Pressure ulcers/injuries can occur in people of any age across all care settings. They have a significant impact on both the person, their families and on caregivers. Pressure ulcers affect an individual physically, socially and emotionally (Gorecki et al, 2009; 2012).
The global prevalence of pressure ulcers has been reported as being 12.8% (Li et al, 2020). In the NHS (NHS England, 2018), between April 2015 and March 2016, 24674 patients were reported to have developed a new pressure ulcer in England. Guest et al (2017) estimated that the daily cost of pressure ulcers to the NHS totals £1.4 million.
Pressure ulcers are defined by the European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Injury Advisory Panel (NPIAP) and Pan Pacific Pressure Injury Alliance (PPPIA) (2019) as:
‘…localised injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear.’
Every health care system is built on a complex network of care processes and pathways. The quality of care delivered by the system depends primarily on how well this network functions, and how well the people who provide services within it work together and manage care.
The AGREE Collaboration (AGREE, 2017) defines guideline quality as:
‘…the confidence that the potential biases of guideline development have been addressed adequately and that the recommendations are both internally and externally valid, and are feasible for practice.’
There is evidence that rigorously developed guidelines have the ‘power to translate the complexity of scientific research findings and other evidence into recommendations for healthcare action’ (Woolf et al, 1999). However, Siering et al (2013) has observed that this may not occur in practice and that there is a real need for consistency.
The overall aim is simple: to provide high-quality care to patients and to improve the health of our population. Yet, as every patient and professional can testify, for every process or pathway that works well, there is another that causes delay, wasted effort, frustration or even harm (Woolf et al, 1999).
It is important to note that pressure ulcers are in the top ten patient safety incidents reported in England (Fletcher, 2022) and, despite the NHS's focus on pressure ulcer prevention, they remain a significant concern. National clinical guidance has been available in the UK for more than two decades and has helped to inform strategy, policy, clinical care, and the recording and reporting of pressure ulcers (National Institute for Health and Care Excellence (NICE), 2014). Specifically, over the past decade, there has been a serious commitment by NHS England to strategically deliver on the pressure ulcer agenda (NICE, 2014; Department of Health and Social Care, 2022; National Wound Care Strategy Programme (NWCSP), 2024).
Essential aspects of planning and delivering pressure ulcer care include skin assessment, categorisation of pressure ulcers, monitoring and evaluation of care and reporting of pressure ulcer injury. Thus guidance and clinical recommendations have the potential to influence the prevention and management of pressure ulcers.
NWCSP (2024) provides guidance to NHS England, making recommendations on the prevention and management of pressure ulcers and setting out a clinical pathway, the aims of which are to:
‘Provide clear advice to health and care practitioners, service managers and commissioners about the fundamentals of evidence-informed care for people who have or are at risk of developing pressure ulcers.’
The aim of the recommendations is to provide a standardised pathway and to act as a signpost to relevant clinical guidelines, as well as to outline evidence-based care with the objective of utilising health and care resources effectively and to achieve better individual outcomes.
In April 2023, a consultation on the proposed NWCSP's pressure ulcer clinical recommendations and clinical pathway was undertaken and reported by Fletcher (2023). The document outlining the pressure ulcer pathway and clinical recommendations was subsequently released in May 2024. The document (NWCSP, 2024) states that implementing the recommendations:
‘Will achieve better individual outcomes and more effective use of health and social care resources.’
The recommendations outline a pathway of care promoting early risk identification and preventative care which will enable access to evidence-informed therapeutic interventions, including escalation of treatment or service provision for those requiring more complex care.
The NWCSP has proposed substantial changes to the categorisation of pressure ulcers. Importantly, the new guidance on the categorisation of pressure ulceration is based on a validated classification tool and is based on the layers of skin, muscle and bone. However, two of the six pressure ulcer categories previously used in clinical practice, as included in current EPUAP et al (2019) guidance, have been removed, namely:
The WCAUK trustees were aware of the debate on these proposed changes within a range of professional forums. More latterly, this has been added to by the Society of Tissue Viability (SoTV) (Worsley, 2024). In addition, several WCAUK members contacted us for advice and expressed concern regarding the proposed changes, with regard to the categorisation and reporting of pressure ulcers. As a result of these member enquires, WCAUK undertook a survey among members to enable them to respond to these amendments, with the aim of publishing and distributing the findings.
Responses to the survey
To elicit the views of WCAUK members and other nurses with an interest/experience in the specialty, a questionnaire was developed with the support of Birmingham City University MSc students on the Wound Healing & Tissue Repair module and WCAUK trustees. We highlighted our interest in gaining members’ views on the changes in an editorial published in this journal in June 2024 (Stephen-Haynes, 2024).
The questionnaire asked respondents about their current practice, whether they were aware of the proposed amendments to the NWCSP recommendations and, if they were, what were their views on the changes. It also included a free-text section for respondents to highlight any concerns not covered in the questionnaire.
We received a total of 177 responses, with nurses identifying themselves as follows in response to the question: ‘Are you a specialist or generalist wound care provider?’
In response to the question, ‘Do you currently provide any pressure ulcer prevention and management in your role?’, the breakdown was as follows:
In addition to the questions above, the survey elicited information on the following aspects of pressure ulcer care and categorisation of pressure damage, in order to gain an understanding of respondents’ general awareness of the proposed NWCSP amendments and, specifically, regarding the changes in pressure injury categorisation as outlined above:
Specific amendments
The responses showed that the majority of respondents (n=107; 60%) were not aware of the proposals to change the categorisation of pressure ulcer injury (Figure 1).
With regard to the specific changes. In terms of the proposal to remove the ‘suspected deep tissue injury’ category, the majority (n=156; 88%) consider that this category of pressure damage should remain, with just 11 (6%) responding to the contrary and 10 (6%) having no preference (Figure 1).
In answer to a question on whether mucosal pressure ulcers should continue to be reported as a category of pressure damage, 156 (88%) responded in the affirmative, with 11 (6%) that they should not continue to be reported as a category of pressure damage. No preference was expressed by 10 (6%) respondents (Figure 1).
With regard to the proposed amendment to remove the category of ‘unstageable’ pressure ulcers, the vast majority (n=148; 84%) of respondents considered that this type of pressure damage should continue to be reported as a separate category. Just 15 participants (8%) responded that ‘unstageable’ pressure ulcers should not be a separate category and 14 (8%) did not have a preference either way.
The experience of almost all 177 respondents (173;98%) was that deep-tissue injuries cause harm, with only 4 (2%) stating that they did not.
Free-text comments
The questionnaire survey concluded by inviting nurses to provide free-text comments on areas of concern about the amendments to pressure ulcer categorisation in the NWCSP recommendations and pathway. The feedback submitted included concerns that the changes did not support the delivery of best practice in pressure ulcer prevention and care.
A number of comments referred to the possible impact that changing from international and European guidance to recommendations specifically aimed at wound care nurses in the England could have. Respondents did express the view that fewer pressure ulcer categories offered an advantage and would reduce the risk of error, which had the potential to reduce the amount of time tissue viability nurses spent on checking and recategorising pressure ulcers.
General concerns
Overarching concerns related to a lack of clarity about how the changes would improve identification of pressure ulcers and support patient care, and whether there was in fact a need for change. Others expressed concern that the amendments meant that guidance in England would differ from international guidance and also make comparison of past and future prevalence difficult.
‘Are we changing something that isn't broken?’
‘The new recommendations are not clear at all.’
‘I don't think we should move away from international and national guidance.’
‘I am frustrated by the change – based on what evidence?
‘I shall wait and see – it seems risky to change.’
‘I am really concerned that this change will make comparisons to previous UK data inconsistent.’
Problematic identification of deep tissue injury
Some respondents had concerns about the removal of the separate classification for ‘suspected deep tissue injury’ (DTI):
‘Deep tissue injury is clearer than vulnerable skin…’
‘‘The term ‘deep tissue injury’ conveys exactly what it is…’
‘I am concerned that many individuals will slip through the net if we continue to identify DTI as vulnerable skin. Many DTI we see in the acute trust develop into significant harm and [I] feel these patients will not get the adequate care and intervention that they need.’
‘Vulnerable skin implies damage has not yet occurred; DTI implies the damage is already there.’
Positive change
A number of comments focused on the positive aspects of having fewer categories and the advantages of this and the importance of care planning, for example:
‘Too much time is spent worrying about categories and getting it right and not enough on prevention QI work. Creating too many categories leaves the generalist nurse confused and uncertain and anxious about making mistakes. This activity has therefore devolved to the specialist nurse who quite frankly has better things to do than run around validating PU categories. Is it a pressure ulcer Yes, or No? If yes, what could we have done to prevent it and why didn't we? Generalist nurses are so very busy nowadays they need this stress releasing, and we all need to get on with preventing and not categorising.’
‘That DTI is not a category doesn't mean that pressure damage won't be captured, or [that] correct prevention can[not] be put in place; if the affected site breaks down it is recorded as a category.’
Broader issues
Further comments highlighted that the changes meant that staff needed to be updated on the new categorisation:
‘We have also put a lot of time and effort into education over the last few years… we are now expected to re-educate staff on the new categories which is going to cause confusion and… time restraints.’
Others identified aspects of care that should remain a priority of wound care nurses, whether or not the changes are ultimately adopted:
‘[A] pressure wound of any type is pressure, any wound small or big – DOCUMENT IT – always. As a nurse or care provider we are accountable.’
‘Pressure ulcer prevention and management is challenging; clinical leaders need clear guidance on the strategy to disseminate these decisions in practice whatever they may be.’
‘I think that the emphasis should be on the care plan.’
Discussion
The concerns raised by the responses to the questionnaire survey highlight the lack of consensus regarding the changes to recommended practice for pressure ulcer categorisation. It was also clear that communication with the generalist nursing population about these changes has not been clear, as reported by the 126 generalist nurses (71% of the total 177 respondents) who completed the survey. This is important because specialist nurses are few in number and, as a result, the prevention and management of pressure ulcers has become the work of non-specialist nurses and allied health professionals.
Although the simplification of the categorisation may appear to offer some benefits, which some survey respondents noted, others expressed concerns about patient safety.
Of note is that 40% of the respondents were unaware of the change; however, despite this, 88% expressed the view that deep tissue injury continues to be recorded as a category of pressure damage. The same number, 88%, stated that mucosal pressure ulcers should continue to be reported as a category of pressure damage, with 84% stating that unstageable pressures ulcers continue to be reported as a category of pressure damage, and there was almost unanimous consensus (98%) that, in their experience, deep tissue injuries cause patient harm.
There was general agreement among respondents that the term ‘suspected deep tissue injury’ conveys the potential seriousness of the damage, and the replacing this with another term, such as ‘vulnerable skin’, would not provide clarification and could even lead to undetected harm.
Although the clinical recommendations and the pathway are welcome, certain areas remain challenging. It would appear from the comments that the recommendations are unlikely to be followed, with respondents indicating that they are unclear, that they do not appear to be evidence based and that they will not support the delivery of high-quality care. The findings suggest that the recommended changes to the categorisation of suspected deep-tissue injury or unstageable pressure ulceration are not widely accepted as either necessary or helpful and are not considered to be based on substantial evidence. There are indications that they would not be widely adopted.
This has also been indicated by other health professionals and organisations, who have expressed their intention to disregard the recommended changes and to continue using both ‘unstageable’ and ‘deep tissue injury’ to classify and describe pressure ulcers, as reported by the SoTV (Worsley, 2024).
It is important to note that recommendations in the Pressure Ulcer Clinical Recommendations and Pathway (NWCSP, 2024) highlight the need to minimise variation in care and the proposals are viewed as a move away from the recommendations in the EPUAP et al (2019). One of the survey respondents commented that moving away from international guidance needed to be substantiated by significant evidence. Additionally, any change, even with a considerable evidence base, warrants testing within clinical practice before it is implemented.
Although pressure ulcer categorisation is essential in clinical pressure ulcer prevention, the challenges of accuracy are recognised. This requires knowledge of the skin, the underlying structures and an appreciation of the anatomy of the human body, especially at pressure points where there may be little or indeed no subcutaneous cushioning.
To ensure that any new system for the categorisation of pressure ulcers is accurate requires careful planning, consensus, education and training. Any changes to the current system must also be based on evidence.
The recommendations to move away from the current agreed international classification of pressure ulcers appear to be based on inadequate evidence, they have been inadequately communicated and any data collected using the new classification would confound any direct comparisons with similar data collected internationally. The new approach could lead to inadequate delivery of pressure ulcer care, with staff providing care that would, in reality, be unsatisfactory for patients. Furthermore, clinical leaders will find it challenging to disseminate education on expected standards of pressure ulcer care, which will ultimately affect patient outcomes.
Strengths and weaknesses
Rowley (2014) discussed the advantages and disadvantages of using a questionnaire survey. In the context of the findings presented in this article it is important to highlight that respondents were representative of the WCAUK, which includes specialist and non-specialist members.
A disadvantage regarding the question, ‘Do you currently provide any pressure ulcer prevention and management in your role?’, was the fact that it was not possible to gain clarity on how ‘regularly’ they undertook this. The majority of respondents (88%) declared that they provided regular care, however the fact that 12% who did not went on to complete the survey may indicate that the content of survey was relevant to their practice.
The lack of awareness of the changes, with 60% responding that they did not know about the proposed changes was most likely because these were new proposed policy amendments, reflecting the brief time frame from announcement to the time the survey was undertaken.
The opportunity for free-text comments added to understanding the WCAUK member perspectives, and will help to inform our response to the implementation of these recommendations. The WCAUK plans to contact the NWCSP with the results of the survey and arrange to discuss the findings. In the interim, the WCAUK will recommend to its members that no changes should be made to the categorisation of pressure ulcers until clarification is offered by the NWCSP.