Accepted Manuscript

Development and psychometric validation of a questionnaire to evaluate nurses'

adherence to recommendations for preventing pressure ulcers (QARPPU)

Ana Belén Moya-Suárez, José Miguel Morales-Asencio, Marta Aranda-Gallardo,

Margarita Enríquez de Luna-Rodríguez, José Carlos Canca-Sánchez

PII: S0965-206X(17)30119-5
DOI: 10.1016/j.jtv.2017.09.003
Reference: JTV 253

To appear in: Journal of Tissue Viability

Received Date: 12 October 2016

Revised Date: 29 May 2017
Accepted Date: 1 September 2017

Please cite this article as: Moya-Suárez AnaBelé, Morales-Asencio JoséMiguel, Aranda-Gallardo M,
Enríquez de Luna-Rodríguez M, Canca-Sánchez JoséCarlos, Development and psychometric validation
of a questionnaire to evaluate nurses' adherence to recommendations for preventing pressure ulcers
(QARPPU), Journal of Tissue Viability (2017), doi: 10.1016/j.jtv.2017.09.003.

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 ACCEPTED MANUSCRIPT
Title page
Development and psychometric validation of a questionnaire to evaluate nurses’
adherence to recommendations for preventing pressure ulcers (QARPPU)

a,*
Ana Belén Moya-Suárez , José Miguel Morales-Asenciob, Marta Aranda-

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Gallardoa, Margarita Enríquez de Luna-Rodrígueza, José Carlos Canca-Sánchez a

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a
Department of Nursing, Agencia Sanitaria Costa del Sol, Ctra. Nacional 340, Km. 187

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Marbella. Málaga, Spain.

b
Department of Nursing and Podiatry, Faculty of Health Sciences, University of

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Malaga, C/Arquitecto Francisco Peñalosa, Ampliación del Campus de Teatinos, 29071
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Málaga, Spain
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Corresponding authors.
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E-mail addresses: abelenms@hcs.es (AB. Moya-Suárez), jmmasen@uma.es (JM.

Morales-Asencio, maranda@hcs.es (M. Aranda-Gallardo), margael@hcs.es (M.
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Enríquez de Luna-Rodríguez), jccanca@hcs.es (JC. Canca-Sánchez)

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Abstract

Aim of the study. The main objective of this work is the development and
psychometric validation of an instrument to evaluate nurses’ adherence to the main
recommendations issued for preventing pressure ulcers.

Material and methods. An instrument was designed based on the main

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recommendations for the prevention of pressure ulcers published in various clinical
practice guides. Subsequently, it was proceeded to evaluate the face and content validity

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of the instrument by an expert group. It has been applied to 249 Spanish nurses took
part in a cross-sectional study to obtain a psychometric evaluation (reliability and

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construct validity) of the instrument. The study data were compiled from June 2015 to
July 2016.

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Results. From the results of the psychometric analysis, a final 18-item, 4-factor
questionnaire was derived, which explained 60.5% of the variance and presented the
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following optimal indices of fit (CMIN/DF: 1.40 p<0.001; GFI: 0.93; NFI: 0.92; CFI:
0.98; TLI: 0.97; RMSEA: 0.04 (90% CI 0.025-0.054).
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Conclusions. The results obtained show that the instrument presents suitable
psychometric properties for evaluating nurses’ adherence to recommendations for the
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prevention of pressure ulcers.

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1. Introduction

Pressure ulcers are a major challenge to patient health and safety, affecting the quality
of life at all levels – physical, psychological and social (1–3) – and increasing the risk of
death (4,5). Their prevalence varies considerably. In European hospitals, pressure ulcers
are suffered by 7.87% of patients in Spain (6) and 8.3% in Italy (7), followed by 8.9%
in France (8) and Iceland (9). Higher values have been reported in Germany, with

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11.1% (10) and Belgium and Portugal, with 12.1%-12.5% respectively (7), while in
Denmark, Ireland, Norway, Netherlands, UK and Sweden, the prevalence ranges from

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15% to 25% (7,9). Other countries, such as Brazil (11), Turkey (12), Mexico (13) and
Indonesia (14) have also conducted prevalence studies, with China reporting a pressure

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ulcer prevalence of less than 2% (15). However, these international values should be
interpreted with caution because measurement methods and criteria may vary from one

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study to another. In the United States and Canada, pressure ulcers continue to present a
problem, despite efforts to improve prevention and the greater use of risk assessment
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instruments (16). In short, notwithstanding the importance of applying preventive
policies to reduce the incidence of pressure ulcers, patients still do not receive adequate
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health care (17,18).

Numerous clinical practice guidelines have been issued. If these recommendations were
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fully implemented in clinical practice, the quality of care offered would be greatly
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improved (19,20). However, healthcare personnel, despite having a positive attitude

towards evidence-based practice, face numerous barriers in this respect, mainly related
to a lack of knowledge about research methods and to insufficient resources for their
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implementation (21). A review of nurses’ application of clinical practice guidelines (22)

has identified various internal and external barriers. In the former respect, the most
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significant factors were found to be attitude (insufficient motivation and resistance to

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change) and inadequate knowledge of the guidelines. The main external barriers
concerned the format of the guidelines, the accessibility of their content, insufficient
time, an absence of leadership and/or feedback and, finally, rigid and change-resistant
organisational environments. Among other reasons for non-adherence by healthcare
personnel to the recommendations made in the guidelines are possible contraindications
and the patients’ own decisions about their care regime (23). With respect to wounds
and pressure ulcers, some authors suggest that adherence to the recommendations is also
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low because they are implemented much less often than is stipulated and, sometimes,
because the quality of the interventions made is inadequate (24–26).

Various papers have explored intervention strategies and models to enhance the
implementation of healthcare recommendations (27–32), including the development of
instruments to evaluate the application of guidelines (29–31) or the adherence by
healthcare personnel to these recommendations (32). As fundamental steps prior to the

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implementation of recommendations, most studies emphasise the need to audit clinical
practice, to provide feedback on the findings obtained and to draft an evaluation plan

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that includes data-compilation instruments. Such audit and feedback activities have
proven effective in enhancing professional practice (33,34). However, according to a

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review published in 2011 (35), of the 20 studies examined, only nine evaluated
professional practice and none provided feedback about the information obtained.

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To measure the variability of adherence to recommendations (the Belgian Guideline for
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the Prevention of Pressure Ulcers, 2002), Paquay et al. (25) designed a three-step
algorithm to evaluate the presence of materials and interventions in accordance with the
Guideline, the presence of materials and interventions not described in the
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recommendations, and the absence of measures of any kind. The authors concluded that
adherence was greater when patients at risk of developing ulcers presented, in addition,
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a high level of dependence, poorer skin condition and had a previous history of pressure
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ulcer. However, the authors were unable to draw any conclusions regarding the quality
of care provided, as their study sample only included a small percentage of the
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interventions recommended. Furthermore, they did not validate the psychometric

properties of the instrument. Other studies (36,37) have also examined professional
practice in this respect, using mixed questionnaires inquiring not only about the actions
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taken by healthcare personnel to prevent pressure ulcers, but also about their knowledge
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and attitudes and the perceived barriers to optimal practice. However, the response rate
obtained by these questionnaires is sometimes low, due to the large amount of
information required. Other assessment instruments (38) have investigated how often
nurses implement clinical interventions when the patient is at risk or presents an injury,
but these studies are subject to the limitation that the answers may be influenced by
barriers to completing the questionnaire (lack of resources, personnel, etc.). A checklist
of the main dimensions of the prevention of pressure ulcers has been used to audit
nursing practice regarding the implementation of a prevention programme in an
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intensive care unit; however, a study of this activity only performed content validation
(39).

The main aim of the present study is to develop and validate an instrument to evaluate
nurses’ adherence to the main recommendations published for the prevention of
pressure ulcers.

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2. Method

2.1. Design

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Two-phase study: in phase one, the instrument was designed and its content validated.
In phase two, psychometric validation was conducted in a multicentre study of nine

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hospitals in Spain, from June 2015 to July 2016.

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2.1.1. Phase 1. Designing the instrument and validating its content
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An instrument was developed with three parts (questionnaire, vignettes and
characteristics of respondents). After a review of various clinical practice guideline of
pressure ulcer prevention (40–42) a total of 28 interventions were selected regarding
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major areas of preventive care of pressure ulcers (risk assessment, skin inspection and
care, managing pressure, position changes, nutritional care and health education). These
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were used to generate the items of the questionnaire. The number of items was chosen
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so as to sample systematically all content that potentially could be relevant to the target
construct. The answers were scored on a 5-point Likert scale representing adherence to
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each recommendation, for a patient at risk of developing pressure ulcers (1: Never, 2:
Rarely; 3: Sometimes; 4: Often; 5: Always). In the second section, two clinical vignettes
were created to illustrate the situations of two typical patients, one at low/moderate risk
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and the other at greater risk. For these situations, 14 and 18 interventions, respectively,
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were considered (including both advisable and inadvisable actions) from which the
respondent was asked to select those considered appropriate for the patient’s prevention
care plan. Finally, a question section was included in order to characterize the
respondents. As part of the face and content validation process, the questionnaire was
presented for its consideration to five experts on pressure ulcers, members of the
Pressure Ulcer Committee at the Costa del Sol Hospital. All of them had an extensive
experience in pressure ulcer care, teaching and research (PhD level). This expert group
assessed the relevance of each item included in the instrument for assessing the
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adherence to preventive recommendations, on the following scale: 1= Not at all
relevant; 2= somewhat relevant; 3= Relevant; 4: Highly relevant.

The content validity index was then calculated, following the parameters suggested by
Lynn (43). The minimum acceptable score for content validity was taken as 0.8 (44).
The same group of experts also evaluated the comprehensibility of each item, on a 5-
point Likert scale (1= Not at all comprehensible; 2= Very little; 3= Somewhat; 4=

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Comprensible; 5= Fully comprehensible). For consensus on comprehensibility, 80% of
evaluators had to agree on median values equal or above value four. The experts did not

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propose any changes to the wording of the questionnaire items or to the response
options. A pilot study was subsequently made of the instrument, which was completed

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by 20 hospital care nurses to assess the manageability, usability and acceptability of the
questionnaire. No modifications were needed (Fig. 1). Finally, the research team

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grouped all the proposed items into five dimensions: risk assessment, skin inspection
and care, position changes, force and pressure relief, health education on measures to
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prevent pressure ulcers.

2.1.2. Phase 2. Psychometric validation: construct validity and reliability

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The psychometric validation performed included an analysis of reliability (by

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Cronbach’s alpha), inter-item correlations and the index of homogeneity. Construct

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validity was tested by exploratory and confirmatory factor analysis. Discriminant

validity was assessed by the instrument’s ability to distinguish between the adherence to
recommendations by healthcare personnel who applied clinical practice guidelines for
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the treatment and prevention of pressure ulcers and by those who did not. In addition,
nursing staff were shown two clinical vignettes and asked to state what intervention
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would be applied in each case. We then determined whether the mean scores produced
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by the instrument differed between those who applied the measures and those who did
not, as an additional assessment of the instrument’s discriminant capacity.

2.2. Procedure

The questionnaire was sent online to nurses at nine hospitals in the regions of
Andalusia, Navarre and the Balearic Islands (Spain). The accompanying text explained
the purpose of the study, how the questionnaire should be completed and the
confidentiality of the information, and requested their agreement to participate.
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2.3. Statistical analysis

The content validity index was calculated following the guidelines proposed by Lynn.
The empirical sample was subjected to exploratory analysis, obtaining frequency
measurements. The normality of the variables was determined by the Kolmogorov-
Smirnov test, and the skewness, kurtosis and histograms of the distributions were all
examined. Bivariate analysis was conducted using the Student t test for normal

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distributions and the Mann-Whitney test otherwise, together with the chi square test.
ANOVA, with measures of central robustness, was employed when non-

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homoscedasticity was observed (according to the Levene Test), using the Welch and
Brown-Forsythe tests. Correlational analysis was conducted using Pearson’s r and

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Spearman’s rho, depending on the normality of variables.

Construct validity was determined by exploratory factor analysis, with extraction by

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principal axis factoring and by oblique rotation. Previously, Bartlett’s test of sphericity
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and the KMO test were performed to determine its relevance. The ceiling/floor effect
was calculated according to the endorsement rate, with a limit of 85%. The fit of the
models was determined by confirmatory factor analysis, using the following indices: the
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penalising function (χ2/gl), which is indicative of good fit for values <3; the root mean
square error of approximation (RMSEA) and its confidence interval (90% CI), taking
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0.05 as the cutoff value for good fit; the Tucker-Lewis index (TLI), the comparative fit
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index (CFI), the goodness of fit index (GFI) and the normative fit index (NFI), with a 0-
1 range and a minimum good fit value of 0.90. The multinormality of the sample was
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calculated using Mardia’s coefficient of multivariate kurtosis. All statistical analysis

was performed using SPSS v.22 and AMOS 21.
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2.4. Ethical considerations

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The study was approved by the research ethics committee of the Costa del Sol Health
Agency and conducted in accordance with the provisions of the Helsinki Declaration.

3. Results

3.1 General characteristics of the sample

The questionnaire was completed by 249 nurses, of whom 182 (79.8%) were female and
46 (20.2%) were male. The respondents were aged between 24 and 63 years, and had an
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average professional experience of 19 years (SD 7.283). In terms of academic
achievement, over 80% had at least a bachelor’s degree and 76.7% had completed
postgraduate studies on prevention, with 80.4% of these having done so in the last five
years. The largest single group was that of the nurses who had completed 0-30 hours of
training in this respect (40.1%). By medical speciality, the largest numbers of
questionnaires were completed by nurses working in medical hospitalisation units

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(36.3%), followed by those in surgical hospitalisation (23.3%), intensive care (16.3%)
and A&E (10%). 21.3% (n=53) of the respondents stated that they did not consult any

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literature on clinical decisions concerning the prevention of pressure ulcers. The general
characteristics of the sample are described in Table 1.

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3.2 Construct validity

An initial exploratory factor analysis was performed on the 28-item version of the

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questionnaire, producing a KMO index score of 0.922. Bartlett’s test of sphericity was
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statistically significant (χ2 = 1972.187, p<0.001). This analysis provided a factorial
structure of five factors that accounted for 49.15% of the variance. These five factors
did not coincide exactly with the five dimensions resulting from the content validity
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process. Therefore, this dimensional structure was tested directly by confirmatory factor
analysis, which reflected an imperfect fit (CMIN/DF: 1.40, p<0.001; GFI: 0.93; NFI:
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0.92; CFI: 0.88; TLI: 0.86; RMSEA 0.65 90% CI: 0.58-0.63). After analysing the
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normalised residuals of the covariances, item-total correlation and Cronbach's alpha if

item deleted, various items were eliminated (questions 5, 7, 8, 9, 11, 15, 22, 26, 27 and
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28), resulting in a four-factor questionnaire with 18 items, presenting a good fit

(CMIN/DF: 1.55 p<0.001; GFI: 0.93; NFI: 0.92; CFI: 0.98; TLI: 0.97; RMSEA: 0.04
90% CI (0.025-0.054).
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The four factors were: 1. Assessment, skin care and selection of special surfaces for
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pressure management; 2. Use of risk prediction instruments; 3. Postural changes; 4.

Force and pressure relief. These factors accounted for 60.5% of the variance (Fig. 2).

The mean score for the 18-item questionnaire was 77.11 (SD = 9.40).
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3.3 Reliability analysis

Cronbach's alpha was 0.89 for the 18-item questionnaire. Partial Cronbach's alpha
values for each factor were 0.86, 0.62, 0.80, and 0.77. The inter-item correlations
produced a mean value of 0.368 (range: 0.030-0.667). Table 2 shows the distribution of
scores and the item-total correlations. Table 3 shows the matrix of inter-item
correlation. None of the items presented a ceiling/floor effect. The highest endorsement

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rate recorded was 69.1%, for item 23.

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3.4 Discriminant power

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Significant differences were found between the type of source consulted by nurses and
the duration of occupational training received. Thus, 43% (n=23) of the nurses who had

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received no training on the prevention of ulcers (n=53) did not use any guide to clinical
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practice as a decision-making instrument (p=0.021).

Analysis of the clinical vignettes also revealed differences in the average score
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produced by the QARPPU instrument for the interventions (see Table 4).

4. Discussion
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In this study, we develop and validate QARPPU, an instrument to evaluate the

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adherence by nurses to the main recommendations published and best practices for the
prevention of pressure ulcers. Such an evaluation makes it possible to identify current
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practices and types of decision making by nurses of patients at risk of developing

pressure ulcers. Moreover, the evaluation of adherence is an essential component of
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audit strategies, providing feedback on the implementation of evidence and facilitating

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improvements. Evaluation, thus, is a major element among active strategies for

multicomponent intervention (establishing training programmes, forming quality
committees, appointing specialists, obtaining feedback, etc.) (45).

Our review of the literature shows that none of the instruments currently being used to
independently evaluate adherence in this field have been subjected to rigorous
psychometric analysis. Incorporating the proposed questionnaire on the approach taken
to clinical cases would allow clinical practice to be audited in a simulation context, thus
reducing the response bias that might arise from barriers to participation (46).
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The results of our study corroborate the reliability and validity of QARPPU. The items
in the initial version of the questionnaire were developed taking into account the main
aspects considered in this field, and after consultation with relevant experts. Content
validity was confirmed according to the parameters established by Lynn. After
psychometric analysis, the final version of the questionnaire provided excellent internal
consistency, and consisted of 18 items, classified into four factors: evaluation, skin care

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and the selection of special surfaces for pressure management; the use of instruments to
predict the risk of a pressure ulcer developing; postural changes; and force and pressure

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relief. The first factor refers to the interventions related to skin assessment and care.
This is a key prevention strategy and includes two items related to the frequency of risk

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assessment, a factor that appears in most intervention guidelines, together with the use
of risk prediction instruments (40,41,47). The importance granted to these questions
arises from the fact that in practice, healthcare staff assess the risk when the skin is first

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inspected, usually during the first few hours after admission, and also if any change
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occurs in the clinical situation, as recommended in specific publications on skin care
(48). In general, once the evaluation information has been compiled, the nurse will
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complete the risk assessment questionnaire, the second factor in our analysis. Research
has corroborated the reliability and validity of various instruments for predicting the
risk of pressure sores developing, in contrast to relying exclusively on the clinical
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judgment of nurses (49). Nevertheless, the authors of this review suggest that the two
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approaches should be considered complementary, with predictive instruments being

complemented by clinical judgement once the patient has been classified according to
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the scale of risk, to take into consideration the fact that the judgement of less
experienced nurses tends to be poorer than that of more senior personnel.
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The separation of these two factors might indicate that the nurses in our study
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population used their clinical judgment first, and later complemented it with the
assessment instrument in order to make a final decision, which they do at two different
times during the health care provided. The factors influencing this circumstance should
be investigated to determine whether, indeed, preventive measures are initiated as soon
as the clinical judgement is reached, and the possible consequences of this for patients
in terms of the incidence of pressure ulcers. Attention should also be paid to the
question of whether a subsequent re-evaluation is carried out, and whether evaluation
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instruments are employed for this purpose or whether the only criterion applied is that
of clinical judgement, based on the changes observed in the patient’s condition.

This factor also includes an item related to the selection of special surfaces for pressure
management, such as alternating pressure mattresses and high-density foam. Although
few indications exist to guide decision making for selecting this type of special surface
according to the patient’s individual needs, it is still included as a recommendation in

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many clinical practice guidelines (40–42). This inclusion is perhaps to be expected, in
view of the fact that studies of the effectiveness of these surfaces have concluded that

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the incidence of pressure ulcers is associated with the clinical risk and with the surface
employed (50). The Wound, Ostomy and Continence Nurses Society recently developed

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and evaluated, by means of content validation, an algorithm (51) which facilitates
clinical decision making in this field, relating the selection of an appropriate surface

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with the risk presented by the patient, according to the results obtained from the Braden
scale. The above considerations led us to include this item, in our own study, in the
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factor on skin evaluation and the risk of ulcers developing, as both of these questions
are related to decision making.
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The third and fourth factors concern repositioning and force and pressure relief. The
importance of both of these areas has been amply demonstrated (52) and they figure
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largely in nurses’ daily clinical practice. Nevertheless, few high-quality studies have
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been conducted in this area (53). International guidelines in this respect refer to the
findings of Defloor, 2005 (54), who concluded that high-risk patients should be placed
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upon a pressure-reducing surface and repositioned every four hours, rather than at
shorter intervals on a standard hospital mattress.
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In our study, the healthcare staff who had never received training on the prevention of
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pressure ulcers stated that they did not consult any guidelines on clinical decision
making. This corroborates previous research findings about the need to promote training
as part of a combined strategy to enhance professional practice (55–57).

Our analysis of nurses’ appreciation of clinical cases, as reflected in the questionnaire

score, shows that their decisions may vary significantly, which suggests that this
questionnaire is sensitive to variations in clinical practice regarding the prevention of
pressure ulcers. Moreover, the final 18-item instrument is short and simple to complete,
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and can be used to reflect the variability of clinical practice in the prevention of pressure
ulcers, or to evaluate the impact of strategies for improving performance in this field.

4.1. Study limitations

One of the main limitations of this study is the response method used. As the
questionnaire was self-applied, the respondents’ answers may be biased towards the

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desired rather than the usual practice.

It is important to note that this questionnaire concerns prevention and hospital care. If it

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is to be used in another context, such as residential or home care, adaptation might be
necessary and should be considered.

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Finally, further analyses to test the invariance of the model and reproducibility of
constructs in different context and settings needs to be developed.

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5. Conclusions

The results of this study indicate that QARPPU, an instrument designed to measure
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adherence to recommendations for the prevention of pressure ulcers, presents

conceptual validity and that its psychometric properties make it suitable for use in
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hospital care.
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2010;19(13-14):1803-11.

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 Table 1. Characteristics of the sample
ACCEPTED MANUSCRIPT (n: 249)
Mean (SD)
or n (%)
Age1
Years of professional activity2 18.9 (7.2)
1
Gender
Male 46 (20.2)
Female 182 (79.8)
Education2
High School education 182 (80.2)
Bachelor’s degree 21 (9.3)

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Master’s degree 12 (5.3)
Specialist 11 (4.8)
Doctorate 1 (0.4)

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2
Occupational training in the prevention of pressure ulcers

Yes 174 (76.7)

No 53 (23.3)

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Duration of training3
0-30 hours 69 (40.1)
30-100 hours 67 (39.0)

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100-300 hours 27 (15.7)
> 300 hours 9 (5.2)
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4
Date of most recent training
< 1 year 30 (17.2)
>1 year <5 years 110 (63.2)
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> 5 years 34 (19.5)

Clinical speciality5
Medical 83 (36.6)
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Surgical 53 (23.3)
Intensive care 37 (16.3)
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A&E 23 (10.1)
Gynaecology 11 (4.8)
Outpatients 5 (2.2)
Paediatrics 5 (2.2)
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4 (1.8)
Operating Room and Recovery
Oncology 3 (1.3)
Palliative care 2 (0.9)
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Other 1 (0.4)
Clinical guidelines consulted to assist in decision making
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American College of Physicians (2015) 4 (1.6)

The National Institute for Health and Care Excellence (2014) 6 (2.4)
National Pressure Ulcer Advisory-European Pressure Ulcer 11 (4.4)
Advisory Panel-Pan Pacific Pressure Injury Alliance (2014)
Conselleria de Sanidad Valencia (2012) 10 (4.0)

Registered Nurses Association of Ontario (2011) 1 (0.4)

Consejería de Salud de La Rioja (2009) 4 (1.6)

Servicio Andaluz de Salud (2007) 121 (48.6)

Technical documents issued by the National Study and 79 (31.7)
Advisory Group on pressure ulcers and chronic injuries
None 53 (21.3)
Missing responses: 1=21; 2=22; 3=77; 4=75; 5=12
 ACCEPTED MANUSCRIPT
Table 3 Inter-item correlation matrix

p1 p2 p3 p4 p6 p 10 p 12 p 13 p 14 p 16 p 17 p 18 p 19 p 20 p 21 p 23 p 24 p 25
p1 1
**
p2 ,452 1
** **
p3 ,197 ,317 1
* ** **
p4 ,150 ,242 ,336 1
** ** ** **
p6 ,199 ,285 ,319 ,431 1
** ** ** **

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p 10 ,030 ,183 ,195 ,339 ,448 1
** ** ** ** **
p 12 ,096 ,258 ,403 ,396 ,506 ,391 1
* ** ** ** ** ** **
p 13 ,142 ,272 ,237 ,343 ,470 ,482 ,622 1
** ** ** ** ** ** ** **
p 14 ,188 ,340 ,342 ,306 ,565 ,450 ,643 ,667 1

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** ** ** ** ** ** ** ** **
p 16 ,221 ,304 ,277 ,330 ,462 ,384 ,519 ,419 ,559 1
** ** ** ** ** ** ** ** ** **
p 17 ,177 ,236 ,327 ,365 ,386 ,360 ,430 ,377 ,449 ,532 1

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* ** ** ** ** ** ** ** ** ** **
p 18 ,157 ,250 ,202 ,245 ,354 ,310 ,431 ,418 ,392 ,441 ,366 1
* ** ** ** ** ** ** ** ** ** **
p 19 ,089 ,150 ,186 ,327 ,432 ,390 ,525 ,470 ,499 ,407 ,538 ,571 1
* ** ** ** ** ** ** ** ** ** **
p 20 ,073 ,138 ,100 ,284 ,422 ,383 ,442 ,426 ,454 ,409 ,328 ,432 ,600 1
** ** ** ** ** ** ** ** ** ** ** ** ** **
p 21 ,199 ,259 ,235 ,388 ,428 ,238 ,368 ,346 ,330 ,397 ,305 ,357 ,338 ,349 1

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** ** ** ** ** ** ** ** ** ** ** ** ** ** **
p 23 ,177 ,188 ,245 ,359 ,438 ,412 ,581 ,519 ,495 ,481 ,459 ,470 ,530 ,419 ,374 1
* ** ** ** ** ** ** ** ** ** ** ** ** ** ** **
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p 24 ,145 ,222 ,230 ,290 ,412 ,387 ,480 ,414 ,471 ,607 ,593 ,387 ,504 ,429 ,375 ,497 1
** ** ** ** ** ** ** ** ** ** ** ** ** ** ** ** **
p 25 ,213 ,343 ,377 ,332 ,405 ,452 ,502 ,500 ,556 ,466 ,470 ,394 ,447 ,388 ,357 ,498 ,536 1
**. Correlation is significant at 0,01 level
**. Correlation is significant at 0,05 level
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[n; %]
Table 4. Clinical cases and QARPPU scores QARPPU: Mean (SD)

Clinical case 1 No Yes p

On admission, evaluate the risk of ulcers forming. [n=19; 7.63] [n=230; 92.36] 0.198
73.52 (14.21) 77.41 (8.87)
Take no prevention measures, as the admission is expected to be short-term. [n=248; 99.59] [n=1; 0.40] 0.378
77.08 (9.40) 85.00 (0)
Apply a barrier cream to the perineum and sacral region after each bowel [n=58; 23.29] [n=191; 76.69] 0.043
movement. 74.74 (10.99) 77.83 (8.77)
Inform the hospital’s nutritionist and/or attending physician of the patient’s [n=37; 14.89] [n=212; 85.09] 0.001
loss of weight, frequent bowel movements and lack of skin firmness. 72.54 (11.55) 77.91 (8.76)

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Advise the patient to change position frequently and to avoid maintaining [n=32; 12.89] [n=217; 87.09] 0.196
the same posture for a long time. 74.96 (11.58) 77.43 (9.02)
Change the patient’s body position every 4 hours. [n=156; 62.69] [n=93; 37.29] 0.411
77.43 (9.34) 76.58 (9.53)

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Apply a moisturising cream to the entire body after bathing, and perform an [n=191; 76.69] [n=58; 23.29] 0.110
energetic massage until the cream is completely absorbed. 77.46 (9.58) 75.98 (8.75)
Monitor the position of the nasogastric tube and move it at least twice daily. [n=52; 20.89] [n=197; 79.89] 0.091
74.96 (11.19) 77.68 (8.81)

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Place a cushioning ring on the wheelchair to alleviate the pressure. [n=167; 67.09] [n=82; 32.89] 0.463
77.35 (9.48) 76.62 (9.26)
Explain to the patient and his daughter the importance of keeping the skin [n=22; 8.79] [n=227; 91.19] 0.037
clean and dry, and of regularly changing body posture in bed and when 72.63 (13.42) 77.55 (8.83)
seated.

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In conjunction with the patient and his daughter, prepare an ulcer prevention [n=44; 17.69] 74.20 [n=205; 82.29] 0.010
and care plan, in writing. (10.63) 77.74 (9.02)
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Encourage the patient, when in bed, to adopt a 90º seated position and thus [n=226; 90.79] [n=23; 9.19] 0.749
avoid possible injuries to the back. 77.03 (9.54) 77.91 (7.97)
Advice the patient not to remain seated in the wheelchair for extended [n=93; 37.29] [n=156; 62.69] 0.174
periods without a cushion to alleviate the pressure. 75.83 (10.85) 77.87 (8.36)
Re-evaluate the risk of ulcer after the surgical intervention and the insertion [n=43; 17.29] [n=206; 82.69] 0.027
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of the gastrostomy tube. 74.00 (11.66) 77.76 (8.75)

Clinical case 2
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No assessment of the risk of this patient developing ulcers is necessary, [n=233; 93.79] [n=16; 6.39] 0.242
since she clearly presents a profile of fragility (advanced age, impaired 77.26 (9.38) 75.00 (9.65)
mobility, cognitive impairment, etc.).
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Place a specific pressure redistribution surface (foam mattress, alternating [n=25; 10.00] [n=224; 90.00] 0.593
overlay, etc.) on the patient’s bed. 75.52 (12.68) 77.29 (8.98)
Inspect the patient’s heels once daily. [n=68; 27.29] [n=181; 72.69] 0.352
77.41 (10.89) 77.00 (8.88)
Conduct a daily assessment of the patient’s skin to determine its integrity, [n=30; 12.00] [n=219; 88.00] 0.273
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and to detect any changes in colour or variations in temperature, firmness 75.26 (11.88) 77.36 (9.01)
and moisture/dryness.
Apply a barrier cream to the heels. [n=96; 38.59] [n=153; 61.39] 0.776
77.17 (9.09) 77.07 (9.62)
Place a dressing on the sacral region. [n=153; 61.39] [n=96; 38.59] 0.001
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75.89 (9.60) 79.06 (8.77)

Place a water-filled balloon beneath the heels to alleviate the pressure. [n=209; 83.89] [n=40; 16.09] 0.390
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77.17 (9.69) 76.72 (7.82)

Design a specific care plan, including changes in body position except at [n=116; 46.59] [n=133; 53.39] 0.856
night, to allow rest. 76.88 (10.28) 77.31 (8.59)
Leave the bedclothes unchanged until the fever abates, in order to avoid [n=244; 98.00] [n=5; 2.00] 0.187
further discomfort. 77.27 (9.26) 69.60 (14.13)
Change the patient’s body position at least every 2 hours. [n=73; 29.29] [n=176; 70.69] 0.642
77.31 (10.08) 77.03 (9.13)
Change the patient’s body position at every shift change. [n=208; 83.49] [n=41; 16.49] 0.956
76.97 (9.87) 77.82 (6.59)
With the patient lying on her right side, the head-section of the bed should [n=147; 59.00] [n=102; 41.00] 0.724
not be raised by more than 30º. 76.89 (9.59) 77.43 (9.15)
Monitor food intake, and keep the rest of the team informed about the [n=48; 19.29] [n=201; 80.69] 0.052
findings. 74.85 (10.81) 77.65 (8.97)
Raise the patient’s heels, with the aid of a pillow, ensuring no contact is [n=44; 17.69] [n=205; 82.29] 0.111
made with any surface. 75.25 (10.54) 77.51 (9.11)
 ACCEPTED MANUSCRIPT
Apply a barrier cream to the diaper area. [n=42; 16.89] [n=207; 83.09] 0.597
76.04 (11.30) 77.33 (8.98)
When the patient is lying down, protect the body areas in contact with the [n=38; 15.29] [n=211; 84.69] 0.759
surface of the bed (e.g. the elbows) with pillows or specific foam surfaces to 76.21 (12.63) 77.27 (8.72)
alleviate the pressure.
With the patient lying on her left side, the bed position should be [n=241; 96.79] [n=8; 3.19] 0.571
maintained at 90º. 77.17 (9.38) 75.37 (10.59)
A urinary catheter should be inserted in order to keep the diaper dry. [n=211; 84.69] [n=38; 15.29] 0.945
77.10 (9.46) 77.18 (9.15)

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Table 2 Distribution of scores and reliability for the 18 items

Scale mean Corrected Cronbach’s

if item item – Total alpha if
deleted correlation item deleted

p1 73.4096 0.278 0.907

p2 73.0281 0.426 0.899
p3 73.1687 0.421 0.899

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p4 73.2932 0.507 0.896
p6 72.6627 0.646 0.891
p 10 72.8795 0.520 0.895
p 12 72.5462 0.693 0.891

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p 13 72.6466 0.646 0.891
p 14 72.5703 0.708 0.890
p 16 72.6908 0.666 0.891

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p 17 72.6506 0.614 0.892
p 18 72.7912 0.560 0.894
p 19 72.7631 0.627 0.892
p 20 72.8313 0.540 0.894

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p 21 73.0763 0.521 0.896
p 23 72.4900 0.650 0.892
p 24 72.7390 0.633 0.891
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p 25 72.7430 0.670 0.890
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Fig. 1 Initial questionnaire to evaluate nurses’ adherence to recommendations for preventing pressure ulcers (QARPPU)

Please indicate how often you perform the following interventions to prevent

Sometimes
pressure ulcers from forming when you treat a patient at risk of this

Seldom

Always
Never

Often
condition.

p1. To assess the risk of pressure ulcers forming, I rely exclusively on my clinical
judgement as a nurse (without the support of risk evaluation instruments).
p2. To assess the risk of pressure ulcers forming, I take into account my clinical
judgement as a nurse, and also apply a validated risk evaluation instrument
(Braden, Emina, Norton, Waterlow or similar).
p3. I conduct risk evaluation when the patient is admitted, always within six hours
of admission.

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p4. I perform a further examination in response to any change in the patient’s
clinical status (for example, after surgery, the worsening of an underlying disease
or a change in mobility).

p5. I prepare an individualised ulcer prevention plan, in writing.

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p6. I perform a daily evaluation of the patient’s skin with respect to its integrity,
possible changes in colour or variations in temperature, firmness and
moisture/dryness.
p7. In areas where erythema is apparent, I determine whether it disappears a few

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seconds after removing the pressure exerted by palpation with a finger.
p8. If non-blanching erythema is present, I evaluate the affected skin more
frequently (at least every two hours).
p9. I inspect the patient’s skin beneath and around treatment apparatus (catheters,
drains, etc.), at least twice daily for alarm signs related to pressure on the

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surrounding skin.

p10. I try to avoid reclining the patient on areas with non-blanching erythema.
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p11. When the patient’s clinical condition allows, I evaluate localised pain, as part
of the skin inspection, asking the patient to identify any areas of skin discomfort
and/or pain.

p12. I ensure the patient's skin is kept clean and dry.

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p13. I ensure the patient’s skin is protected from excessive moisture, using a
barrier product.

p14. I hydrate dry skin with a moisturiser.

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p15. I do not apply massage over bony prominences.

p16. Provided it is not contraindicated by the patient’s clinical status, I apply
postural changes, according to the risk of a pressure ulcer forming.
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p17. Provided the patient’s clinical status allows, I encourage him/her to change
position frequently, depending on the risk presented.
p18. When the patient must be moved, I take care to avoid friction and shear
(using slide sheets, transfer boards, hoists, etc.).
p19. When the patient is sitting in a chair, I ensure that the feet are well
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supported, either directly on the floor or raised on a footrest or stool.

p20. When the patient is in bed, I maintain the 30º position, unless it is
contraindicated by the health situation or is not tolerated.
p21. I place high-risk patients on a special surface for pressure redistribution (e.g.
a dynamic pressure-relieving mattress, or alternating overlay, or a high
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specification foam mattress).

p22. When a patient with reduced mobility sits in a chair for an extended period
of time, I place a surface to redistribute the pressure (pillow, cushion, etc.)
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beneath him/her.
p23. I avoid placing the patient directly on treatment devices such as catheters,
drainage systems, etc., unless it is unavoidable.
p24. I ensure that pressure is relieved from the heel by lifting it such that the
weight of the leg is distributed along the calf, without putting pressure on the
Achilles tendon (e.g. by placing a foam pillow or cushion under the calf, leaving
the heel suspended).
p25. I use dressings (hydrocolloids, foam, silicone, etc.) in risk areas to avoid
friction and shear forces.
P26. On admission, I assess the nutritional risk of each patient, using a validated
instrument.
p27. In patients who have nutritional deficiencies and who are at risk of
developing a pressure ulcer, I ensure the nutritional plan is implemented by
informing the multidisciplinary team (nutritionist, treating physician, etc.) of the
situation.
p28. I involve the patient and/or caregiver in learning about preventive care
techniques.
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Two case histories are presented below. Please indicate with an X which pressure ulcer prevention measures you would take
for each patient.

Case history 1.

A 79-year-old male was admitted for insertion of a gastrostomy tube, due to dysphagia, the result of chemotherapy for oesophageal
malignancy. Background of interest: former smoker, 20 cigarettes/day, arterial hypertension, angina attack two years previously.
The patient was conscious and oriented, and accompanied by a daughter, who had lived with him and cared for him since the disease
was diagnosed six months previously. A nasogastric enteral feeding tube (brought from home) was fitted, together with a peripheral
venous line in the upper left arm for the administration of fluids. The skin was intact, although in some areas it was less firm as a
result of the weight loss experienced in recent months. Frequent episodes of diarrhoea were experienced (2-3 bowel

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movements/day). Mobility was slightly limited due to lack of physical strength. In consequence, a wheelchair was needed for
movement.

Which of the following prevention measures would you take for this patient?

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On admission, evaluate the risk of ulcers forming.

Take no prevention measures, as the admission is expected to be short-term.

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Apply a barrier cream to the perineum and sacral region after each bowel movement.

Inform the hospital’s nutritionist and/or attending physician of the patient’s loss of weight, frequent bowel movements and lack
of skin firmness.

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Advise the patient to change position frequently and to avoid maintaining the same posture for a long time.
AN
Change the patient’s body position every 4 hours.

Apply a moisturising cream to the entire body after bathing, and perform an energetic massage until the cream is completely
absorbed.
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Monitor the position of the nasogastric tube and move it at least twice daily.

Place a cushioning ring on the wheelchair to alleviate the pressure.

D

Explain to the patient and his daughter the importance of keeping the skin clean and dry, and of regularly changing body posture
in bed and when seated.
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In conjunction with the patient and his daughter, prepare an ulcer prevention and care plan, in writing.

Encourage the patient, when in bed, to adopt a 90º seated position and thus avoid possible injuries to the back.

Advice the patient not to remain seated in the wheelchair for extended periods without a cushion to alleviate the pressure.
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Re-evaluate the risk of ulcer after the surgical intervention and the insertion of the gastrostomy tube.
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Case history 2.
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An 85-year-old female was admitted with severe cognitive impairment, presenting advanced-stage Alzheimer's disease and normally
resident in a nursing home. The patient was bedridden, required incontinence pads, and was admitted for IV antibiotic therapy for
pneumonia. The patient had a high fever (over 39° C) and non-blanching erythema on both heels.

Which of the following prevention measures would you take for this patient?

No assessment of the risk of this patient developing ulcers is necessary, since she clearly presents a profile of fragility (advanced
age, impaired mobility, cognitive impairment, etc.).

Place a specific pressure redistribution surface (foam mattress, alternating overlay, etc.) on the patient’s bed.

Inspect the patient’s heels once daily.

Conduct a daily assessment of the patient's skin to determine its integrity, and to detect any changes in colour or variations in
temperature, firmness and moisture/dryness.
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Place a dressing on the sacral region.

Place a water-filled balloon beneath the heels to alleviate the pressure.

Design a specific care plan, including changes in body position except at night, to allow rest.

Leave the bedclothes unchanged until the fever abates, in order to avoid further discomfort.

Change the patient’s body position at least every 2 hours.

Change the patient’s body position at every shift change.

With the patient lying on her right side, the head-section of the bed should not be raised by more than 30º.

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Monitor food intake, and keep the rest of the team informed about the findings.

Raise the patient’s heels, with the aid of a pillow, ensuring no contact is made with any surface.

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Apply a barrier cream to the diaper area.

When the patient is lying down, protect the body areas in contact with the surface of the bed (e.g. the elbows) with pillows or
specific foam surfaces to alleviate the pressure.

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With the patient lying on her left side, the bed position should be maintained at 90º.

A urinary catheter should be inserted in order to keep the diaper dry.

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Fig. 1 Initial questionnaire to evaluate nurses’ adherence to recommendations for preventing pressure ulcers (QARPPU)
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Fig. 2 Factor structure

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Conflict of interests

All authors have completed the Unified Competing Interest form at

www.icmje.org/coi_disclosure.pdf (available from the corresponding author) and
declare they have received no support from any organisation for the paper submitted for
consideration; neither, during the previous three years, have they had financial
relationships with any organisation that might have an interest in the paper submitted,

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nor engaged in other relationships or activities that could appear to have influenced the
work performed.

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