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Pressure injuries

A nursing-sensitive indicator?

Ayello, Elizabeth A. PhD, RN, CWON, ETN, MAPWCA, FAAN; Sibbald, R. Gary MD, DSC (HONS), MED, BSC, FRCPC (MED DERM), FAAD, MAPWCA, JM

doi: 10.1097/01.NURSE.0000569744.58172.98

Elizabeth A. Ayello is the co-Editor-in-Chief of Advances in Skin & Wound Care; Faculty, Excelsior College School of Nursing, Albany, New York; President, World Council of Enterostomal Therapists, President, Ayello Harris & Associates, Inc., Copake, New York; President (1999), National Pressure Ulcer Advisory Panel; and a member of the Nursing2019 Editorial Board. R. Gary Sibbald is the co-Editor-in-Chief of Advances in Skin & Wound Care; Professor, Medicine and Public Health, University of Toronto, Ontario, Canada; Director, International Interprofessional Wound Care Course & Masters of Science in Community Health (Prevention & Wound Care), Dalla Lana Faculty of Public Health, University of Toronto; and President (2008-2012), World Union of Wound Healing Societies.

This editorial originally appeared in Advances in Skin & Wound Care, 2019;32(5):199-200.

This month I'm delighted to present a guest editorial by Elizabeth A. Ayello and R. Gary Sibbald, co-Editors-in-Chief of our sister publication Advances in Skin & Wound Care, on a very important issue in nursing.



May 12 was International Nurses Day. It also marked the 199th birthday of Florence Nightingale (1820-1910), a nurse who was instrumental in paving the way for advancements in skin and wound care. To mark the 160th anniversary of the London publication of her best-known book, Notes on Nursing, Wolters Kluwer has published an updated commemorative edition.1 Several contemporary nurses were asked to contribute a chapter on Nightingale's relevance to today's nurse, including Dr. Ayello.2 Upon rereading Notes on Nursing in preparation for writing, one often-quoted statement stood out to her:1,2

If a patient is cold, if a patient is feverish, if a patient is faint, if he is sick after taking food, if he has a bed sore, it is generally the fault not of the disease, but of the nursing.

However, not everyone is familiar with the remainder of this popular quote:

...By this I do not mean that the nurse is always to blame. Bad sanitary, bad architectural, and bad administrative arrangements often make it impossible to nurse. But the art of nursing ought to include such arrangements as alone make what I understand by nursing, possible.

We believe this puts the first statement in context. It reveals her perspective that the healthcare system may impose restraints on nursing practice (team or facility limitations) that can impact the nurse's ability to provide care.

Nightingale wrote much about the hospital environment and the important role of administration in the delivery of care by healthcare practitioners. We believe that Nightingale would not support labeling pressure injuries (PIs) a nursing-sensitive indicator.3

In modern terms, nurses are an important part of the interprofessional team; they play a critical role in PI care as part of a larger healthcare system. Collectively, the team needs to preserve skin integrity by overcoming barriers and advocating for improved skin and PI prevention and management.

Nightingale's principles to reduce bed sores (now known as PIs) require the nurse to look at the whole system of healthcare practice. Therefore, comprehensive PI care must include eliminating blame, focusing on interprofessional processes across the system, and ensuring that each facility provides the proper resources and environment to deliver that care.

Although we are seemingly far removed from the original printing of Nightingale's Notes on Nursing, many of the same problems she faced are still present in current healthcare systems. Each person with a PI has several risk factors, known and unknown, modifiable and unmodifiable. The detailed causes and modifying factors of PI still are not fully known. We are not sure, at the individual patient level, which factors are modifiable.

Nurses and other providers must examine the pressure from all of the surfaces that influence the skin, including beds, chairs, toilets, and even car seats. They must also consider shear from patient self-transfers and assisted transfers. Further, there are the components in the risk prevention scales. For example, the Braden Scale for Predicting Pressure Ulcer Risk includes patient sensory perception, moisture, activity levels, impaired mobility, nutrition, and friction. Current guidelines urge clinicians to consider all adults and children with a medical device at risk for PIs.

Many healthcare professionals must communicate and coordinate care to preserve or restore the skin. Diagnosing comorbidities is the responsibility of the physician or prescribing healthcare professional (including NPs). The responsibility to assess support surfaces and optimize mobility activities may belong to the allied health and rehabilitation professionals. Registered dietitians bring expertise about the much-needed protein, nutrient, and fluid requirements to maintain skin integrity or heal wounded skin. Finally, the healthcare system needs to provide cost-effective resources and promote coordinated, integrated team care to optimize patient outcomes. Nurses are key patient advocates but are not responsible for patient care beyond their scope of practice.

Consider medical device-related PIs (MDRPIs). Nurses do not select all the medical devices, decide on size, or determine how long to maintain the device and when it should be removed. Why, then, is MDRPI a nursing-sensitive indicator? Many other healthcare professionals, including physicians and respiratory therapists, order and insert medical devices, yet in some facilities MDRPIs are counted in PI incidence data to which nurses are held accountable.

The reality is that the cause of PIs is complex and multifactorial. We propose that the term nursing-sensitive indicator no longer be used in regard to PIs; PIs are truly a team- and system-sensitive indicator. This may require a paradigm shift to replace nursing-sensitive indicator with a more comprehensive term.

At Advances in Skin & Wound Care, from the very beginning, the belief has been that the problem of PIs belongs to no one group of healthcare professionals; all on the healthcare team must work together to diminish their incidence and severity.4 We need to improve healthcare systems to tackle the PI problem and stop blaming the nurses and other healthcare professionals for a systemic issue. Improving PI care requires a translational, coordinated, and innovative approach.



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1. Nightingale F. In: Fitzpatrick J, Kennedy MS, eds. Notes on Nursing; What It Is and Is Not. Philadelphia, PA: Wolters Kluwer; 2019.
2. Ayello EA. From bedsores to pressure injuries: perspectives from Nightingale's Notes on Nursing. In: Fitzpatrick J, Kennedy MS, eds. Notes on Nursing; What It Is and Is Not. Philadelphia, PA: Wolters Kluwer; 2019:56–61.
3. Montalvo I. The National Database of Nursing Quality Indicators (NDNQI). Online J Issues Nurs. 2007;12(3).
4. Abruzzese R. Editorial. Decubitus. 1988;1:7.
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