Pressure Ulcers: Background, Causes, and Quality Treatment Assignment Sample

Chapter 1 : Pressure Ulcers: Background, Causes, and Quality Treatment Assignment

Want the Best Assignment Help in the UK? Look to Native Assignment Help for unparalleled expertise and support. Our dedicated team of professionals goes above and beyond to ensure you receive top-quality assignments that exceed your expectations.

1.1 Introduction: Evaluating UK Pressure Ulcer Care Through Clinical Trial Evidence and Cohort Studies

This chapter is going to focus on pressure ulcers and current conditions in the UK, regarding the issue of pressure ulcers. This chapter is going to discuss the background of pressure ulcers and problem statements regarding the issue of pressure ulcers. In addition, the rationale behind the research topic is going to be covered in this topic. This research paper is going to develop research aims and objectives.

1.2 Background

A pressure ulcer can be defined as localized damage or injury underlying soft tissue developing bony prominences. The injury was identified due to prolonged pressure or the combination of long-time pressure with shear. In contrast, Mitchell, (2018) stated that Pressure Ulcers (PU) is developed due to a lack of blood supply is particularly damaged areas in the skin, as a result of long time pressure. It has been identified that in the UK, pressure ulcers are a common disease. It has been identified that every year approximately 700,000 people face the issue of pressure ulcers (Wood et al. 2019). Further, approximately 18000 new cases of PU are developed every year. It has been identified that PU is associated with multiple consequences, which increase mortality and morbidity rates. Thus, by improving the quality of care, pressure ulcers can be cured. Preventing the severity of pressure ulcers can also reduce the chance of spreading further infections to surrounding body sites.

Terminology

There are different types of names used to define Pressure Ulcer across the globe. The National Pressure Injury Advisory panel currently used the term Pressure Injury to define the issue of pressure ulcers. In addition, “Pressure injury” and “Deformation” terms are also used to describe the issue of skin injury due to long-term pressure (Gefenet al. 2020). This literature stated that Australia, Asia, Canada, and the US used the term pressure injury to describe the issue of injury in skin due to long-term pressure. It has been identified that Europe does not use pressure injury to describe the issue of skin injury for long-term pressure. The National Health Service in the UK uses the terms “Bedsores", “Pressure sores' ' to define the issue of damage to soft tissue due to long-term pressure (Nhs.uk, 2020). Therefore, by focusing on the above information, it can be stated that a pressure ulcer is also recognized as Bedsores, pressure sore and pressure injury.

1.2.1 Concept and symptoms of pressure ulcers

Pressure ulcer is disease that is majorly affects the human skin. Discoloration, patches, dark skins, pale yellow skin and other symptoms can be found while a person is getting affected by PU. Pressure ulcers (PU) are recognized as localized injury to the skin or underlying soft tissue due to long-term shear (Ferris et al. 2019). Pressure ulcers are developed when the blood supply of a particular area on the skin decreases and it develops PU. Here, it can be stated that PU is skin injuries, which develops when the blood supply is diminished due to pressure or long-term shear.

Generally, PU is identified as the bony part of the body, which faces pressure such as heels, elbows and hoops. However, it has to be mentioned here that PU may develop in any region of the body. Now this section is going to focus on multiple symptoms of PI, which are identified in an individual at early stages.

• Discoloration: In the context of pressure ulcers discoloration of the skin or a particular region is one of the common symptoms identified at an early stage of PU (Nhs.uk, 2020). The skin becomes darkly pigmented and many patches appear on the skin. Apart from this, the skin layers become a thing and it is swelling due to the effect of PU. As a result, the colour tone of skin becomes yellow, brown, tan and gray. This is not good for skin, where the skin tissue is getting damaged. Major diseases, such as tumors, cancer and other diseases can obtain. Hence, it is clear that the first symptom of PU is showing by discoloring the skin.
• Patches: Red patches are also identified among people with the issue of PU at an early stage. In addition, people with red and brown complexions faced brown or purple patches on the skin at an early stage of PU (Nhs.uk, 2020).

In the progressive stage, multiple types of symptoms are mentioned as follows

(A: stage 1 of PU, B: stage 2 of PU, C: Stage 3 of PU, D: Stage 4 of PU)

• The presence of an open word or cluster is one of the common symptoms identified at the progressive stage of pressure ulcers. According to the NHS, the open word or blister is generally identified with stage 2 of pressure ulcers (NHS.uk, 2020).
• An in-depth injury to the muscle or bone is identified with the issue of stage four pressure ulcers (Nhs.uk, 2020).

1.2.2 Risk factor of pressure ulcers

This section is going to discuss multiple risk factors of pressure ulcers. Pressure ulcers are tissue damage issues, which develop due to long-term pressure (Ferris et al. 2019).

Above figure indicates common and most frequent risk factors of pressure ulcers. According to Ferris et al. (2019), poor physical activity and poor Activity of Daily Living (ADL) is one of common risk factors to develop the issue of pressure ulcers. It has been identified that poor activity and ADL increase pressure of bony prominences, which increases risk of pressure ulcers. Besides that, discolouration of skin, less blood flow in the skin tissue, mental instability, pain and other risks can occur due to PU. It is important to manage this disease to mitigate all risk factors. It has also been identified that the duration of stay may influence the issue of pressure ulcers.

In addition, diabetes is associated with damage of nerves (neuropathy) and circulation, which may increase the risk of pressure ulcers. Therefore, it can be stated that diabetes is another common risk factor for pressure ulcers. It has been identified that unexplained weight loss sometimes creates an issue of malnutrition, which affects the synthesis of collagen, and it may develop the issue of pressure ulcers. Therefore, by focusing on the above discussion, it can be interpreted that diabetes, low physical activity, minimum daily living activities, low systolic BP, and unplanned weight loss act as major risk factors for pressure ulcers.

Now this section is going to focus on indirect risk factors associated with pressure ulcers. Those indirect risk factors of PU are going to be discussed as follows.

Inequalities and discrimination

Sometimes, many hospitals, healthcare organisations and nursing homes do maintain their responsibilities and majorly focus on discrimination issues. Here, age, gender, income level, educational background and other things are included. Due to this reason, many PU patients do not get proper treatments. This is destroying the healthcare systems, which is against of the healthcare systems and policy. These issues are creating inequality in healthcare system. Contextually, inequalities, disparities, and discrimination are also identified among people while preventing the issue of pressure ulcers. A major treatment gap can be found in these sectors, where poor and less educational people are being underprivileged. They cannot afford treatment fees and huge treatment gap is occurred. Some healthcare management are imposing or fixing their treatment prices, which is difficult to afford for those underprivileged patients. In this aspect, racial, ethnic disparities act as one of the significant risk factors to develop the issue of pressure ulcers. It has been identified that ethnic and racial gaps are also identified among people based on the issue of pressure ulcers. OozageerGunowaet al. (2018) stated that black people are more prone to have pressure ulcers issue compared to white skin complexion patients. This literature stated that major health inequalities and health education discrimination were identified among Black and white people, which lead to changes in pressure ulcers among black people.

The issue of health inequality is still present in England among black and white people (Kingsfund.org.uk, 2021). The socioeconomic gap played another significant role to improve the gap between people and it affects the health and wellbeing of people. In the context of PU, it has been identified that in the UK around 1.4 million is required to provide treatment for PU (Nhs.uk, 2019). Pressure ulcers are cost-based treatment. In the Context of the UK, it has to be mentioned here that around 20% of the total population is living below the poverty line (Parliament.uk, 2021). Therefore, it is clear from above data that 20% of people failed to provide treatment expenses for PU. Here, by keeping on above discussion, it can be interpreted that poor socioeconomic factors create health inequalities in the UK followed by it developing the issue of pressure ulcers.

Health education gap

Lack of quality health services is creating many opportunities to manage the healthcare services for major injured patients. In context, PU disease is majorly affecting people; here, insufficient doctors, skilled health workers, less number of medical treatment procedures and poor educational issues are creating obstacles for pressure ulcer patients. Lesson of cleanliness and proper dressing at the wound sites can be the influencer of better prognosis. In the context of PU lack of health, education issues are identified among people. Al Mutair et al. (2020) argued that poor health education level not only among patients rather poor health knowledge regarding PU among families identified which increased risk of PU. It has been identified that due to lack of proper health education regarding PU, patients and their families failed to build awareness regarding the direct risk factor of PU and it increases the chance of PU. By focusing on the above discussion, it can be interpreted that the lack of proper health education played a significant role in increasing the issue of pressure ulcers.

On other hand, Ebi et al. (2019) reported that poor knowledge and literature access also identified among healthcare professionals and nurses, which affect their concerns. It has been identified that poor knowledge among healthcare professionals regarding PU played another significant role to increase the issue of PU. Therefore, by keeping an eye on the above analysis, it can be stated that lack of health education among healthcare professionals also increased the risk of pressure ulcers.

In the UK, the National Health Service has been focused on public health and wellbeing to undertake their health education (England.nhs.uk, 2016). In this approach, NHS England has been identified that pressure ulcers are one of the common diseases identified among UK people. Based on this data, NHS England has identified poor knowledge and health education issues identified among people in the UK, which affect their health and wellbeing. Therefore, by keeping an eye on the above analysis it can be stated that poor health education or health education violence is identified among UK people, which act as major risks of developing pressure ulcers.

In the context of poor health education, it has been identified that limited health education and poor relation among interpersonal groups are identified which create a significant risk factor for developing pressure ulcer issues (Salford.ac.uk, 2020). Additionally, it has been identified that the lack of proper education among registered nurses regarding the issue of pressure ulcers acts as one of the common risk factors among UK people to ensure the risk of pressure ulcers. The National Wound Care Strategy stated that in the UK effective health education and standard care strategy for pressure ulcers are essential to prevent the issue of PU. Therefore, it can be stated that inadequate education affects the health and wellbeing of people in the UK followed by the development of pressure ulcers.

1.2.3 Causes of pressure ulcers

It has been identified that PU is a skin damage issue due to long-term pressure. Now this section is going to identify key causes behind the issue of skin damage.

1. Contraction and friction: It can state that higher risk of all PU patients can be face more health issues due to changing their metabolism, nutrition, and mental stability. Many adults are facing this issue. Force of rubbing the injured surface can make the infection. Additionally, it can say that the outside surface, such as bed, bench and other surfaces are creating friction and contraction for a PU patient. Due to this reason, the ulcer area is getting more infected. According to Cortés et al. (2021), prolonged contraction or friction identified creates prolonged mechanical pressure. This pressure creates blood supply issues in the pressured region and develops the issue of pressure ulcers. Here, it can be stated that prolonged pressure is one of the common causes identified to develop the issue of PU.
2. Prolonged pressure: In the context of PU, it has been identified that prolonged pressure may affect underlying tissue and it may develop ulcers on skin. Mervis and Phillips, (2019) stated that prolonged pressure in particular one position for the long term may affect an individual with the issue of pressure ulcers. In the context of prolonged pressure, this literature has identified that sustained and pressure from medical devices may develop the issue of pressure ulcers.
3. Reperfusion injury: Reperfusion injury also developed due to the return of blood supply after the issue of ischemia. This literature stated that reperfusion is recognised as one of the common causes of tissue damage and it develops the issue of pressure ulcers.
4. Poor nutrition: Poor nutrition level or malnutrition is open for common reasons to develop the issue of pressure ulcers (Mervis and Phillips, 2019). It has been identified that malnutrition or lack of proper nutrition may affect the function of the immune system, collagen synthesis, and strength of the stencil. These situations affect underlying tissue or soft tissue damage as a result it develops pressure ulcers.
5. Shear force: It has been identified that skin is less resistant to the shear force, which affects surface areas between epidermis and dermis, by which nutrients and oxygen transport systems occur (Mervis and Phillips, 2019). Here, it can be stated that shear force is one of the significant causes behind the development of pressure ulcers. This literature also stated that medical device equipment pressure is one of the leading causes for developing pressure ulcers among the prenatal and neonatal population.

1.2.4 Incident and cases of the pressure of ulcer

Here, the incidence of pressure, ulcers belong within the range of 0.2 to 38% in hospitals. Simultaneously, these non-profit organisations stated 2.3 to 22.9% of the incidence of pressure ulcers belongs in nursing facilities (Npiap.com, 2020). Additionally, 0to 17% incidence of pressure ulcers has been identified in healthcare agencies. With physical-motor limitations, pressure ulcers are one of the common health burdens identified among people across the globe (Borojeny et al. 2020). This literature stated that pressure ulcers are skin industry and underlying cell injury identified due to long-term pressure. It has been identified that on average 7-23% of people in the UK faced the issue of Pressure ulcers (Zarei et al. 2019). The literature also stated that incidents of PU are developed during a long-term hospital stay. Therefore, by focusing on the above discussion, it can be stated that pressure ulcer is one of common incidence across the globe

The intensive care unit (ICU) is one of the common units in hospital settings, which have faced the highest incidence of pressure ulcer disease. This literature stated that 3.3% to 33.9% of PU incidence was identified in ICU departments across the globe. In contrast, Borojenyet al. (2020) argued that only 13.7% of the incidence of PU was identified in the intensive care unit in the hospital. Additionally, the above figure indicates that the orthopaedic department faced 18.5% of cases regarding pressure ulcers. However, only 4.1% of PU cases have been identified in the internal department. By focusing on the above discussion, it can be stated that the ICU and orthopaedic departments face maximum cases of pressure ulcers because of reduction in postural movements. In these two departments, majority of patients are immobile and thus, exertion of pressure on a specific point is higher than others.

1.2.5 Explaining stage of Pressure ulcer

According to the National Pressure Ulcer Advisory Panel pressure ulcers can be classified into six major stages such as stage 1, stage 2, stage 3, stage 4, unstageable and suspected deep tissue injury, characteristics of these six stages are discussed as follows.

The above figure indicates stage 1 of pressure ulcers where the skin is intact with localized red areas (Mervis and Phillips, 2019). In this stage, if the pressure has been applied this redness does not change into white, which is recognized as non-blanch-able erythema. In this stage, redness is identified on the bony prominences (Ferris et al. 2019).

Stage 2 of pressure ulcers identified the outer layer of the skin epidermis and deep layer of the skin dermis. Infection in the epidermis and dermis of the skin indicates sinlessness. It has been identified that in stage 2 partial thickness, skin loss and swallow ulcer was identified (Ferris et al. 2019). In stage 2, pressure ulcers look like open wounds or serum-filled blisters.

Above figure indicates stage 3 of pressure ulcers, which affect the entire thickness of the skin. Stage 3 of pressure ulcer identified in subcutaneous fat, however, the bone tendon is not affected in stage 3 of pressure ulcers (Ferris et al. 2019). In this stage, the underlying tissue is damaged, however; stage 3 of pressure ulcers do not affect muscle and bone tissue. Stage three of pressure ulcers develop deep cavities like words.

Stage four of pressure ulcer is the most severe stage, which faces full thickness of tissue loss. Additionally, this stage exposed ligament, fascia, tendon, muscle, and cartilage in the ulcers (Ferris et al. 2019). It has been identified that in stage 4 pressure ulcers create tissue necrosis with most severe pressure ulcers.

In the unstageable tissue industry, full-thickness tissue loss is identified with the cover of Escher. In this stage, full-thickness tissue loss and presence of Escher is still unknown (Ferris et al. 2019).

In stage six, a deep tissue pressure injury, which indicates a localised area of deep red, maroon, or purple colouration. In this stage, the coloration does not turn white if pressure is applied. Blood filled blisters are also identified in the deep tissue injury stage (Ferris et al. 2019). By focusing on the four-stage, it has been identified that these six stages gradually affect the full thickness of skin and affect underlying tissue and the issue of pressure ulcers.

1.3 Theoretical perspectives

1.3.1 PDSA cycle

PDSA cycle is a four-step problem-solving process such as planning, doing, study, and acting, which help to reduce problems and significantly carry new processes for improvement. In the context of the issue of pressure ulcers among the UK population, the PDSA cycle may be applied to reduce the issue of pressure ulcers and improve patient treatment quality and safety. A collaborative approach through PDSA cycle application can be conducted in multi-care settings of hospitals in the UK, which witnesses over 700,000 patients suffering from pressure ulcers every year. Wood et al. (2019) opined that following National Institute for Health and Care Excellence (NICE) guidelines in the UK suggest that patients’ mobility, skin inspection, nutrition/hydration (SSKIN) model, and moisture play key roles in preventing PU. Nevertheless, considering the high prevalence of PU or bedsores being reported on the NHS Safety Thermometer, quality improvement retorting PU becomes a strict necessity in this economy of the UK.

Project team in the healthcare setting of the UK can implement three PDSA cycles. First stage of the PDSA cycle incorporates a handful of positive preventive interventions such as specialised mattresses, repositioning of patients every 3 hours, and prophylactic dressing of bony prominences. Regarding this PDSA cycle, many doctors, nurses and health workers are trying to grasp the risk management factors and intervention tools to mitigate pressure ulcer. It can state that the first stage of PDSA is an indispensable situation, where the detection of the PU disease needs to be clear for better treatment. However it is essential and integral part of medical system. A further suggestion for participants or patients undertaking local adoptions of models such as SSKIN is also noticed in this stage (Wood et al.2019). Hence, progress can be evaluated continually to ensure the improvement of patients suffering from PU. Implementation of Clostridial Collagenase Ointment (CCO), medical honey and amino membrane are significant approaches to reduce the size of pressure ulcers (Dreyfus et al. 2018).

The second stage of the PDSA cycle can regard learning of preventive interventions of patients along with monitoring the prevalence of pressure injuries among existing patients. Here, all staffs and nurses are detecting the issue and identifying the disease for further treatment. This stage is also important to do major task for all patients. Compliance with the use of specialised mattresses and multidisciplinary wound care can also be facilitated. Goodman et al. (2018) argued that interventions in PDSA cycle 2 could differ in intensive and non-intensive care units. For instance, the promotion of healthy and intact skin is integrated into daily care among the ICU population, while pressure injury risk assessment at every 12-hour interval for non-ICU patients is allocated. In terms of do, COO, amniotic membrane and medical honey approach may be applied among people in the UK.

PDSA cycle’s third stage can determine sustainability of changes in daily care to fortify quality improvement for PU or bedsores. In addition, further clarification from the wound care team can be obtained to implement changes accordingly. Al-Otaibiet al. (2019) reported that hydrocolloid dressing in elderly patients led to a breakdown in skin integrity, and hence, prophylactic dressing was shifted to foam dressing as a preventive measure. In terms of study, COO is more effective compared to the medical honey approach. Therefore, based on the above evidence, the implementation of COO and the amniotic membrane will help to improve patient safety and quality of life by reducing the issue of pressure ulcers.

In the last stage, proper health check up and treatment is needed to apply to mitigate PU disease. The acting stage is helping to take more decisions for major affected patients. With the help of this stage, staff and nurses are implementing their medication practices to reduce all complexities. It is also important to take care of all patients by providing quality food products, medicines and comfortable interior to avoid skin frictions and contraction. In this way, proper action can be taken for all patients. Therefore, it is clear that PDSA cycle is very useful and essential model to detect and mitigate the PU disease (Belova, and Ershova, 2020).

1.3.2 Swiss cheese model

According to the Swiss cheese model, multiple smaller failures and accidents may develop major issues and develop actual hazards (Larouzee and Le Coze, 2020).

This model believes that a major accident is based on multiple smaller components, which develop a clear road for a major accident (Larouzee and Le Coze, 2020). In the context of pressure-ulcer mortality rate among UK people, it has been identified that UK people failed to receive high-quality treatments and services to prevent the issue of pressure ulcers due to lack of proper evidence and system. Since the mortality rate in PU is very high in UK, the condition can be considered as a major accident. It has been identified that the cost of treatment for PU in the UK has been increased by 53%, which affects their health and wellbeing (Nursingtimes.net, 2019). The cost of pressure ulcers in the UK is equal to five knee replacements, five hip replacements and nine pacemaker services (Nursingtimes.net, 2019). Therefore, it can be stated that high cost is one of the significant barriers identified in the UK regarding the treatment of pressure ulcers. Based on the Swiss cheese model it can be stated that poor service availability, poor awareness among people and high-cost act as minor factors, which lead to the increasing mortality rate among UK people due to the PU.

1.4 Problem statement

Pressure ulcers are associated with multiple types of risk factors. It is one of the major problems to identify a particular one and specific risk factors behind the issue of pressure ulcers. According to Mitchell, (2018), shear is one of the common and most significant reasons behind the development of pressure ulcers. On the other hand, Ferris et al. (2019) reported that poor physical activity, low level of ADL is considered as one of the common and most frequent issues with pressure ulcers. In addition, this literature stated that higher humidity conditions, low scores, advanced age, and poor physical activity are common reasons behind the issue of pressure ulcers. Here, it can be interpreted that PU is a significant health burden with poor physical activity. Many underprivileged patients do not get proper treatment; due to this reason, they are facing more problems in their life. The level of infection is increased, mental stability is decreased, skin patches and other challenges are creating more diseases at the same time. Healthcare management is not good; that is why poor patients are lagging behind from advanced treatment (House, and Square, 2020).

Nowadays, pressure ulcers are the third most common disease after cancer is identified among people throughout the globe. Pressure ulcers are one of the most common diseases identified among elderly people due to a lack of motor activity across the globe and approximately 60,000 deaths were identified due to pressure ulcer (Borojeny et al. 2020). Shiferaw et al. (2020) stated that PU is recognised as one of the five most frequent reasons for health hazards. In the UK, around 700 000 people have faced the issue of pressure ulcers every year (Wood et al. 2019). This literature also stated that in the UK, around 18000 new cases developed due to pressure ulcer disease. Therefore, it can be stated that PU is open to common diseases among UK people. It has been identified that full-thickness loss or damage in the skin with huge destruction is associated with pressure ulcers.

The above figure indicates that in the UK around 25% of cases of PU receive inpatient service. This figure also indicates that 11% of patients with PU received a home-based care setting (Ferris et al. 2019). Approximately, 55% of PU patients in the UK received nursing home base care services (Ferris et al. 2019). By focusing on the above discussion, it can be stated that pressure ulcers are one of the common diseases among UK people.

1.5 Rationale and Significance

PU is associated with multiple consequences, which affect the quality of life of an individual. According to Espejo et al. (2018), osteomyelitis is one of the common consequences associated with Pressure ulcers. Damage of muscle, bone, and supporting structure is also identified with the issue of pressure ulcers. Cellulitis, abscess, and bacteremia issues are also identified with pressure ulcers conditions. It has identified data bacteraemia with pressure ulcers is recognised as infrequent issues, however, it played a significant role to ensure mortality rate. It has to be mentioned here that pressure ulcers do not only affect the quality of life, rather it plays an emerging role in increasing the mortality rate. Therefore, by focusing on the above discussion, it can be stated that effective treatment facility and control of PU is essential to reduce the mortality rate due to PU and improve the quality of life of people.

Moreover, it has been identified that PU is associated with high-cost issues, which act as a major burden to control infections and improve quality of life. According to the National Health Service in the UK, treatment of PU is associated with high costs. NHS stated that treatment or sort of PU is around 1.4 million in every day (Nhs.uk, 2019). On the other hand, Mitchell, (2018) stated that the cost of PU is around £2.1 billion in a year. Therefore, by focusing on the above information it can be stated that available treatment is cost-effective which acts as a major burden for UK people. Therefore, effective treatment and treatment quality improvement for PU is essential to improve the health and wellbeing of people.

Choice of solution

At the initiation of quality improvement program, literature review identified that regular position alternation, medical interventions are essential to reduce the burden of pressure ulcers. One study has been utilised the PDSA cycle to maintain quality improvement program for pressure ulcers. In this regard, this research paper is going to identify particular intervention to reduce burden of pressure ulcers and improve quality treatment.

1.6 Scope of the research

This research paper is based on the status of pressure ulcers and possible strategies for pressure ulcers. This research paper will identify the current status in the UK regarding the issue of pressure ulcers. In addition, this research paper will identify current treatment availability in the UK regarding the health burden of pressure ulcers. This research paper will help to determine the condition of the UK regarding the treatment availability of pressure ulcers. This research paper will identify possible solutions to reduce the burden of pressure ulcers and improve the treatment safety of people in the UK.

1.7 Aim and Objectives

Aim: To evaluate the status of pressure ulcers in patients and the available quality treatment processes for the ulcers in the UK

Objectives:

1. To understand the concept and consequences of pressure ulcers
2. To analyse pathophysiology of pressure ulcers reported in UK hospitals
3. To evaluate the status of patient safety and quality intervention regarding pressure ulcers in UK
4. To recommend strategies to reduce the burden of pressure ulcers

Research question

What are the strategies improve quality treatment of pressure ulcers in UK?

Justification of aim and objectives

This research paper has been focused on previous and already published literature to identify information about the concept of pressure ulcers, risk factors, and symptoms of it. In the next stage, this research paper has identified multiple stages of pressure ulcers and their consequences. However, this research paper has not identified enough information about strategies for pressure ulcers and quality treatment. In this regard, this research is performed to identify possible strategies to reduce the issue of pressure ulcers and improve treatment quality.

Chapter 2: Methodology

2.1 Introduction

Research methodology considers specific techniques and procedures, which help to identify, select and analyse a particular topic. This study is going to focus on multiple research methods to identify possible strategies to reduce the issue of pressure ulcers and improve the health and well-being of people in the UK.

2.2 Review of aim and objectives

Section 1.6 of the introduction chapter contains research aim and objectives, the primary purpose of this study is to identify status of pressure ulcers and evaluate its possible strategies to improve quality treatment among people regarding pressure ulcers. This study is going to provide recommendations regarding the treatment of pressure ulcers and to improve quality treatment.

2.3 Study Design

Introduction chapter indicates prevalence of pressure ulcers gradually increased in UK. Further, introduction chapter has been identified that number of cases increased in UK. Based on that, this research paper has been developed research aim and objectives. With the help of research design, this research study is going to be more descriptive and reliable to understand. Here, different research methods and approaches are going to use, which are creating opportunities to make this research more valid. Additionally, Google scholar, websites, and other online articles are going to include in this research session, which is based on pressure ulcer disease. Some inclusion and exclusion factors, thematic analysis and other methods are going to include in this research that makes researchers more selective to proceed with the research topic. 

According to Taylor et al. (2018), secondary thematic analysis has been considered due to its ability to address research questions directly, where this literature reported to a UK health service evaluation through datasets. Considering research objectives, a handful of themes are established, which revolve around pressure ulcers in the UK with their causes, possible treatment, and others. This research paper has used Braun and Clarke's six-step method to develop themes and analyse them.

Step 1: Familiar with the data	In this step, this research paper focuses on collected data and building familiar relations with collected data
Step 2: Develop initial codes	In this step, this research paper develop initial codes based on collected data
Step 3: Search for themes	In the third stage, this research paper focuses on electronic databases to search data regarding strategies of pressure ulcers and improve treatment quality of people in UK
Step 4: Review themes	In this stage, this research paper reviews keywords for developing themes with aligning research aims and objectives.
Step 5: Define themes	This is one of the significant stages, where this research paper develop themes based on possible strategies to reduce the burden of pressure ulcers
Step 6: Write up	This is the final stage of the Braun and Clarke model where this research paper finally developed four different types of themes. Theme 1: Issue of pressure ulcers required urgent quality improvement Theme 2: Local treatment and oral supplement helps to reduce the burden of PU Theme 3: Quality improved intervention of Pressure ulcers Theme 4: Medical intervention improve patient safety and treatment quality against PU

Table 2.1: Braun and Clarke model

2.4 Inclusion and exclusion criteria

In the context of inclusion criteria, this research paper has only focused on authentic, published journals regarding pressure ulcers. This research paper only focuses on the English language while collecting data.

Themes	Inclusion criteria	Exclusion criteria
Theme 1	Direct and indirect risk factors of pressure ulcers are included in this paper. consequencesof PU is included	Risk factors of ulcers or other diseases are strictly excluded. consequencesof ulcers or other ulcer disease are excluded from this study
Theme 2	Treatment availability in the UK regarding pressure ulcers is included.	Quality of available treatment in Uk regarding other disease are strictly excluded from this study
Theme 3	Local treatment and nutritional supplements for pressure ulcers issue are included in this study	Treatment for other diseases except pressure ulcers is excluded from this study
Theme 4	Medical intervention for pressure ulcers is only included	Medical intervention for other disease are excluded from this study

Table 2.2: Inclusion and exclusion criteria

2.5 Search strategy

There are two types of research data such as qualitative and quantitative data. This research has been focused on qualitative or secondary data to identify possible strategies to reduce the burden of pressure ulcers. It has been identified that secondary data is already published data, which contains specific and accurate information. It has been identified that secondary data allow a study to gather in-depth and detailed information. In this aspect, this research paper has been keeping an eye on secondary data to gather accurate and authentic information about strategies for pressure ulcers. Secondary data maintain the reliability and validity of research papers by providing accurate and specific information. In this perspective, this study has maintained the reliability and validity of the research paper by focusing on coronary type of data while identifying specific and accurate strategies to reduce the issue of pressure ulcers. In addition, this research paper has been to maintain reliability and validity of paper while improving quality treatment of people in the UK from the issue of pressure ulcers. It has identified secondary data types that help to understand the attitude of people and focus on human experiences. In this aspect, this research paper focuses on human experiences and patterns of improvement while identifying specific strategies to reduce the issue of pressure ulcers among UK people.

Data collection process

A secondary qualitative data collection is selected to conduct this study, and hence, secondary sources such as Google Scholar, ProQuest, Pubmed, government websites are utilised. These sources are chosen to extract authentic and reliable data, which can be ensured by including peer-reviewed articles. O'Cathain et al. (2019) opined that amalgamation of both primary and secondary data collection could be highly effective in healthcare research to grasp complex interventions to improve healthcare services. However, O’Connor (2020) argued that administrative data linkage could be challenging in research, as primary data collection in NHS England demands confidentiality, recruitment of healthcare practitioners, and more. Therefore, a secondary qualitative data collection is selected to conduct this study. Additionally, keyword strategy is used in this research to find more information and data based on pressure ulcer. Different keywords are using here, such as impact of pressure, prevalence of PU, effect of PU, secondary data collection process, and many other keywords. As a result, researchers and readers can easily find out more information regarding this research topic. While this strategy is used, accurate and significant keywords are needed to use for maintaining the entire process (Talapatra, and Santos, 2019).

Secondary data collection from reliable sources is time and cost-effective. Contrarily, the 'black box of data linkage brings difficulty to gather reliable data while conducting research relating to healthcare in the UK. In addition, it has helped to gather insight into the prevalence of pressure ulcers among the UK population over years, while numeric interpretations are also illustrated through this particular data collection process. Thus, the use of peer-reviewed articles alongside reliable government websites is utilised to gather relevant data concerning PU.

Data sources

This research paper has followed a secondary method to collect data regarding strategies to reduce the burden of pressure ulcers. In order to gather information regarding quality treatment of pressure ulcers, this research paper will focus on authentic electronic databases. In terms of authentic electronic databases, this research paper has been utilised "Google Scholar, "ProQuest", "PubMed". It has been identified that authentic and electronic databases allow a research paper to maintain reliability, validity and authenticity of data. In this regard, this research paper has utilised an authentic and electronic database, which allows this study to maintain reliability and validity of data while identifying the status of pressure ulcers and possible strategies of pressure ulcers to improve treatment of people in the UK.

Data collection components

This research paper has been focused on authentic electronic databases to gather secondary data regarding the status of pressure ulcers and the quality treatment of pressure ulcers. This research paper has been utilised multiple websites, articles and journals while gathering information regarding the quality improvement of pressure ulcers. It has been identified that this research paper has been focused on authentic websites such as the UK government report regarding pressure ulcers. In addition, this research paper has been keeping an eye on the website of NHS UK while gathering information regarding pressure ulcers status and treatment quality in the UK.

Furthermore, since this research has utilised secondary data collection, compliance with Data Protection Act 1988 in the UK is ensured to foster the privacy of essential data related to pressure ulcers among the population of this economy (Legislation.gov.uk, 2021).

Data collection process

This research has been focused on authentic electronic databases to gather information regarding the quality treatment of pressure ulcers. This research has used multiple keywords and Boolean connectors to connect keywords in search platforms. An overview of keyword and Boolean connectors is described as follows.

Theme 1	Theme 2	Theme 3	Theme 4
Risk factor of Pressure ulcers AND	Pressure Ulcers treatment safety and quality AND	Local treatment and oral supplements reduce PU	Medical intervention of pressure ulcers AND
Consequencesof pressure ulcers Incidence of pressure ulcers Prevalence of pressure ulcers 1 Or 2 Or 3	Currently available treatment in UK Cost of treatment 1 Or 2	regular dressing position alteration Nutrition oral supplement 1 or 2 or 3	allogeneic amniotic membrane Clostridial Collagenase Ointment Medical honey 1 Or 2 Or 3

Table 2.3: Data collection process

2.6 Selection process and search outcomes

The selection and search process indicates that this research paper has been undertaken multiple authentic databases to review literature and justify research aim and objectives. Above PRISMA, flow indicates that databases screening indicates that 400 articles identified regarding the status of pressure ulcers and possible strategies to improve quality treatment. Additionally, 10 articles identified from other sources. After that based on duplicates this research paper has been removed 50 articles, and finally identified total 350 articles. Based on inclusion and exclusion criteria, these research paper 200 articles and finally get 150 articles. After hat based on exclusion criteria, this paper has been developed final 10 articles, which has been reviewed in this paper regarding quality treatment of pressure ulcers.

Chapter 3: Result and discussion

3.1 Introduction

This chapter is going to analyse four different themes regarding the status of pressure ulcers and possible strategies to pressure ulcers to reduce their burden and improve patients’ safety. This chapter is going to analyse each theme by gathering information from literature. In addition, this chapter aligns the analysis with literature review of this paper to develop a meaningful interpretation.

3.2 Overview of the studies included

Based on total 10 studies, this research paper has been chosen five observational study (Mervis and Phillips, 2019, Gefen et al. 2020, Luboz et al. 2018, Jaul et al. 2018, Dreyfus et al. 2018). In addition, this research paper has been used two cross sectionals studies (Stolt et al. 2019, Eglseer et al. 2019) to identify status of pressure ulcers and its possible treatment. Further, two randomised control trial study (Dehghani et al. 2017, Li et al 2017) has been identified in this research paper. Finally, this research paper has been used one cohort study (Mearns et al. 2017).

Author and year	Objectives	Methods	Setting	Sample	Findings
Mervis and Phillips, 2019	To identify consequences, risk factors and epidemiology of pressure ulcers	Observational study	Hospital	91	Long term pressure, shear force are reason behind the issue of pressure ulcers
Gefen et al. 2020	To identify consequences of pressure ulcers	Observational study	NA	NA	Shear pressure affect tissue and develop pressure ulcers
Luboz et al. 2018	To identify impact of reduced order model to reduces the issue of pressure ulcers	Observational study	NA	NA	Reduced Order model is effective and help to reduces the burden of pressure ulcers
Stolt et al. 2019	To discuss treatment of pressure ulcers for long time care	Cross sectional study method	Private and public care facilities in Finland	112 patients of pressure ulcers is included	Competent and dedicates nurses that helps to reduces the burden of pressure ulcers
Eglseer et al. 2019	To identify role of national intervention to reduces the burden of pressure ulcers	Cross-sectional study	Australian hospital	Total 1412 number of patients of PU has been included in this study	Nutritional management is suboptimal process to reduce the burden of pressure ulcers.
Jaul et al. 2018	To identify chronic and acute disease with the issue of pressure ulcers	Observational study	NA	NA	Immobility, tissue damage, mal nutrition are the reason behind pressure ulcers
Dreyfus et al. 2018	To discuss impact of clostridial collagenase ointment (CCO) and medical honey to reduces the issue of pressure ulcers	Observational study	Hospital based setting has been followed	48267 number of patients has been included in this study	COO is effective and significant ointment that help to reduces the burden of pressure ulcers
Mearns et al. 2017	To identify cost effective and budget friendly method of pressure ulcers	Cohort study	Hospital based setting	1000 sample	clostridial collagenase ointment is effective and budget friendly method for reducing the issue of pressure ulcers
Dehghani et al. 2017	To compare healing process of pressure ulcers with crypto preserved amniotic membrane and routine care of PU	Randomised clinical trial method	Hospital based setting	24 Patients of PU	Crypto preserved membrane is effective and most significant method to healing the issue of pressure ulcers
Li et al 2017	To identify impact of Moist Exposed Burn Ointment (MEBO) to heal pressure ulcers	Randomised control trial	Hospital absed setting	72 patients of PU	Moist Exposed Burn Ointment (MEBO) is effective and most significant to health pressure ulcers

Author and year	Objectives	Methods	Setting	Sample	Findings
Mervis and Phillips, 2019	To identify consequences, risk factors and epidemiology of pressure ulcers	Observational study	Hospital	91	Long term pressure, shear force are reason behind the issue of pressure ulcers
Gefen et al. 2020	To identify consequences of pressure ulcers	Observational study	NA	NA	Shear pressure affect tissue and develop pressure ulcers
Luboz et al. 2018	To identify impact of reduced order model to reduces the issue of pressure ulcers	Observational study	NA	NA	Reduced Order model is effective and help to reduces the burden of pressure ulcers
Stolt et al. 2019	To discuss treatment of pressure ulcers for long time care	Cross sectional study method	Private and public care facilities in Finland	112 patients of pressure ulcers is included	Competent and dedicates nurses that helps to reduces the burden of pressure ulcers
Eglseer et al. 2019	To identify role of national intervention to reduces the burden of pressure ulcers	Cross-sectional study	Australian hospital	Total 1412 number of patients of PU has been included in this study	Nutritional management is suboptimal process to reduce the burden of pressure ulcers.
Jaul et al. 2018	To identify chronic and acute disease with the issue of pressure ulcers	Observational study	NA	NA	Immobility, tissue damage, mal nutrition are the reason behind pressure ulcers
Dreyfus et al. 2018	To discuss impact of clostridial collagenase ointment (CCO) and medical honey to reduces the issue of pressure ulcers	Observational study	Hospital based setting has been followed	48267 number of patients has been included in this study	COO is effective and significant ointment that help to reduces the burden of pressure ulcers
Mearns et al. 2017	To identify cost effective and budget friendly method of pressure ulcers	Cohort study	Hospital based setting	1000 sample	clostridial collagenase ointment is effective and budget friendly method for reducing the issue of pressure ulcers
Dehghani et al. 2017	To compare healing process of pressure ulcers with crypto preserved amniotic membrane and routine care of PU	Randomised clinical trial method	Hospital based setting	24 Patients of PU	Crypto preserved membrane is effective and most significant method to healing the issue of pressure ulcers
Li et al 2017	To identify impact of Moist Exposed Burn Ointment (MEBO) to heal pressure ulcers	Randomised control trial	Hospital absed setting	72 patients of PU	Moist Exposed Burn Ointment (MEBO) is effective and most significant to health pressure ulcers

Table 3.1: Summary table

3.3 Description of the findings

Theme 1: The issue of pressure ulcers requires urgent quality improvement

This research paper has been focused on Braun and Clarke six six-step models to develop themes. Based on this model, this research paper gathers information regarding the issue and pattern of PU and builds a familiar relationship with the data. In the next stage, this research paper has been to build initial codes to form the theme regarding the status of pressure ulcers. To develop initial codes, this research paper has been focused on familiar data and identified the term “long-term pressure”, “deformed cell”, “and consequences”. Based on these initial codes, this research paper has gathered information regarding pressure ulcers and their consequences. In addition, this research paper has been reviewing themes and defining them as "long term pressure develop deformed cells and lead to the issue of pressure ulcers".

Consequences indicate the in-depth physiology of various abnormal states that contain different functional changes accompanied by specific syndromes, which create negative effect on health and wellbeing. PU generally occurs due to improper balance in pressure inside the tissue that causes wounds. PU includes serious necrosis mainly in the soft tissues that are placed completely between different types of bony prominences. PU can develop when a large amount of pressure is provided on an area of skin for a short period and result into immobility, lack of sensory perception, poor hydration and nutrition which needs quality treatment. An example of PU occurrence is in soft tissue at buttock and various ischia bones (Luboz et al. 2018). Therefore, consequences indicate improper washing of such tissues causes starting of PU. Therefore, above-mentioned consequences indicate that proper treatment and quality improvement are essential to improve health and wellbeing.

Based on the consequences analysis of PU, it is clear that essential treatment or quality improvement is essential for an individual to reduce the issue PU and improve their health and wellbeing. Soft tissues that are compressed for a prolonged time between bony areas cause occlusion in the microvascular parts through which PU can arise within 3 to 4 hours. Consequences of the PU indicate that the presence of excess amounts of moisture can cause maceration and causes a serious breakdown of skin and other tissues (Mervis and Phillips, 2019).

Friction has been identified as another cause of PU that generally takes place due to the rubbing of the skin and resulted in damaging tissue of the skin surface. This issue includes erosion or a complete breakdown of the epidermis of skin that initiates the generation of PU. Therefore, patients of PU need to reduce string rubbing of skins to mitigate the generation of PU problems and it urgent to implement quality improvement to improve their health and wellbeing. .

 Therefore, people need to rest their muscles effectively to eliminate such combinations that cause PU. Moisture adds extra influence in the generation of PU especially in soft tissues that are pressurised between bony areas. The presence of moisture causes a serious issue of maceration that worsens the situation of PU. Muscles are termed as susceptible areas for ischemia due to the high compression of skins. This is an important cause for PU generation due to such prolonged pressure and lack of balance in pressure in different areas of soft muscles. Therefore, it is essential to reduces the long-term pressure and improve quality of life of people through improve patient safety and security.

According to Mervis and Phillips, (2019), normal mobility, body sensation and long-time pressure develop feedback responses that change the position of the body, however when this feedback response is unavailable responses identified affect tissue ischemia and necrosis. Body weights of individuals can also contribute to creating the issues of PU as it work on creating downward force of the skin and between bony prominences and external surfaces subcutaneous fat. In addition, sustained pressure from medical devices may also lead to tissue necrosis or injury and develop the issue of pressure ulcers (Mervis and Phillips, 2019). Therefore, essential treatment is urgent to improve health and wellbeing of people and improve their wellbeing. In the context of medicinal device-related pressure ulcers, pressure in the arterial capillary filling is increased approximately 32 mm Hg, which is more than the pressure of venous capillary outflow. It has to be mentioned here that venous capillary outflow pressure is around 8 to 12 mm Hg (Mervis and Phillips, 2019). This pressure affects blood flow; consequently, it develops tissue hypoxia.

It has been identified that pressure, friction, shear that are influenced by moisture and temperature are common factors that develop the issue of pressure ulcers (Gefen et al. 2020). The above figure indicates that sustained cell and tissue deformation was identified which develop device related pressure ulcers due to increasing trans epidermal water loss. In addition, in the context of external factors vessel occlusion which involved blocking flow through any specific artery, is also identified which affects humidity and develops device related pressure ulcers issues (Gefen et al. 2020). On other hand, tissue deformation decreases inflammation threshold and increases moisture and heat, which lead to the issue of device related pressure ulcers. It has been identified that biochemical tolerances of dermis, epidermis and deeper soft tissue gradually decreased which developed the issue of device related pressure ulcers (Gefen et al. 2020). By focusing on the above discussion, it can be stated that long-term pressure, friction is influenced by temperature and moisture, which increase the issue of pressure ulcers. In order to control friction, pressure and other risk factor essential treatment and patient safety are urgent.

It has been identified that long-term pressure is one of the common risk factors behind the issue of pressure ulcers (Gefen et al. 2020). In the skin of bony prominences, gravity is identified due to long-term pressure or friction, which develops stretch, shear tissue, and affects components of extracellular matrix and deforming cells (Gefen et al. 2020).

It has been identified that long-term pressure affects microvesicular capillaries network in the skin and deeper tissues, which develop the issue of pressure ulcers (Gefen et al. 2020). Due to the sheer force or direct pressure, inflammatory changes are also identified. Above figure indicates that loss of cytoskeleton and plasma membrane integrity has been identified which develop cell deformation (Gefen et al. 2020). The cell deformation issues loss as control and homeostasis. During this condition secretion of inflammatory mediators is identified which increases progressive inflammatory oedema and develops pressure. Gefen et al. (2020) stated that this intestinal pressure develops tissue damage and develops necrosis followed by pressure ulcers. It has to be mentioned here that by the release of reactive oxygen species damage in the amplify tissue is identified. This magnitude and duration of the cell deformation stages and level develop the issue of pressure ulcers (Gefen et al. 2020). On other hand, Mervis and Phillips, (2019) reported that reperfusion of ischemic tissue is also identified which increases reactive oxygen specifics, as a result, it affects inflammatory responses. It has been identified that reperfusion cycles affect more tissue and develop the issue of pressure ulcers.

On the other hand, literature review of this research paper has identified that long-term pressure and shearing forces are common and most significant factors, which affect tissue and develop the issue of pressure ulcers. Therefore, by focusing on the above discussion and literature review it can be stated that long term pressure poor activity, medical devices may develop the issue of pressure ulcers by affecting underlying soft tissues.

Theme 2: Local treatment and oral supplement helps to reduce the burden of PU

With the help of Braun and Clarke's six-step method, all data and information are collected based on ulcer patients and their treatments. At first, relevant data is collect and found some keywords, such as oral supplements, posture alteration, nutrient foods, and many more things. All reliable data or information has effectively increased the condition of ulcer patients. Apart from this, familiar statements need to collect, so that proper treatment can obtain due to having the required needs for patients. After finding some keywords, thematic factors can be found. In this state, brief databases are elaborated to make a clear understanding of ulcer patients and their treatments. After that, the definition of themes is going to demonstrate by focusing on keywords then the proper explanation will be done. These steps are helping to maintain the qualitative research method. However, Braun and Clarke’s model is effectively maintaining the systematic review for better results (Neuendorf, 2018).

A pressure ulcer (PU) is a very critical disease that can be found in the human body. Many patients are suffering from this. Due to this reason, proper treatment is needed for those patients. The first and foremost treatment that can be used for PU is reducing pressure. In this context uses of support surfaces or repositioning can come into act which includes changing positions very often depending on the quality of surface and condition of the patient (Gillespie et al. 2020). Moreover, long-term care is required to provide food supplements, oral supplements, and more care. Usually, older people are facing this problem due to having gastric issues. Junk food, irregular sleep routine, unhealthy food, alcohol consumption and many other causes can affect the human body. It can also be said that PU needs to be prevented by providing essential treatment strategies. According to Stolt et al. (2019), most PU can be prevented with the help of a healthcare treatment strategy. Here, advanced treatment systems, healthcare workers’ education, and guidelines are needed to mitigate PU. 

To collect relevant data, proper observation implementation must be conducted in multiple healthcare organisations. Here, researchers make interviews, questionnaires, and survey processes to know the condition of all ulcer patients. They are measuring gender, injured level, and length of the time, treatment procedures and proper usage of an advanced system implementation for PU patients. In this way, all data on information can be collected through this research method. In this way, readers can get to know the PU condition. However, it is important to take special care of patients. To heal the issue completely the treatment of removing damaged and infected tissue from wounded area can be performed. In this treatment doctor or nurses remove damage tissue from wounded area by cutting damaged tissue i gently flushing the wound area with eater (Saleh et al. 2019). Moreover, treatment quality must be improved, so that all patients can overcome their pain. 

As nutrition is a greater sources of healing wounds therefore while treating patients’ food aspects are needed to be more concerned, so that no spicy food can affect those patients. On other hand, health workers need to be more sincere about their responsibility. They have to be more proficient to treat all patients properly. Regarding this case, Eglseer et al. (2019) stated that malnutrition, oral supplementary and other boil food are needed to provide to patients, so that they recover their health as soon as possible. Usually, major ulcers are needed to be operated on with the help of a surgeon; the surgery process can mitigate the PU issue permanently. After the surgery, health workers need to provide oral supplementary, such as ORS water, liquid food and liquid medicine. In this way, PU treatment can be possible. Other interventions such as drugs can be used to control pain among patients. Drugs such as naproxen sodium (Aleve) and ibuprofen (Motrin IB, Advil) are some nonsteroidal anti-inflammatory drugs which can help in reducing pain (Mayoclinic, 2022).

In contrast, Kim, and Lee, (2019) stated that health workers need to enhance their knowledge and skills to provide effective treatment for patients. They need to provide medicines, nursing care, maintain the environment, and provide nutritious food to upgrade health. Here, all health workers are needed to enhance their performance to provide effective service for PU patients. It can also be said that they need to be proficient regarding time to provide food, medicines and other treatment care, so that patients can recover their health accordingly. As the prevention methods mentioned by the health government of the country should be followed for appropriate mitigation of the incident. PU patients are facing stomach blockage issues, less volume of the stomach, and many more things. Due to this reason, appropriate treatment should be provided to all patients based on their issues. 

In the major case, doctors are focusing on surgical treatment for ulcer patients; in this case, proper rest is needed for them. After a few days, changing body posture is mandatory to be active in other body parts. Taking rest in a bed can affect patients’ bodies; due to this reason, posture alteration is needed. At this time, health workers need to help them to walk into the room. Based on this fact, Gefen et al. (2021) stated that Clinical Practice Guidelines must be implemented for PU patients. Treatment procedures can be enhanced with the help of health care bodies and professionals by following the clinical guidelines and delivering appropriate services. These authors have also said that body posture helps to enhance muscle tissues. Due to this reason, the movement of muscles is very important for all PU patients. 

In most cases, PU patients are facing digest problems, vomiting, nutrition deficiency, drug-addicted and they face many other issues. Apart from this, their health quality is being decreased; due to this reason, their lifestyle has changed and many risks have come in their life. In context, the prevalence of PU can damage the regular lifestyle; make the weak body, poor mental health, and many more risks. Sometimes, critical PU patients have died due to having some major injuries. Based on Kayseret al. (2019) statement, approximately 200 risk factors can be found in PU patients. Therefore, healthcare bodies associated with delivering servie to PU patients need to seriously focus on this issue. From the basic to advanced treatment can recover all patients; in this case, health workers need to provide essential health services to them, so that they can recover their injuries. 

It can be said that many PU patients are suffering from this issue due to having irregular lifestyles; due to this reason, they are facing this kind of issue. However, it is very important to maintain a healthy lifestyle, so that they can avoid ulcer issues in their life. It can also be said that all patients need to be more careful by taking sufficient food, oral supplements, bid and nutrition food. In this way, they can get rid of their health problems. Apart from this, all patients can acquire an injured free life by maintaining all health guidelines. Healthcare providers need to gain more knowledge about the injury, appropriate treatment processes and medical skills for reducing adverse impact of this health complication. In this way, they can manage all patients to evolve their health conditions. 

By aligning with this statement, Beeckman et al. (2019) explained that healthcare costs must be reliable for all patients, so that they can recover their health at a low cost. Here, all health workers need to be more flexible and trustworthy. Proper support, medication, food, provide mattresses and many reliable services are required for PU patients. Altering clothes, mattresses and other healthcare activities are needed to provide to PU patients to enhance their mental and physical health. Many risks may come while treatment is going on; at this time, all patients have to be calm and enhance their potentiality. In this way, their mental health will be stronger and physical injuries will be recovered. 

Theme 3: Quality improved intervention and patient safety in UK regarding Pressure ulcers

This research paper has been keeping an eye on Braun and Clarke six step model while developing the theme and analysing it to meet research aims and objectives. This research paper has been focused on data regarding quality improvement intervention and pressure ulcers. After developing familiar relations, this paper developed the initial code “Quality improvement”, “Pressure ulcers”, “safety and security of UK patients”. Based on initial codes, this research paper has been searching for information regarding initial codes. After that, this research paper reviewed themes and developed the final theme as “Quality improved intervention and patients safety in UK regarding Pressure ulcers”.

It has been identified that pressure ulcers are one of the common disorders, which affect the health, and wellbeing of UK people and it reduces quality of life. According to the NHS, there are multiple treatments available in the UK due to reducing the issue of pressure ulcers (Nhs.uk, 2020).

Position alteration

It has been identified that regular alteration of position is one of the significant processes which help to reduce pressure from ulcers followed by it reduces pressure ulcers formation issue (Nhs.uk, 2020). In the Context of alteration of position, NHS develops the timetable for repositioning which ensures when and how often an individual needs to change their position (Nhs.uk, 2020). For example, the timetable of repositioning states that some people need to change their position every 15 minutes. On other hand, this timetable of repositioning every 2 to 4 hours may also be recommended to prevent the issue of pressure ulcers (Nhs.uk, 2020).

In addition, the NHS recommended that appropriate training and advice regarding repositioning is recommended and applicable among pressure ulcers patients in the UK to prevent this issue. In the context of advice, correct sitting and lying advice are provided under-reporting advice (Nhs.uk, 2020). Therefore, by focusing on the above discussion, it can be stated that regular position alteration is one of the common and most significant factors, which help to reduce the issue of pressure ulcers. Here, it can be stated that UK people received the service of position alteration treatment to prevent the issue of PU.

Mattresses and cushion

It has been identified that the NHS recommended pressure reliving beds, mattresses and seat cushions as specific equipment to reduce the issue of pressure ulcers in both institutional and non-institutional setting. Status foam or dynamic mattress is identified as a common treatment for pressure ulcers among UK people (Nhs.uk, 2020). It has been identified that mattress replacement reduce the incidence of PU compared to any other interventions methods. However, it has to be mentioned here that these mattresses and cushions are only applicable in a minor stage of pressure ulcers issue. On the other hand, the NHS recommended a sophisticated mattress and bed system to reduce the issue of pressure ulcers when they reach a higher level. However, the National Institute for Health and Care Excellence (NICE) stated that limited evidence and availability of multiple devices regarding pressure ulcers affect the treatment quality and services (Nhs.uk, 2020). Therefore, by focusing on the above discussion, it can be stated that mattress and cushion suggestions are only applicable for minute pressure ulcers. Therefore, people in the UK failed to receive effective and high-quality treatment services to reduce the issue of pressure ulcers.

Dressings

The NHS recommended that designed and different types of dressing be available in the UK to reduce the issue of PU and improve quality of life. Alginate dressing is available in the UK, which increases the healing process (Nhs.uk, 2020). Dressing with seaweed, sodium-calcium are identified which increase the healing process of PU. The damage skin is gently cleaned and a bandage is wrapped which keep the wound moist and fasten recovery. Hydrocolloid dressing is also available among UK people, which promotes the growth of new skin and reduces the issue of pressure ulcers. Foam hydrofiber dressings are also available in the UK to reduce the issue of PU (Nhs.uk, 2020). Besides these, debridement of damaged tissue and surgery treatment service is also available in the UK to reduce the issue of pressure ulcers. According to the National Health Service (NHS), around 3.8 million is the daily cost to prevent the issue of pressure ulcers (Jaul et al. 2018). Therefore, it can be stated that the high cost of pressure ulcers treatment is one of the common barriers identified in the UK, which affect the quality of treatment.

 On other hand, the literature review of this research paper has identified that debridement (removing of damaged tissue) treatment is available in the UK to reduce the issue of pressure ulcers. It is a cost based treatment service. Therefore, by focusing on the above discussion, it can be stated that due to poor services and high cost of treatment, people in the UK received poor quality treatment and healthcare services to reduce the issue of pressure ulcers.

Theme 4: Medical intervention improve patient safety and treatment quality against PU

By focusing on Braun and Clarke's six step model, this research paper has developed a familiar relation with strategies of pressure ulcers. After developing the familiar relation, this research paper identifies initial codes to develop themes. In this section, this research paper identified some initial codes such as “medical intervention for pressure ulcers”, “Clostridial Collagenase Ointment”, “Medical honey”, “Strategies to reduce pressure ulcers”. Based on initial codes, this research paper searches for information and develops themes as “Medical intervention improves patient safety and treatment quality against PU”.

It has been identified that due to lack of significant treatment quality and safety for pressure ulcers patients, affects the health and wellbeing of UK people. In this regard, this section is going to develop new suggestions to reduce the issue of pressure ulcers.

According to Dreyfus et al. (2018), Clostridial Collagenase Ointment (CCO) is recognised as only an enzymatic debridement agent, which helps to reduce damage tissue due to the pressure ulcers and improve the safety of patients. CCO consists of protease from Clostridium histolyticum and multiple types of collagens, which helps in epithelialization. In the context of a mixture of collagens, this ointment contains specifically two types of collagens such as collagen G and collagen H. It has to be mentioned here that this ointment helps in multiple bioactive peptides and it continues the autolytic process of debridement. Medical honey is considered as a great approach that helps in reducing the issue of pressure ulcers and improves patient safety and quality of life. In contrast, Mearns et al. (2017) argued that collagenase promotes keratinocytes and reduces the issue of pressure ulcers. Therefore, by focusing on the above discussion and information it can be stated that the application of CCO is one of the significant and most festive methods to reduce the burden of pressure ulcers and improve patient safety and quality treatment.

On the other hand, an allogeneic amniotic membrane is another significant strategy to reduce the issue of pressure ulcers and improve the quality of life of people. Dehghani et al. (2017) stated that an amniotic membrane consists of multiple growth factors, which reduces underlying skin damage and improve quality of life.

The above figure indicates the application of crypto-preserved amniotic membranes, which help to improve wound healing. It has to be mentioned here that the amniotic membrane contains a basic fibroblast growth factor transforming growth factor, which helps to reduce underlying tissue damage and improve quality of life (Dehghani et al. 2017). Therefore, by focusing on the above discussion, it can be stated that the amniotic membrane is another common process, which helps to reduce the issue of pressure ulcers.

According to Li et al. (2017), moist exposed burn ointment is another common and most significant treatment which helps to reduce the issue of pressure ulcers and improve the health and wellbeing of people. It has been identified that this pressure ulcer is associated with sesame oil, berberine and other natural ingredients, which help to reduce the issue of burn and improve health and wellbeing of people. β-sitosterol is another ingredient that is identified with moist exposed burn ointment which helps to reduce the wound and improve health and wellbeing of people. It has been identified that this ointment improves neovascularization in granulation cells and improves proliferation in endothelial cells. Based on these, the ointment heals surrounding connective tissue and improves health and wellbeing of people. Therefore, by focusing on the above discussion, it can be stated that this ointment improves the health and wellbeing of people by reducing the issue of pressure ulcers.

On the other hand, the literature review of this research paper stated that crypto-preserved amniotic membranes, COO, are significant strategies to help to reduce the burden of pressure ulcers. hence, it can be concluded that crypto-preserved amniotic membranes, COO, medical honey and moist exposed burn ointment are significant effective strategies to reduce the issue of pressure ulcers and improve the health and wellbeing of people.

Lam et al. (2018) mentioned that the treatment procedure for PU is costly and quite resource incentives. Therefore it is important to adopt effective strategies and implement prevention guidelines that can help in quality improvement and driving patient safety. It has been identified that significant prevention programmes can reduce the incidence of PU in long term care. Implementing systemic processes while providing care which includes best practices, educating care providers with series of workshops and worked with one-on-one for quality improvement has resulted into reducing rate of PU incidents. 

Chapter 4: Discussion, reflection and implication

4.1 Introduction

This chapter is going to summarised most important finding of the entire research paper. This chapter is going to answer research question, research aim and objectives. It will also evaluate reflection from the entire research paper. Research limitation, strengths and future implication are going to cover in this paper.

4.2 Summary of key findings

Different issues, risk factors, treatment and intervention methods associated with PU have been found out through thematic analysis. This research can be concluded that implementation of COO, crypto-preserved amniotic membrane and moist exposed burn ointment are significant strategies, which help to reduce the burden of pressure ulcers. This research has been identified from the background section that the prevalence of pressure ulcers gradually increased and it created a negative effect on the health and wellbeing of people. From the literature review section, this research paper has identified long-term pressure, shear force; friction may increase the risk of pressure ulcers. This research paper has utilised secondary data collections and thematic data analysis to meet research aims and objectives. In the result and discussion section, this research paper has identified that implementation of nutritional supplements, COO, crypto-preserved amniotic membrane and moist exposed burn ointment will help people to reduce the burden of pressure ulcers and improve their health and wellbeing.

Theme 1 and Theme 2

First thematic analysis is compared with a literature review to connect this particular research objective, which intends to reflect on a handful of risk factors alongside focusing on consequences. The second theme has reflected an inclination to bed among older adults along with inadequate physical activities among children, and others are some fundamental risk factors contributing to PU. Mervis and Phillips (2019) opined that several risk factors and consequences with extrinsic and intrinsic factors influencing tissue trauma demand preventive measures.

Extrinsic or patho-mechanical risk factors incorporate impaired mobility, moisture, prolonged pressure, whereas consequences or intrinsic factors involve age-related changes, emotional stress, medication, nutritional factors, and others. Aloweni et al. (2019) mentioned that surgical patients be at the higher risk of developing PU because of prolonged immobility, anaesthesia or surgical related factors and pre-existing medical condition. Moreover, these themes have highlighted the risk factors and available treatment associated with PU. Thus, linking to this objective is successfully placed by evaluating several risk factors. The theme two has been identified local treatment and nutritional supplement help to reduces the burden of pressure ulcers and improve quality treatment.

Theme 3 and Theme 4

This theme has been focused on quality treatment and quality improvement of pressure ulcers patients in UK. This section has been identified regular alteration of position, mattress, cushion helps to improve treatment quality of pressure ulcers patients. This theme 4 of the research paper reviewed possible intervention to reduce the burden of pressure ulcers. In this section, this research paper has been identified that implementation of Clostridial Collagenase Ointment, medical honey and crypto preservative membrane are significant method which help to reduces the burden of pressure ulcers. It has been found that natural ingredients like berberine, sesame oil can help in reducing the issue of burn associated with PU and contribute to a better health of patients. This section has been concluded that implementation of COO, medical honey help to reduce the burden of pressure ulcers.

4.3 Reflection on key findings

For this section, I have used Kolb’s reflective model, incorporating four aspects. These are concrete learning, reflective observation, abstract conceptualisation, and active experimentation (Sudria et al. 2018). Through this model, my lessons learned and experiences are briefed down in this section of the study.

Concrete learning: I have obtained in-depth knowledge concerning PU or bedsores, and its high prevalence resulting in a burden among UK population has brought insights regarding the same. In this section, I have gathered in depth and detail information regarding quality treatment improvement of pressure ulcers. Though I have found less information related to patient safety issues concerning pressure ulcers, yet conduction of this research has helped me to widen my insight of related risk factors and essential treatments addressing PU.

Reflective observation: During conduction of this entire research, I have found that adequate improvement towards treatment of PU can be initiated in UK hospitals considering its health spending. Hence, I have tried to focus on identifying positive interventions through secondary data collection. I observed supportive perceptions from my team members related to therapeutic interventions, which can improve quality treatment for patients with PU (Atkinson and Cullum, 2018).However, I have faced some issues while utilising PDSA cycle while developing recommendation for patients with the issue of pressure ulcers due to lack of proper knowledge.

Abstract conceptualisation: Active communication with my peers while attempting this research has assisted us to bring some new ideas as positive interventions to improve treatment of patients with PU. Training programs along with a handful of effective therapies are recommended in this study after consultation with my peers. I have identified that the implementation of medical intervention helps to reduce the burden of pressure ulcers.

Active experimentation: I have realised that active training of staff and nurses in NHS UK can be an effective measure to improve quality treatment concerning pressure ulcers. Several shreds of evidence have also exhibited the same, and hence, I believe that it can be implemented locally, which can not only enhance the prospects of this research but also increase abilities of positive interventions to address concerns of PU in UK. I have decided to follow online articles and journals to gather information regarding PDSA cycle to improve my skills and knowledge regarding PDSA cycle.

4.4 Recommendations

This section is going to provide a bunch of recommendations to improve quality treatment through utilising PDSA cycle.

Rosemary ointment

Rosemary ointment is one of the common strategies, which help to heal connective tissue, prevent progression of grade I PU and improve the quality of a patients’ life. It has been identified that this ointment works on connective tissue and improves the wound of pressure ulcers as a result highly used in Intensive Care Unit (ICU) (Parizi et al. 2020). In this regard, patients with pressure ulcers may follow rosemary ointment to reduce the burden of pressure ulcers by improving the proliferation of connective tissues.

Alteration of position

The regular alternation of positions and an effective timetable for position changes is one of the significant strategies to reduce the burden of pressure ulcers and improve health and wellbeing of people. Therefore, by focusing on the above discussion, it can be stated that implementation of rosemary ointment and position alteration will help to improve health and wellbeing of people by reducing the issue of pressure ulcers.

PDSA application in the two quality improvement processes:

1. In context of plan stage, implementation of rosemary ointment and position alteration may be helpful for reduces the burden of pressure ulcers.
2. In do stage, the rosemary ointment and position alteration will be implement among small population.
3. In study stage, the outcomes towards improving quality treatment will measured.
4. In the act stage, if the quality treatment indicates positive result, it will implement among large population. Otherwise, next plan will be developed to reduce burden of pressure ulcers.

4.5 Strength, limitation and Future Research

Strengths

• This research paper has identified possible strategies to reduce the burden of pressure ulcers.
• This research paper has been followed authentic and electronic journals which allow maintaining paper reliability and validity

Weaknesses

• This research paper has faced the issue of old data due to the secondary data collection process undertaken.

Future research

This study has identified that pressure ulcers are a common disorder, which affects the quality of life of people. This paper has been identified that the implementation of nutritional supplements, COO, crypto-preserved amniotic membrane, and moist exposed burn ointment will help people to reduce the burden of pressure ulcers and improve their health and wellbeing. However, a particular surgical method for reducing the burden of pressure ulcers or precaution for pressure ulcers has not been identified.

In future, this research may follow the primary method of surveying patients with pressure ulcers and identifying the real time data. This process will help to gather real time and current data by conducting interviews with the medical service providers and patients who has dealt with the issue. In future, this study will focus on particular surgery to reduce the burden of pressure ulcers.

4.6 Lesion learned

It has been identified that implementation of COO, crypto-preserved amniotic membrane and medical honey help to reduces the burden of pressure ulcers. It has identified that long-term pressure and shear forces may damage tissue and develop the issue of pressure ulcers. This research paper has been focused on Braun and Clarkes’ six-step model to develop four different types of themes and analyse those themes. In addition, this chapter has been aligned with the outcome of themes with literature review of this research paper. Further, this research paper has discussed multiple strategies of pressure ulcers to reduce their burden and improve quality of life. This research paper has been identified that medical intervention, proper nutritional supplements are essential strategies to reduce the burden of pressure ulcers and it improves the health and wellbeing of people.

4.7 Conclusion

This chapter has been identified that implementation of COO, crypto preserved ointment help to reduces the burden of pressure ulcers. Further, this chapter has been discussed reach strength, weakness and future implication. This chapter has been utilised PDSA cycle to provide recommendations to improve quality treatment of pressure ulcers.

Reference list

Journals

Al Mutair, A., Ambani, Z., Al Obaidan, F., Al Salman, K., Alhassan, H. and Al Mutairi, A., 2020. The effectiveness of pressure ulcer prevention programme: A comparative study. International wound journal, 17(1), pp.214-219.

Al-Otaibi, Y.K., Al-Nowaiser, N. and Rahman, A., 2019.Reducing hospital-acquired pressure injuries.BMJ open quality, 8(1), p.e000464.

Aloweni, F., Ang, S.Y., Fook?Chong, S., Agus, N., Yong, P., Goh, M.M., Tucker?Kellogg, L. and Soh, R.C., 2019. A prediction tool for hospital?acquired pressure ulcers among surgical patients: surgical pressure ulcer risk score. International wound journal, 16(1), pp.164-175.

Atkinson, R.A. and Cullum, N.A., 2018. Interventions for pressure ulcers: a summary of evidence for prevention and treatment.Spinal Cord, 56(3), pp.186-198.

Beeckman, D., Serraes, B., Anrys, C., Van Tiggelen, H., Van Hecke, A. and Verhaeghe, S., 2019. A multicentre prospective randomised controlled clinical trial comparing the effectiveness and cost of a static air mattress and alternating air pressure mattress to prevent pressure ulcers in nursing home residents. International journal of nursing studies, 97, pp.105-113.

Belova, K.Y. and Ershova, O.B., 2020. The use of Plan-Do-Study-Act (PDSA) cycle in perfection of fracture liaison service work. Osteoporosis and bone diseases, 22(2), pp.4-13.

Borojeny, L.A., Albatineh, A.N., Dehkordi, A.H. and Gheshlagh, R.G., 2020. The Incidence of pressure ulcers and its associations in different wards of the hospital: A systematic review and meta-analysis. International Journal of Preventive Medicine, 11.

Cochrane Database Syst Rev. 2020 Jun 2;6(6):CD009958. doi: 10.1002/14651858.CD009958.pub3.

Cortés, O.L., Herrera-Galindo, M., Villar, J.C., Rojas, Y.A., delPilarPaipa, M. and Salazar, L., 2021. Frequency of repositioning for preventing pressure ulcers in patients hospitalized in ICU: protocol of a cluster randomized controlled trial. BMC nursing, 20(1), pp.1-10.

Dreyfus, J., Delhougne, G., James, R., Gayle, J. and Waycaster, C., 2018. Clostridial collagenase ointment and medicinal honey utilization for pressure ulcers in US hospitals. Journal of medical economics, 21(4), pp.390-397.

Ebi, W.E., Hirko, G.F. and Mijena, D.A., 2019. Nurses’ knowledge to pressure ulcer prevention in public hospitals in Wollega: a cross-sectional study design. BMC nursing, 18(1), pp.1-12.

Eglseer, D., Hödl, M. and Lohrmann, C., 2019.Nutritional management of older hospitalised patients with pressure injuries. International wound journal, 16(1), pp.226-232.

Espejo, E., Andrés, M., Borrallo, R.M., Padilla, E., Garcia-Restoy, E. and Bella, F., 2018.Bacteremia associated with pressure ulcers: a prospective cohort study. European Journal of Clinical Microbiology & Infectious Diseases, 37(5), pp.969-975.

Ferris, A., Price, A. and Harding, K., 2019. Pressure ulcers in patients receiving palliative care: a systematic review. Palliative medicine, 33(7), pp.770-782.

Gefen, A., 2018. The future of pressure ulcer prevention is here: detecting and targeting inflammation early. EWMA J, 19(2), pp.7-13.

Gefen, A., Alves, P., Ciprandi, G., Coyer, F., Milne, C.T., Ousey, K., Ohura, N., Waters, N. and Worsley, P., 2020. Device-related pressure ulcers: SECURE prevention. Journal of wound care, 29(Sup2a), pp.S1-S52.

Gefen, A., Brienza, D.M., Cuddigan, J., Haesler, E. and Kottner, J., 2021. Our contemporary understanding of the aetiology of pressure ulcers/pressure injuries. International Wound Journal.

Gillespie BM, Walker RM, Latimer SL, Thalib L, Whitty JA, McInnes E, Chaboyer WP.

Goodman, L., Khemani, E., Cacao, F., Yoon, J., Burkoski, V., Jarrett, S., Collins, B. and Hall, T.N., 2018. A comparison of hospital-acquired pressure injuries in intensive care and non-intensive care units: a multifaceted quality improvement initiative.BMJ open quality, 7(4), p.e000425.

Herzog, C., Handke, C. and Hitters, E., 2019. Analyzing talk and text II: Thematic analysis.In The Palgrave handbook of methods for media policy research (pp. 385-401). Palgrave Macmillan, Cham.

House, W. and Square, F., 2020. SkinHealth. Official Journal of the International Foundation for Dermatology, 16(1).

Jaul, E., Barron, J., Rosenzweig, J.P. and Menczel, J., 2018. An overview of co-morbidities and the development of pressure ulcers among older adults. BMC geriatrics, 18(1), pp.1-11.

Kayser, S.A., VanGilder, C.A. and Lachenbruch, C., 2019.Predictors of superficial and severe hospital-acquired pressure injuries: A cross-sectional study using the International Pressure Ulcer Prevalence™ survey. International journal of nursing studies, 89, pp.46-52.

Kim, J.Y. and Lee, Y.J., 2019. A study on the nursing knowledge, attitude, and performance towards pressure ulcer prevention among nurses in Korea long?term care facilities. International wound journal, 16, pp.29-35.

Lam, C., Elkbuli, A., Benson, B., Young, E., Morejon, O., Boneva, D., Hai, S. and McKenney, M., 2018. Implementing a novel guideline to prevent hospital-acquired pressure ulcers in a trauma population: a patient-safety approach. Journal of the American College of Surgeons, 226(6), pp.1122-1127.

Larouzee, J. and Le Coze, J.C., 2020. Good and bad reasons: The Swiss cheese model and its critics. Safety science, 126, p.104660.

Luboz, V., Bailet, M., Grivot, C.B., Rochette, M., Diot, B., Bucki, M. and Payan, Y., 2018. Personalized modeling for real-time pressure ulcer prevention in sitting posture. Journal of tissue viability, 27(1), pp.54-58.

Mervis, J.S. and Phillips, T.J., 2019. Pressure ulcers: Pathophysiology, epidemiology, risk factors, and presentation. Journal of the American Academy of Dermatology, 81(4), pp.881-890.

Mitchell, A., 2018. Adult pressure area care: preventing pressure ulcers. British Journal of Nursing, 27(18), pp.1050-1052.

Neuendorf, K.A., 2018. Content analysis and thematic analysis. In Advanced research methods for applied psychology (pp. 211-223).

O’Connor, S., 2020.Secondary Data Analysis in Nursing Research: A Contemporary Discussion.Clinical Nursing Research, 29(5), pp. 279–284.

O'Cathain, A., Croot, L., Duncan, E., Rousseau, N., Sworn, K., Turner, K.M., Yardley, L. and Hoddinott, P., 2019. Guidance on how to develop complex interventions to improve health and healthcare.BMJ open, 9(8), p.e029954.

OozageerGunowa, N., Hutchinson, M., Brooke, J. and Jackson, D., 2018.Pressure injuries in people with darker skin tones: A literature review. Journal of clinical nursing, 27(17-18), pp.3266-3275.

Parizi, F.M.K., Sadeghi, T. and Heidari, S., 2022. The effect of rosemary ointment on the grade I pressure ulcers in ICU patients: A randomized clinical trial. Nursing Practice Today, 9(1), pp.X-X.

PMID: 32484259

Rodríguez-Núñez, C., Iglesias-Rodríguez, A., Irigoien-Aguirre, J., García-Corres, M., Martín-Martínez, M. and Garrido-García, R., 2019. Nursing records, prevention measures and incidence of pressure ulcers in an Intensive Care Unit. EnfermeríaIntensiva (English ed.), 30(3), pp.135-143.

Saleh, M.Y., Papanikolaou, P., Nassar, O.S., Shahin, A. and Anthony, D., 2019. Nurses' knowledge and practice of pressure ulcer prevention and treatment: An observational study. Journal of tissue viability, 28(4), pp.210-217.

Shiferaw, W.S., Aynalem, Y.A. and Akalu, T.Y., 2020. Prevalence of pressure ulcers among hospitalized adult patients in Ethiopia: a systematic review and meta-analysis. BMC dermatology, 20(1), pp.1-10.

Smith, H.A., Moore, Z. and Tan, M.H., 2019. Cohort study to determine the risk of pressure ulcers and developing a care bundle within a paediatric intensive care unit setting.Intensive and Critical Care Nursing, 53, pp.68-72.

Stolt, M., Hjerppe, A., Hietanen, H., Puukka, P. and Haavisto, E., 2019.Local treatment of pressure ulcers in long-term care: a correlational cross-sectional study. Journal of wound care, 28(6), pp.409-415.

Talapatra, S. and Santos, G., 2019. Main benefits of integrated management systems through literature review. on Quality Innovation and Sustainability, p.85.

Taylor, B., Henshall, C., Kenyon, S., Litchfield, I. and Greenfield, S., 2018. Can rapid approaches to qualitative analysis deliver timely, valid findings to clinical leaders? A mixed methods study comparing rapid and thematic analysis.BMJ open, 8(10), p.e019993.

Wood, J., Brown, B., Bartley, A., Cavaco, A.M.B.C., Roberts, A.P., Santon, K. and Cook, S., 2019.Reducing pressure ulcers across multiple care settings using a collaborative approach. BMJ open quality, 8(3), p.e000409.

Wood, J., Brown, B., Bartley, A., Cavaco, A.M.B.C., Roberts, A.P., Santon, K. and Cook, S., 2019.Reducing pressure ulcers across multiple care settings using a collaborative approach. BMJ open quality, 8(3), p.e000409.

Websites

 England.nhs.uk, 2018.Pressure ulcers: revised definition and measurement, Available at: https://www.england.nhs.uk/wp-content/uploads/2021/09/NSTPP-summary-recommendations.pdf [Accessed on: 03/12/2021]

England.nhs.uk, 2021.Plan, Do, Study, Act (PDSA) cycles and the model for improvement. Available from: https://www.england.nhs.uk/wp-content/uploads/2021/03/qsir-plan-do-study-act.pdf [Accessed 11/12/2021]

Gov.uk, 2018. Pressure ulcers: safeguarding adults protocol. Available at: https://www.gov.uk/government/publications/pressure-ulcers-safeguarding-adults-protocol/[Acssesd on 11^th December 2021.]

Kingsfund.org.uk, 2021.The health of people from ethnic minority groups in England.Avaiable from: https://www.kingsfund.org.uk/publications/health-people-ethnic-minority-groups-england [Accessed 01/12/2021].

Legislation.gov.uk, 2021.Data Protection Act 1998. Available from: https://www.legislation.gov.uk/ukpga/1998/29/contents [Accessed 11/12/2021]

Mayoclinic., (2022). Diagnosis-treatment. Available at: https://www.mayoclinic.org/diseases-conditions/bed-sores/diagnosis-treatment/drc-20355899 [Accessed 26 January 2022].

Nhs.uk, 2020.Pressure ulcers (pressure sores).Available from: https://www.nhs.uk/conditions/pressure-sores/ [Accessed 03 December 2021].

Nhs.uk, 2020.treatment,. Available from: https://www.nhs.uk/conditions/pressure-sores/treatment/ [Accessed on 11/12/2021].

Nhs.uk, 2020.Treatment.Available at: https://www.nhs.uk/conditions/pressure-sores/treatment//[Acssesd on 11^th December 2021.]

Nhs.uk, 2020.Treatment-Pressure ulcers. Available from: https://www.nhs.uk/conditions/pressure-sores/treatment/ [Accessed 11/12/2021]

Nice.org.uk, 2020.NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE.Available from: 03 December 2021].

Npiap.com, 2020.Guidelines.Available from: https://npiap.com/page/Guidelines [Accessed 03 December 2021].

Parliament.uk, 2021.Poverty in the UK: statistics.Available from: https://commonslibrary.parliament.uk/research-briefings/sn07096/ [Accessed 01/12/2021].

Salford.ac.uk, 2020.Patient expectations of pressure ulcer prevention in the NHS, healthcare demands and national policy : a critical commentary. Avaiable from: https://usir.salford.ac.uk/id/eprint/58841/1/bjon.2020.0296_R1.pdf [Accessed 01/12/2021].