J Wound Ostomy Continence Nurs. 2014;41(6):528-534.

Published by Lippincott Williams & Wilkins

WOUND CARE

Patient Perceptions of the Role

of Nutrition for Pressure Ulcer
Prevention in Hospital
An Interpretive Study
Shelley Roberts Ben Desbrow Wendy Chaboyer

ABSTRACT
PURPOSE: The aims of this study were to explore (a) patients
perceptions of the role of nutrition in pressure ulcer
prevention; and (b) patients experiences with dieticians
in the hospital setting.
DESIGN: Interpretive qualitative study.
SUBJECTS AND SETTING: The sample comprised 13 females
and 7 males. Their mean age was 61.3 12.6 years
(mean SD), and their average hospital length of stay
was 7.4 13.0 days. The research setting was a public
health hospital in Australia.
METHODS: In this interpretive study, adult medical patients at risk of pressure ulcers due to restricted mobility
participated in a 20 to 30 minute interview using a
semi-structured interview guide. Interview questions
were grouped into 2 domains; perceptions on the role of
nutrition for pressure ulcer prevention; and experiences
with dieticians. Recorded interviews were transcribed
and analyzed using content analysis.
RESULTS: Within the first domain, patient knowledge
of nutrition in pressure ulcer prevention, there were
varying patient understandings of the role of nutrition
for prevention of pressure ulcers. This is reflected in
5 themes: (1) recognizing the role of diet in pressure
ulcer prevention; (2) promoting skin health with good
nutrition; (3) understanding the relationship between
nutrition and health; (4) lacking insight into the role of
nutrition in pressure ulcer prevention; and (5) acknowledging other risk factors for pressure ulcers. Within
the second domain, patients described their experiences with and perceptions on dieticians. Two themes
emerged, which expressed differing opinions around
the role and reputation of dieticians; they were receptive of dietician input; and displaying ambivalence
towards dieticians advice.
CONCLUSIONS: Hospital patients at risk for pressure ulcer
development have variable knowledge of the preventive role of nutrition. Patients had differing perceptions

528 J WOCN November/December 2014

of the importance and value of information provided by

dieticians.
KEY WORDS: nutrition, patient knowledge, pressure ulcer,
prevention

Introduction
Pressure ulcers (PUs) are associated with significant costs
to both patients and the health care system.1,2 Issues such
as pain, discomfort, decreased mobility and independence, wound exudate, odor, social isolation, and poor
body image have been described by individuals who have
experienced PUs.3 In the hospital setting, PUs are associated with an increased risk of complications and lengthy
healing times, resulting in longer length of stay (LOS) and
higher hospital costs.1-7 In the Australian public hospital
setting, PUs increase LOS of acute admissions by a median
of 4.3 days,8 and a recent study estimated the total cost of
PU in Australian public and private hospitals in 201011
was US$1.64 billion (US$1.05 billion).9 In the United
Kingdom, the estimated annual cost of treating PU to
healing time in hospital and long-term care settings was
1.4 billion to 2.1 billion in 1999 to 2000.10 Clearly, the

 Shelley Roberts, MNutrDiet, PhD candidate, Centre for Health

Practice Innovation, and School of Public Health, Griffith University,
Gold Coast, Queensland, Australia.
 Ben Desbrow, PhD, Associate Professor, Centre for Health
Practice Innovation, Griffith Health Institute, and School of Public
Health, Griffith University, Gold Coast, Queensland, Australia.
 Wendy Chaboyer, PhD, Director, NHMRC Centre for Research
Excellence in Nursing, Griffith Health Institute and Centre for Health
Practice Innovation, Griffith University, Gold Coast, Queensland,
Australia.
The authors declare no conflicts of interest.
Correspondence: Shelley Roberts, MNutrDiet, School of Public
Health, Gold Coast Campus, Griffith University, QLD 4222, Australia
([email protected]).
DOI: 10.1097/WON.0000000000000072

Copyright 2014 by the Wound, Ostomy and Continence Nurses Society

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patient burden and hospital costs associated with PU in

the clinical setting are significant, and preferably avoided
through effective pressure ulcer prevention (PUP).
Historically, risk factors such as pressure, moisture,
shearing forces, and friction have been a primary focus for
PUP.11-13 In addition, research suggests that malnutrition is
an important risk factor for PU development. Malnutrition
is associated with an odds ratio of 2.6 (95% confidence
interval: 1.8-3.5; P < .001) of developing a PU in the public hospital setting in Australia.14 Current evidence suggests that oral nutrition support for patients at risk of PU
is effective in reducing the incidence of PU development
by approximately 26%, resulting in substantial cost savings.15 However, there is no evidence to date that a dietician consultation is associated with a reduction in PU risk.
Hospitalized patients often fail to eat enough to meet
their estimated energy and protein requirements.16-18 It is
crucial, therefore, to improve the nutritional intake of patients at risk for PU, in order to reduce their risk of PU
development. Patients may play a more active role in their
nutritional care in hospitals if they understand the link
between nutrition and PUP. Evidence suggests that patient
education around PUP is lacking. A study of patients in 89
institutions in the Netherlands reported that only 14.7%
of high-risk patients were educated about PU causes and
prevention strategies.19 To our knowledge, research focusing on patients understandings around nutrition of PUP
or their experiences with and opinions of dieticians is
lacking. Therefore, the aims of this study were to explore
(1) patients perceptions on the role of nutrition in PUP
and (2) patients experiences with dieticians.
Understanding patients perceptions around nutrition for
PUP and dietician input in the clinical setting may provide
a foundation for targeted interventions to promote good
nutrition and prevent PUs.

Methods
This interpretive qualitative interview study is part of a
larger, multisite, mixed-methods study conducted across 4
medical wards in 2 metropolitan hospitals in Southeast
Queensland, Australia. Both hospitals have established
PUP programs, and preventive strategies have been implemented into regular clinical practice. Ethical approval for
study procedures was obtained through Queensland
Health (reference number HREC/11/QTHS/111) and
Griffith University (reference number NRS/40/11/HREC).
All participants signed a consent form prior to data
collection.
The sample comprised adult medical patients who received care in 4 inpatient medical units who had reduced
mobility (ie, bed-bound, wheelchair-bound, or requiring a
mobility aid or physical assistance) and were therefore
deemed at risk for PU development. Reduced mobility was
chosen as an inclusion criterion to identify patients at risk
of PU because it is a widely recognized risk factor and

Roberts et al

529

strong predictor of PU in the clinical setting.4,6,20

Participants were eligible for inclusion if they could provide consent (aged 18 years, cognitively intact), had a
hospital LOS of 3 or more days, and met the criteria for
reduced mobility. The study sample was selected using a
maximum variation purposive sampling technique (ie, a
mix of men and women, younger and older patients, patients with and without experience with PU).21

Data Collection
Individual patient interviews were conducted on the ward,
in a quiet area, and at a time convenient for the patient.
The interviews lasted 15 to 30 minutes. Using a semistructured interview guide, patients were asked about their perceptions of the role nutrition played in PUP and their
experiences with and opinions about the role of dieticians.
Three nutrition-related questions were asked. They were
based on literature review and current clinical practice
guidelines, which suggest that nutritional intervention
and education are important components of PUP. Prompts
were used to gain additional information as required.
Individual interviews were conducted by a research assistant with experience in qualitative data collection.
Interviews were recorded with a handheld digital recording device and transcribed for analysis.

Data Analysis
Interview transcripts were analyzed using inductive content analysis, which provides a systematic and objective
means to make valid inferences from verbal data to describe and quantify phenomena.22-24 This technique takes
into account meanings, intentions, consequences, and
the context in which data were collected.20 Because the
interview questions encompassed 2 domains (knowledge
of nutrition in PUP and experience with dieticians), data
from each interview were analyzed in relation to these domains. To become familiar with the data, transcripts were
read and reread, and notes were taken by 2 of the authors.
For each domain, codes were developed from the verbatim
statements of participants, which were then grouped into
subthemes identified from the data. Subthemes were then
classified into themes within each domain. Frequent discussion among the research team was undertaken to ensure that the codes accurately reflected the data, and that
the themes and subthemes adequately encompassed the
data.
Trustworthiness of findings in qualitative data analysis
is often considered in relation to credibility, dependability, and transferability.25 We used purposive sampling
which ensured a broad representation of patients, and
regular meetings with the research team ensured codes,
subthemes and themes accurately reflected the data for
transferability and credibility. A code book and memos
were written to document the analytic process, including
decisions about emerging subthemes and themes, providing an audit trail of the analysis.

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Roberts et al

Results
The sample comprised 13 women and 7 men. Participants
mean age was 61.3 12.6 years (mean SD, range 24-80
years), and their mean hospital LOS was 7.4 13.0 days
(range 3-62 days). After 16 interviews, no new information
was emerging; however, 4 more interviews were completed to ensure data saturation. Within each domain, a
number of themes emerged. A summary of the domains,
themes, and subthemes is provided in Table 1.

Domain 1: Patient Knowledge of Nutrition in PUP

The first domain had 5 themes that expressed respondents perceptions of the role of nutrition for preventing
PUs. Consistent with inductive approaches to qualitative
analysis, we did not identify an overarching theme, nor
was any theme prioritized over the others as each provided a unique perspective. In addition, we refrained from
counting frequencies of emerging themes.
The first theme was recognizing the role of diet for
PUP. Participants acknowledged that nutrition as important for prevention of PUs. Nevertheless, while most patients thought that nutrition played a role in prevention,
they were unsure exactly what that role was. As respondent 1 stated, Im not a dietician and Im not a medical
expert, but I would suggest that nutrition is very, very
important. Some patients stated that consuming a poor
diet will result in a higher likelihood of developing a PU.
Other patients described a good diet as being a protective
factor for PU, and weight loss (in the buttocks area) was
described as a factor that may increase the risk of PU. The
good food is building you up all the time, and you may
even be putting on weight. And its usually when someone loses a lot of weight in their bottom area that these
things happen quicker. The skin comes apart quicker.
Whereas with well-padded bottoms, it takes a while to
happen.
Losing weight if overweight or obese was also described as a measure for PUP and healing. One participant postulated that consuming heavy foods in
hospital would lead to patients feeling full and heavy,
encouraging them to stay in bed rather than resuming
mobility. Another participant, unsure of the role that nutrition played in PUP, supposed that nutrition affects
your blood, and if your bloods out (ie, blood test results abnormal), you may be more likely to develop PU.
On the whole, this theme reflects patients recognition
that nutrition plays a role in PUP, but the description of
that role was ambiguous.
The second theme, promoting skin health with good
nutrition, portrays how patients linked skin health and
nutrition, even if they did not fully understand the mechanisms behind this relationship. Some participants made
general statements that nutrition was related to skin
health, while others said that poor nutrition would cause
skin to break down more easily. Several participants men-

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November/December 2014

tioned dietary protein as an important factor for skin

integrity. Protein was also mentioned as important for
wound healing and prevention of infection. One patient
thought that fluid intake would play a role in PUP; however, they were unsure of its exact role. Although respondents did not articulate the exact relationship between
nutrition and skin health, they appeared to have a broad
understanding of this notion. One respondent noted, I
should assume that if you werent eating properly, and
arent getting the right nutrition, of course your skins
going to break down twice as much. Another observed,
You need vitamins and minerals and proteins in the right
ratio so that your skin, your body tissue maintain its intactness, because if it doesnt maintain intactness, then
youre prone to infection.
The third theme, understanding the relationship between nutrition and health describes the perception that
nutrition was important for health in general and would
be expected to play a role in PUP. As one respondent articulated, I know nutrition is important for all areas of
health, and so it would have a part to play with pressure
sore prevention.
The fourth theme lacking insight into the role of nutrition and PUP depicts the lack of understanding or
knowledge of a relationship between nutrition and PUP
expressed by some participants. Some respondents stated
that they had no idea how nutrition and PUP may be
related, and others reported that they had not given this
potential connection much thought before. One respondent related, Ive got no idea, really. No, none whatsoever. Another observed, I dont think nutrition plays a
role in bed sores. I dont think its to do with nutrition.
I wouldnt have thought so anyway.
The final theme in the knowledge of nutrition and
PUP domain was acknowledging other risk factors for
PU. Within this theme, patients described other risk factors they considered to be of importance for PUP; they
were skin health, age, pressure, shear and friction, and comorbid conditions. Skin health and integrity were mentioned most frequently, but no link was made between
skin health and nutrition. Keeping skin healthy was described as an important way to prevent PUs, and patients
mentioned delicate or thin skin as being associated with
vulnerability to PU development. Age was identified as a
factor affecting skin health and integrity. Participants
noted that aging is linked to more fragile skin that is prone
to skin tears. The combination of older age and medications such as warfarin was linked to fine skin that bruises,
tears, and bleeds easily. Participants also acknowledged
that older patients should be monitored for PU because
they are at high risk. Pressure on the body associated with
lying/sleeping positions and prolonged time spent in bed
were described as factors involved in the development of
PU. Several participants stated that heels rubbing on
the bed acted as a risk factor for PU development. Finally,
patients expressed the belief that various illnesses were

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531

TABLE 1.

Description of Domains, Themes, and Subthemes

Domain

Patient knowledge of
nutrition in PUP

Theme

Recognizing the role of

diet in PUP

Subtheme

Nutrition probably plays a role in PUP

Poor diet/weight loss (especially in the buttocks) is a risk factor for PU
Good diet/weight gain (when underweight) is a protective factor for PU
Heavy food may reduce mobility
If overweight, losing weight is important for PUP and healing

Promoting skin health with Nutrition plays a role as it is related to skin health
good nutrition
Poor nutrition would cause skin to break down more easily
Protein, vitamins, and minerals maintain skin/tissue integrity and prevent infection
High protein diet for skin integrity and healing
Fluid intake may play a role (unsure what)

Patient feedback on
dieticians

Understanding the
relationship between
nutrition and health

Nutrition is important for all areas of health, so it would have a role in PUP
Nutrition plays a role as it is the well-being of the body
Better nutrition results in better health and circulation
If you have a healthy body, you wont get PU as bad

Lacking insight into the

role of nutrition in PUP

Unsure how nutrition and PUP may be related

Has not thought about nutrition as a factor in PUP
Doesnt think nutrition has a role

Acknowledging other risk

factors for PU

Receptive of dietician
input

Feels lucky to be seen by the dietician

Appreciates nutritional information provided
Dieticians are happy and bright

Displaying ambivalence
toward dieticians
advice

Main issue is skin integrity

Pressure, positioning, and medical conditions are important risk factors for PU
Friction/shear as a risk factor
Skin health is important
Age and medications affect skin health
Older patients are at risk

Patients do not think they need to see a dietician

Already knows how to eat
Dietician appointment did not meet expectations
Patient felt disempowered
Conflicting advice from dietician and specialist
Did not gain any new knowledge from dietician
Did not like prescribed diet

Abbreviations: PU, pressure ulcer; PUP, pressure ulcer prevention.

important in PU development. As one participant noted,

I think its to do with the patient, whats wrong with
them, and the way they lie. Another stated, Well the
main reason [for developing a PU] is pressure on the body
from the bed and the angles you sleep. A third respondent observed, I tend to think its more if the skins thinish and delicate.

Domain 2: Patient Feedback on Dieticians

The second domain patient feedback on dieticians comprised 2 themes, describing patients experiences with and
perceptions of dieticians. These included (1) receptive of
dietician input and (2) displaying ambivalence toward dieticians advice.

The theme receptive of dietician input describes

positive experiences during interactions with dieticians.
These participants expressed willingness to participate in
nutritional education and gratitude toward dietetic input.
They tended to describe dieticians as happy and bright
and felt appreciative of the information and services they
provided. As one respondent noted, Im lucky enough to
have been referred, to a dietician. Similarly, another
stated, It had just so much information; leaflets and talking to the nutritionist, it was lovely.
In contrast to theme 1, the theme displaying ambivalence towards dieticians advice reflects conflicting views
of the value of dietetic advice. Some participants expressed
the opinion that they did not need to see a dietician,

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primarily because they already knew how and what to eat

to keep healthy. Some stated that the need to consult with
a dietician never crossed their minds, while others stated
that meeting with a dietician was necessary only if diagnosed with a disease that required a special diet. One
respondent described the need for a dietician, only if I
needed it. Well, if I had any sort of diseases or sicknesses
that needed, um, to be on certain diets, Id be interested
then. But for, like, everyday life Ive got a fair idea whats
good for me and what isnt, you know. So not really, no.
Another patient reported that an appointment with a dietician did not meet her expectations; she further stated
that she left this appointment feeling disempowered. This
participant also discussed receiving conflicting advice between the dietician and her diabetes specialist. She (dietician) was telling me things that were in opposition to
what my specialists were telling me. (Specialist): You need
to lose weight. (Dietician): No, you wont be losing
weight. When youre diabetic you put weight on. Other
participants thought that they did not learn anything new
from their dietician as compared to nutritional information gained from everyday life. As one participant opined,
Well, she [dietician] didnt provide me with anything I
didnt already know. I was quite bored. Some stated they
did not like the diet they were prescribed, or disliked restrictions on certain foods, resulting in discontinuation of
their prescribed diet.

Discussion
This study is the first to our knowledge to explore awareness of the role of nutrition for PUP among patients at risk
for PU development. Participants were patients at 2
Australian hospitals where both PUP and patient education were important parts of clinical practice, and it was
initially postulated that their knowledge of the importance of nutrition in PUP would be adequate. Instead, we
found variable levels of understanding of the role of nutrition in PUP. Some respondents had a personal history of
PU or had experience through family members. These experiences may have influenced their perceptions around
nutrition for PUP and the importance of dieticians.
Nevertheless, study findings suggest that patients had inadequate knowledge of nutrition and PUP despite welldeveloped programs that include consultation with a
dietician and appropriate counseling. We, therefore, recommend additional education focusing on PUP that includes the role of nutrition for all patients deemed at risk
for PU development.
Based on the variable levels of knowledge expressed by
study respondents, we also recommend individual assessment to determine patients level of knowledge and motivation to be involved in their care. Research suggests that
basic literacy levels in adults may not be sufficient to
understand oral or written information regarding their
medical condition and health care.25 Health literacy is

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November/December 2014

defined as an individuals capacity to obtain, process, and

understand information and services needed to make appropriate health decisions.26 Health literacy in the hospital
setting is especially important since education must be
delivered in a setting of an acute illness. A study based in
the United States found that 81% of English-speaking patients over 60 years of age lacked adequate health literacy
to make informed decisions about their health care.27
Researchers have also reported that patient education materials and consent forms in hospital are often above patients reading levels, rendering their comprehension even
more challenging.28-31 We recommend consideration of
patients education, literacy levels, and prior knowledge of
nutrition when planning education for acutely ill persons
at risk for PU development.
Participants in this study expressed differing perceptions of the importance and value of information provided by dieticians. Some patients expressed their gratitude
toward dietetic input in the hospital setting, but others
deemed it unnecessary. These findings suggest that the
role and importance of dieticians are unclear to patients in
the hospital setting, and this lack of knowledge may affect
patients responsiveness to PUP programs that include nutrition education. Interventions such as educational interventions related to nutrition and PUP must be compatible
with individuals values, beliefs, and current needs, and
they must be perceived as feasible and beneficial.32 This
observation is reflected in previous studies exploring staff
perceptions on the role of clinical dieticians.33,34 A study
conducted at a public hospital in Queensland, Australia,
used thematic analysis to explore staff perceptions around
nutrition care.33 They found that the role of the dietician
was unclear to nursing and allied health staff such as pharmacists, speech pathologists, physiotherapists, and occupational therapists. The health care providers also
expressed mixed views on whose responsibility it was to
identify and provide nutritional care to malnourished patients.33 Similarly, a cross-sectional survey of 237 internal
medicine physicians and clinical dieticians in Michigan
found that most responses to questions around the role
and responsibilities of dieticians differed between professions.34 If the role of dieticians is unclear among clinicians
involved in PUP and wound care, it is not surprising that
patients lack an adequate understanding of how consultation with a dietician may provide benefit for prevention of
PU development. Even though evidence supporting the
effectiveness of dietary counseling in PUP or management
of malnutrition in hospitals is lacking,35 nutrition education may be an important component of PUP programs.
This is reflected in international PUP guidelines, which
suggest that patient education is an important aspect of
PUP.36,37 Additional research is needed to determine the
effectiveness of patient and nutritional education on PUP.
Some participants displayed a lack of confidence in dieticians, and they suggested they did not learn anything
new from the dietician, disliked the prescribed dietary

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plan, or thought advice from their dietician contrasted to

information given by their other providers. While dieticians are experts in nutritional care, recent research suggests that general practitioners are the most recognized
health care professional providing nutritional care to
patients with chronic disease in Australia, followed by dieticians.34 Although this study was based in the primary
care setting, it highlights the importance of a consistent
approach to the information provided by all health care
professionals providing care for an individual patient.

Clinical Implications
Three main recommendations arise from this study. We
found that patients at risk of PU development expressed
varying levels of knowledge of the role of nutrition in PUP,
and require tailored education in this area, taking into
account their health literacy. We hypothesize that tailored
education may raise patients knowledge of nutrition and
PU development and increase their participation in their
nutritional care. We also recommend clarification of the
role of dieticians in the clinical setting, as patients appear
to lack an understanding of the potential health gains to
be made from dietetic input and nutritional care in hospital. A better understanding of this role and its importance
in PUP may increase patients responsiveness to dietetic
input and participation in their nutritional care.

Limitations
Interview questions were asked after each patient had participated in an observational study targeting the patients
role in PUP. As patients knew their oral intake was being
monitored, their awareness of a potential role of nutrition
in PUP may have been increased, influencing results of
this study. Participants clinical conditions may have influenced their responses. We sought to minimize this potentially confounding influence by ensuring that
interviews were conducted when patients felt well enough
to participate, ensuring that patients remained comfortable during the interview, and informing participants that
the interview may be ceased at any time if they felt tired
or distressed. Another potential limitation is that analysis
occurred several months after data collection; therefore,
member checking was not possible as patients had been
discharged from hospital. Selection bias is a consideration
in any research. In qualitative research, purposive sampling is used to achieve variation in the experiences being
explored and in this study, recruitment occurred until
data saturation was reached.21 It is always possible that
some views were not represented in our sample.

Conclusions
Findings from this study suggest that patients at risk of
PUs have conflicting views on the role of nutrition in PUP.

Roberts et al

533

Owing to the compromised nutrition seen in many persons at risk for PU development, we believe that selected
patients will benefit from nutritional education aimed at
PUP that is tailored to suit their literacy levels. A better
understanding of the role of dieticians within the clinical
setting may improve patient participation in their nutritional care and associated outcomes.

ACKNOWLEDGMENT

This research received funding from the Area of Strategic

Investment Health and Chronic Diseases, Griffith
University.
Author contributions: Shelley Roberts: Conception and design of the study; collection, analysis, and interpretation
of data; drafting and revision of manuscript; and approval
of final version of manuscript. Wendy Chaboyer and Ben
Desbrow: Conception and design of the study; analysis and
interpretation of data; drafting and revision of manuscript; and approval of the final version of the manuscript.

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DOI: 10.1097/WON.0000000000000100

Copyright 2014 Wound, Ostomy and Continence Nurses Society. Unauthorized reproduction of this article is prohibited.

JWOCN-D-13-00098_LR 534

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