ORIGINAL ARTICLE

Nursing practice in the prevention of pressure ulcers: an observational study of German Hospitals Khadijeh Hoviattalab, Haydeh Hashemizadeh, Gibson D’Cruz, Ruud JG Halfens and Theo Dassen

Aims and objectives. The study aimed to establish the range and extent of preventive interventions undertaken by nurses for patients who are at high risk of developing or currently have a pressure ulcer. Background. Since 2000, the German National Expert Standard for the prevention of pressure ulcers has provided evidence-based recommendations, but limited studies have been published on its adherence in hospitals. There are also limited observational studies that investigated whether patients who are at risk of or have pressure ulcers are provided with appropriate preventative measures. Design. A nonparticipant observational descriptive design was used. Methods. A sample of 32 adult patients who were at high risk of developing or currently had a pressure ulcer were observed during all shifts in medical and surgical wards in two general hospitals in Germany. Results. A range of preventive interventions that were in line with the German National Expert Standard was observed. The most frequent preventive measures were ‘cleaning the patients’ skin’ and ‘minimizing exposure to moisture’ that were undertaken in more than 90% of all patients. The least frequent measures were ‘patient and relative education’, ‘assessment and recording of nutritional status’. Conclusion. This study demonstrates that the pressure ulcers preventive interventions as set out in the German National Expert Standard were not fully implemented. The study highlights the need for further studies on the barriers that impede the undertaking of the interventions that may prevent the development or deterioration of pressure ulcers and the delivery of evidence-based preventative care. Relevance to clinical practice. This study provides an insight into the extent of pressure ulcers preventive practices used by nurses. The results may serve as a basis for developing an effective strategy to improve nursing practice in this area and the promotion of evidence-based practice. However, our results refer to two general hospitals and for a broader population, further studies with larger data samples are needed.

Authors: Khadijeh Hoviattalab, BSN, MSN, RN, Doctoral Student, Nursing Science, Charit
e-Unversit€atsmedizin Berlin, Berlin, Germany; Haydeh Hashemizadeh, BSN, MSN, RN, Lecturer, Department of Nursing, Quchan Branch, Islamic Azad University, Quchan, Iran; Gibson D’Cruz, EdD, RN, RNT, Senior Lecturer, School of Nursing Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK; Ruud JG Halfens, PhD, Associate Professor, Caphri, Department of Health Services

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1513–1524, doi: 10.1111/jocn.12723

What does this paper contribute to the wider global clinical community?

• Developing an effective strategy

•

to improve nursing practice requires an insight into the extent of pressure ulcers preventive practices used by nurses. Organising and implementing a continuing education programme for German nurses can help them adapt to and use the German National Expert Standard consistently and effectively to improve the quality of pressure ulcer prevention.

Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands; Theo Dassen, RN, PhD, Professor, Director, Department for Nursing Science, Charit
eUnversit€ atsmedizin Berlin, Berlin, Germany Correspondence: Khadijeh Hoviattalab, Doctoral student, Nursing Science, University Charit
e Berlin, F€ arberstraße 74 _ 40223 D€ usseldorf, Germany. Telephone: +491732415979. E-mail: [email protected]

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Key words: evidence-based practice, nursing practice, pressure ulcer, pressure ulcer prevention Accepted for publication: 8 September 2014

Introduction and background Pressure ulcers have been identified as a common and worldwide health problem that continues to cause pain and discomfort to patients together with increasing the cost of health care, even though most cases are predictable and preventable (Hopkins et al. 2006, Lewin et al. 2007, Struck & Wright 2007). The recent international prevalence studies by Halfens et al. (2013), compared the results of four annual surveys (from 2009–2012) in Netherlands, Austria and Switzerland and the data were collected on one specific day with the use of a comprehensive and standardised questionnaire. The results revealed that in 2011, Dutch hospitals had the highest prevalence rate of hospital-acquired pressure ulcer among risk patients (7
2%), followed by Swiss (4%) and Austrian hospitals (1
9%) in 2012, the prevalence rate remained higher in Netherlands (6
9%) compared with Austria (2
3%) and Swiss hospitals were not included. In Germany, the Department of Nursing Science of the Charit
e-Universit€atsmedizin, Berlin conducted nationwide surveys annually since 2001 (Lahmann et al. 2005). One of these surveys compared the results of seven pressure ulcer prevalence surveys between 2001–2007 and the overall prevalence rate in German hospitals was 10
2% and the prevalence rates had decreased from 13
9% in 2001 to 7
3% in 2007 (Kottner et al. 2009). Tannen et al. (2007) in their comparative survey of prevalence rates in Germany and Netherlands found that the rates were significantly higher in the Dutch hospitals (ranging from 28
1– 41
4%) than the German hospitals (18
1–28
8%).These results demonstrate that although prevalence rates have decreased, pressure ulcers still present a clinically significant health issue and require attention in Germany. For two decades, several organizations have published guidelines for predicting, preventing and initiating early treatment of pressure ulcers. The National Pressure Ulcer Advisory Panel (NPUAP) in collaboration with the Agency for Healthcare Research and Quality (AHRQ, formerly the Agency for Healthcare Policy and Research (1992)) and the European Pressure Ulcer Advisory Panel (EPUAP 2009) developed guidelines based on available scientific evidence. In 2009, NPUAP in conjunction with EPUAP published new guidelines that provide evidence-based recommenda-

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tions on a full range of areas related to pressure ulcer prevention and treatment including risk assessment, skin assessment, nutrition, repositioning and the use of support surfaces (NPUAP-EPUAP 2009). In Germany, the National Expert Standard for Pressure Ulcer Prevention developed by German Network for Quality Development in Nursing [Deutsches Netzwerk f€ ur Qualit€ atsentwicklung in der Pflege (DNQP)] was published for the first time in 2000 and updated in 2002 and again in 2004. Despite differences regarding some preventive measures and the claimed level of their evidence, all the guidelines have recommended the same preventive interventions (Shahin et al. 2009). Although the guidelines have been in existence for a number of years, the results of several studies demonstrated that the guidelines regarding prevention of pressure ulcers were not fully implemented in clinical practice and nursing actions that are not viewed as recommended practice or included in the guidelines continue to be in € use (Gunningberg et al. 2001, Ozdemir & Karadag 2008, Paquay et al. 2008, Vanderwee et al. 2011, Halfens et al. 2013). There is limited information on nurses’ practice in pressure ulcer prevention and adherence to the recommendations of the German National Expert Standard in general hospital wards in Germany. Most of the information about nurses’ preventive activities was obtained through prevalence surveys that only reviewed a limited number of preventive measures and at one measuring point (Tannen et al. 2007, Wilborn & Dassen 2010). There are very few observational studies on the use of measures to prevent the occurrence or deterioration of pressure ulcers and most of these observed nursing staff during the morning shifts only € (Ozdemir & Karadag 2008, Shahin et al. 2009). Nurses’ job performance and patients outcomes could fluctuate and vary during the course of a day and a number of studies have investigated the effect of shiftwork on nurses’ job performance. For example, Coffey et al. (1998) examined the influence of shifts or working hours on job performance and found that overall job performance was highest among nurses on day shifts followed by the night and afternoon shifts and this implies that observing the conduct of preventive care during morning shifts alone is not likely to provide a comprehensive and full picture.

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1513–1524

Original article

Another limitation of the studies that sought to examine whether patients at risk of or have pressure ulcers received appropriate measures for the prevention or deterioration of pressure ulcers is that they are based on nurses’ self-reports of practice or participant-observers, and not on the observations of an external observer. Data on practice reported by the nurses themselves could be biased as respondents could have tailored their responses to adapt their answer to the aims of the study (Pancorbo-Hidalgo et al. 2007). Observational techniques seem to offer a more objective and direct view of behaviours and it allows for the collection of rich and directly observed data for relatively low costs (Cooper et al. 2004).

Methods Aim and research questions The aims of this study were to determine nurses’ practice in pressure ulcer prevention and the level of adherence to the recommendations of the German Expert Standard for pressure ulcer prevention (DNQP 2004). Based on the aims of this research, the following questions were formulated:

•

•

•

What is the level of congruence between nurses’ practice in pressure ulcer prevention and the measures recommended by German Expert Standard for pressure ulcer prevention (DNQP (German Network for Quality Development in Nursing) (Ed) 2004)? What pressure ulcer preventive measures are used by nurses for hospitalised patients who are at high risk for developing a pressure ulcer or who currently have a pressure ulcer? Are there any differences in nurses’ pressure ulcer preventive practices during morning, evening and night shifts?

Design A nonparticipant observational descriptive study was conducted with medical and surgical patients and nurses in two hospitals across all shifts.

Sample All seven general hospitals in D€ usseldorf, a major city in the western Germany, were invited to participate in the study. A meeting was held with the directors of nursing departments in these hospitals where they were informed of the aims and © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1513–1524

Prevention of pressure ulcers

procedures of the study. Two hospitals accepted the invitation to participate in the study and a second meeting was held with nursing directors of these hospitals to select the wards; one general medical and one general surgical ward were identified as the sites for the data collection. There were an average of 36 patients in both medical and surgical wards in hospital 1 and in the second hospital, 40 patients in medical and 36 in surgical ward. All adult patients (≥18 years) present on the day of observation were screened for eligibility and all patients with medical and surgical diagnoses were included. Only one patient, who had a co-morbid diagnosis of progressive dementia with high degree of aggression that made the observation impossible, was excluded. During the observation period, all patients at high risk for developing pressure ulcer according to the Braden risk assessment scale for pressure ulcers, and who currently had a pressure ulcer were observed. The Braden scale is the most widely used tool in Germany and consists of six subscales: sensory perception, activity, mobility, moisture, friction/shear and nutrition. Each subscale is scored from 1–4, except for friction/shear which is scored from 1–3 and the combined scores range from 6–23. The lowest possible score of six points represents the highest risk for developing a pressure ulcer (Ayello & Braden 2002). In order to identify the patients who were to be observed was to ask the nurses in each shift to review the patient’s computer and medical paper records for the patient’s diagnosis on admission, co-morbidities and a Braden score was then calculated. Patients with a Braden score of ≤12 were then approached and informed of the study objectives and those who gave verbal and written consent were included in this study. During the study none of the patients refused to participate. The researcher gave assurance of anonymity in the study and that all data would be treated in confidence and participants were informed that they could withdraw participation at any time.

Instrument Data were collected using a questionnaire and a patient observational checklist. The questionnaire consisted of demographic data i.e. gender, age, medical diagnosis, length of stay, history of hospitalisation, history of pressure ulcers and current Braden scores. Pressure Ulcer Stages/Categories Pressure ulcer category was determined using the International Pressure ulcer classification system (Category/Stage I: Nonblanchable erythema Category/Stage II: Partial thickness Category/Stage III: Full thickness skin loss Category/Stage IV: Full thickness tissue loss) (EPUAP/ NPUAP 2009).

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Risk assessment undertaken on admission Recording of risk assessment scores Systematic inspection of skin Recording of results of skin inspection Cleaning of the skin Minimum force and friction during cleaning Application of moisturising agents Minimum exposure to moisture Use of barrier against moisture Skin protection during transfers, changing positions and turning Recording the nursing interventions and its results Repositioning Use of a chart for changing position and turning Using devices to prevent contact between bony prominences Heels lifted to decrease pressure Minimising the period in which the head of the bed tilted more than 30 degrees Patient mobilised (where possible) Use of pressure relieving mattress

Preventive measures

Table 1 Patient observation checklist

Observed

Morning’s shift Not observed

Not applicable Observed

Evening’s shift Not observed

Not applicable Observed

Night’s shift Not observed

Not applicable

K Hoviattalab et al.

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1513–1524

Taught how to reposition themselves when sitting on the chair When sitting on the chair position changed every hour or transferred to bed Use of pressure relieving devices on chairs Nutritional assessment Assisted with eating and drinking Recording of nutritional assessment Patients given information on the prevention of pressure sores Relatives given information on the prevention of pressure sores Support staff given information on the prevention of pressure sores

Preventive measures

Table 1 (continued)

Observed

Morning’s shift Not observed

Not applicable Observed

Evening’s shift Not observed

Not applicable Observed

Night’s shift Not observed

Not applicable

Original article Prevention of pressure ulcers

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1513–1524

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K Hoviattalab et al. Table 2 Patient characteristics (n = 32) Characteristics

n

Age (years) 51–60 4 61–70 0 71–80 12 81–90 16 Gender Female 17 Male 15 Type of the wards Surgical 17 Medical 15 Length of stay (days) 1–10 21 11–20 6 21–30 3 More than 31 2 History of hospitalisation Previously hospitalised 32 Not previously hospitalised 0 History of pressure ulcers No previous ulcers 23 History of previous ulcers 9 Presence of pressure ulcers (at time of study) Present 10 No ulcer present 22

%

12
5 0 37
5 50 53
1 19
9 53
1 46
9 65
8 18
7 9
3 6
2 100 0 71
9 28
1 31
2 68
8

To observe the use of preventive measures in the participants, a checklist was developed based on the German Expert Standard for pressure ulcer prevention (DNQP (German Network for Quality Development in Nursing) (Ed) 2004). In order to provide a more comprehensive overview, the interventions were then grouped into the themes that were suggested by € Ozdemir and Karadag (2008) which related to pressure ulcers prediction and prevention in adults. The checklist (Table 1) consisted of 27 preventive interventions covering five themes of pressure ulcer prevention: risk assessment (two interventions), skin inspection and care (nine interventions), positioning, mobilisation and support surfaces (10 interventions), nutrition (three interventions) and education (three interventions). Each item was then categorised: ‘observed’, ‘not observed’ and ‘not applicable’ if the measure was not appropriate for the patient.

Pilot study Prior to the main data collection, a pilot study was conducted to test the applicability of the data collection instruments and for the researcher to become familiar with the study setting. In addition, the pilot study facilitated the ward nurses familiarisation with the researcher and to be accustomed to the presence of an observer so as to minimise the possibility of a ‘Hawthorne effect’, i.e. when people notice that they are being observed, they might modify their behaviours (Burns & Grove 2004). The pilot was carried out for four weeks in both hospi-

Figure 1 Preventive pressure ulcer interventions (risk assessment and skin assessment) for patients at high risk for pressure ulcers.

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© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1513–1524

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Figure 2 Preventive pressure ulcer interventions (positioning, mobilisation and support surfaces) for patients at high risk for pressure ulcers.

tals and during different shifts. The data collected during the pilot stage was not included in the main study.

Data collection Data were collected in four months, between the end of February and first week of July 2011 and all observations were carried out by the primary researcher of this study who is an experienced nurse practitioner and who was a member of faculty in a nursing department of a medical university. The researcher had no prior experience in either of the participating hospitals and did not participate in care during the observations. Schedules and plans were prepared for observations to take place on six days of the week and were adhered to until all patients in both hospitals were observed. During each shift, only one patient was observed and in the instances where there was more than one high-risk patient on the day of observation, the patient who was admitted earlier was observed first. All interventions, structural or otherwise, were observed and counted during each shift. The observation commenced from the time of handover from one set of nurses to the next until the end of that particular shift. Patients’ files are accessed for collecting data on patients’ risk assessment on admission, results of risk assessments, results of skin inspection and nurses’ interventions, use of © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1513–1524

chart for changing position, records of patients’ nutritional status and deficits as well as reports from dieticians. Prior to observation at the beginning of each shift, the observer checked the medical and nursing plan for each high riskpatient for that particular shift. If the patient had a long procedure like haemodialysis, the observation was postponed to the next shift. The primary researcher was personally present in the patient’s room and remained by the patient’s side for the entirety of every shift in order to observe all the interventions and the duration of the patient’s specific positions. If a preventive intervention was provided, it was marked as ‘observed’; if not provided, the observer marked ‘not observed’ and if a preventive measure was unnecessary in regards to the patient’s condition, it was marked as ‘not applicable’. The observer took into consideration all the details of the patient’s history and their clinical condition and individual situation in order to determine whether a preventive intervention should be considered as ‘observed’, ‘not observed’ or ‘not applicable’. For instance: interventions for chair-bound patients when the patient was not confined to a chair and family education when the patient had no family were considered as ‘not applicable’. The patients without pressure relieving mattresses needed their position changed every two hours. Changing the position further than that was considered ‘not observed’.

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Figure 3 Preventive pressure ulcer interventions (nutrition and education) for patients at high risk for pressure ulcers.

Ethical consideration Ethical approval for this study was granted by the Ethics € Committee of Arztekammer Nordrhein (State Medical Board of Registration).

Data analysis Data were coded and entered into the statistical software package SPSS (Chicago, IL, USA), version 16. Descriptive and inferential analyses were then undertaken. The data were normally distributed and the variance of data in all shifts was the same. Then, the one-way analysis of variance (ANOVA) was used in comparing three shifts. The level of significance was set at p ≤ 0
05 and the unit of analysis in comparison was the number of observations across different shifts. In order to establish the levels of preventive care (‘adequate’ or ‘not adequate’) for each patient, all ‘not applicable’ preventive measures were deleted and percentages of preventive interventions were then calculated. Preventive care was considered to be ‘not adequate’ if the interventions occurred in 49% or less of applicable situations and ‘adequate’ if the intervention occurred in 50% or more of applicable situations.

Results Sample description The study sample consisted of 32 patients: 16 patients in each hospital, eight in medical and eight in surgical wards. All patients were observed once during each shift (morning,

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afternoon and night), resulting in a total number of 96 observations. The length of each observation was for the entire period of that particular shift except in one case where all preventive measures applied for the patient early than the end of shift. Demographic characteristics of patients are summarised in Table 2. Slightly more than 50% of the patients were female and nine (28%) of the participants had pressure ulcers previously and 10 (31
2%) had one or more pressure ulcers of category 2 or worse at the time of data collection.

Use of preventative measures The results of the observations on preventive interventions provided for patients at high risk for pressure ulcers are shown in Fig. 1 (the group of interventions related to risk assessment and skin assessment); Fig. 2 (positioning, mobilisation and support surfaces) and Fig. 3 (nutrition, education). Figure 1 shows that risk assessment on admission to the ward was undertaken in only 11(34
3%) of all patients, while skin assessment was seen to have taken place very rarely (15
6%) and 28 (87
5%) patients had no recording of a skin inspection having taken place. The most frequent interventions undertaken by nurses were cleaning the skin 30 (93
8%), minimum exposure to moisture 31(98
8%) and skin protection when patients were being transferred e.g. from a chair to a bed, changing position or turning 29 (90
63%). The use of barriers creams against moisture and moisturising agents on dry skin occurred in one-fifth (28
1%) of patients. © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1513–1524

Original article

Figure 2 demonstrates that repositioning was observed in less than half of the patients (40
6%) and a turning schedule was used in only one-third of all patients (31
2%). Half of all patients 16 (50%) did not receive any heel offloading and almost two-thirds (71
9%) of them spent a long period of time in the sitting position when they were in bed. Pressure-reducing mattresses were not used in more than the half (56
2%) of the patients. Pressure-redistributing devices were also not used when the patients were seated in a chair and patients did not receive any information about how they could shift their weight or reposition themselves when seated in a chair. The findings in Figure 3 demonstrate that the patients’ relatives and the auxiliary/support staff did not receive any information about pressure ulcers; only one patient was informed about pressure ulcer prevention. The assessment and recording of the patient’s nutritional status and deficits were observed very infrequently. In this study, there was no statistical differences in the number of pressure ulcer preventive measures carried out by nurses between patients who were at risk of or have pressure ulcers in different work shifts (p = 0
1).

Discussion This direct observational study aimed to determine nurses’ practice in pressure ulcer prevention and level of adherence to the recommendations of the German Expert Standard for pressure ulcer prevention in two German hospitals during all nurses’ shifts. The result of this study revealed that patients at high risk and patients with pressure ulcers did not receive adequate preventive pressure ulcer care in these two German hospitals. The results of the study also revealed that all the preventive measures that were undertaken were in accordance with the German Expert Standard for pressure ulcer prevention. Although half of the patients had the risk assessment scores recorded, risk assessment were not performed on admission for almost two-thirds of the patients. Skin assessment, recording of the results of skin inspection and care planning to prevent pressure sores were observed infrequently. These findings are consistent with the study by Gunningberg et al. (2011) which showed that risk and skin assessment within 24 hours after admission only occurred in 41% of patients at risk and prevention protocols were in place for only 19
3% of patients. This is in contrast with results from Shahin et al. (2009) who reported that the skin of 91
7% of patients at risk for pressure ulcers in intensive care units was assessed but no care plans were developed for those © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1513–1524

Prevention of pressure ulcers

at risk. In the study by Gunningberg et al. (2012), prevalence and preventative care in two hospitals (one university and one general hospital) in Sweden were compared with 207 hospitals in the USA participating in the Collaborative Alliance for Nursing Outcomes (CALNOC) and the rates in the Swedish hospitals were significantly lower; almost 100% of patients in the CALNOC study had undergone a risk and skin assessment and the patients who were at risk were commenced on a prevention protocol. Some pressure ulcer preventive care like cleaning the skin with minimum force and friction, protecting the skin during transfers and turning, and minimum exposure to moisture were performed frequently and these measures appeared to be a main part of nurses’ daily routine. The application of moisturising lotions on dry skin and the use of creams to act as a barrier against moisture was observed in less than two-thirds of the patients. Repositioning and support surfaces were used for less than half of patients and a turning schedule plan was not in place for more than two-thirds of the patients and this is similar to the findings of Gunningberg (2006), de Laat et al. (2007), Shahin et al. (2009) and Kaitani et al. (2010). The study of Halfens et al. (2013) revealed the same results in the use of support surfaces in Austria and Switzerland too but a high range of use was observed in Netherlands, while repositioning was applied in only onefourth of at-risk patients in all three countries. The gold standard of turning patients is a minimum of two hours, and this may be less frequent if support surfaces are being used (Lyder & Ayello 2008). The suboptimal use of these two preventive measures is crucial as it can have a negative impact on pressure ulcer outcomes and this needs to be addressed and strategies need to be in place to ensure that this is undertaken more frequently and as a matter of routine. There is consequently a need for more studies to identify level of nurses’ knowledge and attitudes towards the use of support surfaces and turning schedules. The result of this study demonstrates that heels were not protected adequately and this is in line with Vanderwee et al. (2011), Gunningberg et al. (2011), Van Gaal et al. (2013) and Halfens et al. (2013) who also reported similar findings. One possible explanation for this low rate could be that no heel protection devices were available in both hospitals. Consequently, pillows were placed under the patients’ calves but this may not be effective because the pillows are not robust enough to provide enough elevation to maintain the heels of patients especially those who were obese, off bed surfaces. Selection

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of the appropriate heel protection devices need to consider patients’ risk factors, especially level of mobility and weight. In our study, preventative measures for patients who were sitting on a chair were only undertaken sparsely. Gunningberg et al. (2011) reported that almost 95% of patients in five Swedish hospitals did not receive preventive care while in chair, and an Italian study conducted by Baldi et al. (2010) showed the same results. WannHansson et al. (2008) also showed similar findings with no position changes occurring in patients whilst they were seated and pressure-redistributing cushions were only used for a quarter of patients. Our findings showed that although 70% of the patients received assistance for their nutritional intake, there were no recording of the patient’s nutritional assessment, nutritional status and deficits. In the instances where the patient did not eat or finish their meals, nurses did not document this or report it during handovers to the next group of staff. In addition, none of the patients in our study was seen by a dietician or had sought advice from them. Prevention of dehydration and/or malnutrition is reported as being important by Halfens et al. (2013) and occurred in less than half of patients in the Netherlands and in one-fifth of all patient at-risk in Austria and Switzerland. Patient education is a vital component of the nursing process as it enables patients to be involved in treatment decisions, increases their motivation and satisfaction with their care, maximises the individual’s independence and ensures the continuity of care (Dreeben 2010). However, in this study, it appears that patient education is not a feature of the work of nurses and there were no written materials for patients in any of the four wards of our € study settings. Ozdemir and Karadag (2008) in their observational study also reported similar results, while Halfens et al. (2013) revealed that only one-tenth of Austrian patients received information and instructions whilst it was more frequent in Switzerland. In this survey, more than two-thirds of Dutch patients did not receive any information about pressure ulcers prevention and this contrast with Shahin et al. (2009) who found that 40% of the patients and over one-fifth of families and carers received some form of education. Another key aim of the study was to determine if there were any differences in the nurses’ preventive practices undertaken during morning, evening and night shifts. The findings demonstrated that regardless of hospital, there was no statistically difference in the number of interventions during the different shifts.

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The results from this study demonstrate that while some preventive measures are being undertaken, there is a significant room for improvement in the pressure ulcers preventions care.

Limitations The limitations of this study were the relatively small sample size and the sample was not-randomised. For these reasons, these findings cannot be generalised to the broader population and further empirical studies with larger data samples are needed for generalisation.

Conclusion This observational study set out to establish what actions to prevent the development of pressure ulcers nurses actually take in real practice rather than what they say they did or would do in a hypothetical scenario and this gives this study considerable strength. The findings revealed that, there were no statistically significant differences in the number of interventions during the different shifts. The study also has demonstrated that preventive interventions were provided inadequately for patients at high risk for pressure ulcers. Some of the areas where the practice of nurses do not adhere to the national guidelines include undertaking risks assessments as well as nutritional assessments, the use of support surfaces when patients were either in bed or in a chair and patient education. While reasons can be put forward to explain these deficiencies, there is an obvious need to organise and implement a continuing education programme for German nurses in order to help them adapt to and use the German National Expert Standard consistently and effectively to improve the quality of pressure ulcer prevention.

Relevance to clinical practice This study provides an insight into the extent of pressure ulcers preventive practices used by nurses. The results may serve as a basis for developing an effective strategy to improve nursing practice in this area and the promotion of evidence-based care. Barriers concerning the implementation of preventive measures must be recognised and dealt with in order to improve the quality of practice.

Acknowledgements Sincere thanks to the staff, patients and their families for participating in this study. © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1513–1524

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or revising it critically for important intellectual content and (3) final approval of the version to be published.

Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ ethical_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, (2) drafting the article

Conflict of interest The authors declare that they have no conflict of interest.

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