interviewed nurses on the con- a private location, chosen by the nurse-participant, ensuring their
tributing factors to the development and deterioration of PIs in participation was not known to members of their clinical unit. The
hospital and community settings. Factors included patient char- interviews were audio recorded and transcribed verbatim by an
acteristics, staff views and commitment, and the aforementioned independent transcription company. Field notes were also made
organisational factors. Overall, nurses placed less value on PIPM during the interviews. Participants were offered the opportunity
than on other aspects of patient care. The authors recommended to review their individual transcript, or a summary of the analysed
 M. Barakat-Johnson et al. / Collegian 26 (2019) 95–102 97

Table 1
Semi-structured interview guide.

Interview guide

What is your current level of employment?

From your experience, how successful is the current organisational approach
to hospital-acquired pressure injuries (HAPI)?
Describe your experience with a recent patient you cared for who had
developed a HAPI.
(What factors influenced the development?)
(What impact did it have on the patient?)
Figure 1. Thematic diagram showing four core themes from the analysis of nurse
(What worked/what didn’t work?)
interviews.
Reflecting on this experience, what was the outcome? What would you
recommend or change in relation to prevention of HAPI?
What are the barriers on a day-to-day basis you experience related to 2.6. Rigour
prevention and management of HAPI?
To ensure methodological rigour of the study, the framework of
credibility, authenticity, criticality and integrity guided this study
data. None elected to take up this offer. Data collection continued (Whittemore, Chase, & Mandle, 2001). A senior female research offi-
for each clinical unit until data saturation was reached. cer with a PhD and long-standing experience in qualitative research
conducted the interviews. She had no relationship with the par-
2.4. Ethical considerations ticipants. Interviews were transcribed verbatim, transcripts were
anonymised, and participants were invited to review and comment
The study was approved by the LHD Human Research Ethics on their transcripts. The researchers then analysed the transcripts
Committee (ref:HREC/15/RPAH/482). Ethical standards for this individually and met to review and confirm interpretation, field
study were upheld in accordance with The National Statement notes, and develop codes and themes. An audit trail that outlined
on Ethical Conduct in Human Research (The National Health & the processes that guided the interpretation of the data, as well as
Medical Research Council, The Australian Research Council, & The personal notes of the interviewer, was maintained (Koch, 2006).
Australian Vice-Chancellor’s Committee, 2007). Each participant
was informed of the aims of the study and written consent was 3. Findings
obtained. Confidentiality was ensured by the de-identification of
participants during data entry into a secure electronic database. The purposive sample comprised of 20 female nurses, who had
an average of 11.9 years of experience (range 4–26 years, data
2.5. Data analysis missing for 1 participant) (Table 2). Four themes were identified
to capture the nurses’ experiences of providing PIPM in a hospi-
Data were managed using managed using NVivo 10 software. tal setting: (1) managing competing demands in complex clinical
The software. The data obtained from the participants were the- settings; (2) the importance of knowledge and skill; (3) clarifying
matically organised and analysed using an approach outlined by organisational expectations, purpose and successes and; (4) ethi-
Braun and Clarke (2006). Re-reading of the transcripts by the first cally challenged when unable to provide quality patient care.
two authors assisted in identifying emerging concepts and codes.
The first two authors coded the data separately and then reviewed 3.1. Managing competing demands in complex clinical settings
the codes together until there was congruence to form subthemes.
To enhance credibility, all members of the research team were Study participants described managing competing priorities
involved in data analysis. The third and fourth authors, who are and responsibilities, including PIPM, in the context of a complex
experts in qualitative research, reviewed the sub-themes to con- clinical setting, as being particularly difficult. Competing demands
firm interpretation and assisted the development of four themes that were consistently reported by participants included the time
(Figure 1 ). and process of providing quality PIPM; increased workload; time

Table 2
Characteristics of the nurse participants and the method of interview (N = 20).

Interview number Nursing role Years of Experience Gender Clinical Unit Method

1 1 CNE, 1 NUM, 1 RN 8, 26, 15 Females Acute Aged Care Group

2 1 CNC 17 Female Surgical Oncology Individual
3 1 RN 8 Female Neurosurgical Individual
4 1 CNS 9 Female Intensive Care Services Individual
5 1 RN 4 Female Intensive Care Services Individual
6 1 CNC 18 Female Transplant Individual
7 1 CNE 6 Female Vascular Individual
8 1 RN Missing data Female Vascular Individual
9 1 EEN 20 Female Orthopaedics Individual
10 1 CNE 6 Female Orthopaedics Individual
11 1 RN 7 Female Orthopaedics Individual
12 1 RN 5 Female Orthopaedics Individual
13 2 RNs 20, 18 Females Medical and Aged Care Group
14 1 RN 8 Female Rehabilitation Individual
15 1 NUM 18 Female Acute Aged Care Individual
16 1 CNS 17 Female Alla Individual
17 1 CNE 15 Female Acute Aged Care Individual

Job title: CNE = Clinical Nurse Educator, NUM = Nurse Unit Manager, RN = Registered Nurse, CNC = Clinical Nurse Consultant, CNS = Clinical Nurse Specialist, EEN = Endorsed
Enrolled Nurse.
a
A hospital-wide clinical nurse specialist who worked across all clinical units in one hospital.
98 M. Barakat-Johnson et al. / Collegian 26 (2019) 95–102

constraints and limited resources; and complexities presented by participants were concerned about the lack of sufficient resources
patients. or their inability to access to them, particularly equipment, to move
patients or care for the PI.
3.1.1. Time and process of providing quality PIPM
The process of PIPM involves numerous steps such as 3.1.3. Complexities presented by patients
assessment, diagnosis, documentation, and preventative and man- All participants identified patient comorbidities and resistance
agement interventions. These steps place great demand on nurses’ as two key barriers to enabling PIPM. Comorbidities that hindered
skills, capabilities, and time to ensure quality PIPM is provided. nurses’ ability to provide effective PIPM included stroke, malnour-
ishment, incontinence, obesity, fragility, being underweight, old
“Staff knowing what they’re looking at. How to document it and
age or being a post-operative patient. Participants explained that
how to report it properly, which is a lot of the time and then them
most of the patients they encountered had more than one of these
knowing what is the most appropriate dressing to use.” (P4)
conditions.
Participants reflected on how difficult it was to incorporate PIPM
“Lack of mobility and also his – he was quite unwell so he wasn’t
into their existing tasks and responsibilities to multiple patients.
moving and repositioning himself in bed so they did have an air
Some voiced concern over the quality of care provided under the
mattress in place when he was in intensive care but I think it was
current workload.
due to the fact that he was not mobilising and he had anaemia and
“. . .there’s too much paperwork for them to do, there’s too much he had a lot of other complications going on. He was on a lot of
other things going on that they don’t have time to do those tiny little medication as well.” (P8)
things that could prevent so many pressure injuries from happen-
Patient resistance came in the form of either refusing to move in
ing.” (P7)
accordance with recommendations or assistance from the nurses,
or repositioning themselves after being turned in a position to
3.1.2. Increased workload, time constraints and limited resources relieve pressure in the affected area. Most participants stated that
Many nurses reported being embedded in a setting where they resistance played a major role in the development of PIs they
faced competing priorities, increased workload, time constraints, encountered.
limited resources, and felt a sense of powerlessness to provide
quality care. “So he didn’t move much, wasn’t very compliant with nursing care.
Like he would come around eventually but I think when I started
“. . .as good as our intentions are and we would love to be able looking after him he’d already been in hospital for a few days but I
to turn every patient hourly to second hourly we just don’t have just think the fact that he wasn’t willing to help us, well, not help
that capacity within our staffing to be able to do that because the us but move around so much, got this pressure injury. He just was
patient’s about to have a fall or the patient that’s occluding their lying in bed not doing much at all.” (P11)
airway or the confused patient that you’re trying to resettle takes
up that time away from going, ok, let’s go and turn this patient, let’s Limited resources combined with competing priorities and
go and turn this patient. So I think a lot of it is – comes down to patient characteristics made existing complications, challenges and
what we’re able to do within an eight hour shift limits.” (P1, group PIs more difficult to prevent and manage. Participants believed that
interview) some patients subsequently developed preventable PIs.
“. . .the compliance decreases because we have a lot of things to do “I mean, an issue we have recently. . .was an extremely obese
and lot of paperwork to do and you are doubling the paper and patient and she was difficult, because we didn’t have a bariatric
doubling the documentation part.” (P9) bed to nurse her on and to be able to roll her and do pressure area
When nurses struggled to manage competing demands, this care on her was extremely difficult and requires more than one
led to fragmented communication between staff regarding PIPM. nurse to actually do it, so she ended up with a few pressure injuries
Staff communication was seen as crucial to ensure that PIPM mea- as a result, but that was because of a lack of bodies and lack of
sures were in place. Such measures included periodic turning and equipment to be able to do that for her.” (P8)
contacting specialist nurses, such as wound nurses, PI nurses or
continence nurses in a timely manner for appropriate advice and 3.2. The importance of knowledge and skill
care.
Participants emphasised the importance of building knowledge
“Sometimes they [casual staff] don’t tell us, and we had to tell them
and skills on PIPM particularly in relation to the diagnosis of PIs, the
– if you see any pressure sores, you can write up a risk file – some-
use of one’s own clinical judgement, patient education, and family
times they don’t tell us. Then the following day we found out, she
involvement. Participants (1,2,3,4) explained that a lack of knowl-
didn’t tell me, or he didn’t tell me.” (P10)
edge among staff about misdiagnosing and documenting PIs as skin
Participants explained that nurse responsibilities to other tears and dermatitis had implications not only for reporting but
patients, particularly high-dependency patients such as immobile also for appropriate treatment. Participants felt that nurses needed
(or bed bound) patients, also lowered the priority of PIPM. more education and awareness on PIPM to be more adept at recog-
nising when a PI may develop in order to implement preventative
“. . .10 quite dependent people on the wards so that’s a third for our
measures.
staff to turn and, so from time alone to turn them at that second
hourly that we need to, it just doesn’t become a priority.” (P1, group “. . .there needs to be more education about what is a pressure area,
interview) so we’re getting lots of documentation of skin tears, of dermatitis,
incontinent dermatitis, that aren’t necessarily pressure injuries but
Nurses contended with competing demands in the context of
they’re being put in [reported] as such so I know that there’s a gap
staffing constraints. Whilst participants in this study supported the
in education of what is a pressure area. . .” (P1, group interview)
need to prioritise PIPM, stretched staff numbers made it difficult to
carry out such tasks. Participants described turning patients reg- Participants highlighted that when a risk assessment was con-
ularly as challenging without adequate staff; particularly patients ducted with a tool such as the Waterlow (Waterlow, 2017), it
who were obese and required several staff to turn safely. Several was important to use one’s own clinical judgement. Participants
 M. Barakat-Johnson et al. / Collegian 26 (2019) 95–102 99

described the feeling of having their clinical judgement taken away One participant suggested having a checklist of tasks, such as
from them due to pressure to complete mandated assessment tools regular skin assessments and turns would be helpful. The use of
that became ‘tick box’ activities. extra healthcare staff to assist with repositioning, such as turning
teams, was another suggestion made by several participants (P1,
“A lot of clinical judgement and autonomy has been taken away
group interview; P4; P7; P8).
from nursing in a sense that we just go by numbers, we’re colouring
in the lines and I think that whole clinical thinking and critical “. . .I think probably as an organisational approach it could be more
thinking has been taken away.” (P1, group interview) coordinated, . . .where I suppose from our point of view there’s not a
dedicated turning team in the hospital, there’s an ad-hoc approach
Knowledge on PIs were not only seen in the context of nurses’
to mattress provision and selection” (P1, group interview).
knowledge but also patient education and knowledge, and fam-
ily involvement. Participants found that involving patients in their In terms of education, participants emphasised the importance
care and informing them in advance what PI preventative care of hands-on education rather than formal educations sessions or
entailed enabled patients to understand the importance of such courses.
assessments and strategies.
“Maybe calling a few nurses around at the one time and doing the
“So after we noticed it, we got it assessed by one of the Wound CNSs, assessment all together, just to get a few people on board so they feel
and we put the appropriate dressing on there and we re-educated more comfortable. . .More practical-based education, not so much
him, encouraged him that he needs to reposition frequently and in-services, because you retain the information,. . ..” (P19)
just comply with that for us. . .He was quite good, and it’s actually
Participants explained that the success of education initiatives
improving now.” (P18)
or activities was linked to the organisation’s support for providing
Families were described by some participants as having an optimal PIPM.
important role in motivating patients to reposition themselves, if
physically able, and were even seen as potential partners of busy
3.4. Ethically challenged when unable to provide quality patient
nurses.
care
“. . .if they’re aware and their families are aware they’ll talk about it
more and then the nurses will hear it more and then it will happen Although there was a strong belief held by participants that PIPM
more. . .Because if you’re busy and they can just remind them to was important and should be part of routine patient care, it was
move or do something to help. . .Get them motivated, or oh, you also acknowledged that there was a lack of quality PIPM within
haven’t moved for a bit, or something, yeah. Involving families into their organisation. Participants provided a pragmatic account of the
everything is always important.” (P7) realities of working in a complex setting with competing priorities,
limited resources, lack of nurse awareness and skill regarding PIPM,
and challenging organisational factors.
3.3. Clarifying organisational expectations, purpose and successes
“. . .there are so many issues, a lot of barriers. . .. if we can prevent
Several participants described that having organisational sup- them it would be so much better than to dress a stage 4 pressure
port was crucial to ensure effective PIPM, particularly in the areas injury” (P9)
of the provision of educational opportunities and initiatives, and Reflecting on the bigger picture, participants in this study
the streamlining of PIPM documentation. When their organisation wanted to deliver the care required to prevent the development
had policies and guidelines that were consistent, participants knew of PIs but considered the limitations of their resources and other
what was expected and what should be done. clinical and organisational factors to be a hindrance. Participants
“So I’m very proud of our ward because I think everyone’s on top expressed an internal ethical conflict when the provision of qual-
of it, because everyone knows and we know what our goals are ity patient care was compromised by factors largely out of their
and even when we’re washing patients, I think our nurses are very control.
diligent to look, because we have these goals that we’re trying to “. . .when they [pressure injuries] do develop past that stage two,
reach. And so if we reach. . .a goal of 50 days or something [without there’s almost no stopping them. . .. and it’s incredibly distress-
a PI], we’ll have a little celebration to reward ourselves. . .So that ing for the staff, we’re always so upset, the family are beside
motivates people.” (P11) themselves. . .” (P4)
Meetings with fellow staff about patients with PIs to examine Carrying out quality PIPM and meeting the demands of other
how they were managed and cared for were seen as educational nursing duties and responsibilities was experienced as a balancing
opportunities. Participants felt supported by their organisation act that many participants struggled with at the expense of patient
when educational resources were available, specialist staff were care and compliance with best practice.
accessible, and there were opportunities to attend PIPM education.
Another area participants reported as requiring improvement
by the organisation was a streamlined approach to managing the 4. Discussion
documentation of PIPM. Participants expressed concern about the
volume of paperwork and the inconsistencies with documenting To the best of our knowledge, this is the first qualitative study
PIs. It was common to find duplicate documentation concerning conducted in Australia to gain insight into the experiences of hos-
reporting, preventing and managing PIs on paper and electroni- pital nurses concerning PIPM. This study highlights the importance
cally. This led to confusion as to where the information should be of understanding the experiences of nurses conducting PIPM as just
documented. one aspect of patient care and should not be considered on its own
to change existing practice. There is a responsibility and account-
“It’s great that I’m seeing them and that people see and we’re report- ability for patient care that sits with nurses, and effective PIPM
ing, it’s all wonderful, but it’s actually not treating the patient first, should be understood within the broader concept of nursing work
so I think that’s where the gap is that the paperwork process but being delivered in a complex healthcare system influenced by deci-
then the patient’s still not being cared for.” (P1, group interview) sions made at a higher level, either at an organisational, district or
100 M. Barakat-Johnson et al. / Collegian 26 (2019) 95–102

a health department level. Therefore, how the decision or change ous research reviewing the barriers to PIPM (Kharabsheh, Alrimawi,
in practice becomes operationalised and how it impacts on nursing Assaf, & Saleh, 2014; Mwebaza et al., 2014; Sving et al., 2012;
work is often not fully understood until the changes are imple- Tubaishat et al., 2013).
mented. The findings from this study are just one aspect of care There is a link between the first and the last theme as patients
provided by nurses required to ensure quality and safety of patient with increased medical complexities require extra resources result-
care in hospitals. Findings from this study confirm and extend exist- ing in an increased workload, leaving less time to provide essential
ing research in this area. Overall, participants were aware of the patient care. Many participants felt that staffing was inadequate
importance of PIPM and were able to identify existing successful to address increasing patient acuity and patient needs. Consis-
practices and opportunities for improvement. However, partici- tent with Dilie and Mengistu (2015), delivering quality PIPM
pants considered providing quality PIPM to be a difficult task due to was impeded by the disproportionate nurse-to-work ratio leav-
competing priorities and challenges faced at both an organisational ing nurses feeling discouraged whilst balancing effective PIPM
and patient level. Furthermore, participants were ethically chal- and meeting the demands of their responsibilities. Participants
lenged when they were unable to provide effective PIPM. Increased struggled with these demands at the expense of patient care and
paperwork, high workloads, and limited resources, caused PIPM compliance with best practice. The clinical imperative as a practi-
compliance and quality of patient care to decrease. tioner to prioritise the best interest of the patient and ensure that
Consistent with previous studies (Athlin et al., 2010; Beeckman, they receive optimal care was being tested by the tasks they faced
Defloor, Schoonhoven, & Vanderwee, 2011; Dilie & Mengistu, 2015; and competing demands.
Kallman & Suserud, 2009; Moore & Price, 2004; Mwebaza, Katende, Mandated risk tools were perceived by participants to be time-
Groves, & Nankumbi, 2014; Nuru, Zewdu, Amsalu, & Mehretie, consuming and frustrating to use. Risk tools did not provide an
2015; Strand & Lindgren, 2010; Sving et al., 2012; Tubaishat, accurate representation of a patient’s risk of developing a PI and
Aljezawi, & Qadire, 2013), the combination of increased work- were seen by participants to be a mandated ‘tick box’ tool that
load, lack of resources, and lack of time described by most of the added extra work instead of guiding PIP strategies. Participants in
participants in our study, had implications for delivering effec- this study felt that the act of mandating a tool meant their clini-
tive PIPM. Participants believed PIPM was time-consuming and cal judgment was devalued. The mandated use of risk tools were
they had insufficient staffing to assist with repositioning. Subse- not found to lead to better prediction and prevention of PIs (Park,
quently, attending to PIPM practices became a lower priority. This Lee, & Kwon, 2016), especially when nurses view them as a hin-
is concerning as there is substantial evidence to suggest that the drance rather than a guide. Additionally, PI risk tools have been
nurse-to-patient ratio impacts on patient safety and quality care shown to have low sensitivity, hence, are not a reliable tool in pre-
(Brown & Wolosin, 2013; Dykes & Collins, 2013; Heslop & Lu, 2014; dicting PI development or to guide prevention strategies (Kottner,
Solomita, 2009). Significant risks are posed when workloads are Dassen, & Tannen, 2009; Pancorbo-Hidalgo, Garcia-Fernandez,
increased due to patient acuity or comorbidities and processes are Lopez-Medina, & Alvarez-Nieto, 2006; Park et al., 2016; Webster,
not put in place to meet these demands. However, as demonstrated Gavin, Nicholas, Coleman, & Gardner, 2010).
by He, Staggs, Bergquist-Beringer, and Dunton, 2016, sufficient Participants in this study encountered a high volume of paper-
staffing levels safeguard quality patient care, and reduce the devel- work which meant less time was available to provide effective
opment of PIs. PIPM. Documentation is critical to patient care as it outlines what
Nationally, in recent years, there has been attention given to has been done. Documentation also informs next steps and is
nurse-to-patient ratios to ensure safer nursing workloads, delivery important for clinical handover (Australian Commission on Safety
of quality nursing care, and to avoid adverse patient outcomes. As & Quality in Health Care, 2012). Participants acknowledged that
a consequence, the nurse-to-patient ratios to ensure safe work- paperwork is a fundamental part of patient care and handover;
loads have been mandated in several states such as New South however, they felt their ability to properly complete it was hindered
Wales, Victoria, and Queensland (Australian Nursing & Midwifery by the large volume imposed on them. These findings correspond
Federation, 2015; Gordon, Buchanan, & Bretherton, 2008; NSW with a number of studies where clinicians believed the large vol-
Nurses & Midwives Association, 2015; Queensland Government, ume of paperwork to be time-consuming and a barrier to effective
2016). Therefore, it can be argued that with the improved nurse-to- patient care (Christino et al., 2013; Cunningham, Kennedy, Nwolisa,
patient ratio, effective PIPM would be easier to maintain. However, Callard, & Wike, 2012; Siegler, Patel, & Dine, 2015). There are a
in practice, this is not straightforward. Competing priorities and number of areas related to patient care that nurses must report
lack of communication between nursing staff are not often taken and record, as well as the mandatory requirements of completing
into account when calculating nurse-to-patient ratios. Additionally, assessment forms. For example, in New South Wales there have
short-term or casual staff may compromise effective PIPM (Athlin been a number of forms that have been mandated, which has placed
et al., 2010). Participants in this study perceived PIPM to be diffi- a burden on nurses carrying out fundamental care. A review of
cult to perform when communication was fragmented, particularly current mandated documentation and its impact on nurses under-
caused by a lack of staffing which impacted on staff handover and taking fundamental patient care is therefore warranted.
continuity of care. PIPM was challenging to enact along with exist- The need for targeted education was highlighted by most par-
ing tasks and responsibilities. Additional organisational efforts and ticipants, especially on the diagnosis and classification of PIs.
processes are necessary to address these challenges so that when Skin conditions were often misdiagnosed then reported and docu-
the workload is increased, patient care is not compromised. mented as a PI, such as incontinence-associated dermatitis (IAD).
In describing their experiences with staffing, time and processes, The implications of misdiagnosis of skin conditions go beyond
participants reflected on difficult moments when they felt power- incorrect assessment and classification. Patients may consequently
less and proper care could not be provided, particularly for patients receive inappropriate treatment, and the organisation accumulates
with increasing complexity. Firstly, they felt internal conflict when a higher reported PI rate. Much of the literature shows that IAD pre-
caring for critically ill patients who have other areas of care to pri- disposes a patient to developing a PI and is often mistaken for a PI
oritise. Secondly, nurses put in place PIP strategies for critically ill (Beeckman, Schoonhoven, Boucque, Van Maele, & Defloor, 2008;
patients only for a PI to develop, leaving nurses feeling despondent. Doughty et al., 2012). PI education campaigns should emphasise
Thirdly, patients who were resistant to care, aggressive, or con- the importance of correct diagnosis and classification of PIs and
fused, hindered nurses in providing effective PIPM. The challenges skin conditions so that nurses feel confident making differential
expressed by participants in this study are consistent with previ-
 M. Barakat-Johnson et al. / Collegian 26 (2019) 95–102 101

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