Reframing pressure ulcer prevention through fundamental care: Findings from a hospital-based action research study

Pressure ulcer prevention remains a significant patient safety challenge despite the availability of evidence-based guidelines. Many recommended preventive interventions, including mobility support, skin care, nutrition and patient engagement, correspond to activities recognised as fundamental nursing care. However, limited evidence exists regarding how pressure ulcer prevention is enacted through the relational, physical and contextual dimensions described in the Fundamentals of Care Framework.

To characterise the practice of fundamental care in the management of pressure ulcer risk among hospitalised older adults as part of a participatory action research study designed to improve nursing care.

A qualitative descriptive observational study was conducted in an internal medicine ward of a Portuguese general hospital. Data were collected through 112 h of structured participant observation undertaken between July and October 2022. Seventeen nurses were observed during routine care delivery. An observation guide was developed using international pressure ulcer prevention guidelines and the Fundamentals of Care Framework. Data were analysed using reflexive thematic analysis supported by webQDA.

Findings were organised according to the three dimensions of the Fundamentals of Care Framework: relationship, integration of care and care context. Within the relationship dimension, nurses engaged older adults in discussions about comfort, positioning and care preferences, although patient preferences were not always accommodated. The integration of care dimension included skin care, mobility and positioning, nutrition, and nursing documentation. Preventive practices varied in their implementation, including approaches to skin assessment, hygiene, moisturisation, repositioning, mobilisation and documentation. Differences were also observed between documented care and enacted practices. Within the care context dimension, organisational routines, documentation systems, staffing patterns and coordination with other services influenced the prioritisation and delivery of preventive care. Across all dimensions, pressure ulcer prevention emerged as a multidimensional practice involving interactions between nurses, older adults, care processes and organisational structures.

Pressure ulcer prevention was enacted through interconnected relational, physical and contextual dimensions of fundamental nursing care. Organisational routines, documentation processes and ward-level structures influenced how preventive interventions were prioritised, delivered and recorded in everyday practice. Applying the Fundamentals of Care Framework provides a useful lens for understanding pressure ulcer prevention as an integrated and person-centred nursing practice and may inform future quality improvement initiatives and research.