Nurses’ perceptions of a pressure ulcer prevention care

Nurses’ perceptions of a pressure ulcer
prevention care bundle: a qualitative
descriptive study
Shelley Roberts1*, Elizabeth McInnes2

, Marianne Wallis3

, Tracey Bucknall4

, Merrilyn Banks5 and Wendy Chaboyer1

Abstract
Background: Pressure ulcer prevention is a critical patient safety indicator for acute care hospitals. An innovative
pressure ulcer prevention care bundle targeting patient participation in their care was recently tested in a cluster
randomised trial in eight Australian hospitals. Understanding nurses’ perspectives of such an intervention is
imperative when interpreting results and translating evidence into practice. As part of a process evaluation for the
main trial, this study assessed nurses’ perceptions of the usefulness and impact of a pressure ulcer prevention care
bundle intervention on clinical practice.
Methods: This qualitative descriptive study involved semi-structured interviews with nursing staff at four Australian
hospitals that were intervention sites for a cluster randomised trial testing a pressure ulcer prevention care bundle.
Four to five participants were purposively sampled at each site. A trained interviewer used a semi-structured
interview guide to question participants about their perceptions of the care bundle. Interviews were digitally
recorded, transcribed and analysed using thematic analysis.
Results: Eighteen nurses from four hospitals participated in the study. Nurses’ perceptions of the intervention are
described in five themes: 1) Awareness of the pressure ulcer prevention care bundle and its similarity to current
practice; 2) Improving awareness, communication and participation with the pressure ulcer prevention care bundle;
3) Appreciating the positive aspects of patient participation in care; 4) Perceived barriers to engaging patients in
the pressure ulcer prevention care bundle; and 5) Partnering with nursing staff to facilitate pressure ulcer
prevention care bundle implementation.
Conclusions: Overall, nurses found the care bundle feasible and acceptable. They identified a number of benefits
from the bundle, including improved communication, awareness and participation in pressure ulcer prevention care
among patients and staff. However, nurses thought the care bundle was not appropriate or effective for all patients,
such as those who were cognitively impaired. Perceived enablers to implementation of the bundle included
facilitation through effective communication and dissemination of evidence about the care bundle; strong
leadership and ability to influence staff behaviour; and simplicity of the care bundle.
Keywords: Care bundle, Evidence-based practice, Implementation science, Knowledge translation, Nurses, Patient
engagement, Patient participation, Pressure injury prevention, Pressure ulcer prevention, Process evaluation

* Correspondence: s.roberts@griffith.edu.au 1
NHMRC Centre of Research Excellence in Nursing, Menzies Health Institute
Queensland, Griffith University, Gold Coast Campus, Queensland 4222,
Australia
Full list of author information is available at the end of the article

© The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Roberts et al. BMC Nursing (2016) 15:64
DOI 10.1186/s12912-016-0188-9

Background
Pressure ulcer prevention (PUP) is a significant priority
in hospitals given the high incidence of pressure ulcers
(PUs) [1], the severe consequences they have for patients

[2], and the large costs they incur to the health care sys-
tem [3, 4]. Nurses have a primary role in PUP; however

patients may also contribute through active participation
in PUP care [5, 6]. Patient participation in care has been

shown to result in improved patient safety [7] and satis-
faction with care [8]. Patient participation is endorsed by

the World Health Organisation [9] and is included in
health service standards internationally [10, 11]. Nurses
partnering with patients in PUP may be an effective
strategy for reducing pressure ulcers (PU) among at-risk
individuals.
Our team developed a pressure ulcer prevention care
bundle (PUPCB) targeted at both patients and nurses,
encouraging patient participation in PUP care with three
simple evidence-based messages: 1) Keep moving; 2)
Look after your skin; and 3) Eat a healthy diet [12].
These messages were delivered to patients with a poster,
brochure and DVD. Nurses received training on how to

partner with patients in PUP by encouraging active par-
ticipation in their care. The effectiveness of the care

bundle for PUP was tested in a cluster randomised trial,

the INTroducing A Care bundle To prevent pressure ul-
cers (INTACT) trial, in eight Australian hospitals [13].

Hospitals were randomly assigned to the intervention

(PUPCB) or control group. Medical, surgical and re-
habilitation wards considered to have a high number of

patients at risk of PU were included in the study.
The INTACT trial showed a significant reduction in
PU incidence in the intervention group at the hospital
(cluster) level, but this difference was not significant at

the individual patient level. Whilst there are many pos-
sible reasons for these findings, the research team con-
cluded the study was underpowered [13]. Given this, it

seems logical to further investigate the processes relating

to the intervention itself and its use. The success or fail-
ure of interventions, or the extent to which they work,

may in part be explained by processes relating to imple-
mentation [14]. Hence, a pre-specified process evalu-
ation was conducted alongside the INTACT trial to give

insight into the trial’s findings. Process evaluations pro-
vide an understanding to assist with future implementa-
tion of interventions, recognising that moving research

into routine practice is difficult [15]. Grant et al.’s frame-
work for process evaluations of cluster randomised trials

[16] guided our evaluation.
This paper reports in detail on the response of nursing
staff (clusters) to the intervention; one domain of the

process evaluation framework. It is important to under-
stand nurses’ experience with and perceptions of an

intervention; particularly one that involves nurses

partnering with patients in care. Their perspectives of
the intervention and the evidence around it, the context
in which it used, and characteristics of nurses themselves

are likely to influence its adoption in practice and ultim-
ately, its effect [17]. This study aimed to explore nurses’

perceptions of a PUPCB, including its impact and how it

might be incorporated into usual practice, to give in-
sights into the main trial findings, wider PUPCB imple-
mentation, and translation into routine practice.

Methods
Study design and setting

This qualitative descriptive study [18] involved semi-
structured interviews with nursing staff working on

wards where the PUPCB was implemented, in four acute
care hospitals (public and private) that were intervention

sites for the cluster randomised trial across two Austra-
lian states. Ethical approval was gained at each hospital

intervention site and from the participating university.
Participants and recruitment
Nurses of any designation working on the INTACT
study wards who were (a) permanent full time or part
time employees; and (b) employed during the INTACT

trial were eligible to participate in the study. With assist-
ance from the nurse unit manager, potential participants

meeting inclusion criteria were identified. Purposive
sampling was used to recruit four to five nurses per site,
depending on the point at which data saturation was
reached, to include a mix of nurses in terms of gender,
area of speciality and years’ experience in nursing. All

nurse participants were provided with a participant in-
formation sheet and written informed consent was

gained from those agreeing to participate. The number
of participants was determined when data saturation was

reached (i.e. data collection ceased when no new infor-
mation was identified).

Data collection
A semi-structured interview guide was developed based
on published methodology [16, 19] and piloting of the

intervention [20]. An iterative process of reviewing, pilot-
ing and refining the interview guide was undertaken, in-
volving senior members of the research team with

experience in acute care, hospital-based nursing and quali-
tative research. Questions were structured within four

main domains: (1) Awareness of the INTACT trial and

intervention; (2) Perceptions of the intervention; (3) Per-
ceived impact of the intervention; and (4) Utility of the

PUPCB in usual practice. Questions and prompts for each
domain are shown in Table 1.
Individual interviews were conducted on site by a trained

research assistant, at a time and location that was conveni-
ent for the participant. A conversational style of

Roberts et al. BMC Nursing (2016) 15:64 Page 2 of 10

interviewing was used with the semi-structured interview

guide providing direction for the interviewer. Direct ques-
tions were asked when conversations did not elicit re-
sponses about the PUPCB. Interviews lasted approximately

15–20 min and were digitally recorded and later tran-
scribed for analysis.

Data analysis

Thematic analysis was used to analyse the semi-
structured interview data [21, 22]. Interview transcripts

were read and re-read; codes were developed based on
participants’ verbatim statements; and data relevant to
each code were collated into sub-themes and themes
based on commonality. Analysis was led by one member
of the research team, with close conferral with another
team member and input from the whole research team

to clarify findings. Trustworthiness of findings was en-
hanced by: (a) discussing findings among the research

team to ensure data were interpreted in line with the
emergent codes, sub-themes and themes (credibility);

and (b) using purposive sampling to ensure broad repre-
sentation of nurses (transferability) [23].

Results
Eighteen nurses participated in interviews across the
four hospitals (at least four nurses from each site). The
majority of nurses were female (n = 15, 83%). Nurses
came from a mix of medical, surgical and rehabilitation
wards. Participants’ experience in nursing ranged from 3

to 30 years. No participants who were approached de-
clined to participate.

Nurses answered questions about their perceptions of
the intervention related to the domains outlined above.
Their responses were then able to be grouped into five
themes: 1) Awareness of the PUPCB and its similarity to

current practice; 2) Improving awareness, communica-
tion and participation with the PUPCB; 3) Appreciating

the positive aspects of patient participation in care; 4)
Perceived barriers to engaging patients in the PUPCB;
and 5) Partnering with nursing staff to facilitate PUPCB
implementation. Nurses spent longer responding to

questions about their perceived impact of the interven-
tion and the utility of the PUPCB in practice (i.e. do-
mains 3 and 4), which was reflected in the themes. The

themes and their sub-themes are outlined in Table 2 and
described in further detail below.

Awareness of the PUPCB and its similarity to current
practice

All nursing staff were aware of the INTACT trial hap-
pening on their ward. Most nurses had heard about the

study either at an in-service or from a colleague. In this

theme, nurses described their perceptions of the inter-
vention (PUPCB), including their understanding of what

it involved and how they thought it compared with their
current practice.

Table 1 Semi-structured interview domains and questions
Domain Example questions and prompts
1) Awareness of the INTACT trial and
intervention

• What was the purpose of the INTACT trial?
• What were the main messages you took from the INTACT trial?

2) Perceptions of the intervention • What was good/bad about the PUPCB?
•What did you think of the poster/brochure/DVD?

3) Perceived impact of the intervention • Were there any benefits or limitations for your unit being involved in the INTACT study? Why/why not?

• Were staff affected in any way? How?

4) Utility of the PUPCB in usual practice • Do you think this intervention/care bundle should be adopted by the ward for all patients at risk of

PU? Why/why not?
• What barriers or enablers do you see for using this in practice?

Note: Generic prompts included: ““Can you tell me more about this?”; “Can you explain this further / expand on this?” and “What do you mean when you
say ____?”

Table 2 Themes and sub-themes
Themes Sub-themes
Awareness of the PUPCB and its
similarity to current practice

Understanding the PUPCB
Comparing the PUPCB and
current practice

Improving awareness, communication
and participation with the PUPCB

Increasing awareness of PUP
Enhancing nurse and patient
communication about PUP
Active participation in PUP

Appreciating the positive aspects of
patient participation in care

Understanding and supporting
patient participation in care
Realising the benefits of patient
participation

Perceived barriers to engaging
patients in the PUPCB

Cognitive impairment restricts
participation in PUP
Taking a passive approach to
health care
Undervaluing of PUP by
patients

Partnering with nursing staff to
facilitate PUPCB implementation

Communication and
dissemination
Leadership and influence
Keeping the PUPCB simple
Roberts et al. BMC Nursing (2016) 15:64 Page 3 of 10

Understanding the PUPCB
Most nurses had a good understanding of the PUPCB’s
purpose (PUP); key concepts (nurse-patient partnership
and patient participation); and messages (keep moving,
look after your skin, eat a healthy diet). Most nurses said
they had not seen the intervention materials in much

detail but generally, those that had gave positive feed-
back about the components of the PUPCB, stating that

they were simple and easy for patients to understand.
…patient involvement in their own care for preventing
pressure injuries. And also, staff engaging with the
patients so it’s a more collaborative approach to
looking after the patients. (Site 2, N7)
Educating the patients to help themselves as well, so to
move more, and healthy diet… and to work with staff
was a big part of it as well. (Site 2, N8)
Comparing the PUPCB and current practice
Nurses discussed the PUPCB in terms of their current
practice. Some suggested their practice already reflected
the PUPCB, so it didn’t add anything new to nursing
practice on that ward. For this reason some nurses
expressed doubt that the PUPCB would work. Others
were more accepting of the PUPCB, recognising it could
assist in PUP.
I’m not really sure if it will work for orthopaedic
because the patients are bed ridden and we check
their skin regularly ourselves. So I’m not really sure if
it would be really beneficial. (Site 3, N14)
Others however, favourably compared the PUPCB to
their current practice, describing how it aligned with
other initiatives or strengthened what they were already
doing in practice.
It did tie in very nicely with what we’re trying to
do already, which is a lot more patient involvement.
(Site 2, N7)
Improving awareness, communication and participation
with the PUPCB
Nurses described the potential benefits of the PUPCB
for both patients and staff, discussing several changes
they believed occurred on the ward; including increased

awareness of PUP, improved nurse and patient commu-
nication about PUP and active participation in PUP.

Increasing awareness of PUP
Nurses expressed there was increased awareness of PUP

amongst both patients and staff as a result of the inter-
vention. They believed the intervention raised nurses’

awareness of PU, PUP and patients who may be at risk
of PU. One nurse believed the PUPCB messages aimed

at patients also resonated with staff, stating that it en-
couraged nurses to consider patients’ nutritional status,

skin care and mobilisation in everyday care.
It was beneficial, because it raised awareness not only
amongst the patients that were chosen to be part of
the trial…. but awareness of staff as well. (Site 3, N13)
I guess it makes you think more about who’s at risk.
(Site 4, N15)
Participants thought nurses became more aware of
the concept of patient participation, which facilitated
nurses to allow patients to be more independent in
their care.
It made us nurses aware as well….because when you’re
in a hurry you tend to do things for them [patients].
But it made you…stop and think, and make them
[patients] more independent to take control of what
they’ve got to do. (Site 3, N12)
Participants perceived that after receiving the
PUPCB, patients became more interested in and
aware of PU, and had a better understanding of what
they needed to do in terms of PUP activities and why
they needed to do it.
They [patients] become curious about pressure sores
and who gets them and how do you get them and how
common they are. (Site 2, N6)
Enhancing nurse and patient communication about PUP
Nurses thought the intervention resulted in improved

communication amongst patients and staff (i.e. patient-
to-nurse, nurse-to-nurse, and patient-to-patient inter-
actions) around PUP. Nurses said patients were more

often engaging with them in conversations about repo-
sitioning, including asking if they needed to be turned

or communicating to staff that they were moving them-
selves. Nurses thought the intervention made it easier

to start conversations with patients about PUP.
It actually helped the staff to generate the
conversations (about PUP) with the patient. (Site 3,
N4)
Nurses also expressed the PUPCB helped patients

understand why nurses implement certain interven-
tions such as repositioning. They stated that often

patients did not like moving themselves or being
repositioned by nursing staff due to pain or
Roberts et al. BMC Nursing (2016) 15:64 Page 4 of 10

immobility, but once patients understood what was
happening and why, they were more compliant and
less anxious with being repositioned or moving
themselves.
Rather than us nagging them constantly, they’re kind
of aware why we want to roll them. (Site 2, N6)

The intervention was believed to have generated con-
versations about PUP amongst staff and encouraged a

team approach to PUP. One nurse described how she
witnessed a patient conversing with another patient
about what he had learned from the PUPCB.
Another patient who had just had the DVD shown to
him ended up having a conversation with the patient
across from him…..he started showing the patient the
brochure from his bedside, saying ‘here, this is what
they told me’ and ‘this is the poster they put up on the
wall’ and he started telling him about what he was
just taught. I was quite surprised as to how much he
retained and what he actually had a conversation
with the other patient. (Site 3, N13)
Active participation in PUP
Nurses explained how they thought the intervention

encouraged more active participation in PUP by pa-
tients; particularly in terms of moving. They believed

patients became more independent, active and inter-
ested in moving; needing less direction and encour-
agement to move. Nurses described how patients

often rolled or repositioned themselves without being
asked; or, if they needed help repositioning, they were
more likely to ask.
Most of the patients that I was taking care of that
received that information… were actively changing
their positions without being told to do so. (Site 1, N4)
Some people got really into it. And they’d say things like
‘do I need to be turned?’ and things like that. (Site 1, N3)
Appreciating the positive aspects of patient participation
in care
Nurses had overwhelmingly positive views of patient

participation in care. Appreciation took two forms in-
cluding understanding and supporting participation; and

realising the benefits of patient participation in care.
Understanding and supporting patient participation in care

Nurses explained how they understood patient participa-
tion in care, including what they thought it meant in

theory and what activities it involved in practice. They
described aspects of participation such as shared

responsibility and knowledge/information exchange, and

also acknowledged considerations such as patients’ abil-
ities and level of engagement when involving them in

their care. They discussed their personal views on and
experiences with patient participation, with most nurses
advocating an active role for patients in care.
The more information we can provide to the patient to
start taking some form of responsibility right from
admission throughout their journey, I think that’s
imperative. We need to give some of the responsibility
back to them as well. (Site 3, N13)
It’s good for them to have an awareness that they’re
responsible and they are playing a part in their own
health care and their processes of getting… discharged
out of hospital. (Site 2, N7)
Realising the benefits of patient participation

Nurses described many perceived benefits of patient par-
ticipation in their health care to both patients and staff.

Nurses expressed when patients participate in their care,
this provides ‘whole care’ and patients experience better
outcomes. They thought patients had an improved
mindset about their own care and were more satisfied
with their hospital stay when they participated in care.
They also thought that participation seemed to improve
a patient’s mood.
It’s good if they participate as well because it’s a whole
care. Rather than for us to keep implementing but
there will be no effect, because it’s up to the patient to
agree with the treatment or with the implementation.
So it’s very good if they know exactly what we are
doing for them and they know the benefits and they
can help us in that way. (Site 1, N2)
Another perceived benefit of patient participation was
that it sometimes saved work for nurses. For example,
participants conveyed that when patients are taught to
participate in their own care, they are enabled to care
for themselves proactively without being asked or
reminded.
If we teach the patients on how to take control of their
own care, then we can enable them to do it more
proactively than waiting on the nurses to tell them
what to do and everything. (Site 1, N4)
Nurses also thought sharing more information with
patients was beneficial for both patients and health care

professionals, as patients usually reciprocated by provid-
ing important information back to the nurse or being

more willing to participate in care.

Roberts et al. BMC Nursing (2016) 15:64 Page 5 of 10

…the more information you share, the more education
that you give them, they actually help you. And in
return you get what you need, which is the optimum
outcome which is for them to be discharged with good
health or get into the right frame of mind about their
own health care. (Site 2, N7)
Perceived barriers to engaging patients in the PUPCB
Nurses suggested that whilst the PUPCB may work for

some, it was not appropriate for all patients as it re-
quired active participation and engagement, to which

there were many barriers. Three sub-themes were evi-
dent: ‘Cognitive impairment restricts participation in

PUP’, ‘Taking a passive approach to health care’ and
‘Undervaluing of PUP by patients’.
Cognitive impairment restricts participation in PUP
Many nurses believed that cognitively impaired patients,
who may be at higher risk of PU, were unable to benefit
from this intervention. Patients with dementia, delirium
or confusion were described as being very high risk, but

being unable to participate in PUP activities due to lim-
ited ability to self-care and being unable to understand

or retain information provided in PUP education. It was
interesting that nurses did not acknowledge differences
in patients’ abilities to participate depending on their
stage of dementia (i.e. early or advanced dementia).
However, nurses did often mention a solution to this
barrier, which was involving the family or carers in the
patient’s care. Educating carers and family members
around PU risk factors and PUP strategies was seen to
be extremely important for patients with cognitive
impairment.
If they’re a person with failing memory or a bit of
dementia, I don’t know about its [PUPCB] effectiveness
or their ability to retain the information. However, if
they’re a patient who has family visiting it’s good to
educate the family as well I believe. At least the family
are more aware so when they come and visit… they
may be on the lookout for these things more often. (Site
3, N11)
Taking a passive approach to health care

Nurses discussed how some patients had a passive ap-
proach or negative attitude towards their health care,

which was perceived as a barrier to participation. They

said some patients didn’t believe it was their responsibil-
ity to participate, thought nurses should do everything

for them, would not take ownership of their care, and
assumed the ‘sick role’ whilst in hospital. Nurses did not
think all patients were willing to participate in their care
and acknowledged this as a limitation. One nurse

mentioned that in these cases, a solution may also be to
involve the family in the patient’s care.
….it works for a certain percentage….. it doesn’t work
for everyone. It depends on the person… whether or not
people believe it’s their responsibility to take part in
that role and I think for some patients it’s a bit
difficult for them to take ownership of what their
responsibilities are. (Site 2, N7)
Undervaluing of PUP by patients
Another barrier to patient participation in PUP care

mentioned by nurses was patients’ perceived lack of im-
portance of PUP. This may be due to failing to under-
stand one’s own PU risk, or having other issues that

patients prioritise higher than PUP. Nurses said that
some patients, especially those who were younger or had
never had a PU, may not acknowledge they are at risk of
developing a PU. They also stated that patients who
were bedridden, in pain, or too unwell may not realise
the importance of PUP, or were unlikely to prioritise this
in terms of other health issues they were experiencing in
hospital
You’d say to them you need to start moving but they
wouldn’t really because they’re like, ‘I’m young’; but
they still do get red bottoms and red heels. (Site 2, N9)
But unless they’ve had a pressure sore they’re not
really aware of how easily it can happen. (Site 2, N6)
Partnering with nursing staff to facilitate PUPCB
implementation
Most nurses thought the PUPCB tested in the INTACT
trial should be adopted by their ward as usual practice.
Participants highlighted how important it was that the

research team partnered with nursing staff to success-
fully implement the care bundle into practice, and dis-
cussed a number of perceived barriers and enablers to

implementation.
Communication and dissemination

Nurses expressed the importance of communicating in-
formation and disseminating evidence in successful im-
plementation of the PUPCB (or any intervention). Many

nurses stated that for future implementation, education
sessions or inservices would be needed to introduce the
bundle to staff, familiarise them with what it involves
and train them in its use. Nurses thought ideally, these

sessions should be frequent, brief and concise; and in-
volve all staff on the ward. The importance of providing

evidence to nurses around the effectiveness of the
PUPCB and the benefits of patient participation in care
was also emphasised. They thought nurses need to view
Roberts et al. BMC Nursing (2016) 15:64 Page 6 of 10

the intervention as necessary and important in order for
it to be adopted in practice, and providing evidence was
a way to ensure this.
Providing some evidence about how much more the
patients participate… doing an inservice on how
pressure areas have gone down since the INTACT trial
started, some hard evidence on the stuff. (Site 1, N3)
Leadership and influence
Another important factor mentioned by nurses for
implementing a PUPCB was leadership. A few nurses
suggested there needs to be someone leading and driving
implementation. This person was described as needing
to be persistent, dedicated, having time to implement

the intervention and probably being internal to the or-
ganisation so as to have some influence on staff. An ex-
ternal facilitator to provide staff education was also

raised as being helpful during the INTACT trial. As lack

of time and the risk of the intervention losing momen-
tum over time were mentioned as potential barriers;

having dedicated staff to facilitate implementation
seemed important to nurses.
You do need somebody to drive that responsibility or
that role and it can’t just be something that you
expect a ward to develop or to do. It has to be driven
by somebody. (Site 2, N7)
….having an independent person to come in and that’s
been their focus, to educate the staff. (Site 4, N16)
Using hospitals’ key performance indicators (i.e. PUP
and patient participation) to influence staff and show

them the significance of the intervention was also men-
tioned as a strategy for implementation.

Keeping the PUPCB simple
In order for the intervention to work in practice, nurses

raised a number of issues relating to the care bundle it-
self and processes of implementation. Many mentioned

extra documentation was a major barrier and would hin-
der nurses from adopting the intervention; hence, they

thought the intervention should not involve much
paperwork.
A tick-box on a care plan would be good… Not further
reams of documentation. Nurses should be encouraged

to feel that this conversation is easy to have, and ne-
cessary and not time consuming. (Site 1, N1)

Nurses thought the intervention should be brief, sim-
ple and easy to deliver, in order to address another bar-
rier frequently mentioned; lack of time. One suggested

the DVD shown to patients as part of the PUPCB could
be put on the patients’ television screens in hospital to
save time. Several nurses thought the education should
start pre-admission (for elective surgical patients) or on
admission (for other patients) so that post-operatively,

the message is just reinforced. Nurses said that as pa-
tients already received too much information post-
operatively, receiving a message they had already heard

would be easier to understand.
When they come for their preoperative day about two
weeks before surgery for knees and hips for example, it
could perhaps be incorporated at that time. Before
they start receiving their care when they’ve got time to
think about it learn a bit more. (Site 3, N10)
Discussion
This study explored nurses’ perceptions of a PUPCB, as
part of the process evaluation of a cluster randomised
trial (INTACT) [13]. Overall, nurses had positive views

and found the PUPCB feasible and acceptable. Their re-
sponses were represented in five themes: 1) Awareness

of the PUPCB and its similarity to current practice; 2)
Improving awareness, communication and participation
with the PUPCB; 3) Appreciating the positive aspects of

patient participation in care; 4) Perceived barriers to en-
gaging patients in the PUPCB; and 5) Partnering with

nursing staff to facilitate PUPCB implementation.

Whilst several systematic reviews of complex PUP in-
terventions and PUP programs have been published [24,

25], we are unaware of any other process evaluations of
PUP studies. The systematic reviews identify variable
quality in previous trials; most are pre-post studies, and
provide limited descriptions of intervention fidelity or
implementation strategies [24, 25]. To our knowledge,
none have assessed nurses’ perceptions of interventions

or their views on implementation and sustainability. Pre-
vious studies suggest that acutely ill hospital patients

want to be involved in their PUP care [5]; and this study

shows that nurses support efforts to increase patient in-
volvement and resources such as PUPCB can facilitate

participation.

The positive response of nurses to a PUPCB promot-
ing patient participation in PUP care may be partly due

to the PUPCB being developed in collaboration with end
users; that is, the views of patients and nurses were

sought in a pilot study and their feedback was incorpo-
rated into the final design of the intervention [6, 20].

This is in line with an integrated knowledge translation
approach, which is used to develop interventions that

are likely to be relevant, acceptable and usable to end-
users [26]. As the PUPCB reflected current clinical prac-
tice guidelines [27] and nurses found it acceptable in

Roberts et al. BMC Nursing (2016) 15:64 Page 7 of 10

terms of understanding, using and seeing the benefits of
it, the PUPCB may be a simple way to promote
evidence-based practice and patient participation in
care.
Translating research into routine clinical practice is
recognised as a major challenge in health care [17]. The

uptake of new interventions (innovations) may be af-
fected by: (a) factors relating to the intervention itself

and the evidence surrounding it; (b) the context in
which it is implemented; and (c) the characteristics of

adopters (clinicians) [17, 28, 29]. As most of these chal-
lenges revolve around how adopters perceive, under-
stand, utilise, communicate, implement or sustain an

intervention within a certain context, it is imperative to

explore their perspectives of it before attempting imple-
mentation. The current study provides important insight

for possible implementation of a PUPCB by exploring
nurses’ experiences with and perceptions of the
intervention.

Uptake of an innovation is likely to be affected by fac-
tors relating to the intervention itself and evidence sur-
rounding it [17, 28]. A systematic review identified

attributes of innovations that affect their uptake, which

included the key elements of Rogers’ ‘Diffusion of Inno-
vations’ theory [28, 30]. When adopters perceived an

innovation to be advantageous; compatible with their
values, norms and needs; simple to use; able to be

experimented with; and the benefits were visible, innova-
tions were more easily adopted and implemented [28].

In the current study, nurses acknowledged advantages of

the PUPCB in terms of their perceived benefits to pa-
tients and nurses; improved awareness, communication

and participation in care (i.e. relative advantage). Nurses
seemed to respond more positively to the PUPCB when

they thought it aligned with current ward or hospital ini-
tiatives such as patient participation in care and PUP; or

when they personally agreed with the concept of patient-
centred care used in the bundle (compatibility). The vast

majority of nurses understood the PUPCB and thought

it was easy to use; and they further highlighted the im-
portance of low complexity in terms of implementation

in the sub-theme ‘Keeping the PUPCB simple’. Trialabil-
ity was discussed in terms of being able to adapt the

PUPCB to patients with different needs, such as involv-
ing family members for patients who are cognitively

impaired or allowing patients to participate to different
extents. Finally, nurses described the importance of
observability across several themes, discussing perceived
benefits of the PUPCB in themes ‘Improving awareness,
communication and participation with the PUPCB’ and

‘Appreciating patient participation in care’, and highlight-
ing the importance of providing evidence to nurses

around the effectiveness of the PUPCB in ‘Strategies for
implementing a PUPCB’.

According to the Promoting Action on Research Im-
plementation in Health Services (PARIHS) framework,

successful implementation of research depends on the

dynamic and simultaneous relationships between evi-
dence, context and facilitation [29]. Credible evidence

from high quality research studies, as well as from clin-
ical and patient experiences, is likely to influence imple-
mentation and adoption [29]. In this study, nurses

expressed their desire for evidence on the effectiveness
of the PUPCB and of patient participation in care; they
thought that providing nurses with this evidence would
facilitate uptake of the PUPCB. Another study found
that nurses desired learning opportunities for research

utilisation, such as education and mentoring, to under-
stand research findings and implement them in practice

[31]. In terms of clinical experience, nurses in the
current study reflected on the intervention by describing

it and comparing it to current practices, as well as dis-
cussing the perceived effects and benefits of the inter-
vention. Patient experience was also raised; nurses

described how they thought the PUPCB changed patient
behaviour and how and why they thought patients did
or did not participate in PUP care.
The context in which a new innovation is introduced is
also likely to have a large impact on implementation success
[17, 28, 29]. Features of the health care organisation such as
the absorptive capacity for new knowledge and a receptive
context for change are positively associated with adoption of
innovations [28]. Elements of these, which are consistent
with the description of context in the PARIHS framework,
include culture, evaluation and leadership [28, 29]. Nurses
spoke about the strong culture of patient participation in
their wards or hospitals; suggesting the philosophy of
patient-centred care was influencing nurses at the front line.
Participants explained how the PUPCB aligned with an
existing culture of patient participation in care, consistent
with Rogers’ theory around compatibility of interventions
[30] and Greenhalgh’s ‘Innovation-system fit, whereby an ’
innovation that fits with the organisation’s existing values,
norms, strategies and goals is more likely to be successfully
implemented [28].
The organisation’s capacity to evaluate the innovation, by
monitoring the change; evaluating its impact; and feeding

results back to those involved, affects assimilation and sus-
tainment [28]. In the current study, nurses requested feed-
back from the trial about the effectiveness of the care

bundle for PUP in their wards, suggesting this would help
facilitate uptake of the intervention. To some extent,
nurses also evaluated the intervention themselves in
terms of benefits for patients and staff they perceived.
However, because this was a trial, feedback to nurses
did not occur until after the study was completed. If
the PUPCB was to be adopted in practice, it appears
regular feedback would be important. Audit and
Roberts et al. BMC Nursing (2016) 15:64 Page 8 of 10

feedback is one strategy that is moderately effective in
changing practice [32].
Leadership [29], communication and influence [28] are

imperative for implementing new innovations. Interper-
sonal communication and influence through social net-
works in a health care system is the most effective

medium for promoting uptake of innovations [28]. This

may be achieved by engaging individuals who have par-
ticular impact on their colleagues, such as opinion

leaders, champions and boundary spanners [28]. This

ties in with the concept of facilitation, that is, enable-
ment of implementation of evidence into practice, which

requires an individual with the appropriate roles, skills,
knowledge and authority to apply evidence in practice
[29, 33]. Nurses in the current study highlighted the
need for a designated person to drive implementation of
the PUPCB for successful adoption. This person, who

would be labelled a facilitator in PARIHS [29], was per-
ceived to ideally possess appropriate knowledge and

skills and be in a suitable role to drive implementation.
Finally, the characteristics of those adopting or using

the intervention are important determinants of its up-
take. These may include individual clinicians’ knowledge,

capability and motivation to use new evidence or inno-
vations [28]. Individuals may also have different con-
cerns at different stages of implementation [28].

Concerns in pre-adoption relate to awareness of an
innovation, knowing what it does and how to use it, and
understanding how it will affect them as users [28].

Nurses in the current study described their understand-
ing of the PUPCB and that they became aware of it

through attending inservices; their perceived benefits of

the intervention; and barriers and enablers to its imple-
mentation and use in usual practice. Early involvement

and commitment of staff at all levels during implemen-
tation increase the likelihood of success [28]. The find-
ings of the current study related to implementation and

maintenance of the PUPCB by adopters also resonate with

Normalisation Process Theory. This theory considers co-
herence (meaning), cognitive participation (commitment),

collective action (effort) and reflexive monitoring (com-
prehension) as important aspects of implementation [34,

35]. In the current study, nurses established coherence of
the intervention by describing their understanding of its
components and its similarities and differences to their
usual practice. Cognitive participation in or commitment

to the intervention seemed apparent through initiation, le-
gitimation, enrolment and activation [34]. That is, most

nurses agreed it should become part of routine practice,

acknowledged the benefits of the intervention and de-
scribed how they partnered with patients in PUP. Collect-
ive action or effort is the work required to organise and

enact a practice [34]. Participants perceived that partner-
ing with nurses, by communicating information and

disseminating evidence on the PUPCB; having appropriate
leadership and influence for facilitating implementation;
and keeping the intervention simple and easy to deliver

were key aspects of successful uptake of the PUPCB. Re-
flexive monitoring is considered after the intervention has

been in place for some time, however nurses still sug-
gested the results of the main trial be disseminated to staff

in order for them to see it as valuable and advantageous;
something that occurred several months after the study’s
completion.
This was a relatively small study of 18 nurses from
four Australian hospitals, so there is the possibility that
the variation in all nurses’ views were not represented in

our findings. However, we used maximum variation pur-
posive sampling to improve generalisability; continued

data collection until saturation was reached; and in-
cluded both public and private hospitals across two

states. These strategies may have increased the relevance
of our findings for other similar settings. Secondly, the
study included an evaluation of one particular PUPCB.

While this may make the findings specific to this par-
ticular PUPCB, the findings may have applicability for

the implementation and use of other multi-component
PUP strategies [24, 25, 36].
Conclusions
This study found that nurses responded positively to a

PUPCB involving nurse-patient partnership to promote pa-
tient participation in care. Nurses saw the bundle as benefi-
cial to both patients and nurses through improved

awareness, communication and participation in care related
to PUP. They found the PUPCB easy to understand, use
and implement; however acknowledged barriers to engaging

some patients in PUP care. Participants suggested that part-
nering with nursing staff through communication and dis-
semination, leadership and influence, and keeping the

PUPCB simple were crucial for facilitating its implementa-
tion. As the PUPCB reflects current clinical practice guide-
lines and nurses in this study found the PUPCB was

acceptable, its use may be an effective strategy for promoting
evidence-based PUP care that is easily and cheaply
implemented.
Abbreviations
PU: Pressure ulcer; PUP: Pressure ulcer prevention; PUPCB: Pressure ulcer
prevention care bundle
Acknowledgements
The authors would like to thank Mandy Tallott, Edel Murray, Louise Webber
and Margarette Somerville for their contribution to the research.
Funding
This study received no funding.
Availability of data and material
Data from the current study are available from the corresponding author on
reasonable request.

Roberts et al. BMC Nursing (2016) 15:64 Page 9 of 10

Authors’ contributions
SR and WC contributed to study conception and design, analysis and
interpretation of data, drafting and revising the article, and final approval of
the submitted article. LM, MW, TB and MB contributed to study conception
and design, acquisition of data, interpretation of data, revising the article and
approval of the submitted article.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Not applicable (no individual patient data reported).
Ethics approval and consent to participate
This study was approved by Gold Coast Hospital and Health Service Human
Research Ethics Committee (reference number: HREC/13/QGC/192). All
participants provided informed consent to participate in the study.
Author details
1
NHMRC Centre of Research Excellence in Nursing, Menzies Health Institute
Queensland, Griffith University, Gold Coast Campus, Queensland 4222,
Australia. 2
Nursing Research Institute, St Vincent’s Health Australia (Sydney)
and School of Nursing, Midwifery and Paramedicine, Australian Catholic
University, North Sydney, NSW 2060, Australia. 3

School of Nursing, Midwifery
and Paramedicine, University of the Sunshine Coast, Locked Bag 4,
Maroochydore DC, QLD 4558, Australia. 4

Centre for Quality and Patient
Safety, School of Nursing and Midwifery, Deakin University, Geelong, VIC
3220, Australia. 5
Department of Nutrition and Dietetics, Royal Brisbane and

Women’s Hospital, Herston, QLD 4019, Australia.
Received: 28 July 2016 Accepted: 10 November 2016
References
1. Graves N, Zheng H. The prevalence and incidence of chronic wounds: a
literature review. Wound Pract Res. 2014;22(1):4–19.
2. Gorecki C, Brown JM, Nelson EA, Briggs M, Schoonhoven L, Dealey C, et al.
Impact of pressure ulcers on quality of life in older patients: a systematic
review. J Am Geriatr Soc. 2009;57(7):1175–83.
3. Graves N, Zheng H. Modelling the direct health care costs of chronic
wounds in Australia. Wound Pract Res. 2014;22(1):20–33.
4. Nguyen K-H, Chaboyer W, Whitty J. Pressure injury in Australian public
hospitals: a cost of illness study. Aust Health Rev. 2015;39(3):329–36.
5. Latimer S, Chaboyer W, Gillespie B. Patient participation in pressure injury
prevention: giving patient’s a voice. Scand J Caring Sci. 2014;28(4):648–56.
6. Gillespie BM, Chaboyer W, Sykes M, O’Brien J, Brandis S. Development and
pilot testing of a patient-participatory pressure ulcer prevention care
bundle. J Nurs Care Qual. 2014;29(1):74–82.
7. Weingart SN, Zhu J, Chiappetta L, Stuver SO, Schneider EC, Epstein AM, et
al. Hospitalized patients’ participation and its impact on quality of care and
patient safety. Int J Qual Health Care. 2011;23(3):269–77.
8. Dwamena F, Holmes-Rovner M, Gaulden CM, Jorgenson S, Sadigh G,
Sikorskii A, et al. Interventions for providers to promote a patient-centred
approach in clinical consultations. Cochrane Database Syst Rev. 2012; doi:10.
1002/14651858.CD003267.pub2.
9. World Health Organisation. Patients for patient safety. Geneva: World Health
Organisation; 2007.
10. Australian Commission on Safety and Quality in Health Care. National safety
and quality health service standards. Sydney: ACSQHC; 2011.

11. Joint Commission on Accreditation in Healthcare Organizations. Patient-
inclusive care: encouraging patients to be active participants in their care. Jt

Comm Perspect Patient Saf. 2006;5(11):1–8.
12. Chaboyer W, Bucknall T, Webster J, McInnes E, Banks M, Wallis M, et al.
INTroducing A Care bundle To prevent pressure injury (INTACT) in at-risk
patients: a protocol for a cluster randomised trial. Int J Nurs Stud. 2015;
52(11):1659–68.
13. Chaboyer W, Bucknall T, Webster J, McInnes E, Gillespie BM, Banks M, et
al. The effect of a patient centred care bundle intervention on pressure
ulcer incidence (INTACT): a cluster randomised trial. Int J Nurs Stud.
2016;64:63–71.

14. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M.
Developing and evaluating complex interventions: the new Medical
Research Council guidance. Int J Nurs Stud. 2008;50(5):587–92.
15. Grol R, Grimshaw J. From best evidence to best practice: effective
implementation of change in patients’ care. Lancet. 2003;362(9391):1225–30.
16. Grant A, Treweek S, Dreischulte T, Foy R, Guthrie B. Process evaluations for
cluster-randomised trials of complex interventions: a proposed framework
for design and reporting. Trials. 2013;14(1):15.
17. Bucknall T. Knowledge transfer and utilization: implications for home
healthcare pain management. J Healthc Qual. 2006;28(1):12–9.
18. Sandelowski M. Whatever happened to qualitative description? Res Nurs
Health. 2000;23(4):334–40.
19. Whiting LS. Semi-structured interviews: guidance for novice researchers.
Nurs Stand. 2008;22(23):35.
20. Chaboyer W, Gillespie BM. Understanding nurses’ views on a pressure ulcer
prevention care bundle: a first step towards successful implementation. J
Clin Nurs. 2014;23(23–24):3415–23.
21. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol.
2006;3(2):77–101.
22. Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analysis:
implications for conducting a qualitative descriptive study. Nurs Health Sci.
2013;15(3):398–405.
23. Shenton AK. Strategies for ensuring trustworthiness in qualitative research
projects. Educ Inf. 2004;22(2):63–75.
24. Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient
safety strategy: a systematic review. Ann Intern Med. 2013;158:410–6.
25. Niederhauser A, Lukas CV, Parker V, Ayello EA, Zulkowski K, Berlowitz D.
Comprehensive programs for preventing pressure ulcers: a review of the
literature. Adv Skin Wound Care. 2012;25(4):167–88.
26. Canadian Institute of Health Research. Guide to knowledge translation
planning at CIHR: integrated and end-of-grant approaches. Ottawa: Her
Majesty the Queen in Right of Canada; 2012.
27. European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory
Panel, Pan Pacific Pressure Injury Alliance. Prevention and treatment of
pressure ulcers: quick reference guide. Perth: Cambridge Media; 2014.
28. Greenhalgh T, Robert G, Bate P, Kyriakidou O, Macfarlane F, Peacock R. How
to spread good ideas: a systematic review of the literature on diffusion,
dissemination and sustainability of innovations in health service delivery
and organisation. In: Report for the National Co-ordinating Centre for NHS
Service Delivery and Organisation R & D (NCCSDO). Queen’s Printer and
Controller of HMSO, Secretary State for Health; 2004. http://www.nets.nihr.
ac.uk/__data/assets/pdf_file/0017/64340/FR-08-1201-038.pdf. Accessed 19
Jan 2016.
29. Rycroft M. The PARIHS Framework – a framework for guiding the
implementation of evidence-based practice. J Nurs Care Qual. 2004;
19(4):297.
30. Rogers EM. Diffusion of innovations. New York: Schuster; 1995.
31. Brown CE, Wickline MA, Ecoff L, Glaser D. Nursing practice, knowledge,
attitudes and perceived barriers to evidence-based practice at an academic
medical center. J Adv Nurs. 2009;65(2):371–81.
32. Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, et
al. Audit and feedback: effects on professional practice and healthcare
outcomes. Cochrane Database Syst Rev. 2012; doi:10.1002/14651858.
CD000259.pub2.
33. Harvey G, Kitson A. Implementing evidence-based practice in healthcare: a
facilitation guide. London and New York: Routledge; 2015.
34. May C, Finch T. Implementing, embedding, and integrating practices: an
outline of Normalization Process Theory. Sociology. 2009;43(3):535–54.
35. Murray E, Treweek S, Pope C, MacFarlane A, Ballini L, Dowrick C, et al.
Normalisation process theory: a framework for developing, evaluating and
implementing complex interventions. BMC Med. 2010;8(1):63.
36. Soban LM, Hempel S, Munjas BA, Miles J, Rubenstein LV. Preventing
pressure ulcers in hospitals: a systematic review of nurse-focused quality
improvement interventions. Jt Comm J Qual Patient Saf. 2011;37(6):245.