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The participants felt that the calibre of skin care that patients received was strongly influenced by the value that a nurse placed on pressure ulcer prevention and other factors:

Catherine (2nd year student): “The quality of pressure area care was very good on

my first ward, but on my last placement, in gynaecology, I was the only one completing the patients’ pressure sore risk assessments. The gynaecology nurses didn’t take any preventative measures or keep the patient’s pressure area care plan up to date because they didn’t expect to see patients with pressure sores as they had a high turnover of patients.”

Joanne (3rd year student): “The standard of pressure area care really varies. If

you’ve got a member of staff that is really interested in that subject, they tend to be more up on it. On my last ward (placement), one of the nurses devised her own wound care chart and every day we would measure and describe what the wound looked like in the chart. The nurse on this ward had actually devised that (wound care) chart herself and implemented its use on the ward, which worked really well. So I think the calibre of (pressure area) care is down to the nursing staff.”

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The reported variations in the quality of skin care that are highlighted by the participants are consistent with what is known about values and their impact on a person’s behaviour. To put it simply, the participants’ assertions reinforce the point that is made in the previous section about the relationship between a nurse’s values and actions. Thus, the participants’ views about variations in care add credence to the idea that nurses who place a high value on pressure ulcer prevention deliver a higher standard of skin care than their colleagues who place a low value on pressure ulcer prevention.

It is possible that patients on a gynaecology ward are less likely to develop pressure ulcers than those in other settings, but the hospital policy in this trust states that all ward based nursed are expected to ensure that their patients’ pressure ulcer related documentation is accurate and up to date. The importance of maintaining accurate and up to date pressure ulcer related documentation is emphasised in policies that underpin nursing practice like the Essence of Care (D.H 2011a) and the Fundamentals of Care (Welsh Government 2003). In addition, poor pressure ulcer related documentation is one of the issues that can lead to a healthcare professional being prosecuted for harming a patient if they subsequently develop a pressure ulcer under the Protection of Vulnerable Adult (POVA) scheme (D.H 2009). Therefore, all nurses have a legal imperative to assess all their patients for the risk of skin disintegration and to maintain accurate and contemporaneous pressure ulcer related patient documentation.

The reports that there are some nurses who do not assess their patients’ risk of developing pressure ulcers or maintain up to date pressure ulcer related documentation suggests that these nurses are contravening the Trust’s policy and not fulfilling their legal responsibilities as set out in documents like the NMC (2008c) guidance on record-keeping for nurses. Although this a cause for concern, a more measured view of nurses in clinical practice is required because these accounts of the manner in which some nurses deliver skin care to their patients are not supported by any direct evidence. There may also be other

explanations which account for the observations that are made by the participants in this study. One such explanation is that the participants’ colleagues may have assessed their patient’s risk of skin disintegration and delivered the requisite care, but simply did not get round to documenting it in the patients notes. If it is true that there are some nurses who deliver care to maintain skin integrity but do not get round to documenting the care given, it

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is difficult to see how these nurses would be able to defend themselves from a legal and professional standpoint if one of their patients subsequently developed a pressure ulcer. The evidence from Trust policy and other documents that underpin the delivery of nursing care in clinical practice appear to bolster the participants’ assertion that nurses who do not assess their patients risk of skin disintegration or document the care given to maintain their skin integrity, place a low value on pressure ulcer prevention. It must be noted that the practice of nurses who place a low value on pressure ulcer prevention is solely based on the participants’ statements. So, there may be other factors that account for the variations in care that the participants highlighted.

The participants conceded that there were issues that affected a nurse’s ability to deliver skin care that was consistent with their values. Despite these issues, the participants argued that they did all that they could to prevent pressure ulcers:

Joanne (3rd year student): “The calibre of pressure sore prevention care that

patients receive is down to interest of a particular nurse and the staffing levels on the ward, because when the nurses are short staffed and under a lot of pressure to a lot of get things done, patients don’t get moved as regularly as they should be and dressing changes are postponed.”

Cordelia (Senior Staff Nurse): “We have occasions where we are extremely busy and

pressure areas get missed. I’m one of these nurses that even if I’ve got a group of patients to care for, I like to check their bums myself. “

The participants’ assertions that time pressures and staffing levels tend to push pressure ulcer prevention down the list of priorities is validated by the results of other studies. Nurses have been found to place a low priority on aspects of nursing that require direct patient contact like pressure ulcer prevention in studies by Irurita (1996) and Bowers Lauring et al. (2001). These studies both used a qualitative research method, which limits the extent to which their findings can be applied to other settings. On the other hand, both studies had relatively large numbers of participants for qualitative studies and reported similar findings on the prioritisation of patient care even though they were undertaken in different settings, which suggest that their results are worth noting. The generalisability of these studies is limited, but they provide robust evidence which validates the participants’ view that pressure ulcer prevention can be pushed down the list of priorities by other factors in clinical practice.

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The findings that have been presented thus far suggest that the prioritisation and delivery of skin care to patients are influenced by the value that a nurse places on pressure ulcer

prevention. There also appear to be other factors that affect the prioritisation and delivery of care to prevent ulcers. These factors and their impact on patient care will now be examined in greater detail in the next few sections.