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

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
Summary of relevance
Problem or issue
The experiences of hospital nurses concerning pressure injury
care has received little qualitative exploration.
What is already known?
Hospital-acquired pressure injuries are perceived to be an
indicator of poor quality nursing care. Existing international
research on the prevention and management of pressure
injuries has focused on nurses’ knowledge, attitudes, and per-
ceptions through quantitative studies.
What this paper adds?
Nurses deliver pressure injury prevention and management
under difficult circumstances at a clinical, educational, and
organisational level. Nurses are internally conflicted about the
quality of pressure injury care, which they perceived to be, in
part, determined by factors out of their control.
Tudor, Wei Ng, Morrow, 2015). Recently, in Australia, PIs have been
identified as the fifth most costly commonly occurring preventable
complication in hospitals and have subsequently been included as
one of the eight national standards to improve safety and qual-
ity care nationally (Australian Commission on Safety & Quality in
Health Care, 2017).
Following an unexplained increase of reported incidents of
HAPIs (by 63% from 2010 to 2014) in a local health district (LHD)
comprising of four hospitals in Sydney, Australia, an in-depth anal-
ysis on all aspects of pressure injury prevention and management
(PIPM) was conducted as an overall study to understand reasons
for the increased HAPI rate. One component of the overall study
sought to determine perceptions and attitudes of nurses to PIPM,
which had provided insight into nurses’ perspective, but raised
further questions for the research team. This article presents the
findings of a qualitative study on the experiences of hospital nurses
in delivering PIPM.
Research spanning three decades has highlighted that the
majority of PIs could be avoided through interventions by clinicians,
patients and carers. HAPIs are considered an indicator of poor qual-
ity care, particularly nursing care (Heslop & Lu, 2014; Jull & Griffiths,
2010; Savitz, Jones, & Bernard, 2005). This is because nurses play an
integral role in preventing skin care complications (Lyder & Ayello,
2008). At the frontline, nurses engage with skin care practices at
all stages, from prevention to treatment, and are thus the most
appropriate discipline to lead and implement initiatives for prac-
tice changes (Hiser et al., 2006; Yap & Kennerly, 2011). However,
despite best efforts to deliver effective care to patients, the daily
challenges faced by nurses with PIPM can be underestimated.
Few qualitative studies (Athlin, Idvall, Jernfalt, & Johansson,
2010; Samuriwo, 2010a; Samuriwo, 2010b; Sving, Gunningberg,
Hogman, & Mamhidir, 2012) have considered nurses’ experiences
of PIPM in a hospital setting. Particularly their perceptions and
values concerning PIPM, which affect care delivery and priorities.
Samuriwo (2010b) and Sving et al. (2012) showed that nurses’
efforts at PIPM are challenged by organisational and environmental
factors such as hospital flow, time constraints and the prioritisation
of other nursing tasks. Even when processes to decrease PI rates
are implemented, compliance with certain PI practices and policy
guidelines by nurses are low (Niederhauser et al., 2012; Sving et al.,
2012).
Similarly, Athlin et al. (2010) interviewed nurses on the con-
tributing factors to the development and deterioration of PIs in
hospital and community settings. Factors included patient char-
acteristics, staff views and commitment, and the aforementioned
organisational factors. Overall, nurses placed less value on PIPM
than on other aspects of patient care. The authors recommended
further research to gain a deeper understanding of factors that
affect PIPM.
An insight into nurses’ experience of PIPM is therefore war-
ranted to identify areas for practice improvement, education, and
ultimately, better patient care and outcomes. Complexities encoun-
tered when providing PIPM, and successful strategies employed by
nurses, were of key interest. To the best of our knowledge, this is the
first study to report qualitative data in Australia of hospital nurses’
experiences of PIPM.
The aim of this study was to gain an in-depth understanding of
the experiences of nurses concerning PIPM in a hospital setting.
2. Methods
2.1. Design
A qualitative exploratory research design using semi-structured
interviews was employed (Sandelowski, 2000). The methods of this
study were guided by the “consolidated criteria for reporting qual-
itative research” (COREQ) (Tong, Sainsbury, & Craig, 2007). This
study was one element of a broader study in the LHD examining
the substantial increase in HAPIs.
2.2. Sampling and participants
Purposive sampling was used to ensure that the cohort included
both senior and junior nurses from orthopaedic, cardio-vascular,
transplant, acute and medical aged care, neurosciences, rehabili-
tation and intensive care units. These units were selected as they
had the highest incidence (just over 32%) of reported HAPIs over
a 12 month period compared to other units in this district. Addi-
tionally, it has been consistently demonstrated that patients in
these units are at high risk of developing PIs (National Pressure
Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel &
Pan Pacific Pressure Injury Alliance, 2014). The sample comprised
of registered nurses, enrolled nurses, clinical nurse educators, clin-
ical nurse specialists, and nurse unit managers in four hospitals
across the LHD.
Participation was voluntary. Prospective participants returned
written or verbal expression of interest to the lead author subse-
quent to the distribution of an information flyer. Also, a member
of the research team invited nurses to participate at the nurses’
afternoon handover at each of the clinical units identified as hav-
ing a high incidence of PIs. To maintain anonymity, age was not
collected, however years of experience, and the participant’s role
were collected.
2.3. Data collection
A semi-structured interview guide comprising of demographic
and open questions was developed by the authors to allow a more
in-depth exploration of nurses’ experiences (Table 1). The semi-
structured interview guide was reviewed by two expert wound
nurses and two qualitative research experts, and piloted on five
senior and junior nurses. Data were collected between May and
September 2016. Interviews lasted between 20–40 minutes. Of
these, two group interviews were conducted and the remaining
were held individually (Table 2). All interviews were conducted in
a private location, chosen by the nurse-participant, ensuring their
participation was not known to members of their clinical unit. The
interviews were audio recorded and transcribed verbatim by an
independent transcription company. Field notes were also made
during the interviews. Participants were offered the opportunity
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?)
(What worked/what didn’t work?)
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
prevention and management of HAPI?
data. None elected to take up this offer. Data collection continued
for each clinical unit until data saturation was reached.
2.4. Ethical considerations
The study was approved by the LHD Human Research Ethics
Committee (ref:HREC/15/RPAH/482). Ethical standards for this
study were upheld in accordance with The National Statement
on Ethical Conduct in Human Research (The National Health &
Medical Research Council, The Australian Research Council, & The
Australian Vice-Chancellor’s Committee, 2007). Each participant
was informed of the aims of the study and written consent was
obtained. Confidentiality was ensured by the de-identification of
participants during data entry into a secure electronic database.
2.5. Data analysis
Data were managed using managed using NVivo 10 software.
The software. The data obtained from the participants were the-
matically organised and analysed using an approach outlined by
Braun and Clarke (2006). Re-reading of the transcripts by the first
two authors assisted in identifying emerging concepts and codes.
The first two authors coded the data separately and then reviewed
the codes together until there was congruence to form subthemes.
To enhance credibility, all members of the research team were
involved in data analysis. The third and fourth authors, who are
experts in qualitative research, reviewed the sub-themes to con-
firm interpretation and assisted the development of four themes
(Figure 1 ).
Figure 1. Thematic diagram showing four core themes from the analysis of nurse
interviews.
2.6. Rigour
To ensure methodological rigour of the study, the framework of
credibility, authenticity, criticality and integrity guided this study
(Whittemore, Chase, & Mandle, 2001). A senior female research offi-
cer with a PhD and long-standing experience in qualitative research
conducted the interviews. She had no relationship with the par-
ticipants. Interviews were transcribed verbatim, transcripts were
anonymised, and participants were invited to review and comment
on their transcripts. The researchers then analysed the transcripts
individually and met to review and confirm interpretation, field
notes, and develop codes and themes. An audit trail that outlined
the processes that guided the interpretation of the data, as well as
personal notes of the interviewer, was maintained (Koch, 2006).
3. Findings
The purposive sample comprised of 20 female nurses, who had
an average of 11.9 years of experience (range 4–26 years, data
missing for 1 participant) (Table 2). Four themes were identified
to capture the nurses’ experiences of providing PIPM in a hospi-
tal setting: (1) managing competing demands in complex clinical
settings; (2) the importance of knowledge and skill; (3) clarifying
organisational expectations, purpose and successes and; (4) ethi-
cally challenged when unable to provide quality patient care.
3.1. Managing competing demands in complex clinical settings
Study participants described managing competing priorities
and responsibilities, including PIPM, in the context of a complex
clinical setting, as being particularly difficult. Competing demands
that were consistently reported by participants included the time
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
patients.
3.1.1. Time and process of providing quality PIPM
The process of PIPM involves numerous steps such as
assessment, diagnosis, documentation, and preventative and man-
agement interventions. These steps place great demand on nurses’
skills, capabilities, and time to ensure quality PIPM is provided.
“Staff knowing what they’re looking at. How to document it and
how to report it properly, which is a lot of the time and then them
knowing what is the most appropriate dressing to use.” (P4)
Participants reflected on how difficult it was to incorporate PIPM
into their existing tasks and responsibilities to multiple patients.
Some voiced concern over the quality of care provided under the
current workload.
“. . .there’s too much paperwork for them to do, there’s too much
other things going on that they don’t have time to do those tiny little
things that could prevent so many pressure injuries from happen-
ing.” (P7)
3.1.2. Increased workload, time constraints and limited resources
Many nurses reported being embedded in a setting where they
faced competing priorities, increased workload, time constraints,
limited resources, and felt a sense of powerlessness to provide
quality care.
“. . .as good as our intentions are and we would love to be able
to turn every patient hourly to second hourly we just don’t have
that capacity within our staffing to be able to do that because the
patient’s about to have a fall or the patient that’s occluding their
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
go and turn this patient. So I think a lot of it is – comes down to
what we’re able to do within an eight hour shift limits.” (P1, group
interview)
“. . .the compliance decreases because we have a lot of things to do
and lot of paperwork to do and you are doubling the paper and
doubling the documentation part.” (P9)
When nurses struggled to manage competing demands, this
led to fragmented communication between staff regarding PIPM.
Staff communication was seen as crucial to ensure that PIPM mea-
sures were in place. Such measures included periodic turning and
contacting specialist nurses, such as wound nurses, PI nurses or
continence nurses in a timely manner for appropriate advice and
care.
“Sometimes they [casual staff] don’t tell us, and we had to tell them
– if you see any pressure sores, you can write up a risk file – some-
times they don’t tell us. Then the following day we found out, she
didn’t tell me, or he didn’t tell me.” (P10)
Participants explained that nurse responsibilities to other
patients, particularly high-dependency patients such as immobile
(or bed bound) patients, also lowered the priority of PIPM.
“. . .10 quite dependent people on the wards so that’s a third for our
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
interview)
Nurses contended with competing demands in the context of
staffing constraints. Whilst participants in this study supported the
need to prioritise PIPM, stretched staff numbers made it difficult to
carry out such tasks. Participants described turning patients reg-
ularly as challenging without adequate staff; particularly patients
who were obese and required several staff to turn safely. Several
participants were concerned about the lack of sufficient resources
or their inability to access to them, particularly equipment, to move
patients or care for the PI.
3.1.3. Complexities presented by patients
All participants identified patient comorbidities and resistance
as two key barriers to enabling PIPM. Comorbidities that hindered
nurses’ ability to provide effective PIPM included stroke, malnour-
ishment, incontinence, obesity, fragility, being underweight, old
age or being a post-operative patient. Participants explained that
most of the patients they encountered had more than one of these
conditions.
“Lack of mobility and also his – he was quite unwell so he wasn’t
moving and repositioning himself in bed so they did have an air
mattress in place when he was in intensive care but I think it was
due to the fact that he was not mobilising and he had anaemia and
he had a lot of other complications going on. He was on a lot of
medication as well.” (P8)
Patient resistance came in the form of either refusing to move in
accordance with recommendations or assistance from the nurses,
or repositioning themselves after being turned in a position to
relieve pressure in the affected area. Most participants stated that
resistance played a major role in the development of PIs they
encountered.
“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
looking after him he’d already been in hospital for a few days but I
just think the fact that he wasn’t willing to help us, well, not help
us but move around so much, got this pressure injury. He just was
lying in bed not doing much at all.” (P11)
Limited resources combined with competing priorities and
patient characteristics made existing complications, challenges and
PIs more difficult to prevent and manage. Participants believed that
some patients subsequently developed preventable PIs.
“I mean, an issue we have recently. . .was an extremely obese
patient and she was difficult, because we didn’t have a bariatric
bed to nurse her on and to be able to roll her and do pressure area
care on her was extremely difficult and requires more than one
nurse to actually do it, so she ended up with a few pressure injuries
as a result, but that was because of a lack of bodies and lack of
equipment to be able to do that for her.” (P8)
3.2. The importance of knowledge and skill
Participants emphasised the importance of building knowledge
and skills on PIPM particularly in relation to the diagnosis of PIs, the
use of one’s own clinical judgement, patient education, and family
involvement. Participants (1,2,3,4) explained that a lack of knowl-
edge among staff about misdiagnosing and documenting PIs as skin
tears and dermatitis had implications not only for reporting but
also for appropriate treatment. Participants felt that nurses needed
more education and awareness on PIPM to be more adept at recog-
nising when a PI may develop in order to implement preventative
measures.
“. . .there needs to be more education about what is a pressure area,
so we’re getting lots of documentation of skin tears, of dermatitis,
incontinent dermatitis, that aren’t necessarily pressure injuries but
they’re being put in [reported] as such so I know that there’s a gap
in education of what is a pressure area. . .” (P1, group interview)
Participants highlighted that when a risk assessment was con-
ducted with a tool such as the Waterlow (Waterlow, 2017), it
was important to use one’s own clinical judgement. Participants
 M. Barakat-Johnson et al. / Collegian 26 (2019) 95–102
described the feeling of having their clinical judgement taken away
from them due to pressure to complete mandated assessment tools
that became ‘tick box’ activities.
“A lot of clinical judgement and autonomy has been taken away
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
thinking has been taken away.” (P1, group interview)
Knowledge on PIs were not only seen in the context of nurses’
knowledge but also patient education and knowledge, and fam-
ily involvement. Participants found that involving patients in their
care and informing them in advance what PI preventative care
entailed enabled patients to understand the importance of such
assessments and strategies.
“So after we noticed it, we got it assessed by one of the Wound CNSs,
and we put the appropriate dressing on there and we re-educated
him, encouraged him that he needs to reposition frequently and
just comply with that for us. . .He was quite good, and it’s actually
improving now.” (P18)
Families were described by some participants as having an
important role in motivating patients to reposition themselves, if
physically able, and were even seen as potential partners of busy
nurses.
“. . .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
more. . .Because if you’re busy and they can just remind them to
move or do something to help. . .Get them motivated, or oh, you
haven’t moved for a bit, or something, yeah. Involving families into
everything is always important.” (P7)
3.3. Clarifying organisational expectations, purpose and successes
Several participants described that having organisational sup-
port was crucial to ensure effective PIPM, particularly in the areas
of the provision of educational opportunities and initiatives, and
the streamlining of PIPM documentation. When their organisation
had policies and guidelines that were consistent, participants knew
what was expected and what should be done.
“So I’m very proud of our ward because I think everyone’s on top
of it, because everyone knows and we know what our goals are
and even when we’re washing patients, I think our nurses are very
diligent to look, because we have these goals that we’re trying to
reach. And so if we reach. . .a goal of 50 days or something [without
a PI], we’ll have a little celebration to reward ourselves. . .So that
motivates people.” (P11)
Meetings with fellow staff about patients with PIs to examine
how they were managed and cared for were seen as educational
opportunities. Participants felt supported by their organisation
when educational resources were available, specialist staff were
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
documentation of PIPM. Participants expressed concern about the
volume of paperwork and the inconsistencies with documenting
PIs. It was common to find duplicate documentation concerning
reporting, preventing and managing PIs on paper and electroni-
cally. This led to confusion as to where the information should be
documented.
“It’s great that I’m seeing them and that people see and we’re report-
ing, it’s all wonderful, but it’s actually not treating the patient first,
so I think that’s where the gap is that the paperwork process but
then the patient’s still not being cared for.” (P1, group interview)
99
One participant suggested having a checklist of tasks, such as
regular skin assessments and turns would be helpful. The use of
extra healthcare staff to assist with repositioning, such as turning
teams, was another suggestion made by several participants (P1,
group interview; P4; P7; P8).
“. . .I think probably as an organisational approach it could be more
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
to mattress provision and selection” (P1, group interview).
In terms of education, participants emphasised the importance
of hands-on education rather than formal educations sessions or
courses.
“Maybe calling a few nurses around at the one time and doing the
assessment all together, just to get a few people on board so they feel
more comfortable. . .More practical-based education, not so much
in-services, because you retain the information,. . ..” (P19)
Participants explained that the success of education initiatives
or activities was linked to the organisation’s support for providing
optimal PIPM.
3.4. Ethically challenged when unable to provide quality patient
care
Although there was a strong belief held by participants that PIPM
was important and should be part of routine patient care, it was
also acknowledged that there was a lack of quality PIPM within
their organisation. Participants provided a pragmatic account of the
realities of working in a complex setting with competing priorities,
limited resources, lack of nurse awareness and skill regarding PIPM,
and challenging organisational factors.
“. . .there are so many issues, a lot of barriers. . .. if we can prevent
them it would be so much better than to dress a stage 4 pressure
injury” (P9)
Reflecting on the bigger picture, participants in this study
wanted to deliver the care required to prevent the development
of PIs but considered the limitations of their resources and other
clinical and organisational factors to be a hindrance. Participants
expressed an internal ethical conflict when the provision of qual-
ity patient care was compromised by factors largely out of their
control.
“. . .when they [pressure injuries] do develop past that stage two,
there’s almost no stopping them. . .. and it’s incredibly distress-
ing for the staff, we’re always so upset, the family are beside
themselves. . .” (P4)
Carrying out quality PIPM and meeting the demands of other
nursing duties and responsibilities was experienced as a balancing
act that many participants struggled with at the expense of patient
care and compliance with best practice.
4. Discussion
To the best of our knowledge, this is the first qualitative study
conducted in Australia to gain insight into the experiences of hos-
pital nurses concerning PIPM. This study highlights the importance
of understanding the experiences of nurses conducting PIPM as just
one aspect of patient care and should not be considered on its own
to change existing practice. There is a responsibility and account-
ability for patient care that sits with nurses, and effective PIPM
should be understood within the broader concept of nursing work
being delivered in a complex healthcare system influenced by deci-
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
in practice becomes operationalised and how it impacts on nursing
work is often not fully understood until the changes are imple-
mented. The findings from this study are just one aspect of care
provided by nurses required to ensure quality and safety of patient
care in hospitals. Findings from this study confirm and extend exist-
ing research in this area. Overall, participants were aware of the
importance of PIPM and were able to identify existing successful
practices and opportunities for improvement. However, partici-
pants considered providing quality PIPM to be a difficult task due to
competing priorities and challenges faced at both an organisational
and patient level. Furthermore, participants were ethically chal-
lenged when they were unable to provide effective PIPM. Increased
paperwork, high workloads, and limited resources, caused PIPM
compliance and quality of patient care to decrease.
Consistent with previous studies (Athlin et al., 2010; Beeckman,
Defloor, Schoonhoven, & Vanderwee, 2011; Dilie & Mengistu, 2015;
Kallman & Suserud, 2009; Moore & Price, 2004; Mwebaza, Katende,
Groves, & Nankumbi, 2014; Nuru, Zewdu, Amsalu, & Mehretie,
2015; Strand & Lindgren, 2010; Sving et al., 2012; Tubaishat,
Aljezawi, & Qadire, 2013), the combination of increased work-
load, lack of resources, and lack of time described by most of the
participants in our study, had implications for delivering effec-
tive PIPM. Participants believed PIPM was time-consuming and
they had insufficient staffing to assist with repositioning. Subse-
quently, attending to PIPM practices became a lower priority. This
is concerning as there is substantial evidence to suggest that the
nurse-to-patient ratio impacts on patient safety and quality care
(Brown & Wolosin, 2013; Dykes & Collins, 2013; Heslop & Lu, 2014;
Solomita, 2009). Significant risks are posed when workloads are
increased due to patient acuity or comorbidities and processes are
not put in place to meet these demands. However, as demonstrated
by He, Staggs, Bergquist-Beringer, and Dunton, 2016, sufficient
staffing levels safeguard quality patient care, and reduce the devel-
opment of PIs.
Nationally, in recent years, there has been attention given to
nurse-to-patient ratios to ensure safer nursing workloads, delivery
of quality nursing care, and to avoid adverse patient outcomes. As
a consequence, the nurse-to-patient ratios to ensure safe work-
loads have been mandated in several states such as New South
Wales, Victoria, and Queensland (Australian Nursing & Midwifery
Federation, 2015; Gordon, Buchanan, & Bretherton, 2008; NSW
Nurses & Midwives Association, 2015; Queensland Government,
2016). Therefore, it can be argued that with the improved nurse-to-
patient ratio, effective PIPM would be easier to maintain. However,
in practice, this is not straightforward. Competing priorities and
lack of communication between nursing staff are not often taken
into account when calculating nurse-to-patient ratios. Additionally,
short-term or casual staff may compromise effective PIPM (Athlin
et al., 2010). Participants in this study perceived PIPM to be diffi-
cult to perform when communication was fragmented, particularly
caused by a lack of staffing which impacted on staff handover and
continuity of care. PIPM was challenging to enact along with exist-
ing tasks and responsibilities. Additional organisational efforts and
processes are necessary to address these challenges so that when
the workload is increased, patient care is not compromised.
In describing their experiences with staffing, time and processes,
participants reflected on difficult moments when they felt power-
less and proper care could not be provided, particularly for patients
with increasing complexity. Firstly, they felt internal conflict when
caring for critically ill patients who have other areas of care to pri-
oritise. Secondly, nurses put in place PIP strategies for critically ill
patients only for a PI to develop, leaving nurses feeling despondent.
Thirdly, patients who were resistant to care, aggressive, or con-
fused, hindered nurses in providing effective PIPM. The challenges
expressed by participants in this study are consistent with previ-
ous research reviewing the barriers to PIPM (Kharabsheh, Alrimawi,
Assaf, & Saleh, 2014; Mwebaza et al., 2014; Sving et al., 2012;
Tubaishat et al., 2013).
There is a link between the first and the last theme as patients
with increased medical complexities require extra resources result-
ing in an increased workload, leaving less time to provide essential
patient care. Many participants felt that staffing was inadequate
to address increasing patient acuity and patient needs. Consis-
tent with Dilie and Mengistu (2015), delivering quality PIPM
was impeded by the disproportionate nurse-to-work ratio leav-
ing nurses feeling discouraged whilst balancing effective PIPM
and meeting the demands of their responsibilities. Participants
struggled with these demands at the expense of patient care and
compliance with best practice. The clinical imperative as a practi-
tioner to prioritise the best interest of the patient and ensure that
they receive optimal care was being tested by the tasks they faced
and competing demands.
Mandated risk tools were perceived by participants to be time-
consuming and frustrating to use. Risk tools did not provide an
accurate representation of a patient’s risk of developing a PI and
were seen by participants to be a mandated ‘tick box’ tool that
added extra work instead of guiding PIP strategies. Participants in
this study felt that the act of mandating a tool meant their clini-
cal judgment was devalued. The mandated use of risk tools were
not found to lead to better prediction and prevention of PIs (Park,
Lee, & Kwon, 2016), especially when nurses view them as a hin-
drance rather than a guide. Additionally, PI risk tools have been
shown to have low sensitivity, hence, are not a reliable tool in pre-
dicting PI development or to guide prevention strategies (Kottner,
Dassen, & Tannen, 2009; Pancorbo-Hidalgo, Garcia-Fernandez,
Lopez-Medina, & Alvarez-Nieto, 2006; Park et al., 2016; Webster,
Gavin, Nicholas, Coleman, & Gardner, 2010).
Participants in this study encountered a high volume of paper-
work which meant less time was available to provide effective
PIPM. Documentation is critical to patient care as it outlines what
has been done. Documentation also informs next steps and is
important for clinical handover (Australian Commission on Safety
& Quality in Health Care, 2012). Participants acknowledged that
paperwork is a fundamental part of patient care and handover;
however, they felt their ability to properly complete it was hindered
by the large volume imposed on them. These findings correspond
with a number of studies where clinicians believed the large vol-
ume of paperwork to be time-consuming and a barrier to effective
patient care (Christino et al., 2013; Cunningham, Kennedy, Nwolisa,
Callard, & Wike, 2012; Siegler, Patel, & Dine, 2015). There are a
number of areas related to patient care that nurses must report
and record, as well as the mandatory requirements of completing
assessment forms. For example, in New South Wales there have
been a number of forms that have been mandated, which has placed
a burden on nurses carrying out fundamental care. A review of
current mandated documentation and its impact on nurses under-
taking fundamental patient care is therefore warranted.
The need for targeted education was highlighted by most par-
ticipants, especially on the diagnosis and classification of PIs.
Skin conditions were often misdiagnosed then reported and docu-
mented as a PI, such as incontinence-associated dermatitis (IAD).
The implications of misdiagnosis of skin conditions go beyond
incorrect assessment and classification. Patients may consequently
receive inappropriate treatment, and the organisation accumulates
a higher reported PI rate. Much of the literature shows that IAD pre-
disposes a patient to developing a PI and is often mistaken for a PI
(Beeckman, Schoonhoven, Boucque, Van Maele, & Defloor, 2008;
Doughty et al., 2012). PI education campaigns should emphasise
the importance of correct diagnosis and classification of PIs and
skin conditions so that nurses feel confident making differential
 M. Barakat-Johnson et al. / Collegian 26 (2019) 95–102
diagnoses, appropriate treatment is initiated, and PIs are correctly
reported.
It is interesting and encouraging that most participants identi-
fied some successful strategies despite the challenges faced when
delivering effective PIPM. To assist them to overcome the difficul-
ties carrying out PIPM, some participants reflected on what had
worked despite competing priorities. Successful practices were
related to ownership and leadership of PIPM, standardisation of
care, and engagement with nursing peers and patients. Partici-
pants emphasised the importance of including patient and family
members in PIPM practices. Strategies were employed to not only
educate patients about the importance of preventing PIs but also
give reasons and encouragement to comply with care. Previous
studies (Athlin et al., 2010; Roberts et al., 2016) have similarly noted
that increasing patient and family awareness and participation in
care was crucial to the success of effective PIPM.
5. Limitations
This study had several limitations. Firstly, purposive sam-
pling was used to recruit participants from clinical units with a
higher incidence of HAPIs, based on hospital data and existing
literature. The results of this study may not reflect the experi-
ences of nurses in clinical units with low incidence of HAPIs.
Secondly, all the participants were female. Therefore, the sam-
ple in this study did not represent the views of male nurses. In
2015, approximately 10.7% of registered nurses in the Australian
workforce were male (Australian Institute of Health & Welfare,
2016) reflecting the nursing industry, which is female-dominant.
Finally, the first author, a senior clinician, was known to some of
the participants, which may have affected their responses. Efforts
to minimise this involved employing a non-clinician researcher
with no association to the participants to conduct the inter-
views.
6. Conclusion
Participants in this study identified that delivering quality care
to prevent complications such PIs is essential, but not a task as
easy as one would assume within the constraints of organisational
barriers. Our study provides an in-depth insight into nurses’ expe-
riences concerning PIPM and supports previous research on the
challenges nurses face on a day-to-day basis. Organisational and
patient-related factors were significant determinants of carrying
out effective PIPM. These findings indicate that PIPM delivery is
more complex than suggested. However, despite this, participants
in this study were able to identify successful practices and oppor-
tunities for improvement.
The perception of PIs as a consequence of poor quality nursing
care should change. Organisations need to consider the importance
of providing adequate resources and its impact on the quality of
patient care. Efforts to support nurses with the challenges faced,
along with adequate leadership and staffing, are necessary to pre-
vent harm to patients, as well as the distress experienced by nurses
when they are unable to provide the necessary care.
Funding statement
This study was supported by a Clinician Researcher Scholarship
by Sydney Research received by the lead author.
Conflict of interest
No conflict of interest has been declared by the authors.
101
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