Art & science tissue viability supplement

Nurses’ knowledge of pressure

ulcer risk assessment
Joseph J, Davies Clifton S (2013) Nurses’ knowledge of pressure ulcer risk assessment.
Nursing Standard. 27, 33, 54-60. Date of submission: June 21 2012: date of acceptance: January 11 2013.

Abstract for patients, including pain, disfigurement, poor

quality of life and high morbidity rates (Lindgren
Pressure ulcers are a largely avoidable, but serious health problem in et al 2002, Bates-Jensen et al 2007, Moore and
the UK. Nurses should be knowledgeable of the signs and symptoms Cowman 2008). Therefore, the prevention of
of pressure ulcers, and preventive strategies to reduce their incidence. pressure ulcers, which are largely avoidable,
This article explores the literature on nurses’ understanding and remains a priority for all nurses.
use of risk assessment tools to identify patients at increased risk of A literature review was conducted by the
developing pressure ulcers and how, if at all, this contributes to fewer authors to investigate nurses’ understanding of
pressure ulcers in the healthcare setting. risk assessment and the importance of clinical
judgement in relation to pressure ulcers, with
Authors the aim of ascertaining whether use of a risk
Jamuna Joseph assessment tool affects patient outcomes, and how
Staff nurse, Rookwood Hospital, Cardiff and Vale University Health recognition and assessment of pressure ulcers can
Board, Cardiff. be improved in the healthcare setting.
Sian Davies Clifton
Retired, was lecturer, School of Nursing and Midwifery Studies, Literature search strategy
Cardiff University, Cardiff.
Correspondence to: [email protected] A search of the literature was conducted using the
databases Cumulative Index of Nursing and Allied
Keywords Health Literature (CINAHL), Ovid and the British
Nursing Index, as well as the internet search
Pressure ulcers, preventive strategies, risk assessment, wound care engines Google, Google Scholar and Yahoo.
Manual searches of journals, books and websites
Review for professional, government and voluntary
All articles are subject to external double-blind peer review and organisations in relation to nursing and health care
checked for plagiarism using automated software. were also carried out. In addition, back-chaining
was used to search reference lists of relevant
Online articles to identify other articles not identified by
the original search (Holland and Rees 2010).
Guidelines on writing for publication are available at The keywords used were pressure ulcers,
www.nursing-standard.co.uk. For related articles visit the archive pressure sores, bed sores, pressure damage,
and search using the keywords above. pressure injuries and decubitus ulcers. Some
words were used in combination using the
Boolean operator ‘AND’, including pressure ulcer
Pressure ulcers are a major health problem prevention, nurses’ knowledge, nurses’ attitudes,
(Padula et al 2008) and can have a significant nurses’ education, causes of pressure ulcers,
financial effect on health providers (Barrett et al research, risk assessment and hospital. Inclusion
2010), with estimates of £1.4-2.1 billion being criteria were that articles had to be written in
spent annually in the UK (Strand and Lindgren English and published between 1995 and 2011
2010). Costs may be related to treatment, but also to ensure relevance to practice. No geographical
include prolonged hospital stay, and additional limits were imposed. Research-based articles on
resources and time required to care for people pressure ulcer prevention focused on adult patients
with pressure ulcers (Bennett et al 2004). Despite in medical wards were included in the review,
increasing efforts to reduce the incidence of while articles on pressure ulcer care and treatment
pressure ulcers, they are still common (Jaul 2010). and those related to patients with spinal cord
Pressure ulcers can have serious consequences injuries, surgical patients, and paediatric patients,

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 Art & science tissue viability supplement

as well as the studies conducted in settings other are several pressure ulcer risk assessment tools
than hospitals were excluded. available, including the Norton scale (Norton
The initial search before applying inclusion et al 1962), Waterlow score (Waterlow 1985)
and exclusion criteria resulted in 1,700 articles. and Braden scale (Bergstrom et al 1987).
After adapting the inclusion and exclusion criteria, Risk assessment is an integral component
91 articles were identified, and of these, 26 were of pressure ulcer prevention and its use is
reviewed fully because of their relevance to the recommended by international guidance (National
nurse’s role in the prevention of pressure ulcers. Institute for Health and Clinical Excellence (NICE)
The 65 remaining articles were used for reference 2005, Moore and Cowman 2008) in combination
throughout the work. with nurses’ clinical judgement (Pancorbo-Hidalgo
Several themes emerged from the articles. et al 2006). While risk assessment is necessary to
However this article focuses on the use of risk ascertain the likelihood of individuals developing
assessment scales in clinical practice, nurses’ pressure ulcers, the decision to initiate preventive
knowledge of pressure ulcer risk assessment and interventions and the timing and appropriateness of
the importance of clinical judgement in preventing these depends on nurses’ knowledge and their duty
pressure ulcers. of care as professionals (Benbow 2009a). Increasing
nurses’ knowledge of the causes of pressure ulcers
can help to prevent their development (Nixon 2001,
Findings Wright and O’Connor 2007).
Although pressure ulcers are mostly avoidable, their Anthony et al (2002) suggested that increasing
incidence remains high (Moore 2004). Nurses are age, incontinence, poor nutrition and immobility
in a pivotal position to promote best practice in are the main risk factors for the development
relation to pressure ulcer prevention (Collins 2001). of pressure ulcers. Benbow (2009a) stated that
This is particularly salient as it has been recognised the numeric value identified following use of
that nurses’ views, values, knowledge and a risk assessment scale is only useful if used in
competence can affect incidence and development conjunction with nurses’ clinical judgement
of pressure ulcers, as can organisational structure and knowledge of the patient. For example, the
and availability of resources (Athlin et al 2010). numeric risk score of a patient may be high as a
Nurses have a duty of care to meet the needs of result of previous disease, however the patient may
their patients and prevent harm to patients while be mobile and able to self-care, and have overall
in their care (Nursing and Midwifery Council good health, which may not be identified by the
(NMC) 2008). Therefore, prevention of pressure risk assessment scale (Benbow 2009a).
ulcers, particularly those that may develop while the A number of studies indicate that there is
patient is in hospital, should be a priority. insufficient evidence to ascertain the usefulness,
Timely and accurate assessment of pressure effectiveness and prediction value of risk
ulcers depends on individual nurses’ knowledge assessment scales in pressure ulcer prevention
of and attitude towards pressure ulcers, with (Anthony et al 2002, Moore and Cowman 2008,
education on skin and risk assessment forming Griffiths and Jull 2010, Kottner and Balzer 2010).
a key component of this (Riordan and Voegeli This is compounded by the weak validity and
2009). Nixon (2001) suggested that knowledge reliability of many risk assessment scales (Lepistö
of pressure ulcer aetiology supports best practice et al 2001, Kottner and Balzer 2010).
in pressure ulcer care by improving nurses’ Moore and Cowman (2008) conducted a review
understanding of how such ulcers might develop. to determine whether using structured, systematic
Knowledge of risk factors for pressure ulcer pressure ulcer risk assessment tools reduces the
development is essential. Comprehensive and incidence of pressure ulcers. Randomised controlled
accurate patient assessment should be carried out trials (RCTs) comparing the use of structured,
to ensure that appropriate preventive strategies systematic pressure ulcer risk assessment tools with
and treatment are implemented in a timely manner non-structured risk assessment, or unaided clinical
(Clay 2000, Theaker et al 2000). judgement were included in the study. The initial
literature search resulted in 105 studies. None of the
Risk assessment scales studies were found to meet the inclusion criteria,
Nurses need to be knowledgeable of the causes and therefore demonstrating the lack of RCT evidence
risk factors associated with pressure ulcers (Lepistö available to identify whether risk assessment
et al 2001, Anthony et al 2002). Risk assessment reduces the incidence of pressure ulcers (Moore and
scales can be used to identify patients who are Cowman 2008).
more likely than others to develop pressure ulcers RCTs are viewed as highly reliable, valid and
(Pancorbo-Hidalgo et al 2006, Guy 2007). There accurate (Rees 2003), and therefore are a reliable

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 Art & science tissue viability supplement

means of assessing the effectiveness of risk be an unnecessary distraction, delaying care and
assessment in pressure ulcer prevention (Griffiths contributing to the development of pressure ulcers.
and Jull 2010). Findings from the literature search The study identified poor inter-rater reliability for
demonstrate a lack of evidence for the use of risk the Waterlow score risk assessment tool and found
assessment in preventing pressure ulcers, therefore that some nurses were not using the tool correctly,
indicating the need for future RCT studies to be which meant that some nurses might give the same
carried out in this area. Since risk assessment scales patient a different score (Kelly 2005). This can
are used as an indicator for the provision and be particularly problematic in the clinical setting,
allocation of resources, such as nursing time and where different healthcare professionals may care
pressure redistributing devices, their validity and for the same patient and resources are limited
reliability are important (O’Tuathail and Taqi 2011). (Benbow 2009a). For example, a patient who is less
likely to develop a pressure ulcer may be given a
Nurses’ knowledge of pressure ulcer risk high score depending on who assessed him or her.
assessment If an intervention is applied according to the score
Risk assessment scales should be used in conjunction alone, this may result in unnecessary treatment
with nurses’ knowledge and skills to reduce the and use of resources.
incidence of pressure ulcers (Halfens et al 2000). Providing education and increasing awareness
The European Pressure Ulcer Advisory Panel and among healthcare professionals on the correct
National Pressure Ulcer Advisory Panel (2009) use and interpretation of risk assessment scales
recognised the need for healthcare professionals to is essential to ensure that patients are treated
be educated about how to undertake a structured appropriately. Anthony et al (2002) highlighted
approach to conducting and recording pressure the importance of education and training to
ulcer risk assessment and identified that the ensure that healthcare professionals use risk
use of elements such as a risk assessment scale, assessment scales in the same way and as they are
comprehensive skin assessment and clinical intended to be used. They also indicated that to
judgement is important for the formation of a complete a risk assessment score on each patient
structured approach to risk assessment. admitted to the hospital would be a ‘pointless
Evidence suggests that if these elements are exercise’ because scoring can be unreliable and
used in combination with education programmes, nurses may interpret the results differently.
for example educating professionals on how Therefore, training and education about the risk
to conduct skin assessment by teaching the factors involved in developing pressure ulcers
technique for identifying blanching response and action to be taken may be more useful than
of the skin, and care protocols, it can reduce reliance on risk assessment scales, which may be
the development of pressure ulcers (European open to individual interpretation (Gould 2001,
Pressure Ulcer Advisory Panel and National Anthony et al 2002).
Pressure Ulcer Advisory Panel 2009). NICE (2005) states that initial and ongoing
Kelly (2005) conducted a study to assess the pressure ulcer assessment is the responsibility of
inter-rater reliability of the Waterlow score for all healthcare professionals. An audit conducted
pressure ulcer risk assessment completed by by Jones et al (2003) demonstrated that risk
different nurses. The sample included 110 nurses assessment was being carried out within 24 hours
who used the scale in their daily work and were of admission for 54% of patients, with 16% of
delegates at a five-day study course on pressure risk assessment forms completed but not dated,
ulcer prevention. The nurses were asked to and 18% of forms not completed. A total of 12%
complete a risk assessment for a patient in a case of forms were satisfactory, but were completed
study. The results indicated that nurses tended to after 24 hours. Jones et al (2003) suggested that
overrate rather than underrate the patient’s risk nurses considered completion of risk assessment
of developing a pressure ulcer, with only 13 of the forms a paper exercise instead of recognising risk
110 nurses accurately rating the patient’s risk of assessment as an opportunity to provide holistic
developing a pressure ulcer. Possible consequences patient care.
of overrating risk include unnecessary instigation Benbow (2007) stated that the responsibility
of interventions and use of equipment. This may and, therefore, accountability for undertaking risk
not only result in a waste of resources and nurses’ assessment lies with the nurse. This is important
time, placing increased financial burden on health as the NMC (2008) highlights that nurses are
services, but may also compromise patient comfort accountable for their actions and any omission
and quality of life. of care may be deemed to be neglect, calling into
Kelly (2005) argued that complicated question nurses’ fitness to practise and endangering
algorithms used in risk assessment scales might their registration.

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 Importance of clinical judgement 2000). However, Anthony et al (2008) argued that
Phaneuf (2008) identified that in clinical judgement an experienced nurse can identify a patient at high
nurses will be combining pieces of information risk of pressure ulcers using clinical judgement
to analyse, associate and interpret data to reach alone. Moore (2010) suggested that experienced
conclusions. For example by seeing a patient who nurses will make better clinical decisions than
is dehydrated, is bed-bound, has poor appetite and those with less experience, and it may not only
restricted mobility, the nurse will identify that the be related to knowledge, but can be related to
individual is at risk of developing pressure ulcers the ability to assimilate this knowledge to make
and will provide early preventive measures. Phaneuf decisions. Stephen-Haynes (2006) recognised
(2008) argues that in this example if each condition that nurses’ clinical judgement is based on their
is assessed separately rather than associating with clinical experience and educational exposure, and
each other, the nurse will fail to reach this conclusion. highlighted the importance of experienced staff
Anthony et al (2002) emphasised that although risk providing support to less experienced staff.
assessment scales can be helpful for some patients, The ability to make good clinical decisions
education of the nurse and increased knowledge may depend on the degree of exposure to patients
of the risk factors involved may be responsible for with pressure ulcers and also the quality of the
reduced incidence of pressure ulcers, not the use of exposure. For example, some nurses may continue
risk assessment scales. Risk assessment scales may to follow outdated practices because they have
focus on quantitative elements such as scoring, used these in the past rather than applying
ignoring qualitative elements such as the patient’s up-to-date evidence-based practice (Halfens and
general condition and potential for rehabilitation Eggink 1995, Moore 2004).
(Benbow 2009b, Kottner and Balzer 2010). Holistic assessment of the patient may be better
Risk assessment scales should not be used as than over-reliance on risk assessment scales (Schott
a replacement for clinical judgement (Gould et al and Henley 2000). Nursing intuition may also be

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 Art & science tissue viability supplement

useful when assessing patients at risk of developing to pressure ulcer prevention (Maylor 2000). Staff
pressure ulcers (Billay et al 2007). Truman (2003) shortages may mean that risk assessment is not
acknowledged that although it is difficult to carried out regularly and that pressure ulcers go
measure or quantify intuition, it comprises a mix unnoticed, thereby compromising patient care.
of knowledge, skill and practice, with associated
benefits of enhanced clinical judgement and
effective decision making, crisis aversion, holistic Conclusion
patient assessment and improved nurse-patient Risk assessment is important in the prevention and
relationships. Therefore encouraging the use of treatment of pressure ulcers, however more RCTs
intuition in nursing, which is not measurable, are necessary to identify the link between use of risk
(Truman 2003) allows nurses to think outside assessment scales and reduced incidence of pressure
the box or more holistically, which will improve ulcers. The literature review identified that nurses
the quality of assessment, especially in pressure may use risk assessment scales for the same patient
ulcer prevention, and reduce over-dependence on differently and that interpretation may be subjective,
quantitative assessment. leading to problems in consistency of care. This
Knowledge can lead to early identification of indicates the need to educate healthcare professionals
pressure ulcers and prevent further deterioration about the risk factors involved in the development of
(Wright and O’Connor 2007). However, pressure ulcers to improve their overall awareness.
Panagiotopoulou and Kerr (2002) argued that Risk assessment scales are not a replacement
knowledge alone is insufficient because nurses need for good clinical judgement, and it is essential
to be able to apply this knowledge appropriately and that patient assessment includes a combination
this may be affected by personal and organisational of nursing knowledge, clinical judgement and risk
variables. For example, if healthcare staff have an assessment scales to prevent the development of
increased workload, high priority may not be given pressure ulcers NS

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