Pressure ulcer is a major health problem. According to previous 10 years nationwide studies, 10% to 15% of the general population suffers from chronic pressure ulcers. In addition, Reddy, Gill and Rochon (cited in Walton-Geer, 2009) approximated 60,000 patients every year will die from hospital acquired pressure ulcers and the treatment of these wounds costs approximately $11 billion per year. These findings are significant in some areas such as patients in intensive care units, critical care units and nursing home residents. These situations cost patient in terms of suffering, impaired quality of life, reduced independence and even increased morbidity and mortality. The patients delay in hospital discharge and decrease the efficiency and efficacy of health services. The health industry is also concerned about lack of sources, work force hours to manage the problem. Various industries and government agencies are disconcerted to either treat these ulcers in early intervention or encourage prevention (Lippincott Williams & Wilkins, 2007). However, a good quality care is important in preventing these sores and nurses come at front to provide this care. In identifying the nurses attitude towards care and perception of barriers in that case may solve this situation.

Search strategy

The literature search was conducted by using the databases- Cinahl, Pro Quest, Pub med and Waiariki library catalogues. These databases identified the published studies, nursing journals and conference proceedings. The search engine used the terms for search were pressure ulcers and nursing, nurse and bedsores, nurse and hospital, pressure ulcer and patient, and nursing management and decubitus ulcers to search out the articles. The articles only written in English were retrieved for review. This literature review is based on the prevention strategies. Prevention and management of pressure ulcer is of major concern in health care system. Most of the studies revealed the appropriate knowledge of nurses for prevention. The gaps could be in the lack of performance in their practice. The hospital routines for early assessment and culture may be responsible for nurses to practice efficiently. Despite of increasing expenditure neither incidence nor prevalence is reducing. The attitude and supervision towards care of patient are significant review in whole populations generally. The search was wide to find the reliable material and needed to exclude some for relevance. The search boundaries were elaborated for nursing practice and attitude. The access to literature was sometimes limited to abstract only.

Eighteen published articles were reviewed for possible inclusions in the final review. Among those ten articles were taken from previous conducted researches, three were the literature reviews and two relevant articles were based on life story of patients. One textbook and two non-research articles were kept for background information. The first line of defense in preventing the pressure ulcer development is the nurse practitioners’ behavior towards patient, nursing care by using various devices, patients’ status for devolving risk factors and hospital polices for further improvements. All ages were viewed as inclusion criteria with high-risk abilities. Four articles were more than ten years old and excluded to gather current knowledge for practice. One study was excluded because of emphasize was put on various positions of the patient that are inefficient for critical care units to take efforts in rising out of bed and were not valid. Two researches based studies were included to assess nurse’s knowledge in prevention and treatment strategies that were mainly researched for assessing the nurses’ knowledge about pressure ulcers and impact on practical decision-making skills and utilizations of various devices. The research literatures on pressure ulcer development filled the education and reliability assessment of nurses. One group of researchers created the longitudinal examination of hospital registered staffing to improve the quality of care and revealed the limited support for quality with number of registered nurses. These variations in favor of care presents a cross comparison of results, at best. Another research study revealed the influence of handling technique, and patients’ weight and disability that causes serious back injuries to nurses. One research supported computers for prevention and treatment of pressure ulcers at LCD hospital was included because the system reminds documentation to nurses. One life story article included tells about the negligence in care that leads towards the death of a woman, because of bone deep bedsores that remained untreated in last six months of her life.

The selection criteria in three researches have been taken for use of preventive devices that underline the risk of pressure ulcers early assessment at time of admission. The potential inclusion admits a risk assessment tool, Braden scale in predicting pressure sore risk in hospitalized patients. However, two included studies exposed issues regarding the lack of clinical trials for effectiveness and the quality improvement implementations in nursing homes that associated with organizational culture. As the review included all ages, hospitalized and outside patients, one study assures about the sitting behavior of people lead towards building the risk of pressure ulcers.

Nurse’s knowledge and attitude

In 2004, Moore agreed the development of pressure ulcer is linked to nurses’ attitude, education and competence. Education increases awareness of the problem and gives a pathway for developing and maintaining competency. Thus, the successful prevention is dependent on staff knowledge, skill and attitude. This argument was underlined the content and quality of education, a major concern in decision-making. Hulland (cited in Moore, 2004) was able to identify nurses’ action, beliefs and opinion on pressure ulcer prevention and treatment. Anthony (cited in Moore, 2004) also agreed, however, nurses have good knowledge for prevention, still usage is inappropriate in practice. Maylor and Torrance (cited in Moore, 2004) supported the value of the attitude of nurses for preventive practices of pressure ulcers in clinical practice. Ousey (2010) accented the need of evidence-based education for whole staff involved in care of pressure ulcers. Another study by Wiechula in 1997 described the focus of quality improvement ought to on the appropriate education program that contains the instructions and guidelines of current and evidence based practice. The education program should include the etiology and risk factors along with risk assessment tools and application in demonstrating the positioning for prevention of pressure ulcers. In this study, the stress was also put on the accurate documentation and monitoring. Another cross-sectional study by a group of researchers explored the comparison between the knowledge among past time and present time nurses. The sample was large (n=522 nurses in 2003 compared with n=351 nurses in 1991), with written questionnaire method. The authors identified the knowledge of nurses in 2003 is better and nurses know the usefulness of preventive measures. However, the raised issue was again the knowledge did not come in practice in the organizations that monitored pressure ulcers (Hulsenboom, Bours & Halfens, 2007). Comparing the views of all authors, one group of researchers conducted a one-time survey. Fifteen nurses were subjected to check the use of system increase their knowledge and skills. The study resulted in no effective knowledge about pressure ulcers and decision-making skills in practice (Zielstorff et al, 1997). Among various researches, one study by Smith and Waugh in 2009 uncovered the nurses’ knowledge of pressure ulcer prevention and treatment along with the perception of barrier in providing effective care. After using the Pieper Pressure Ulcer Knowledge Test among 96 nurses, the study revealed the nurses’ knowledge was higher significantly but the barrier such as the weight of patient, patients’ refusal, unavailability of equipments, not having enough time and staff was significantly considerable. Nevertheless, Mark, Harless, McCue and Xu in 2004 found limited support for enduring the belief that improvement in registered nurse staffing improves the quality of care. In addition, Skotte and Fallentin in 2008 supports the barrier by assessing the low back load on health care workers while using preventive techniques such as repositioning and use of friction reducing devices that is higher than patients weight and disability. Pulkkinen (2009) explores this argument in an article about a health care worker’s second-degree criminal mistreatment. The evidence shows that the treatment for bedsores was not provided to Harrison and ultimately because of gangrene infection of bone deep ulcers, he died.

Use of appliances in practice

In 1997, Wiechula described the assessment of risk is important to consider causative and contributing factors that can eliminate the negative effects. This skin care assessment of patient should be at the time of admission, after change in condition and for long-term patients at regular intervals. Specifically, to relieve pressure, attempt should be put on positioning and turning frequently. The major concern was preventing contact on between prone areas and support surface by using devices such as pillows and foams and use of alternating pressure mattress for high-risk patients. Ousey (2010) explored the early detection and effective documentation of pressure ulcers is a key component of quality care if the nurses can identify risk development behavior appropriately. The study assures manual repositioning and pressure relieving support surfaces are important in preventive measures. The early detection includes the assessment within six hours of admission in hospital and in community settings; it should be at first visit of practice nurse. However, Wiechula in 1997 outlined, turning of patient every 2 hours is a reliable and cheap method of prevention. Schoonhoven (cited in Ousey, 2010) disputed the effectiveness of preventive measures in some patients. Based on this notion, Ousey agreed the pressure ulcer tool will be helpful for high-risk individuals if practice with professional jugdement. Stotts and Gunningberg in 2007 supported one evidence-based article for use of Braden scale, a good assessment tool. Considering the reliability and validity, Braden scale is affective to practice with the difference in patients’ culture. In the matter of devices in care of pressure ulcers, the Australian Medical sheepskin is a new pressure-relieving device is effective in relieving pressure with moisture absorbing capacities (Mistiaen et al, 2008). Gardner, Frantz, Bergquist and Shin (2005) explored another perspective study for measuring the wound healing is pressure ulcer scale for healing. When the workers apply this evidence-based tool at weekly intervals, it provides accuracy in differentiating healing of pressure ulcer from non-healing in tracking changes in pressure ulcer status. This study outlined the use of PUSH score can achieve changes during extended follow-ups during the time when pressure ulcers take more than 3 months to heal. As explained by Wiechula in 1997, massage on bony prominences ought to avoid and the ring shaped devices are ineffectiveness in practice. Ousey (2010) agreed the view of not rubbing the skin vigorously to prevent the damage of superficial and deep tissues. Interestingly, one cross-sectional study unveiled the use of these preventive devices and documentation is suboptimal even for high-risk patients. In practice, the documentation and preventive devices are important for all patients who are at risk and having pressure ulcers to note the status of patients. A research nurse to ascertain the use of pressure ulcer devices examined the patients. After examination, 68% patients were documented for pressure ulcers. Among those 15% of patients had preventive devices and 51% receive those were at high-risk. In multiple analyses, the type and stage of pressure ulcer were not associated with high-risk patient but the use of preventive devices (Rich, Shardell, Margolis & Baumgarten, 2010). Similarly, Moore (2004) identified the use of pressure relieving devices are not as much helpful in reducing the prevalence of pressure ulcers without nurses positive attitude.

Hospital policy

The cost of treatment of pressure ulcers can be enormous and significantly run out the health system resources. According to Posnett & Franks (cited in Ousey, 2010) the estimated cost for the treatment of pressure ulcer is between 1.8 billion pounds to 2.6 billion pounds annually. In 2009, Walton-Geer gave views on for the improvement in patient care the interventions should be initiated on evidence-based practice.

Patient’s status

AHCPR (cited in Wiechula, 1997) recommended the important link of malnutrition with the development of pressure ulcers. Wiechula (1997) indicated, on admission nutritional assessment should also be monitored such as weight changes, loss of appetite and decreased dietary intake. Patients with poor hygiene and skin moisture degrade the integrity of skin that further helps in developing sores. One literature review supported the components of Braden scale such as nutrition, sensory perception, evidence of moisture, activity level and mobility status are the most important predictive of developing risk of pressure ulcers. It is apparent in the study that the risk increases with the susceptibility of tissue tolerance and poor peripheral circulation that relates with poor nutritional status (Schultz, 2005). Ousey in 2010 outlined some intrinsic and extrinsic factors responsible for pressure ulcer development. Intrinsic factors included patients’ age, mobility, incontinence, medication, anemia, thin skin, nutritional status and disease condition. The considered extrinsic factors were friction, moisture, poor handling and changing position. The stress was also put on initial assessment of all patients to improve nutritional intakes. Williams et al (cited in Ousey, 2010) considered poor nutrition and decreased tissue perfusion, the main cause of pressure ulcer development. Bain and Ferguson-Pell in 2002 considered the knowledge of sitting behavior of patients outside the hospital especially for wheel chair users who sit continuously for long time. The study tested the use of remote monitoring pressure distributing logger that keeps the record of sitting behavior after testing its feasibility.