What are the perceived challenges and barriers faced by nurses in the prevention and management of pressure ulcers among hospitalised adults and associated care settings?

Chapter 1: Introduction and Context.

1.1 Background

Pressure ulcers, also known as pressure injuries or bedsores injuries or bedsores in the patient, are a major in problem as the patient body due to sustained pressure experiences damaged skin area and tissues. Pressure ulcer is defined as localised damage to the skin and underlying tissue, which is usually caused by the prolonged pressure or the combination of pressure and shear, pressure ulcers are generally well-known as highly preventable adverse events. It happens in stages (1,2,3,4) as the patient is at a high risk , if skin is thin, less elastic, patient is bedridden, poor nutrition, has to deal with inconsistence. Even though, the patient needs frequent repositioning, and support like specialised foam, air filled mattress (Sia et al. 2026), National Pressure Injury Advisory Panel [NPIAP] and Pan Pacific Pressure Injury Alliance [PPPIA], 2019).

Statista reported that in 2025, UK alone has 500,000 people developing into pressure ulcer cases annually in 2024-2025, with newly diagnosed 180,000 new cases being reported every year. In the United Kingdom, the cost of treating aggregate pressure ulcers is estimated at 1.4-2.1 billion a year to the National Health Service (NHS) (NHS Improvement, 2018, as cited in Oozageer Gunowa et al., 2025). The United States has estimated the annual expenses related to the treatment of hospital-acquired pressure injuries to exceed USD 27 billion (Oozageer Gunowa et al., 2025).

The role of nurses in pressure ulcer prevention and control is central and cannot be replaced. Nurses are the key primary line of defence who act through constant clinical observation. Their role in execution of the “SSKIN” bundle (Surface, Skin, Keep moving, Incontinence, Nutrition), and the use of risk-assessment tools like the Waterlow scale are instrumental to care quality for such patients. Registered nurses being the largest healthcare professionals’ group have the responsibility to perform risk assessment, preventive measures, organize care, and educate patients and carers (Li et al., 2022). International (e.g., the EPUAP, NPIAP and PPPIA, 2019) and national (e.g., the National Institute of Health and Care Excellence, 2014) The earliest clinical practice was based on the initial guidelines formed in 2014, that constituted contain evidence-based case studies culminating into guidelines. Guideline CG179 by NICE focussed in prevention and management of pressure ulcers. It developed standard QS81, which defined quality standards for monitoring and reducing incidence of pressure ulcers in all UK hospitals and also in care homes. Later in the year 2019, EPUAP has come together with PPPIA (Pan Pacific pressure injury alliance) and NPIAP (National Pressure injury advisory panel) to release a documented International guideline. The attempt was to spread the standardised practice at global level and improve each nation’s capability to address scope of improving risk assessment efficacy, offer nutrition to patients, and develop support surfaces. Abbreviated as SSKIN bundle (Support surfaces, Skin inspection, Keep moving, Incontinence-moisture management, Nutrition-hydration) forms a more comprehensive version, ASSKING, offer useful guidelines that nurses can apply to provide structured pressure ulcer prevention (Taylor et al., 2021).

1.2 Significance and Rationale

Existing literature on prevention of pressure ulcers has been on clinical outcomes, intervention efficacy or guideline development. It is important to understand the obstacles and difficulties that nurse encounter, in their everyday practice to design meaningful, specific strategies to enhance care. A qualitative study of community nurses and allied healthcare professionals in London by Taylor et al. (2021) revealed that although all participants reported their high motivation to prevent pressure ulcers, a variety of barriers still affected the provision of best practice. These were self-reported gaps in in allied healthcare professionals, challenges with starting conversations with patients regarding risk, high workloads, and clutter in the homes of patients (Taylor et al., 2021).

This issue has an impact on more than clinical practice as it also touches on education, workforce planning, training and the broader healthcare policy. Nurses in long-term care facilities have reported to experience unique challenges, that are very different compared to those in acute settings. It pertains to lack of formalised guidelines unique to their setting, severe understaffing, and inadequate access to specialist wound care services (Na et al., 2024). Factors like home setting, non-adherence in patients, family, and inability to perform a comprehensive skin assessment on patients, with varying skin tones have further complicated the situation in the community setting (Taylor et al., 2021; Oozageer Gunowa et al., 2025). Multicenter qualitative studies described globally have been carried out in three tertiary hospitals in Singapore and have continued to note the synergistic effects of cognitive, emotional, resource, and biomedical factors in the complex issue of effective pressure injury prevention (Sim et al., 2024).

One of the least studied but still the most crucial dimensions is the evaluation of the pressure injuries in dark-skinned patients. The qualitative descriptive study by Oozageer Gunowa et al. (2025) in community nurses in the South of England revealed that nurses had serious problems with identifying pressure injuries at an early stage for those individuals with a dark complexion. This showed practice gap mainly attributed to lack of nurse training, non-availability of diverse patient demographic by ethnicity, and representative clinical materials. Considering the scope and depth of the barriers discussed in literature, carrying out a focused secondary research would help the length and breadth of aggregate challenges faced by nurses in preventing and managing pressure ulcers. This type of review will be able to synthesise data available in existing literature, find common themes, and indicate gaps in current knowledge to guide educational and policy advancements in nursing.

1.4 Nursing Practice/Policy Relevance

The study is especially applicable to the nursing practice on the various levels. On the individual care delivery level, knowledge of the obstacles encountered by nurses can be used to create more sensitive educational programmes, approaches to clinical training and supervision and application based best practice directions. Organisational perspective emphasis, contribution towards staffing shortages, resource constraints, and equipment shortages can be used to appraise the workforce, work methods planning and procurement. At policy level, the knowledge about the unequal use of guideline implementation and equity disparities in the care delivery, to pressure ulcer patients, dark skin tone patient group, has the consequences in NHS commissioning, regulatory requirements, impacting the efficacy of the curricula in nurse education.

In the Nursing and Midwifery Council (NMC, 2018) Code, the registered nurses are expected to follow strict guidelines based patient safety, upholding the nursing professional knowledge, and maintain standards of excellence at institutional level evidence-based care as a priority. NHS England and NHS Improvement explicitly name the prevention of pressure ulcers as one of the patient safety priorities, and the avoidance of preventable pressure ulcers can be a serious incident in the context of NHS governance frameworks (Taylor et al., 2021). The direct implication of identifying and overcoming the barriers that nurse’s encounter in the delivery of best practice to patients is thus on professional accountability and patient outcomes.

1.5 Dissertation Organisation.

This dissertation is outlined in five chapters. Chapter 1 has introduced the review, its contextual background and its rationale as well as the research question is clearly stated. Chapter 2 defines the methodology that will be used, such as the search strategy, the choice of databases, inclusion and exclusion criteria, and the critical appraisal method. Chapter 3 critically discusses the methodological soundness of the five primary studies chosen. Chapter 4 summarises the results of the reviewed studies with regard to the research question and outlines the main themes and comments on the implications. The final chapter of the dissertation is a discussion on how the findings of the review would impact nursing practice, policy, education, and future research.

Chapter 2: Methodology

2.1 Introduction

In this chapter, a clear and reproducible record of the methodological process that was employed to identify and select the primary empirical literature that guides this review is given.

2.2 Review Approach

2.3.4 Developing the Research Question: The PEO Framework.

An organized approach is necessary when formulating a well-focused and responsive review question (Stern, Jordan and McArthur, 2014). In this review, PEO framework was chosen because it is specifically developed to formulate questions to use in the qualitative, observational, and experiential inquiry and is therefore very applicable in the formulation of questions about perceptions, experiences and barriers (Booth et al., 2019; Methley et al., 2014). The PEO model takes into account the Population, Exposure and Outcome of interest and offers an organized approach to the generation of search terms which are elaborated in Table 1 below.

Table 1: PEO Framework for Research Question Development

PEO Element	Definition	Application to this Review
Population (P)	The group of interest in the review	Adult patients (≥18 years) in hospital or associated care settings (acute wards, long-term care facilities, integrated community care)
Exposure (E)	The condition, context or circumstance being examined	Nursing involvement in pressure ulcer prevention and management, including risk assessment, care planning, repositioning, skin inspection, and patient education
Outcome (O)	The area of interest regarding the population’s experience or status	Perceived challenges and barriers experienced by nurses in delivering pressure ulcer prevention and management

Qualitative Approach

The question, “What are perceived as the challenges and barriers to preventing and managing pressure ulcers in hospitalised adults and related care settings serviced by the nurses” was answered by using the qualitative research method only. The qualitative research will attempt to understand the human phenomena which offer descriptions and explanations of these phenomena in detail (Lim, 2025) explaining the ‘why and how’ of research phenomenon. The qualitative method has depth at its forefront and the participants’ viewpoints at the core (Chivanga & Monyai, 2021) in relation to their lived experiences in specific institutional setting in respective country. Critically, qualitative research study has been acknowledged that qualitative literature reviews may not be systematic and therefore, is less reliable evidence can be missed by chance and not through (rigorous means) which (Bryda & Costa, 2023) point out that rigour (sometimes termed as trustworthiness) can be attained by transparency and reporting of the systematic process adopted.

1.3 Research Question

The literature review question is: ‘?’

The question is formulated based on the PEO (Population, Exposure, Outcome) framework, which is especially suitable to qualify or experience-based investigation (Booth et al., 2019). The Population in PEO, consists of adult patients (18 years and above) in hospital or other related care facilitiessuch as acute wards, long-term care, and integrated community care facilities with links to hospitals. The Exposure in PEO, means the engagement of registered nurses in the prevention and management of pressure ulcers along with their clinical duties, decision-making and care delivery. The Outcome in PEO includes the perceived difficulties and obstacles faced by nurses in accomplishing these roles.

2.4 Search Strategy

2.4.1 Databases Searched

A total of five academic databases were searched in a systematic way so as to cover a representative and complete identification of the relevant literature. The databases chosen were CINAHL (Cumulative Index to Nursing and Allied Health Literature) (Dhippayom et al. 2023), PubMed/MEDLINE (Jin, Leaman, & Lu, 2024), Scopus (Kumpulainen & Seppänen, 2022), Web of Science (Szabó et al. 2025), and the Cochrane Library. They were selected based on different reasons. CINAHL is the largest database of nursing and allied health literature, which provides a wide range of coverage of peer-reviewed journals pertinent to the clinical practice of nursing, and it is always advised when conducting a literature review of nursing (Wright, Golder and Lewis-Light, 2015). PubMed/MEDLINE offers a wide scope of biomedical and clinical research and can be actively involved in the review of the health sciences (Bramer et al., 2017). Scopus and Web of Science are multidisciplinary databases that provide citation monitoring and access to international peer-reviewed literature in health and social sciences that allow a broader search of the relevant literature (referenced). Background information on systematic reviews related to the pressure ulcer care was searched in Cochrane Library, because Cochrane reviews did not receive priority in the appraisal chapters as primary sources (Yang et al. 2025). This is in accordance with the methodological approach of this review.

It is also within the scope of best practice advice of literature reviews in nursing to limit the search to specialist nursing and health databases (Coughlan and Cronin, 2021; Beecroft, Booth and Rees, 2015). CINAHL combined with MEDLINE in particular has proven to provide the best coverage of nursing-related issues (Bramer et al., 2017). They did not restrict the search to full-text articles initially because it would limit significant published work to the search (Aveyard, 2023), but full texts were acquired later to all studies included in the search.

2.4.2 Search Terms and Boolean Operators.

The search terms were made based on the components of the PEO framework and utilized to ensure cohesive and consistent searching in databases. Concepts were combined with the help of Boolean operators (AND, OR) and truncated (truncation) with the help of the special sign (Coughlan and Cronin, 2021; Whitehead and Maude, 2016). The key search terms used are summarised in table 2 below.

Table 2: PEO-Based Search Terms

PEO Element	Search Terms
Population	hospitalised adults OR adult patients OR acute care OR hospital settings OR long-term care OR community care settings
Exposure	nurs* OR “nursing staff* OR registered nurses OR pressure ulcer prevention OR pressure injury management
Outcome	barrier* OR challenge* OR perception* OR obstacle* OR attitude* OR experience*

Terms like nurse, barrier, challenge, and hospital were truncated to ensure that a variety of grammatical forms and variations is represented and the search is not limited unnecessarily. The retrieval of synonymous terms in each PEO element was broadened by the application of Boolean operator expanding the search output impacting the research scope and select relevant research article for selection.

2.5 Inclusion and Exclusion criteria.

Table 3: Inclusion and Exclusion Criteria

Inclusion Criteria	Exclusion Criteria
Studies focusing on registered nurses involved in pressure ulcer prevention and/or management	Studies focusing primarily on non-nursing staff (e.g., healthcare assistants, domestic workers, students) where nurses’ perspectives are absent
Studies conducted in hospital or hospital-associated care settings (acute wards, long-term care facilities, rehabilitation units, integrated community care with hospital linkage)	Studies conducted in settings where organisational type defines hospital care (e.g., home-only, community settings without hospital linkage)
Studies involving adult patients aged 18 years and above	Studies focused solely on pediatric or neonatal populations
Studies exploring perceived challenges, barriers, attitudes, or experiences of nurses in relation to pressure ulcer prevention and/or management	Studies examining clinical effectiveness of interventions only, without exploring nurse perspectives or barriers
Primary empirical research (qualitative, quantitative, or mixed-methods designs)	Opinion pieces, editorials, conference abstracts, letters, and grey literature
Peer-reviewed journal articles published in English	Non-peer-reviewed publications and those not available in English
Studies published between 2018 and 2025	Studies published before 2018, except where cited for contextual background in Chapter 1
Studies for which full text is available	Studies where full text is unavailable after attempts to retrieve via interlibrary loan

Search Strategy limitations.

The search strategy has a number of limitations, which should be mentioned. To begin with, the limitation of the search to English-language publications might have caused the elimination of other pertinent studies (Aveyard, 2023). Second, date limitation (2018-2025) was used; to guarantee the recency and relevance to the modern practices, but omitting outdated, yet valuable studies.

PRISMA

New studies included in review

(n =0 )

Reports of new included studies

(n =0 )

Identification of new studies via databases and registers

Screening

Records screened

(n =321)

Records excluded

(n =231 )

Reports sought for retrieval

(n = 90)

Reports not retrieved

(n =0 )

Reports assessed for eligibility

(n = 90)

Reports excluded:n=85

Reason 1 Studies are not on core topic (n =22 )

Reason 2 Study was not Cochrane (n =31 )

Reason 3 No adult end of life pain experiences (n = 32)

etc.

Studies included in previous version of review (n = 321)

Previous studies

Total studies included in review

(n =5 )

Reports of total included studies

(n = 5)

Included

Identification

Records identified from*:

Databases (n = 4)

MEDLINE (n=111)

CINHAL (n=51)

APA PsychInNFO (n=109)

Academic search (n=50)

Records removed before screening:

Duplicate records removed (n =106 )

Records marked as only abstracts (n =25 )

Records removed as non english (n =10 )

This two-step procedure is aligned with the method suggested by Page et al. (2021) in the new PRISMA (Preferred Reporting Items to Systematic Reviews and Meta-Analyses) instruction of how to conduct literature searching in a structured manner.

2.6 Study Selection Process

The selection of the study was carried out in two phases. During the initial step, all of the retrieved records were filtered by screening their titles and abstracts based on the inclusion and exclusion criteria. At this point, records that were obviously not relevant were excluded. The second stage involved obtaining and evaluating the full-text of the potentially eligible studies against the same criteria. Causes of omission at the full-text level were recorded.

Included studies were also screened on reference list and any other study identified during this process was then evaluated against the inclusion criteria. After this, five main empirical studies that fit all inclusion criteria were identified and were chosen to undergo critical appraisal in Chapter 3. Table 4 below summarizes all these five studies.

Table 4: Summary of Included Studies

Author(s) & Year	Country / Setting	Design	Sample	Focus
Taylor, Mulligan & McGraw (2021)	UK – Integrated community care (London NHS Trust)	Qualitative; TDF-informed semi-structured interviews	9 registered nurses, 4 allied health professionals	Barriers and enablers to evidence-based PU prevention and management
Li, Marshall et al. (2022)	China – Large tertiary hospital (Beijing)	Qualitative descriptive; SEIPS model; semi-structured interviews	27 registered nurses	Nurses’ approaches to and factors influencing PU prevention
Na, Yoo & Kweon (2024)	South Korea – Long-term care facilities	Interpretive description; semi-structured interviews	10 registered nurses	Nurses’ experiences of pressure sore care in LTCFs
Sim, Choi et al. (2024)	Singapore – 3 tertiary hospitals	Multicenter qualitative; grounded theory; interviews and focus group discussions	10 inpatient nurses (+ 10 caregivers)	Conceptual framework of barriers to pressure injury prevention
Oozageer Gunowa, Adomako Kwame & Jackson (2025)	UK – Community nursing (South of England)	Qualitative descriptive; focus groups and individual semi-structured interviews	17 community registered nurses	Nurses’ experiences assessing early-stage PIs in people with dark skin tones

2.7 Critical Appraisal

The systematic evaluation of the research evidence used to identify its quality, rigour and relevance and it is a vital part of any evidence-based literature review (Aveyard, 2023; Tod, Booth and Smith, 2021). To conduct this review, Critical Appraisal Skills Programme (CASP) checklists were chosen as the most popular appraisal tools. Kryshtafovych et al. (2023) argued that CASP they have become widely used in nursing research, are accessible to both undergraduate and postgraduate nursing students, and can be used for various types of studies. CASP provides checklists to assess qualitative studies, cohort studies, and any other research design separately, allowing an appropriate methodological assessment of each study included (CASP, 2018). Each of the five included studies utilised a qualitative design (four with predominantly qualitative methods and one (Sim et al., 2024) with a multicenter qualitative grounded theory design) and all were assessed with the CASP Qualitative Checklist. It is advisable to use a standardized and methodology-internalized appraisal tool as a best practice to make sure that the standards used are suitable to the nature of the evidence under appraisal (Majid and Vanstone, 2018).

Chapter Three

Study 1: Taylor, Mulligan & McGraw (2021) – Barriers and Enablers to Evidence-Based Practice in Pressure Ulcer Prevention and Management in an Integrated Community Care Setting

Research Issue, Aim and Objectives

Although both international and national clinical guidelines on prevention and management of pressure ulcer (PU) exist, there is evidence that reflects that such guidelines are poorly implemented in community healthcare. This implementation gap is a major issue of patient safety, and is part of preventable harm, higher treatment costs and longer hospital stay. Taylor, Mulligan, and McGraw (2021) fill this gap by discussing the reasons why evidence translation to practice continues to be an issue in integrated community care. The main objective was to understand some perceived barriers and enablers of health practitioners in implementing evidence-based PU prevention and management recommendations. The goal was to come up with practical insights that could be used to guide specific improvement efforts on both service and policy levels.

Research Appraisal

The conceptual foundation of Theoretical Domains Framework (TDF) is a highlight of the study in terms of methodology (Lawton et al. 2015). The TDF is based on 33 behavioural theories and consists of 14 domains, and offers a lens of theoretical and empirical validity to study the cognitive, affective, social, and environmental factors in clinical behaviour (Atkins et al. 2017). Birken et al. (2017) stated that its use takes the analysis beyond the surface description elements to explanatory level- a step in the right direction in comparison to the antecedent atheoretical studies in the field. The two-method analytical strategy, which uses deductive TDF-informed coding and inductive belief statement generation, introduces analytical rigour and makes the results always based on the meaning of the participants.

Research Appraisal

The qualitative exploratory design was utilized and data were collected by semi-structured, face-to-face individual interviews using a topic guide, informed by TDF (Phillips et al 2015). The guide was pilot tested using three practitioners who had similar characteristics with the targeted sample and then refined. Each interview lasted 25-35 minutes and was audio-taped and transcribed word-to-word. Braun & Clarke (2022) stated thematic analysis which was conducted in a five-step process that was systematic and included deductive coding, development of belief statements, calculation of frequency, independent verification and determination of domain relevance, though it also is criticised from lacking in depth, research rigour impacting outcome findings quality (Vaismoradi et al. 2013). After thirteen interviews, data saturation was achieved.

Sampling and Selection

The sampling technique used was purposive, where the registered nurses and allied health professionals (occupational therapists and physiotherapists) were recruited in this study, which has also been seen (Roots & Li, 2013). It was based on the locality NHS Trust-based extended primary care teams within the locality. There were 9 nurses and 4 therapists. Healthcare assistants had to be excluded considering their different accountability obligations. An a priori saturation criterion was used to select sample size based on the Francis et al. (2010) framework. However, sample meets the critical criteria of over 12 respondents which (Vasileiou et al. 2018) critically justified in health research, thereby meeting the use of theory in a qualitative research (Collins & Stockton, 2018).

Research Ethics

City, University of London School of Health Sciences Research Ethics Committee approved the study and provided extra supplementary NHS governance approval. The sample was led to participate at will, and informed consent upon every interview in writing was obtained. The first author, who is a specialist in tissue viability and is a nurse in the organisation, was keen to avoid researcher bias and, therefore, did not include skin care champions in the sample because they have a direct professional relationship with her service.

Study 2:Li, Marshall et al. (2022) Approach to Pressure Injury Prevention: A Descriptive Qualitative Study

Although China reported much lower levels of hospital-acquired pressure injury (HAPI) prevalence rates (1.1 to 1.8 percent) compared to those in the global rate (12.8 percent), the reasons behind this difference are not well comprehended, and inconsistent rates of adherence to prevention measures continue which is the main research problem. Li, Marshall et al. (2022) is the first reported qualitative research study on the subject of pressure injury prevention (PIP) practice in registered nurses in mainland China. Research by Li et al. (2022), described the ways in which nurses approach PIP, such as their perceived roles and the prioritisation of prevention. In this research, along with contextual factors, in a Chinese tertiary hospital context, the research goal is to produce knowledge that can be used to inform future practice enhancement based on theory and evidence.

Research Appraisal

The fact that the model of the Systems Engineering Initiative of Patient Safety (SEIPS) is used to both collect and analyze data is a significant strength of a study (Sampson, Back & Drage, 2021). Carayon et al. (2006) argued as it gave the strength to the research a logical coherent framework by which to analyze the work processes, structures, and outcomes in the form of a systems-level analysis. The theoretical foundation brings the study to greater heights compared to macro and micro level interpretation of PIP care delivery. Analytical depth is also enhanced by the fact that both the deductive and inductive content analysis was used which (Graneheim, Lindgren, & Lundman, 2017) argued to bring in more abstraction and interpretation about research dimensions happening in reality. Nevertheless, single-site recruitment causes a lack of transferability, and the 100 percent female sample reduces the gender diversity which (Magliozzi, Saperstein, & Westbrook, 2016) argued to undermine the outcome quality of research.

Research Method

The design was qualitative descriptive. Semi-structured interviews were held in Chinese, usually face to face, via audio recordings, during the period of August 2020 to December 2020. Three PhD-qualified experts reviewed and piloted a SEIPS-informed 10 question interview guide. Content analysis was performed by iterative deductive-then-inductive analysis and managed in NVivo 11 to analyse data. This approach was similarly used by (Li et al. 2022), while the aspect of research rigour was ensured using credibility, transferability and auditability strategies such as memo keeping and team reflexivity (Wood, Sebar, & Vecchio, 2020).

Sampling and Selection

In this research a small sample of two medical and two surgical wards, stratified by role, experience level, and PI training history, in a large Beijing tertiary hospital, were used as maximum variation purposive sampling, to recruit 27 registered nurses. Smetana et al. (2006) had similar arguments in American college of physicians.

Research Ethics

The hospital involved provided dual ethical approval (IRB No.2020/003) and Griffith University (GU Ref No. 2020/466). Informed consent was obtained on written consent before every interview and confidentiality was achieved by de-identifying participants which met the participation perspective as highlighted by (Alhabsi, 2024).

Study 3:Na, Yoo & Kweon (2024)

Investigating the Nurses experience of pressure sore treatment in long-term care facilities.

Research Issue

Na, Yoo & Kweon (2024) research set in South Korea, in particular, intensive growth of LTCFs, has not been accompanied by the respective enhancement in the care quality, which generates the urgent necessity to conduct empirically supported, context-specific research on the lived professional realities of nurses.

Aim and Objectives of the research.

The main objective of the study is to reveal the variations and issues facing nurses in pressure ulcers management in South Korea, in the long-term care facilities. The research purpose is to produce a more contextually grounded, in-depth insight into nursing experiences in this field. Watson et al. (2025) acknowledged the critically understanding issues, research methods and contextual factors are important, which (Zou & Zhai, 2026) emphasized in developing specific, evidence-based interventions to enhance nursing practice and patient outcomes. The objective is suitably sized to a qualitative investigation, focusing on the depth of knowledge rather than statistical generalisation which have been studied in nursing homes in Korea (Lee, Kwon, & Chang (2022) that extended care procedural challenges in different setting.

Research Method

A qualitative methodology with an interpretive description design was used, as it was appropriate to the study due to its abilities to bring complexity, nuance, and practicality into applied healthcare settings for understanding the variations and issues facing nurses in pressure ulcers which has been used (Lindhardt, Beck, & Ryg, 2020), (Lavallée et al. 2018) . This qualitative method allows flexibility in data collection and analysis, and allows indepth exploration of issues (Chen et al. 2025) that the current researcher has captured iteratively and context-sensitively experiences of the participants. The data collection was through individual interviews that were semi-structured and lasted an average of 60 to 90 minutes. Due to COVID-19 restrictions, 7 interviews were performed in-person, and 3 by telephone, and the rest of the sessions were discussed with the participants by telephone to balance the lack of visual effects. This is a limitation of the research, with low sample size as discussed by (Crouch, & McKenzie, 2006), but pertinent as study setting and context was unique which was also highlighted by (Lee et al. 2023). The analysis of the data was conducted according to six stages of the reflexive thematic analysis provided by Braun and Clarke, with two trained coders analysing the data under the supervision of the researcher to result in higher reliability and less interpretive bias. The research based on the study followed the COREQ reporting rules, enhancing research transparency in its methods, which (Walsh et al. 2020) argued is a best practice for qualitative research adherence.

Sampling and Selection

To sample ten registered nurses in four small-to-middle sized LTCFs in South Korea, purposive sampling with snowball referral was employed. Participants had to have at least a year of clinical experience in pressure sore care and nurse managers were excluded to ensure their attention was limited to frontline views which (Na, Yoo, & Kweon, (2024) acknowledged about how long term study and cross sectional study that adds value. There were three males and seven females in the sample, aged 26-44 years, with a clinical experience of one or up to eighteen years. Eight were employed in the general wards, one in a surgical ward, and one in an emergency department. Critically appraising the research, it is evident that though the sample size is small, it is in line with the qualitative paradigm. The emphasis in on the information depth and not numerical range and the snowballing approach was suitably used to exploit the available professional networks. This research showed how to get nurses with substantive and relevant experience which (Manthorpe & Martineau, 2017) argued is important to understand failures of pressure ulcer problems.

Research Ethics

The IRB of Chonnam National University gave formal approval to the study (IRB No. 1040198200619-HR-066-01), and the study was conducted in compliance to the Declaration of Helsinki. All the participants were informed and provided consent after a thorough explanation of the purpose of the study, study procedures and risks involved. Participation was verified to be purely voluntary and the right to withdraw is at any point without consequence was granted. The audio-recorded interviews were transcribed with the help of the Google Speech-to-Text software and after that the accuracy was checked though research ethics ensured participant anonymity. Past research on patient safety in Korean context for nurse experience (Kim, & Lee, 2020), showed that ethics for institution, patient, caregiver is critical. The anonymity and confidentiality were strictly ensured by encrypting the data and de-identifying it. Interviews were conducted in a supportive, empathetic manner in order to cope with emotional distress that may arise. Ethical respect these were given a gift voucher of KRW 20,000 conditionally irrespective of whether they participated in the interview or not.

Study 4:Sim, Choi et al. (2024)- Why Do Pressure Injuries Still Occur? A Multicenter Qualitative Study of Nurses and Caregivers

Research Issue, Aim and Objectives

Sim et al. (2024) carried out the study in three tertiary hospitals in Singapore to examine the lived experiences of nurses and caregivers to develop a conceptual framework that elucidates how pressure injuries ever occur, even with preventive measures. The goal was to determine the interacting barriers to care and create evidence-based solutions to be used by the healthcare institutions that was reported (Naghibi, Mohammadzadeh, & Azami-Aghdash, 2021) and (Duncombe, 2018) in a multi institutional context studies.

Research Appraisal

The most notable contribution of this research is the development of the framework that includes cognitive, emotional, resource, biomedical, sustainability, and learning constructs into a coherent explanatory model that was also noted in (Kim et al. 2016) preparing a biopsychosocial framework. The use of grounded theory to base the analysis boosts conceptual rigour and the use of both caregivers and nurses to give the analysis both perspectives. The current research also refers to (Taylor, Mulligan, & McGraw, 2021) study where community care setting, using evidence based practice. are seldom studied together gives the analysis significant triangulation value. The authors state, though, that the findings might be limited in generalisability to other contexts of mixed public-private and highly subsidised healthcare settings in other countries like Singapore that corresponds to earlier study where perceptions about challenges was explored (Chen et al. 2025).

Research Method

The qualitative design was a multi-center design that used semi-structured individual interviews and focused group discussions. This approach was also reported by (Roberts et al. 2016), which tested prevention care bundle. Current research carried out face-to-face in three hospitals in February to July 2023. A narrative inquiry approach was used to collect the data which were analysed using grounded theory with the ATLAS.ti software and through multiple iterative open, focused and axial codes until theoretical saturation which was similarly found in research work of (García-Sánchez, Martínez-Vizcaíno, & Rodríguez-Martín, 2019). The research was in accordance with COREQ guidelines which has been a best practice approach followed in (Hultin et al. 2022).

Sampling and Selection

Ten inpatient nurses having more than one year experience and ten community caregivers were selected by purposive sampling, word-of-mouth. Saturation occurred in line with the qualitative dermatological literature standards of participants.

Research Ethics

The National Healthcare Group Domain Specific Review Board gave its ethical approval (reference 2022/00470). Informed consent had been received in writing by all the participants before the data was collected.

Study 5: Oozageer Gunowa, Adomako Kwame & Jackson (2025)

Oozageer Gunowa, Adomako Kwame & Jackson (2025) research aimed to understand the capacity to effectively evaluate the presence of the early stages of pressure injuries in patients with dark skin colour. The issue in a larger discussion on health equity, racial bias in medical education, and avoidable patient harm but pertinent issue applicable in any country with mixed population as (Black et al. 2023) (Sugathapala et al. 2025) and combination of both dark-light skin tones (Zamarripa, 2021). The argument is quite justified, as pressure injuries are expensive, disabling, and increasing in number, but the current body of research on the experiences of nurses in the field almost completely excludes the aspect of skin tone diversity, a structural gap with direct patient safety consequences. The main purpose is to investigate the experiences of community nurses regarding working with people with dark skin color that are at the risk of pressure injuries which has been researched before (Gunowa, Oti Adomako, & Jackson, 2025). This goal further elaborates this purpose by aiming at defining the issue of particular challenges, best practices, and areas of improvement in the clinical assessment about the contextual challenge in terms of application methods against nursing challenges (Kottner et al. 2020) (Bates‐Jensen et al. 2019). They are sufficiently scaled to a qualitative inquiry – they are not confirmatory, but exploratory, and do not aim at generalisability, but at depth of understanding, which is appropriate methodologically in the adopted design.

It used a qualitative descriptive design based on the Consolidated Criteria of Reporting Qualitative Research (COREQ), which provides procedural clarity to the study which was also found in research of (Li et al. 2022) using same methodology. The registered nurses employed in the District Nursing Teams in the South of England were recruited through purposive sampling because it is a methodologically adequate approach in the circumstances where the target population was very specific. Among the 22 enquiries that were received, 17 individuals were eligible to participate in the research, which is all women, which is an important demographic attribute of the nursing workforce in this area. The adequacy of sample size over 12 has been maintained in this research meeting (Crouch, & McKenzie, 2006). Between November 2023 and March 2024, data were gathered using a mixture of three online focus groups (3-6 each) and six 30-minute to one-hour semi-structured interviews, though studies (Nixon et al. 2015) exist in the context using mixed research. This blended media provided the group discussion with interactive quality and the richness of personal reflection. Past research on the topic of skin tone diversity and pressure injuries in educational institutions was used to inform the interview guide in its theoretical basis. The verbatim transcripts were analyzed using thematic analysis by the six-phase framework by Braun and Clarke (2006). Research ethics showed that act of rigour was strengthened by the credibility, transferability, dependability and confirmability criteria of trustworthiness used by Lincoln and Guba (1985) coupled with an audit trail, reflexivity practices and member checking of the findings at the end of every interview.

Chapter 4: Synthesis

4.1 Discussion

Qualitative research synthesis plays a pivotal role in the determination of efficient and proper healthcare system. It entails the ability to be strategic using a combination of various information in the midst of a central theme in order to solve problems and get answers.

The review incorporated four qualitative researches by study 1: Taylor, Mulligan & McGraw (2021), study 2:Li, Marshall et al. (2022), study 3:Na, Yoo & Kweon (2024), study 4:Sim, Choi et al. (2024), study 5: Oozageer Gunowa, Adomako Kwame & Jackson (2025) which examined the lived experiences. Three studies included were all in English, and published within the past 10 years.

Appendix 4 helped to compare the relation of the papers to each other and simplified approach to thematic analysis has been used in Appendix 5 and and 6 (Aveyard, 2023), which identified several themes and developed four major themes:

In the analysis below, the research findings of five studies, covering a wide range of geographical and clinical settings such as community care in London, tertiary hospitals in China, long-term care facilities (LTCFs) in South Korea, and home-based care in Singapore and England, are synthesised. Using multiple theoretical frameworks (Theoretical Domains Framework (TDF), the System Engineering Initiative of patient Safety (SEIPS), and Grounded Theory these studies find that there is a complicated combination of professional, systemic, and social variables that affect the effectiveness of prevention and management of pressure injury (PI).

Theme 1: The Centrality of Nursing Leadership and Professional Identity

Registered nurses (RNs) are all considered the main coordinators and leaders of pressure injury prevention (PIP). The Chinese tertiary environment provides nurses with the leadership of the work system, where they make the most crucial decisions connected with the assessment of risks, the execution of measures, and the record-keeping. On the same note, community nurses in the UK regard PI care as a massive component of their daily practice, and they apply models such as ASSKING to plan their interventions. South Korean LTCFs, nurses believe that PI care is the highest level of nursing achievement and tend to think that they are the only responsible member of the team, even when other personnel are also involved. This was found in other studies (Galvão et al. 2017) Nonetheless, this leadership requirement is usually stretched by the upsurge in responsibilities to allied healthcare professionals (AHPs), who occasionally feel unprepared or uneasy with intimate checks. This was highlighted in past research (Worsley et al. 2017), which has been discussed (Ackbarally, 2024), like in the UK research. Therapists complained they were embarrassed at the time of skin checks, while (Sarre et al. 2019) showed in longitudinal study of teams at ward level is able to find better treatment outcomes.

Theme 2: Gaps in Undergraduate Education and Specialized Knowledge

One of the key conclusions is the inseparability of formal education to equip clinicians with the nature of PI care. In the UK, AHPs indicated that their undergraduate training lacked PI content, and therefore they rely on asking a colleague instead of consulting some official guidance. This is reflected even in South Korea, where the novice nurses said that they felt bewildered when presented with severe ulcers, that there was no practical training in the nursing colleges. The greatest educational lapse is seen to be in the treatment of dark-skinned populations. This research in England, medical literature and nursing programmes is more or less white-centric, which is why community nurses are unable to identify any early signs of damage, including non-blanchable erythema. Lo et al. (2025) study stated that ability of nurses observe pressure ulcers in diverse skin tones, as they appear as ashy-grey or purple tones instead of red when occurring on darker skin bringing out the gap, which (Black et al 2023) acknowledged in nursing training and treatment process as a gap. This means that dark-skinned patients usually are diagnosed in their later stages (Category 2 or higher) due to missed early warning signs.

Theme 3: Systemic Barriers: Staffing, Resources, and Environmental Constraints

The organizational and physical environment is a determinant of quality of care. Understaffing and workloads in Singapore and China are mentioned as the main negative factors to the implementation of time-consuming clinical activities such as two-hourly repositioning. The research points to the effect of desensitization, in which nurses (due to chronic understaffing) begin to provide care in a more robotic way, or even abandon more complex cases because of time constraints. Wong et al. (2024) stated that outside of staffing, the availability of resources differs greatly, with Singaporean caregivers getting government subsidies on equipment. The Chinese nurses in hospital wards noting lack of special support surfaces and prophylaxis, which are often limited by insurance laws also highlighted by (Wong et al. 2019). The physical home setting, in the context of UK communities, which was also found in Singapore (Goh, & Zhu, 2024), brings forth distinct challenges, including the issue of “clutter” within the home of patients, thus preventing the installation of a hoist or even providing sufficient space to perform skin checks.

Theme 4: The Reinforcing Feedback Loop of Caregiver Participation and Learning

Caregiver-nurse partnership is linked with the efficacy of PIP in community and home-care settings. The Singaporean study suggests a model in which cognitive awareness and emotional motivation are the driving forces of a learning cycle. Caregivers might be unaware of the severity of PIs until an infection sets in, in which case it creates a reinforcing feedback loop of learning and commitment that has been discussed by (Chen et al. 2025). In China, family presence is guaranteed by the culture of filial piety but these lay carers do not always have the professional knowledge to recognize early skin changes. Family members were found to play both enabling roles (as eyes and ears) and inhibiting roles (denying recommended equipment) which was discussed by other studies (Haesler et al. 2022). The main idea of all the studies is that caregiver training should not be reduced to a one or two days before discharge strategy to make it sustainable in the long-term, that was highlighted in earlier study of (Jafari et al. 2021) who found that in order to avoid the occurrence of the same thing at home knowledge sharing is important.

Theme 5: Clinical Judgment vs. Standardized Risk Assessment Tools

One of the common arguments is the restrictiveness of standardized instruments such as Braden or Waterlow. Results in China, though structured risk assessments are required, nurses have to be very dependent on the so-called clinical judgment, which takes into account other variables like the nutritional status, disease frailty that a tool could not capture. In UK, other clinicians described their experience of automaticity in PIP care in which PIP is now more of a routine and not an act of conscious decision making. On the other hand, lack of this experience among individuals will compel them to use unclearly outdated guidelines in LTCFs, which drives them to look up information on the internet or via Naver (the Korean Google). It was reported by (Gubert, 2025), and in USA (Crowley et al. 2022). It is thus making the practice inconsistent and potentially old fashioned that was raised by (Giovenco, 2021) as COVID19 disruption required towards adopting holistic care as found by (Jackson, Turner, & Paterson, 2023). This is further complicated by the studies on dark skin colour, which point out that currently used tools which measure redness are inherently ineffective with varied populations (McCreath et al. 2016) citig Munsell colour charts, or use of Bates‐Jensen wound assessment tool as per (Bates‐Jensen et al. 2019), or adopt a framework combining tool and technology as per (Toner , 2024) that a change to palpation (assessing warmth and oedema) and the use of terms such as discolouration is necessary.

Theme 6: The Emotional and Psychological Burden of PI Care

Nurses in the profession, specifically in these studies report an intense emotional impact relating to PI (personal injury) outcomes. In the UK and South Korea, nurses experienced a range of ambivalent feelings, which include guilt and self-blame when an ulcer became worse despite their efforts. It is reported that there is a fear of being judged by colleagues or the management, especially in China and the UK where PIs are regarded as a never event, or severe safety incident (Wickramasekera, 2025) that is treading thin line in ethical practice and ethical reporting. Zhao et al. (2025) highlighted this fear may result in under-reporting or concealment of possible PIs because of the need to safeguard the collective honour of the ward. There needs open disclosure with truth as per (Saleh, J. (2023), on the other hand, a PI healing is a great form of accomplishment and professional pride, and it confirms the nurse to the patient.

Conclusion

The aggregate results suggest that reducing the global burden of pressure injuries requires more than just clinical guidelines. These international studies collectively show that prevention of pressure injury (PIP) is a multidimensional health care problem that requires a paradigm shift of treatment focus toward a system-wide prevention approach. Although registered nurses are invariably seen as the keystone of the PIP work system, the interaction of cognitive awareness, emotional motivation, and physical resource availability are critical modulators affecting their success. The results indicate that there is a critical gap in educational preparation in the world we currently live in with an emphasis on light skin colour and standardized testing instruments having created a gap in scientific training making clinicians unprepared to work with people of divergent backgrounds. Moreover, the physical and organizational context, such as persistent understaffing in hospitals or “clutter” at home, is a major factors influencing the successful implementation of evidence-based guidelines in practice. Finally, pressure injury care is justified as the highest goal of nursing, which demanded a complex of clinical and technical expertise, as well as a strong collaboration with other health care experts and family caregivers.

5.1 Implications for practice

The implications of these findings on the nursing profession and even healthcare systems at large is that there will have to be an urgent reformation of the undergraduate and continuing education program to integrate the diversity of skin colour into the curriculum so that clinicians are taught to detect the presence of early-stage damage by palpating the skin and recognising the presence of non-red discolouration like ashy grey or purple skin colour.

. Implementation of specialized roles including Pressure Ulcer Implementation Facilitators has been found to help heal the gap between theory and practice on the front lines and thus should be given priority by healthcare organizations.

. Also, the concept of caregiver training needs to be redesigned as a longitudinal process, not a short pre-discharge training but may be facilitated by digital health devices and education apps offering real-time support to lay carers at home.

. At the clinical level, clinicians should be advised to add clinical judgment to established risk assessment measures and pay more attention to such aspects as nutritional state, the vulnerability of the disease, and skin texture alterations.

. Lastly, to enhance patient safety, organizations should cultivate a non-punitive reporting atmosphere that alleviates the emotional weight of guilt and fear of being judged so that all injuries are openly recorded and used to learn together.

5.2 Recommendations

Educational Reform: Incorporating skin tone diversity and practical PI management into undergraduate curricula for both nurses and AHPs.
Structural Support: Addressing understaffing and providing novel roles, such as the Pressure Ulcer Implementation Facilitator seen in the UK, to bridge the gap between theory and practice.
Technological Integration: Utilizing mobile working solutions and tele-support to enhance documentation and real-time troubleshooting in community settings.
Empowering Caregivers: Developing targeted, culturally sensitive educational interventions (such as educational apps) to support the sustainability of home-based care.

By addressing these themes, healthcare systems can move from a reactive treatment model to a proactive, inclusive, and sustainable prevention paradigm.