Journal of Tissue Viability 26 (2017) 260e270

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Journal of Tissue Viability

journal homepage: www.elsevier.com/locate/jtv

Development and psychometric validation of a questionnaire to

evaluate nurses' adherence to recommendations for preventing
pressure ulcers (QARPPU)

n Moya-Sua
Ana Bele
rez a, *, Jose

Miguel Morales-Asencio b, Marta Aranda-Gallardo a,
Margarita Enríquez de Luna-Rodríguez a, Jose
Carlos Canca-Sa
nchez a
a
Department of Nursing, Agencia Sanitaria Costa del Sol, Ctra. Nacional 340, Km. 187 Marbella, Ma
laga, Spain
b ~ alosa, Ampliacio
Department of Nursing and Podiatry, Faculty of Health Sciences, University of Malaga, C/Arquitecto Francisco Pen
n del Campus de

laga, Spain
Teatinos, 29071, Ma

a r t i c l e i n f o a b s t r a c t

Article history: Aim of the study: The main objective of this work is the development and psychometric validation of an
Received 12 October 2016 instrument to evaluate nurses' adherence to the main recommendations issued for preventing pressure
Received in revised form ulcers.
29 May 2017
Material and methods: An instrument was designed based on the main recommendations for the pre-
Accepted 1 September 2017
vention of pressure ulcers published in various clinical practice guides. Subsequently, it was proceeded to
evaluate the face and content validity of the instrument by an expert group. It has been applied to 249
Keywords:
Spanish nurses took part in a cross-sectional study to obtain a psychometric evaluation (reliability and
Pressure ulcer prevention
Nursing
construct validity) of the instrument. The study data were compiled from June 2015 to July 2016.
Instrument development Results: From the results of the psychometric analysis, a final 18-item, 4-factor questionnaire was
Reliability derived, which explained 60.5% of the variance and presented the following optimal indices of fit (CMIN/
Validity DF: 1.40 p < 0.001; GFI: 0.93; NFI: 0.92; CFI: 0.98; TLI: 0.97; RMSEA: 0.04 (90% CI 0.025e0.054).
Conclusions: The results obtained show that the instrument presents suitable psychometric properties
for evaluating nurses' adherence to recommendations for the prevention of pressure ulcers.
© 2017 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction
Pressure ulcers are a major challenge to patient health and
safety, affecting the quality of life at all levels e physical, psycho-
logical and social [1e3] e and increasing the risk of death [4,5].
Their prevalence varies considerably. In European hospitals, pres-
sure ulcers are suffered by 7.87% of patients in Spain [6] and 8.3% in
Italy [7], followed by 8.9% in France [8] and Iceland [9]. Higher
values have been reported in Germany, with 11.1% [10] and Belgium
and Portugal, with 12.1%e12.5% respectively [7], while in Denmark,
Ireland, Norway, Netherlands, UK and Sweden, the prevalence
ranges from 15% to 25% [7,9]. Other countries, such as Brazil [11],
* Corresponding author.
E-mail addresses: abelenms@hcs.es (A.B. Moya-Sua
rez), jmmasen@uma.es
(J.M. Morales-Asencio), maranda@hcs.es (M. Aranda-Gallardo), margael@hcs.es
(M. Enríquez de Luna-Rodríguez), jccanca@hcs.es (J.C. Canca-S

anchez).
Turkey [12], Mexico [13] and Indonesia [14] have also conducted
prevalence studies, with China reporting a pressure ulcer preva-
lence of less than 2% [15]. However, these international values
should be interpreted with caution because measurement methods
and criteria may vary from one study to another. In the United
States and Canada, pressure ulcers continue to present a problem,
despite efforts to improve prevention and the greater use of risk
assessment instruments [16]. In short, notwithstanding the
importance of applying preventive policies to reduce the incidence
of pressure ulcers, patients still do not receive adequate health care
[17,18].
Numerous clinical practice guidelines have been issued. If these
recommendations were fully implemented in clinical practice, the
quality of care offered would be greatly improved [19,20]. However,
healthcare personnel, despite having a positive attitude towards
evidence-based practice, face numerous barriers in this respect,
mainly related to a lack of knowledge about research methods and

http://dx.doi.org/10.1016/j.jtv.2017.09.003
0965-206X/© 2017 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.

rez et al. / Journal of Tissue Viability 26 (2017) 260e270
A.B. Moya-Sua
to insufficient resources for their implementation [21]. A review of
nurses' application of clinical practice guidelines [22] has identified
various internal and external barriers. In the former respect, the
most significant factors were found to be attitude (insufficient
motivation and resistance to change) and inadequate knowledge of
the guidelines. The main external barriers concerned the format of
the guidelines, the accessibility of their content, insufficient time,
an absence of leadership and/or feedback and, finally, rigid and
change-resistant organisational environments. Among other rea-
sons for non-adherence by healthcare personnel to the recom-
mendations made in the guidelines are possible contraindications
and the patients' own decisions about their care regime [23]. With
respect to wounds and pressure ulcers, some authors suggest that
adherence to the recommendations is also low because they are
implemented much less often than is stipulated and, sometimes,
because the quality of the interventions made is inadequate
[24e26].
Various papers have explored intervention strategies and
models to enhance the implementation of healthcare recommen-
dations [27e32], including the development of instruments to
evaluate the application of guidelines [29e31] or the adherence by
healthcare personnel to these recommendations [32]. As funda-
mental steps prior to the implementation of recommendations,
most studies emphasise the need to audit clinical practice, to pro-
vide feedback on the findings obtained and to draft an evaluation
plan that includes data-compilation instruments. Such audit and
feedback activities have proven effective in enhancing professional
practice [33,34]. However, according to a review published in 2011
[35], of the 20 studies examined, only nine evaluated professional
practice and none provided feedback about the information
obtained.
To measure the variability of adherence to recommendations
(the Belgian Guideline for the Prevention of Pressure Ulcers,
2002), Paquay et al. [25] designed a three-step algorithm to
evaluate the presence of materials and interventions in accordance
with the Guideline, the presence of materials and interventions
not described in the recommendations, and the absence of mea-
sures of any kind. The authors concluded that adherence was
greater when patients at risk of developing ulcers presented, in
addition, a high level of dependence, poorer skin condition and
had a previous history of pressure ulcer. However, the authors
were unable to draw any conclusions regarding the quality of care
provided, as their study sample only included a small percentage
of the interventions recommended. Furthermore, they did not
validate the psychometric properties of the instrument. Other
studies [36,37] have also examined professional practice in this
respect, using mixed questionnaires inquiring not only about the
actions taken by healthcare personnel to prevent pressure ulcers,
but also about their knowledge and attitudes and the perceived
barriers to optimal practice. However, the response rate obtained
by these questionnaires is sometimes low, due to the large amount
of information required. Other assessment instruments [38] have
investigated how often nurses implement clinical interventions
when the patient is at risk or presents an injury, but these studies
are subject to the limitation that the answers may be influenced
by barriers to completing the questionnaire (lack of resources,
personnel, etc.). A checklist of the main dimensions of the pre-
vention of pressure ulcers has been used to audit nursing practice
regarding the implementation of a prevention programme in an
intensive care unit; however, a study of this activity only per-
formed content validation [39].
The main aim of the present study is to develop and validate an
instrument to evaluate nurses' adherence to the main recommen-
dations published for the prevention of pressure ulcers.
261
2. Method
2.1. Design
Two-phase study: in phase one, the instrument was designed
and its content validated. In phase two, psychometric validation
was conducted in a multicentre study of nine hospitals in Spain,
from June 2015 to July 2016.
2.1.1. Phase 1. designing the instrument and validating its content
An instrument was developed with three parts (questionnaire,
vignettes and characteristics of respondents). After a review of
various clinical practice guideline of pressure ulcer prevention
[40e42] a total of 28 interventions were selected regarding major
areas of preventive care of pressure ulcers (risk assessment, skin
inspection and care, managing pressure, position changes, nutri-
tional care and health education). These were used to generate the
items of the questionnaire. The number of items was chosen so as to
sample systematically all content that potentially could be relevant
to the target construct. The answers were scored on a 5-point Likert
scale representing adherence to each recommendation, for a pa-
tient at risk of developing pressure ulcers (1: Never, 2: Rarely; 3:
Sometimes; 4: Often; 5: Always). In the second section, two clinical
vignettes were created to illustrate the situations of two typical
patients, one at low/moderate risk and the other at greater risk. For
these situations, 14 and 18 interventions, respectively, were
considered (including both advisable and inadvisable actions) from
which the respondent was asked to select those considered
appropriate for the patient's prevention care plan. Finally, a ques-
tion section was included in order to characterize the respondents.
As part of the face and content validation process, the questionnaire
was presented for its consideration to five experts on pressure ul-
cers, members of the Pressure Ulcer Committee at the Costa del Sol
Hospital. All of them had an extensive experience in pressure ulcer
care, teaching and research (PhD level). This expert group assessed
the relevance of each item included in the instrument for assessing
the adherence to preventive recommendations, on the following
scale: 1 ¼ Not at all relevant; 2 ¼ somewhat relevant; 3 ¼ Relevant;
4: Highly relevant.
The content validity index was then calculated, following the
parameters suggested by Lynn [43]. The minimum acceptable score
for content validity was taken as 0.8 [44]. The same group of ex-
perts also evaluated the comprehensibility of each item, on a 5-
point Likert scale (1 ¼ Not at all comprehensible; 2 ¼ Very little;
3 ¼ Somewhat; 4 ¼ Comprensible; 5 ¼ Fully comprehensible). For
consensus on comprehensibility, 80% of evaluators had to agree on
median values equal or above value four. The experts did not pro-
pose any changes to the wording of the questionnaire items or to
the response options. A pilot study was subsequently made of the
instrument, which was completed by 20 hospital care nurses to
assess the manageability, usability and acceptability of the ques-
tionnaire. No modifications were needed (Fig. 1). Finally, the
research team grouped all the proposed items into five dimensions:
risk assessment, skin inspection and care, position changes, force
and pressure relief, health education on measures to prevent
pressure ulcers.
2.1.2. Phase 2. psychometric validation: construct validity and
reliability
The psychometric validation performed included an analysis of
reliability (by Cronbach's alpha), inter-item correlations and the
index of homogeneity. Construct validity was tested by exploratory
and confirmatory factor analysis. Discriminant validity was
assessed by the instrument's ability to distinguish between the
adherence to recommendations by healthcare personnel who
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A.B. Moya-Sua

Please indicate how often you perform the following interventions to prevent

Sometimes
pressure ulcers from forming when you treat a patient at risk of this

Seldom

Always
Never

Often
condition.

p1. To assess the risk of pressure ulcers forming, I rely exclusively on my clinical
judgement as a nurse (without the support of risk evaluation instruments).
p2. To assess the risk of pressure ulcers forming, I take into account my clinical
judgement as a nurse, and also apply a validated risk evaluation instrument
(Braden, Emina, Norton, Waterlow or similar).
p3. I conduct risk evaluation when the patient is admitted, always within six hours
of admission.
p4. I perform a further examination in response to any change in the patient’s
clinical status (for example, after surgery, the worsening of an underlying disease
or a change in mobility).

p5. I prepare an individualised ulcer prevention plan, in writing.

p6. I perform a daily evaluation of the patient’s skin with respect to its integrity,
possible changes in colour or variations in temperature, firmness and
moisture/dryness.
p7. In areas where erythema is apparent, I determine whether it disappears a few
seconds after removing the pressure exerted by palpation with a finger.
p8. If non-blanching erythema is present, I evaluate the affected skin more
frequently (at least every two hours).
p9. I inspect the patient’s skin beneath and around treatment apparatus (catheters,
drains, etc.), at least twice daily for alarm signs related to pressure on the
surrounding skin.

p10. I try to avoid reclining the patient on areas with non-blanching erythema.
p11. When the patient’s clinical condition allows, I evaluate localised pain, as part
of the skin inspection, asking the patient to identify any areas of skin discomfort
and/or pain.

p12. I ensure the patient's skin is kept clean and dry.

p13. I ensure the patient’s skin is protected from excessive moisture, using a
barrier product.

p14. I hydrate dry skin with a moisturiser.

p15. I do not apply massage over bony prominences.

p16. Provided it is not contraindicated by the patient’s clinical status, I apply
postural changes, according to the risk of a pressure ulcer forming.
p17. Provided the patient’s clinical status allows, I encourage him/her to change
position frequently, depending on the risk presented.
p18. When the patient must be moved, I take care to avoid friction and shear
(using slide sheets, transfer boards, hoists, etc.).
p19. When the patient is sitting in a chair, I ensure that the feet are well
supported, either directly on the floor or raised on a footrest or stool.
p20. When the patient is in bed, I maintain the 30º position, unless it is
contraindicated by the health situation or is not tolerated.
p21. I place high-risk patients on a special surface for pressure redistribution (e.g.
a dynamic pressure-relieving mattress, or alternating overlay, or a high
specification foam mattress).
p22. When a patient with reduced mobility sits in a chair for an extended period
of time, I place a surface to redistribute the pressure (pillow, cushion, etc.)
beneath him/her.
p23. I avoid placing the patient directly on treatment devices such as catheters,
drainage systems, etc., unless it is unavoidable.
p24. I ensure that pressure is relieved from the heel by lifting it such that the
weight of the leg is distributed along the calf, without putting pressure on the
Achilles tendon (e.g. by placing a foam pillow or cushion under the calf, leaving
the heel suspended).
p25. I use dressings (hydrocolloids, foam, silicone, etc.) in risk areas to avoid
friction and shear forces.
P26. On admission, I assess the nutritional risk of each patient, using a validated
instrument.
p27. In patients who have nutritional deficiencies and who are at risk of
developing a pressure ulcer, I ensure the nutritional plan is implemented by
informing the multidisciplinary team (nutritionist, treating physician, etc.) of the
situation.
p28. I involve the patient and/or caregiver in learning about preventive care
techniques.

Fig. 1. Initial questionnaire to evaluate nurses' adherence to recommendations for preventing pressure ulcers (QARPPU).

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A.B. Moya-Sua 263

Two case histories are presented below. Please indicate with an X which pressure ulcer prevention measures you would take
for each patient.

Case history 1.

A 79-year-old male was admitted for insertion of a gastrostomy tube, due to dysphagia, the result of chemotherapy for oesophageal
malignancy. Background of interest: former smoker, 20 cigarettes/day, arterial hypertension, angina attack two years previously.
The patient was conscious and oriented, and accompanied by a daughter, who had lived with him and cared for him since the disease
was diagnosed six months previously. A nasogastric enteral feeding tube (brought from home) was fitted, together with a peripheral
venous line in the upper left arm for the administration of fluids. The skin was intact, although in some areas it was less firm as a
result of the weight loss experienced in recent months. Frequent episodes of diarrhoea were experienced (2-3 bowel
movements/day). Mobility was slightly limited due to lack of physical strength. In consequence, a wheelchair was needed for
movement.

Which of the following prevention measures would you take for this patient?

On admission, evaluate the risk of ulcers forming.

Take no prevention measures, as the admission is expected to be short-term.

Apply a barrier cream to the perineum and sacral region after each bowel movement.

Inform the hospital’s nutritionist and/or attending physician of the patient’s loss of weight, frequent bowel movements and lack
of skin firmness.

Advise the patient to change position frequently and to avoid maintaining the same posture for a long time.

Change the patient’s body position every 4 hours.

Apply a moisturising cream to the entire body after bathing, and perform an energetic massage until the cream is completely
absorbed.

Monitor the position of the nasogastric tube and move it at least twice daily.

Place a cushioning ring on the wheelchair to alleviate the pressure.

Explain to the patient and his daughter the importance of keeping the skin clean and dry, and of regularly changing body posture
in bed and when seated.

In conjunction with the patient and his daughter, prepare an ulcer prevention and care plan, in writing.

Encourage the patient, when in bed, to adopt a 90º seated position and thus avoid possible injuries to the back.

Advice the patient not to remain seated in the wheelchair for extended periods without a cushion to alleviate the pressure.

Re-evaluate the risk of ulcer after the surgical intervention and the insertion of the gastrostomy tube.

Case history 2.

An 85-year-old female was admitted with severe cognitive impairment, presenting advanced-stage Alzheimer's disease and normally
resident in a nursing home. The patient was bedridden, required incontinence pads, and was admitted for IV antibiotic therapy for
pneumonia. The patient had a high fever (over 39° C) and non-blanching erythema on both heels.

Which of the following prevention measures would you take for this patient?

No assessment of the risk of this patient developing ulcers is necessary, since she clearly presents a profile of fragility (advanced
age, impaired mobility, cognitive impairment, etc.).

Place a specific pressure redistribution surface (foam mattress, alternating overlay, etc.) on the patient’s bed.

Inspect the patient’s heels once daily.

Conduct a daily assessment of the patient's skin to determine its integrity, and to detect any changes in colour or variations in
temperature, firmness and moisture/dryness.

Fig. 1. (continued).
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A.B. Moya-Sua

Apply a barrier cream to the heels.

Place a dressing on the sacral region.

Place a water-filled balloon beneath the heels to alleviate the pressure.

Design a specific care plan, including changes in body position except at night, to allow rest.

Leave the bedclothes unchanged until the fever abates, in order to avoid further discomfort.

Change the patient’s body position at least every 2 hours.

Change the patient’s body position at every shift change.

With the patient lying on her right side, the head-section of the bed should not be raised by more than 30º.

Monitor food intake, and keep the rest of the team informed about the findings.

Raise the patient’s heels, with the aid of a pillow, ensuring no contact is made with any surface.

Apply a barrier cream to the diaper area.

When the patient is lying down, protect the body areas in contact with the surface of the bed (e.g. the elbows) with pillows or
specific foam surfaces to alleviate the pressure.

With the patient lying on her left side, the bed position should be maintained at 90º.

A urinary catheter should be inserted in order to keep the diaper dry.

Fig. 1. (continued).

applied clinical practice guidelines for the treatment and preven-
tion of pressure ulcers and by those who did not. In addition,
nursing staff were shown two clinical vignettes and asked to state
what intervention would be applied in each case. We then deter-
mined whether the mean scores produced by the instrument
differed between those who applied the measures and those who
did not, as an additional assessment of the instrument's discrimi-
nant capacity.
2.2. Procedure
gl), which is indicative of good fit for values < 3; the root mean
square error of approximation (RMSEA) and its confidence interval
(90% CI), taking 0.05 as the cutoff value for good fit; the Tucker-
Lewis index (TLI), the comparative fit index (CFI), the goodness of
fit index (GFI) and the normative fit index (NFI), with a 0e1 range
and a minimum good fit value of 0.90. The multinormality of the
sample was calculated using Mardia's coefficient of multivariate
kurtosis. All statistical analysis was performed using SPSS v.22 and
AMOS 21.

The questionnaire was sent online to nurses at nine hospitals in

2.4. Ethical considerations
the regions of Andalusia, Navarre and the Balearic Islands (Spain).
The accompanying text explained the purpose of the study, how the
The study was approved by the research ethics committee of the
questionnaire should be completed and the confidentiality of the
Costa del Sol Health Agency and conducted in accordance with the
information, and requested their agreement to participate.
provisions of the Helsinki Declaration.

2.3. Statistical analysis

The content validity index was calculated following the guide-
lines proposed by Lynn. The empirical sample was subjected to
exploratory analysis, obtaining frequency measurements. The
normality of the variables was determined by the Kolmogorov-
Smirnov test, and the skewness, kurtosis and histograms of the
distributions were all examined. Bivariate analysis was conducted
using the Student t-test for normal distributions and the Mann-
Whitney test otherwise, together with the chi square test.
ANOVA, with measures of central robustness, was employed when
non-homoscedasticity was observed (according to the Levene Test),
using the Welch and Brown-Forsythe tests. Correlational analysis
was conducted using Pearson's r and Spearman's rho, depending on
the normality of variables.
Construct validity was determined by exploratory factor anal-
ysis, with extraction by principal axis factoring and by oblique
rotation. Previously, Bartlett's test of sphericity and the KMO test
were performed to determine its relevance. The ceiling/floor effect
was calculated according to the endorsement rate, with a limit of
85%. The fit of the models was determined by confirmatory factor
analysis, using the following indices: the penalising function (c2/
3. Results
3.1. General characteristics of the sample
The questionnaire was completed by 249 nurses, of whom 182
(79.8%) were female and 46 (20.2%) were male. The respondents
were aged between 24 and 63 years, and had an average profes-
sional experience of 19 years (SD 7.283). In terms of academic
achievement, over 80% had at least a bachelor's degree and 76.7%
had completed postgraduate studies on prevention, with 80.4% of
these having done so in the last five years. The largest single group
was that of the nurses who had completed 0e30 h of training in this
respect (40.1%). By medical speciality, the largest numbers of
questionnaires were completed by nurses working in medical
hospitalisation units (36.3%), followed by those in surgical hospi-
talisation (23.3%), intensive care (16.3%) and A&E (10%). 21.3%
(n ¼ 53) of the respondents stated that they did not consult any
literature on clinical decisions concerning the prevention of pres-
sure ulcers. The general characteristics of the sample are described
in Table 1.

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A.B. Moya-Sua 265

Table 1 resulting in a four-factor questionnaire with 18 items, presenting a

Characteristics of the sample. good fit (CMIN/DF: 1.55 p < 0.001; GFI: 0.93; NFI: 0.92; CFI: 0.98;
(n: 249) TLI: 0.97; RMSEA: 0.04 90% CI (0.025e0.054).
Mean (SD) or n (%) The four factors were: 1. Assessment, skin care and selection of
Age1 special surfaces for pressure management; 2. Use of risk prediction
Years of professional activity2 18.9 (7.2) instruments; 3. Postural changes; 4. Force and pressure relief. These
Gender1 factors accounted for 60.5% of the variance (Fig. 2).
Male 46 (20.2)
The mean score for the 18-item questionnaire was 77.11
Female 182 (79.8)
Education2 (SD ¼ 9.40).
High School education 182 (80.2)
Bachelor's degree 21 (9.3) 3.3. Reliability analysis
Master's degree 12 (5.3)
Specialist 11 (4.8)
Doctorate 1 (0.4)
Cronbach's alpha was 0.89 for the 18-item questionnaire. Partial
Occupational training in the Cronbach's alpha values for each factor were 0.86, 0.62, 0.80, and
prevention of pressure ulcers2 0.77. The inter-item correlations produced a mean value of 0.368
Yes 174 (76.7) (range: 0.030e0.667). Table 2 shows the distribution of scores and
No 53 (23.3)
the item-total correlations. Table 3 shows the matrix of inter-item
Duration of training3
0e30 h 69 (40.1) correlation. None of the items presented a ceiling/floor effect. The
30e100 h 67 (39.0) highest endorsement rate recorded was 69.1%, for item 23.
100e300 h 27 (15.7)
>300 h 9 (5.2) 3.4. Discriminant power
Date of most recent training4
<1 year 30 (17.2)
>1 year < 5 years 110 (63.2) Significant differences were found between the type of source
>5 years 34 (19.5) consulted by nurses and the duration of occupational training
Clinical speciality5 received. Thus, 43% (n ¼ 23) of the nurses who had received no
Medical 83 (36.6)
training on the prevention of ulcers (n ¼ 53) did not use any guide
Surgical 53 (23.3)
Intensive care 37 (16.3) to clinical practice as a decision-making instrument (p ¼ 0.021).
A&E 23 (10.1) Analysis of the clinical vignettes also revealed differences in the
Gynaecology 11 (4.8) average score produced by the QARPPU instrument for the in-
Outpatients 5 (2.2) terventions (see Table 4).
Paediatrics 5 (2.2)
Operating Room and Recovery 4 (1.8)
Oncology 3 (1.3) 4. Discussion
Palliative care 2 (0.9)
Other 1 (0.4) In this study, we develop and validate QARPPU, an instrument to
Clinical guidelines consulted to
evaluate the adherence by nurses to the main recommendations
assist in decision making
American College of Physicians (2015) 4 (1.6) published and best practices for the prevention of pressure ulcers.
The National Institute for Health 6 (2.4) Such an evaluation makes it possible to identify current practices
and Care Excellence (2014) and types of decision making by nurses of patients at risk of
National Pressure Ulcer Advisory-European 11 (4.4) developing pressure ulcers. Moreover, the evaluation of adherence
Pressure Ulcer Advisory Panel-Pan
Pacific Pressure Injury Alliance (2014)
is an essential component of audit strategies, providing feedback on
Conselleria de Sanidad Valencia (2012) 10 (4.0) the implementation of evidence and facilitating improvements.
Registered Nurses Association of Ontario (2011) 1 (0.4) Evaluation, thus, is a major element among active strategies for
Consejería de Salud de La Rioja (2009) 4 (1.6) multicomponent intervention (establishing training programmes,
Servicio Andaluz de Salud (2007) 121 (48.6)
forming quality committees, appointing specialists, obtaining
Technical documents issued by the 79 (31.7)
National Study and Advisory feedback, etc.) [45].
Group on pressure ulcers and chronic injuries Our review of the literature shows that none of the instruments
None 53 (21.3) currently being used to independently evaluate adherence in this
Missing responses: 1 ¼ 21; 2 ¼ 22; 3 ¼ 77; 4 ¼ 75; 5 ¼ 12. field have been subjected to rigorous psychometric analysis.
Incorporating the proposed questionnaire on the approach taken to
clinical cases would allow clinical practice to be audited in a
3.2. Construct validity simulation context, thus reducing the response bias that might
arise from barriers to participation [46].
An initial exploratory factor analysis was performed on the 28- The results of our study corroborate the reliability and validity of
item version of the questionnaire, producing a KMO index score of QARPPU. The items in the initial version of the questionnaire were
0.922. Bartlett's test of sphericity was statistically significant developed taking into account the main aspects considered in this
(c2 ¼ 1972.187, p < 0.001). This analysis provided a factorial field, and after consultation with relevant experts. Content validity
structure of five factors that accounted for 49.15% of the variance. was confirmed according to the parameters established by Lynn.
These five factors did not coincide exactly with the five dimensions After psychometric analysis, the final version of the questionnaire
resulting from the content validity process. Therefore, this dimen- provided excellent internal consistency, and consisted of 18 items,
sional structure was tested directly by confirmatory factor analysis, classified into four factors: evaluation, skin care and the selection of
which reflected an imperfect fit (CMIN/DF: 1.40, p < 0.001; GFI: special surfaces for pressure management; the use of instruments
0.93; NFI: 0.92; CFI: 0.88; TLI: 0.86; RMSEA 0.65 90% CI: 0.58e0.63). to predict the risk of a pressure ulcer developing; postural changes;
After analysing the normalised residuals of the covariances, item- and force and pressure relief. The first factor refers to the in-
total correlation and Cronbach's alpha if item deleted, various terventions related to skin assessment and care. This is a key pre-
items were eliminated (questions 5, 7, 8, 9, 11, 15, 22, 26, 27 and 28), vention strategy and includes two items related to the frequency of
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A.B. Moya-Sua

Fig. 2. Factor structure.

risk assessment, a factor that appears in most intervention guide-
lines, together with the use of risk prediction instruments
[40,41,47]. The importance granted to these questions arises from
the fact that in practice, healthcare staff assess the risk when the
skin is first inspected, usually during the first few hours after
admission, and also if any change occurs in the clinical situation, as
recommended in specific publications on skin care [48]. In general,
once the evaluation information has been compiled, the nurse will
complete the risk assessment questionnaire, the second factor in
our analysis. Research has corroborated the reliability and validity
of various instruments for predicting the risk of pressure sores
developing, in contrast to relying exclusively on the clinical judg-
ment of nurses [49]. Nevertheless, the authors of this review sug-
gest that the two approaches should be considered
complementary, with predictive instruments being complemented
by clinical judgement once the patient has been classified according
to the scale of risk, to take into consideration the fact that the
judgement of less experienced nurses tends to be poorer than that
of more senior personnel.
The separation of these two factors might indicate that the
nurses in our study population used their clinical judgment first,
and later complemented it with the assessment instrument in or-
der to make a final decision, which they do at two different times
during the health care provided. The factors influencing this
circumstance should be investigated to determine whether, indeed,
preventive measures are initiated as soon as the clinical judgement
is reached, and the possible consequences of this for patients in
terms of the incidence of pressure ulcers. Attention should also be
paid to the question of whether a subsequent re-evaluation is
carried out, and whether evaluation instruments are employed for

rez et al. / Journal of Tissue Viability 26 (2017) 260e270
A.B. Moya-Sua 267

Table 2
Distribution of scores and reliability for the 18 items.

Scale mean if item deleted Corrected item e Total correlation Cronbach's alpha if item deleted

p1 73.4096 0.278 0.907

p2 73.0281 0.426 0.899
p3 73.1687 0.421 0.899
p4 73.2932 0.507 0.896
p6 72.6627 0.646 0.891
p 10 72.8795 0.520 0.895
p 12 72.5462 0.693 0.891
p 13 72.6466 0.646 0.891
p 14 72.5703 0.708 0.890
p 16 72.6908 0.666 0.891
p 17 72.6506 0.614 0.892
p 18 72.7912 0.560 0.894
p 19 72.7631 0.627 0.892
p 20 72.8313 0.540 0.894
p 21 73.0763 0.521 0.896
p 23 72.4900 0.650 0.892
p 24 72.7390 0.633 0.891
p 25 72.7430 0.670 0.890

Table 3
Inter-item correlation matrix.

p1 p2 p3 p4 p6 p 10 p 12 p 13 p 14 p 16 p 17 p 18 p 19 p 20 p 21 p 23 p 24 p 25

p1 1
p2 ,452** 1
p3 ,197** ,317** 1
p4 ,150* ,242** ,336** 1
p6 ,199** ,285** ,319** ,431** 1
p 10 ,030 ,183** ,195** ,339** ,448** 1
p 12 ,096 ,258** ,403** ,396** ,506** ,391** 1
p 13 ,142* ,272** ,237** ,343** ,470** ,482** ,622** 1
p 14 ,188** ,340** ,342** ,306** ,565** ,450** ,643** ,667** 1
p 16 ,221** ,304** ,277** ,330** ,462** ,384** ,519** ,419** ,559** 1
p 17 ,177** ,236** ,327** ,365** ,386** ,360** ,430** ,377** ,449** ,532** 1
p 18 ,157* ,250** ,202** ,245** ,354** ,310** ,431** ,418** ,392** ,441** ,366** 1
p 19 ,089 ,150* ,186** ,327** ,432** ,390** ,525** ,470** ,499** ,407** ,538** ,571** 1
p 20 ,073 ,138* ,100 ,284** ,422** ,383** ,442** ,426** ,454** ,409** ,328** ,432** ,600** 1
p 21 ,199** ,259** ,235** ,388** ,428** ,238** ,368** ,346** ,330** ,397** ,305** ,357** ,338** ,349** 1
p 23 ,177** ,188** ,245** ,359** ,438** ,412** ,581** ,519** ,495** ,481** ,459** ,470** ,530** ,419** ,374** 1
p 24 ,145* ,222** ,230** ,290** ,412** ,387** ,480** ,414** ,471** ,607** ,593** ,387** ,504** ,429** ,375** ,497** 1
p 25 ,213** ,343** ,377** ,332** ,405** ,452** ,502** ,500** ,556** ,466** ,470** ,394** ,447** ,388** ,357** ,498** ,536** 1

**Correlation is significant at 0,01 level

**Correlation is significant at 0,05 level

this purpose or whether the only criterion applied is that of clinical
judgement, based on the changes observed in the patient's
condition.
This factor also includes an item related to the selection of
special surfaces for pressure management, such as alternating
pressure mattresses and high-density foam. Although few in-
dications exist to guide decision making for selecting this type of
special surface according to the patient's individual needs, it is still
included as a recommendation in many clinical practice guidelines
[40e42]. This inclusion is perhaps to be expected, in view of the fact
that studies of the effectiveness of these surfaces have concluded
that the incidence of pressure ulcers is associated with the clinical
risk and with the surface employed [50]. The Wound, Ostomy and
Continence Nurses Society recently developed and evaluated, by
means of content validation, an algorithm [51] which facilitates
clinical decision making in this field, relating the selection of an
appropriate surface with the risk presented by the patient, ac-
cording to the results obtained from the Braden scale. The above
considerations led us to include this item, in our own study, in the
factor on skin evaluation and the risk of ulcers developing, as both
of these questions are related to decision making.
The third and fourth factors concern repositioning and force and
pressure relief. The importance of both of these areas has been
amply demonstrated [52] and they figure largely in nurses' daily
clinical practice. Nevertheless, few high-quality studies have been
conducted in this area [53]. International guidelines in this respect
refer to the findings of Defloor, 2005 [54], who concluded that high-
risk patients should be placed upon a pressure-reducing surface
and repositioned every 4 h, rather than at shorter intervals on a
standard hospital mattress.
In our study, the healthcare staff who had never received
training on the prevention of pressure ulcers stated that they did
not consult any guidelines on clinical decision making. This cor-
roborates previous research findings about the need to promote
training as part of a combined strategy to enhance professional
practice [55e57].
Our analysis of nurses' appreciation of clinical cases, as reflected
in the questionnaire score, shows that their decisions may vary
significantly, which suggests that this questionnaire is sensitive to
variations in clinical practice regarding the prevention of pressure
ulcers. Moreover, the final 18-item instrument is short and simple
to complete, and can be used to reflect the variability of clinical
practice in the prevention of pressure ulcers, or to evaluate the
impact of strategies for improving performance in this field.
268
rez et al. / Journal of Tissue Viability 26 (2017) 260e270
A.B. Moya-Sua

Table 4
Clinical cases and QARPPU scores.

[n; %]
QARPPU: Mean (SD)

No Yes p

Clinical case 1
On admission, evaluate the risk of ulcers forming. [n ¼ 19; 7.63] [n ¼ 230; 92.36] 0.198
73.52 (14.21) 77.41 (8.87)
Take no prevention measures, as the admission is expected to be short-term. [n ¼ 248; 99.59] [n ¼ 1; 0.40] 0.378
77.08 (9.40) 85.00 (0)
Apply a barrier cream to the perineum and sacral region after each bowel movement. [n ¼ 58; 23.29] [n ¼ 191; 76.69] 0.043
74.74 (10.99) 77.83 (8.77)
Inform the hospital's nutritionist and/or attending physician of the patient's loss of weight, frequent bowel movements [n ¼ 37; 14.89] [n ¼ 212; 85.09] 0.001
and lack of skin firmness. 72.54 (11.55) 77.91 (8.76)
Advise the patient to change position frequently and to avoid maintaining the same posture for a long time. [n ¼ 32; 12.89] [n ¼ 217; 87.09] 0.196
74.96 (11.58) 77.43 (9.02)
Change the patient's body position every 4 h. [n ¼ 156; 62.69] [n ¼ 93; 37.29] 0.411
77.43 (9.34) 76.58 (9.53)
Apply a moisturising cream to the entire body after bathing, and perform an energetic massage until the cream is [n ¼ 191; 76.69] [n ¼ 58; 23.29] 0.110
completely absorbed. 77.46 (9.58) 75.98 (8.75)
Monitor the position of the nasogastric tube and move it at least twice daily. [n ¼ 52; 20.89] [n ¼ 197; 79.89] 0.091
74.96 (11.19) 77.68 (8.81)
Place a cushioning ring on the wheelchair to alleviate the pressure. [n ¼ 167; 67.09] [n ¼ 82; 32.89] 0.463
77.35 (9.48) 76.62 (9.26)
Explain to the patient and his daughter the importance of keeping the skin clean and dry, and of regularly changing body [n ¼ 22; 8.79] [n ¼ 227; 91.19] 0.037
posture in bed and when seated. 72.63 (13.42) 77.55 (8.83)
In conjunction with the patient and his daughter, prepare an ulcer prevention and care plan, in writing. [n ¼ 44; 17.69] [n ¼ 205; 82.29] 0.010
74.20 (10.63) 77.74 (9.02)
Encourage the patient, when in bed, to adopt a 90 seated position and thus avoid possible injuries to the back. [n ¼ 226; 90.79] [n ¼ 23; 9.19] 0.749
77.03 (9.54) 77.91 (7.97)
Advice the patient not to remain seated in the wheelchair for extended periods without a cushion to alleviate the [n ¼ 93; 37.29] [n ¼ 156; 62.69] 0.174
pressure. 75.83 (10.85) 77.87 (8.36)
Re-evaluate the risk of ulcer after the surgical intervention and the insertion of the gastrostomy tube. [n ¼ 43; 17.29] [n ¼ 206; 82.69] 0.027
74.00 (11.66) 77.76 (8.75)
Clinical case 2
No assessment of the risk of this patient developing ulcers is necessary, since she clearly presents a profile of fragility [n ¼ 233; 93.79] [n ¼ 16; 6.39] 0.242
(advanced age, impaired mobility, cognitive impairment, etc.). 77.26 (9.38) 75.00 (9.65)
Place a specific pressure redistribution surface (foam mattress, alternating overlay, etc.) on the patient's bed. [n ¼ 25; 10.00] [n ¼ 224; 90.00] 0.593
75.52 (12.68) 77.29 (8.98)
Inspect the patient's heels once daily. [n ¼ 68; 27.29] [n ¼ 181; 72.69] 0.352
77.41 (10.89) 77.00 (8.88)
Conduct a daily assessment of the patient's skin to determine its integrity, and to detect any changes in colour or [n ¼ 30; 12.00] [n ¼ 219; 88.00] 0.273
variations in temperature, firmness and moisture/dryness. 75.26 (11.88) 77.36 (9.01)
Apply a barrier cream to the heels. [n ¼ 96; 38.59] [n ¼ 153; 61.39] 0.776
77.17 (9.09) 77.07 (9.62)
Place a dressing on the sacral region. [n ¼ 153; 61.39] [n ¼ 96; 38.59] 0.001
75.89 (9.60) 79.06 (8.77)
Place a water-filled balloon beneath the heels to alleviate the pressure. [n ¼ 209; 83.89] [n ¼ 40; 16.09] 0.390
77.17 (9.69) 76.72 (7.82)
Design a specific care plan, including changes in body position except at night, to allow rest. [n ¼ 116; 46.59] [n ¼ 133; 53.39] 0.856
76.88 (10.28) 77.31 (8.59)
Leave the bedclothes unchanged until the fever abates, in order to avoid further discomfort. [n ¼ 244; 98.00] [n ¼ 5; 2.00] 0.187
77.27 (9.26) 69.60 (14.13)
Change the patient's body position at least every 2 h. [n ¼ 73; 29.29] [n ¼ 176; 70.69] 0.642
77.31 (10.08) 77.03 (9.13)
Change the patient's body position at every shift change. [n ¼ 208; 83.49] [n ¼ 41; 16.49] 0.956
76.97 (9.87) 77.82 (6.59)
With the patient lying on her right side, the head-section of the bed should not be raised by more than 30 . [n ¼ 147; 59.00] [n ¼ 102; 41.00] 0.724
76.89 (9.59) 77.43 (9.15)
Monitor food intake, and keep the rest of the team informed about the findings. [n ¼ 48; 19.29] [n ¼ 201; 80.69] 0.052
74.85 (10.81) 77.65 (8.97)
Raise the patient's heels, with the aid of a pillow, ensuring no contact is made with any surface. [n ¼ 44; 17.69] [n ¼ 205; 82.29] 0.111
75.25 (10.54) 77.51 (9.11)
Apply a barrier cream to the diaper area. [n ¼ 42; 16.89] [n ¼ 207; 83.09] 0.597
76.04 (11.30) 77.33 (8.98)
When the patient is lying down, protect the body areas in contact with the surface of the bed (e.g. the elbows) with [n ¼ 38; 15.29] [n ¼ 211; 84.69] 0.759
pillows or specific foam surfaces to alleviate the pressure. 76.21 (12.63) 77.27 (8.72)
With the patient lying on her left side, the bed position should be maintained at 90 . [n ¼ 241; 96.79] [n ¼ 8; 3.19] 0.571
77.17 (9.38) 75.37 (10.59)
A urinary catheter should be inserted in order to keep the diaper dry. [n ¼ 211; 84.69] [n ¼ 38; 15.29] 0.945
77.10 (9.46) 77.18 (9.15)

Bold signifies the statistical significance.


rez et al. / Journal of Tissue Viability 26 (2017) 260e270
A.B. Moya-Sua
4.1. Study limitations
One of the main limitations of this study is the response method
used. As the questionnaire was self-applied, the respondents' an-
swers may be biased towards the desired rather than the usual
practice.
It is important to note that this questionnaire concerns pre-
vention and hospital care. If it is to be used in another context, such
as residential or home care, adaptation might be necessary and
should be considered.
Finally, further analyses to test the invariance of the model and
reproducibility of constructs in different context and settings needs
to be developed.
5. Conclusions
The results of this study indicate that QARPPU, an instrument
designed to measure adherence to recommendations for the pre-
vention of pressure ulcers, presents conceptual validity and that its
psychometric properties make it suitable for use in hospital care.
Conflict of interests
All authors have completed the Unified Competing Interest form
at www.icmje.org/coi_disclosure.pdf (available from the corre-
sponding author) and declare they have received no support from
any organisation for the paper submitted for consideration; neither,
during the previous three years, have they had financial relation-
ships with any organisation that might have an interest in the paper
submitted, nor engaged in other relationships or activities that
could appear to have influenced the work performed.
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