Challenges Faced by Nurses in Prevention of Pressure Ulcers in UK Healthcare Settings

This study explores the challenges faced by nurses in preventing pressure ulcers in UK healthcare settings. The study is divided into three themes: workplace context, organization in healthcare settings, and implementation of prevention of pressure ulcers. The workplace context includes challenges such as staff shortage, increased workload, patient attributes, models of care, and clinical skills and knowledge. The organization in healthcare settings includes guidelines and equipment maintenance. Implementation of prevention of pressure ulcers includes teamwork, education, and communication and documentation.

Portfolio 3C
In the United Kingdom’s healthcare settings, what challenges do nurses face in prevention of pressure ulcers?
Introduction 300
Pressure ulcer is defined as the sore pressure or bedsore which is usually represent the injuries to the aspect of skins and
underlying tissue that is primarily cause the prolong pressure on the skins. They are usually happening to anyone but they
affect the people which may show the confined in order to provide the aspect of bed and who sit in the chair or the wheelchair
for the longer period of the associated time. There are various of pressure ulcer which may show the aspect which is related
with the under pressure. It is also show the aspect which is related with the most common part of the body which include
heels, elbows, hips and base of the spine. They usually develop and create the complication with the patient. in addition, the
nurse also faces the issue of challenge which may related with the context that provide the optimum symptoms which may
affect the patient in all the ways. For the nurses, they face the issue of challenge and major difficulties which is associated with
the pressure ulcer that is immobility where patient face the issue of homebound and for the nurses it is difficult to examine the
progressive rate or disease progression which may create complication with the patient and they fail in such cases to provide
the proper prevention. The analysis toward the chronic wound is also not determined by the nurses and they not provide
adequate and proper intervention for the prevention. Therefore, the last one is incontinence which also show the failure of
nurses to provide proper treatment to the patient with the pressure ulcers.
A pressure ulcer is an ischemic lesion that develops in the skin and underlying tissues due to a constant amount of pressure,
which is associated with sickness and poor mobility. The issue poses serious challenges both to patients and to healthcare
providers. Despite the fact that nurses adhere to all available pressure ulcer prevention recommendations and methods,
pressure ulcers remain a concern in hospitals and nursing homes. This study aims to explore challenges confronted by nurses
while trying to prevent pressure ulcers for the patients in the United Kingdom’s healthcare settings.
Ten peer-reviewed articles have been chosen to expose about the challenges of pressure ulcers prevention. These
challenges are grouped into the challenges in the workplace context, the challenges due to organization in the healthcare
settings and the challenges derived from the implementation of the prevention of pressure ulcers. This classification resulted
in establishing the three themes of this study.

Critical Appraisal 200 words
The critical appraisal is defined as the aspect which is relevant in order to provide the proper criteria which is analysed within the article.
It majorly includes clarity of the research paper, methodology and many more which is related with the article or journals which may
show the aspect which is related with the context of CASP. The CASP is useful to assess the quality of research paper because they offer
the critical skills training, workshops and tools which is used by CASP in order to review and evaluate the data which is must in organised
from which is suitable to analyse the information and data. The CASP is help to read and check the health result which is related with
the trustworthiness, result and relevance. In addition, the CASP tool is useful in order to reduce the burden which may be associated
with the context of focus which is related with the article that is relevant which is associated with the question which indicate the
challenge of nurses while dealing with the patient with the pressure ulcer. The literature is used to evaluated on the high quality article
or paper which may provide the context which is related with the determination of high level research which is relevant with the
practices.
Pape
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Check
list
Clearl
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defin
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resea
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aims
?
Appropri
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methodol
ogy?
Appropr
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samplin
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recruitm
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Data
collec
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reflec
ts
resea
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aims?
Reflexiv
ity?
Ethical
considera
tions
discusse
d?
Data
analysis
appropri
ate and
thoroug
h?
Findings
demonst
rated
clearly?
Overall
researc
h
value?
Smith et al
Yes Ye
s
Ye
s
Ye
s
Some Not
required
Yes Ye
s
Limited
interpretatio
n of review
findings due
to varied
ANP
definitions
Jones et al Yes Ye
s
Ye
s
Ye
s
Some Yes,
clearly
Yes Ye
s
Need for
further
research
highlighted
Collins et
al. Yes Ye Ye Ye Some Not Yes Ye Identifies
need for

s s s required s further
research
Hopkins Yes Ye
s
Ye
s
Ye
s
No Not
required
Yes Ye
s
Non-medical
professional
s seen to
add benefit.
Further
research to
include
RCTs
Using a critiquing Tool – Example
Data extraction 100 words plus appendix
The data extraction method is defined as the aspect which is taken within the report or research process in order to provide the data and
information which may show their relevance. In addition, the mixed method is used in order to gather the information which is state the
listed finding. The mixed method is usually consisting of qualitative and quantitative data which is common as per the researcher which is
frequently used in order to gather and extract the information.
Development of themes 100 words plus appendix
Paper Theme 1 Theme 2 Theme 3 Theme 4
Smith et al
Endless pain Restricted life Coping with pressure
ulcer
Treatment pain
Jones et al
Pain Coping with pressure
ulcer
Poor nutrition Equipment pain
Collins et al. Unnecessary pain Comparison Poor sensory perception
and response
Progressive sign and
symptoms
Hopkins et. al., Unhealthy life Acceptance Poor perfusion Psychological impact

Findings 2000 words
Present your findings from the papers under the theme headings linked to your review question (approx. 4 themes). In this section you
will be comparing and contrasting information from the papers and strengths and weaknesses of the evidence related to the theme
By using PubMed as a data base and following inclusion and exclusion criteria, ten peer reviewed articles were gathered for this
dissertation. The research question was kept in mind and was used as appropriate analysing method: a qualitative content analysis in a
deductive way.
Based on research question: In the United Kingdom’s healthcare settings, what challenges do nurses face in prevention of pressure ulcers,
and the systematic literature reviews, three main themes have been emerged. The themes are divided into subcategories as presented below:
1. The workplace context:
a. Shortage of staff.
b. Increase workload
c. Patient attributes
d. Models of care
e. Clinical skills and knowledge
2. The organization in the healthcare settings
a. Guidelines
b. Equipment’s maintenance
3. Implementation of the prevention of pressure ulcers
a. Teamwork
b. Education
c. Communication and documentation
1.The workplace context:
In nurses' working areas, different situations create challenges, which interfere with how nurses attempt to prevent pressure ulcers in
patients. As a result of thoroughly reading all the collected articles, the following categories describing workplace challenges will be
presented:

a) Shortage of staff. As a result of staff shortage, pressure ulcer prevention poses a significant challenge because it is time-
consuming (Wood et al, 2019). In the same way, Lavallée et al (2019) mentioned that the
majority of participants in their study mentioned staff shortage as a barrier due to the fact that pressure ulcer prevention requires
a team of people and requires a substantial amount of time and resources, for example the patient’s repositioning. Also,
Barakat-Johnson et al (2019) added that nurses mentioned that a lack of staff makes it difficult to turn patients, especially obese
patients, regularly. Madueño and Sayer (2022) emphasising that, as a result of COVID-19, the patients in the ICU needed full
assistance for their activities of daily living, resulting in prolonged immobility. With low staffing levels and an increased
patient-to-nurse ratio, regular repositioning was compromised. During the COVID-19 pandemic, in ICU, the shortage of staff
was caused by a variety of factors, including staff shielding due to health issues, infected staff with SARS-CoV-2, and
reassigned staff who were unaccustomed with working in a highly specialised department.
b) Increase workload
The process of conducting pressure injury prevention and management requires steps such as assessment, diagnosis, documentation
and management interventions. Such steps place a great time pressure for nurses within short time period of working hours. Nurses
are already being overloaded with lots of paperwork as well as many other important things to carry out. So, the nurses reflected
that increase workload and inability to perform all steps of pressure injury prevention into their daily work have prevented them
from giving quality nursing care (Barakat-Johnson et al, 2018). Similarly, Chaboyer & Gillespie (2014) found that adding new
things such as Pressure ulcer prevention care bundle to the nurses’ work might increase their work when they are already busy and
create barrier to adopt new things such as PUP care bundle. So, high workloads mean less priority will be given to pressure ulcer
prevention.
Assessment, diagnosis, documentation, and management measures are all stages in the process of preventing and managing
pressure injuries. Such actions place nurses under a great deal of time pressure in a short period of time. Nurses are already
overworked, with a lot of paperwork to complete as well as a slew of other critical tasks. As a result, the nurses stated that their
increased workload and inability to incorporate all aspects of pressure injury prevention into their daily work has hampered their
ability to provide effective nursing care (Barakat-Johnson et al, 2018). Analogously, Chaboyer and Gillespie (2014) discovered that
adding new tasks to nurses' workloads, such as a pressure ulcer prevention care bundle, could increase their workload when they are
already overworked and present a barrier in adopting new practises.
c) Patient attributes
The patient attributes may act as barriers to full engagement in the pressure area care. These are

physical and sensory ability and cognitive ability. Patients with chronic conditions like cerebrovascular accident, nutritional deficiencies,
urinary and bowel incontinence, overweight, frailty, underweight, clinically vulnerable and old age are unable to engage in health-
promoting activities and impede nurses' ability to provide effective pressure injury prevention and management. In terms of sensory ability,
the presence of pain, limited mobility as well as the refusal to reposition. Because in the case of a spinal cord injury, the absence of pain
leads to non-alertness of the brain, resulting in skin injury and pressure ulcers in multiple places (Lavallee et al, 2019). Besides, Madueño
and Sayer (2022) stated that in COVID 19, the low oxygen delivery to the tissues causes ischaemia and increases the likelihood of
developing pressure ulcers in COVID-19 patients. The risk is therefore enhanced significantly by inflammation and coagulation problems
that are common in critically ill COVID-19 infected individuals. The cytokine storm seen in severe disease causes microthrombi, which
interact with two of the three primary aetiological factors in device-related PUs, inflammation and ischaemia, causing an increase in PUs in
COVID-19 patients.
According to Lavallée et al. (2018), patients with cognitive impairment like confusion, delirium, or dementia are frequently unable to take
part in pressure ulcer preventive care due to self-limited capabilities or inability to process information. McGraw (2019) added that these
individuals sometimes are declining nurses' assistance, resulting in poor adherence and making it difficult for nurses to provide pressure
ulcer care. Also, patients with the mental capacity to understand, refuse to follow recommendations on occasion. This kind of
resistance from patients is perceived as a challenge for nurses (Carlsson & Gunningberg, 2017).
d) Models of care.
The effectiveness of nurses' pressure ulcer prevention techniques is dependent on the models of care of their work healthcare
settings. For example, according to Sving et al. (2012), willingness to follow PU prevention recommendations varied among
three settings. In the first setting, nurses followed the scheduled daily tasks in conformity with the requirements. However, in
the second unit, nurses attempted to perform as per prescribed standards but reported challenges due to inadequate acceptance
between co-workers, whereas and in the third unit, nurses did not use any systematic pressure ulcers prevention guidelines and
had unplanned tasks related to pressure ulcers prevention strategies. As a result, pressure ulcers care fails due to a lack of good
habits and structural system in working places (Sving et al, 2012).
e) Clinical skills and knowledge. Samuriwo & Dowding (2014) mentioned that insufficiency of knowledge and skills concerning
pressure ulcer prevention and management among some healthcare staff still persists in hospital and nursing homes, making it
difficult for nurses to provide efficient pressure ulcer care. Not all healthcare staff have completed specific hours of education in
the pressure ulcers area. The majority of nurses pointed that pressure ulcers education must be delivered on a regular basis and
should be made mandatory. A few nurses also believed that knowledge is lacking, and that more education is required. Even
though PU education is provided in nursing homes, it is not made mandatory for all healthcare staff. As a result, the level of
knowledge regarding pressure ulcers care remains debatable, as to whether it is adequate and up to date.
According to some study findings of Samuriwo & Dowding (2014), some nurses have a lack of knowledge about pressure
ulcers prevention. As an example, few nurses responded that repositioning is not required if the patient is already lying on the

pressure-relieving air mattress. On this study, nurses and student nurses acknowledged that they had been educated about the
significance of pressure ulcer prevention in their nursing schools, as well as training, but they did not pay close attention to it
until they met or cared for patients with severe pressure ulcers. After approaching patients with the most severe pressure ulcers,
nurses learned to care for pressure ulcers more effectively and also, to emphasise the importance of prevention. As a
result, delivering adequate care for pressure ulcer prevention is dependent on nurses' personal experience and how they value
pressure ulcer prevention (Samuriwo & Dowding 2014). According to Lavallée et al. (2018), a lack of awareness of pressure
ulcers contributed to misdiagnosed and misdocumented wounds, some pressure ulcers being misinterpreted as skin breaks
or dermatitis. As a result, the nurses underlined the importance of education in the accurate diagnosis and classification of
pressure ulcers. Community nurses and tissue viability nurses, on the other hand, highlighted a lack of caregiver understanding
of residents' skin changes and a failure to report them in a reasonable timeframe. Such caregiver incapacity leads to additional
skin degeneration and the development of pressure ulcers. As well, the struggle to assess a patient with high risk of pressure
ulcers development, suggests lack of clinical skills among nurses.
2. Organization in healthcare settings. Developing a pressure ulcer while hospitalised has a detrimental impact on patients, their
families, and healthcare providers, and it also suggests poor quality of healthcare services. As pressure ulcer formation is an
indicator of poor care, accelerating pressure ulcer treatment, by decreasing the time necessary to close the ulcer is an indicator of
excellent care. As a result, quality of care and pressure ulcer management in hospitals are linked. (Samuriwo & Dowding, 2014.
a) Guidelines. Organizational involvement in the form of policies and regulations is essential for ensuring successful pressure ulcer
prevention. Providing support during education ensures that employees succeed and could even help them attend educational
sessions if the resources are available (Barakat-Johnson et al., 2019). Organized work based on established guidelines and the
working approach enable nursing care to be safe and aid in the early detection of pressure ulcer risk. In a healthcare setting, a
nutritional evaluation and treatment plan should be performed in accordance with the organization's requirements. (Sving et al,
2012). Similarly, Chaboyer and Gillespie (2014), said that a patient-centred pressure wounds prevention care bundle could
encourage more consistent implementation of pressure ulcer prevention interventions and also, an active patient engagement in his
own care. It is vital to include the care bundle into the practise routine and the organisation should ensure that healthcare staff use
the bundle on a regular basis.
b) b) Equipment’s maintenance. Pressure relief devices must be reviewed, repaired and user instructions must be provided. Medical
equipment such as hospital beds and pressure-relief mattresses can assist in pressure wounds prevention, but they must be
maintained in order to retain their quality and functionality. (McGraw, 2019).
3. Implementation of the prevention of pressure ulcers. Collaboration among members of the health care team has been found to be helpful
in preventing pressure ulcers (Lavallée et al, 2018). The advantage of a pressure ulcer prevention care bundle for nurses and patients is that

it raises knowledge of the idea of pressure ulcer prevention, improves communication among patients and staffs, and encourages patients to
be active participants involved in their own care (Chaboyer and Gillespie, 2014).
a) Teamwork. Once nurses form a professional relationship between them, they may interact to gain a better picture of the clinical
condition, evaluation, and diagnosis of the patient. Trusting and communicating with each other and sharing knowledge can help in
determining the best pressure ulcer prevention strategy for the patient. In a survey done by Chaboyer and Gillespie (2014), the
nurse highlighted a number of challenges in utilising the pressure ulcers prevention care bundle, with an emphasis on patient
characteristics and their right or ability to choose whether or not to take an active part. The authors of this study gave an example
that nurses should discuss with the patients about their personal requirements and decide on a repositioning schedule together.
It is known that collaboration between health care professions is important in order to prevent pressure ulcers, and the knowledge of
every staff member is vital. Sving et al. (2012) said that it is important to ensure the task is balanced between the different health
care professions and to unite them to work together. As a result of the teamwork, skin inspections will be carried out in an ongoing
manner and the patient will be closely monitored. It is likely that communication will encourage team members to do routine tasks
properly, and it will bring awareness of teamwork and contribute to success of the team in carrying out wound rounds and
providing shift reports.
b) Education. Every profession in the health field requires evidence-based knowledge. This includes more than just scientific
knowledge; it also entails practical experience. By practice and experience, the knowledge will develop step by step (Samuriwo &
Dowding (2014).
Madueño & Sayer (2022) suggested that it must be developed department’s schemes in the area of pressure wounds prevention. It is
critical that established practices involving device selection, application (including tapes and fixation techniques for intubated
patients) and documentation to be in place and accessible to all health providers. Within each department, a 'champion' should be
designated to establish and implement standardised processes, monitor compliance, and ensure proper documentation of all devices
used in pressure ulcers prevention.
c) Communication and documentation. Communication is seen as an important interpersonal skill. Accuratelly documented
information is essential for making proper patient care choices and is serving as a communication tool amongst nurses. In a
study, Sving et al. (2012), shown that there was a lack of documentation and a suitable care plan for pressure ulcers preventative
care, as well as a communication failure between nurses and care assistants. This deficient nurse documentation and lack
of communication have led to poor optimal meal intake and inadequate repositioning of 19 patients.
Lavallée et al (2018) accentuates that patients' requirements vary on a regular basis, necessitating an open communication and
collaboration approach to pressure ulcers prevention. Person-centred care allows individuals to determine and address their own
needs. It is critical to have patients' participation and discuss with them when they require position turning and balanced diet.
Communication might be represented in documents that contains information about the patient's condition. The
recorded information might be utilised to record earlier actions or incidents and, as well, to do the next care plan.

McGrow (2019) added that effective communication skills are especially useful in dementia patients. Participants highlighted
situations when healthcare providers failed to properly interact with cognitively impaired individuals.
Conclusion
The study well concluded that the pressure ulcer is defined as the chronic disease which may create complication with the health.
Therefore, the challenge that is occur in the front of nurses is deal with patient with the pressure ulcer. The all-time support and care is
not possible to the patient because the nurses have workload and they manage other patient within the time. They usually configure
the time and routine of medication and make proper communication which is related with the complexities. The future
recommendation is well focus on the context which may support the people with the pressure in their diet and habit that may reduce
some of the major complication. The challenges which is face by nurses within the healthcare organisation is nurses have tight schedule
with the heavy workload and inadequate staff which is showing lack of tie that is 81 percent, shortage of resource and equipment that
us 67.7 percent and improper training which is also analysed up to 63.3 percent. In addition, the future recommendation is well focus on
the training and development where the recruitment is held which is based to reduce the shortage of staff and collaboration decision
making which may show the impact that reduce the issue of patient with pressure ulcer.
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