Effect of preventive care interventions on pressure ulcer rates in a national sample of rural and urban nursing units: Longitudinal associations over 4 years

Int J Nurs Stud. 2020 May:105:103455. doi: 10.1016/j.ijnurstu.2019.103455. Epub 2019 Nov 5.


Background: Pressure ulcer rates are persistently high despite years of research and practice policies focused on prevention. Prior research found crosssectional associations between care interventions, hospital and nursing unit characteristics and pressure ulcer rates. Whether these associations persist over time is unknown. Finally, comparisons of quality measures across rural and urban location have mixed findings.

Objective: Our study examined effects of care interventions on unit-acquired pressure ulcer rates over 4 years controlling for community, hospital, and nursing unit characteristics in rural and urban locations.

Design: Guided by contingency theory a longitudinal study was conducted to examine associations between context, staffing, care interventions, nurse outcomes, and pressure ulcer rates, using unit-level data from the National Database of Nursing Quality Indicators 2010-2013 (16 quarters) augmented with data on rural classifications and case mix index. Ulcer rates were measured as percentage of patients with a nursing unit-acquired pressure ulcer. The three care interventions were unit-percentage of patients receiving skin assessment on admission, receiving risk assessment on admission, and receiving any risk assessment before the pressure ulcer. Nursing unit characteristics were RN staffing, education, and experience. Nurse outcomes were job satisfaction and intent-to-stay.

Participants: We included 5761 units (332 rural and 5429 urban) in 772 hospitals (89 rural and 683 urban) that reported ulcer rates in two or more quarters during the study period.

Methods: Rural and urban units were examined separately using multilevel binomial regression in which within-unit changes in pressure ulcer rates were related to the within-unit changes in the explanatory variables, controlling for region, hospital size, unit type, case mix index, and percentage of patients at risk for pressure ulcers.

Results: An increase in the three care interventions, RN skill mix, and the two nurse outcomes were associated with a decrease in unit-acquired pressure ulcers. For example, in rural units a 10% increase in unit-percentage of any risk assessment and in urban units a 10% increase in skin assessment on admission were associated with a 21% and 5% decrease in the odds of developing an ulcer. A 10% increase in RN skill mix was associated with 17-18% and 5-6% decrease in ulcer rates in rural and urban units respectively.

Conclusion: Hospitals aiming to improve pressure ulcer prevention should focus on organizational structures that support improved nurses work environments and workflow that will enhance nursing care interventions. Future studies should include both contextual and patient characteristics along with care interventions.

Keywords: Contingency theory; Job satisfaction; Longitudinal study; Nurse staffing; Pressure injury; Pressure ulcer; Prevention interventions; Rural and urban hospitals.

MeSH terms

  • Humans
  • Longitudinal Studies
  • Personnel Staffing and Scheduling*
  • Practice Patterns, Nurses'*
  • Pressure Ulcer / epidemiology*
  • Pressure Ulcer / etiology
  • Pressure Ulcer / nursing
  • Pressure Ulcer / prevention & control
  • Rural Health Services
  • Skin Care*
  • United States / epidemiology
  • Urban Health Services