DISCUSSION PAPER

A new pressure ulcer conceptual framework

Susanne Coleman, Jane Nixon, Justin Keen, Lyn Wilson, Elizabeth McGinnis, Carol Dealey, Nikki
Stubbs, Amanda Farrin, Dawn Dowding, Jos M.G.A. Schols, Janet Cuddigan, Dan Berlowitz, Edward
Jude, Peter Vowden, Lisette Schoonhoven, Dan L. Bader, Amit Gefen, Cees W.J. Oomens &
E. Andrea Nelson

Accepted for publication 1 March 2014

Correspondence to S. Coleman: COLEMAN S., NIXON J., KEEN J., WILSON L., MCGINNIS E., DEALEY C.,
e-mail: medscole@leeds.ac.uk STUBBS N., FARRIN A., DOWDING D., SCHOLS J.M.G.A., CUDDIGAN J.,
BERLOWITZ D., JUDE E., VOWDEN P., SCHOONHOVEN L., BADER D.L.,
Susanne Coleman BSc (Hons) RGN
PURPOSE Programme Manager and Project Lead, G E F E N A . , O O M E N S C . W . J . & N E L S O N E . A . ( 2 0 1 4 ) A new pressure ulcer con-
Leeds Institute of Clinical Trials Research, ceptual framework. Journal of Advanced Nursing 70(10), 2222–2234. doi:
University of Leeds, UK
10.1111/jan.12405
Jane Nixon PhD RN
Professor of Tissue Viability
Leeds Institute of Clinical Trials Research,
Abstract
University of Leeds, UK Aim. This paper discusses the critical determinants of pressure ulcer development
and proposes a new pressure ulcer conceptual framework.
Justin Keen MSc PhD
Professor of Health Politics
Background. Recent work to develop and validate a new evidence-based pressure
Leeds Institute of Health Sciences, University of ulcer risk assessment framework was undertaken. This formed part of a Pressure
Leeds, UK
UlceR Programme Of reSEarch (RP-PG-0407-10056), funded by the National
Lyn Wilson MA RGN Institute for Health Research. The foundation for the risk assessment component
PURPOSE Programme Manager incorporated a systematic review and a consensus study that highlighted the need
Leeds Institute of Clinical Trials Research,
University of Leeds, RM&G officer Mid to propose a new conceptual framework.
Yorkshire Hospital NHS Trust, UK Design. Discussion Paper.
Data Sources. The new conceptual framework links evidence from
Elizabeth McGinnis MSc PhD RGN
Nurse Consultant – Tissue Viability biomechanical, physiological and epidemiological evidence, through use of data
Leeds Teaching Hospitals NHS Trust, UK from a systematic review (search conducted March 2010), a consensus study
Carol Dealey PhD RGN
(conducted December 2010–2011) and an international expert group meeting
Honorary Professor in Tissue Viability (conducted December 2011).
School of Health & Population Sciences,
Implications for Nursing. A new pressure ulcer conceptual framework
University of Birmingham, UK
incorporating key physiological and biomechanical components and their impact
Nikki Stubbs MSc RGN on internal strains, stresses and damage thresholds is proposed. Direct and key
Clinical Lead
Wound Prevention and Management
indirect causal factors suggested in a theoretical causal pathway are mapped to
Service, Leeds Community Healthcare the physiological and biomechanical components of the framework. The new
NHS Trust, UK
proposed conceptual framework provides the basis for understanding the critical
Amanda Farrin MSc determinants of pressure ulcer development and has the potential to influence risk
Professor of Clinical Trials and Evaluation of assessment guidance and practice. It could also be used to underpin future
Complex Interventions
Leeds Institute of Clinical Trials Research,
research to explore the role of individual risk factors conceptually and
University of Leeds, UK operationally.

continued on page 2223

2222 © 2014 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and
no modifications or adaptations are made.
JAN: DISCUSSION PAPER Proposal of a new PU conceptual framework

Dawn Dowding PhD RN Conclusion. By integrating existing knowledge from epidemiological,

VNSNY Professor of Nursing
Columbia University School of Nursing, Columbia physiological and biomechanical evidence, a theoretical causal pathway and new
University, New York, New York, USA conceptual framework are proposed with potential implications for practice and
research.
Jos M.G.A. Schols MD PhD
Professor of Old Age Medicine
Department of Family Medicine and Department Keywords: conceptual framework, nursing, pressure ulcer, risk factors, tissue via-
of Health Services Research, Caphri – School for
Public Health and Primary Care, Maastricht bility
University, the Netherlands

Janet Cuddigan PhD RN FAAN

Associate Professor
Chair, Adult Health and Illness Department,
Interim Chair, Community Based Health
Department, College of Nursing – Omaha
Division, University of Nebraska Medical Center
(UNMC), Omaha, Nebraska, USA Why is this research or review needed?

Dan Berlowitz MD MPH

Co-Director/Professor
• To update the pressure ulcer conceptual framework in light of recent systematic review

Center for Healthcare Organization and

evidence that highlighted the complex interplay of pressure ulcer risk factors.
Implementation Research, Bedford VA Hospital, • To link epidemiological, physiological and biomechanical evidence to facilitate
Massachusetts, USA
increased understanding of the pressure ulcer development.
and Boston University School of Public Health,
Massachusetts, USA
What are the key findings?
Edward Jude MD MRCP
Consultant Physician, Diabetologist and
Endocrinologist/Reader
• The proposal of a theoretical causal pathway for pressure ulcer development that sug-
Department of Medicine, Tameside Hospital NHS gests direct causal factors, key indirect causal factors and other potential indirect cau-
Foundation Trust/University of Manchester, UK sal factors.

Peter Vowden MD FRCS • The proposal of a new pressure ulcer conceptual framework suggesting the relation-
Consultant Vascular Surgeon/Visiting Honorary ships between five key biomechanical components and nine risk factors identified from
Professor/Clinical Director
epidemiological evidence and a consensus study.
Bradford Teaching Hospitals NHS Foundation
Trust/University of Bradford/NIHR Wound
Prevention and Treatment Healthcare Technology How should the findings be used to influence policy/practice/research/education?
Co-operative, UK

Lisette Schoonhoven PhD RN

• The proposed conceptual framework and theoretical causal pathway could be used to
Senior Research Fellow/Reader underpin future research to explore the role of individual risk factors and further
IQ Healthcare, Radboud University Nijmegen increase our knowledge of pressure ulcer development.
Medical Centre, the Netherlands
and Faculty of Health Sciences, University of • The proposed conceptual framework and theoretical causal pathway provide the foun-
Southampton, UK dation for development of evidence-based pressure ulcer risk assessment in clinical
practice.
Dan L. Bader PhD DSc
Professor/Part-Time Professor
Faculty of Health Sciences, University of
Southampton, UK
and Biomedical Engineering Faculty, Eindhoven
University of Technology, the Netherlands

Amit Gefen PhD

Professor Introduction
Department of Biomedical Engineering, Faculty of
Engineering, Tel Aviv University, Israel Pressure ulcers are associated with ill health and poor
mobility and are defined as ‘localized injury to the skin
Cees W.J. Oomens PhD
Associate Professor and/or underlying tissue usually over a bony prominence, as
Biomedical Engineering Department, Biomedical a result of pressure, or pressure in combination with shear’
Engineering Faculty, Eindhoven University of
Technology, the Netherlands (NPUAP/EPUAP 2009). They are a considerable healthcare
problem worldwide (Schoonhoven et al. 2007, Vowden &
E. Andrea Nelson PhD RGN
Head of School and Professor of Wound Healing
Vowden 2009, Pieper 2012) in relation to the detrimental
School of Healthcare, University of Leeds, UK effect they have on the patients’ quality of life (Gorecki

© 2014 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd. 2223
S. Coleman et al.

et al. 2009, 2012), as well as the financial burden to health- Braden and Bergstrom, in their conceptual model impli-
care organizations (Severens et al. 2002, Bennett et al. cated intensity and duration of pressure and tissue tolerance
2004, Schuurman et al. 2009, Berlowitz et al. 2011, Dealey (Braden & Bergstrom 1987). The latter related to the
et al. 2012). The impact pressure ulcers have from both a ability of the skin and its underlying structures to tolerate
quality of life and a financial perspective is influenced by pressure without damage. It was proposed that tissue toler-
their severity. ance would be influenced by extrinsic and intrinsic factors.
Pressure ulcers are categorized according to the interna- Defloor developed his conceptual scheme highlighting the
tional NPUAP/EPUAP (2009) classification system. Cate- importance of pressure (in the form of compressive and
gory I pressure ulcers are areas of skin redness, which do shearing forces), while recognizing that tissue tolerance is
not blanch under light pressure, whereas category II pres- an important consideration (Defloor 1999). However, he
sure ulcers involve skin damage, and category III or IV viewed the latter as an ‘intermediate variable and not a cau-
pressure ulcers involve loss of fat, muscle and bone. Addi- sal factor’. Benoit and Mion developed their conceptual
tional categories of unstageable (full thickness tissue loss model for critically ill patients and also incorporate pres-
where actual depth of the ulcer is completely obscured by sure and tissue tolerance with the latter highlighting extrin-
slough and/or eschar) and suspected deep tissue injury sic factors (Braden moisture and friction and shear) and
(depth unknown: purple or maroon localized area of discol- intrinsic factors (metabolic supply and demand, pressure
oured intact skin or blood-filled blister due to damage of distribution capacity and threats to skin integrity) (Benoit
underlying soft tissue from pressure and/or shear) are also & Mion 2012).
incorporated in the classification system (NPUAP/EPUAP Another conceptual framework was proposed by
2009). To avoid the development of such lesions in clinical NPUAP/EPUAP (2009) and underpins international guid-
practice, much effort is afforded to identifying patients for ance on the prevention and treatment of pressure ulcers. It
whom pressure ulcer prevention interventions are needed. is based on factors that influence mechanical boundary con-
This is achieved by considering patient characteristics or ditions and the susceptibility of the individual. The frame-
risk factors, which predispose them to pressure ulcer devel- work provides a theoretical model of the important
opment, a process known as risk assessment. As risk assess- biomechanical and physiological conditions (of both the
ment is considered the cornerstone to prevention (AHCPR local area and systemically), which influence the develop-
1992, NICE 2003, NPUAP/EPUAP 2009), it is important ment of pressure ulcers. A summary of physiological and
that it is underpinned by an up-to-date conceptual frame- biomechanical evidence is described below.
work. This paper describes the work of an international
expert group and the proposal of a new pressure ulcer con-
Physiological and Biomechanical Evidence
ceptual framework.
The primary cause of pressure ulcers is mechanical load in
the form of pressure or pressure and shear, applied to soft
Background
tissues, generally over a bony prominence (NPUAP/EPUAP
Pressure Ulcer conceptual frameworks provide a theoretical 2009). Key biomechanical terms are defined in Table 1.
model of the critical determinants of pressure ulcer develop- Load that is distributed in a non-uniform or localized man-
ment. This is important for both research and clinical prac- ner, as opposed to a uniform distribution, is potentially far
tice. From a research perspective, pressure ulcer studies more damaging to the tissues and shear forces are thought
should be underpinned by a conceptual framework that is to increase tissue damage caused by pressure (Dinsdale
informed by evidence from all relevant fields of inquiry. 1974, Defloor 1999, Linder-Ganz & Gefen 2007). While it
This guides study aims and objectives and allows theory to is universally recognized that both intensity and duration of
be tested, to further develop the evidence base and concep- pressure are of prime relevance in the development of pres-
tual framework. From a clinical perspective, conceptual sure ulcers, it is difficult to determine the relative contribu-
frameworks are used to underpin pressure ulcer risk assess- tion of these two parameters.
ment guidance and tools/scales used in practice. It is, there- Laboratory and animal studies propose several aetiologi-
fore, critically important that they are updated as new cal mechanisms by which stress and internal strain interact
evidence emerges to facilitate translation of evidence into with damage thresholds to result in pressure ulcer develop-
clinical care. Several pressure ulcer conceptual frameworks ment including localized ischaemia, reperfusion injury,
have been proposed over the course of the last three impaired lymphatic drainage and sustained cell deformation
decades. (Bouten et al. 2003):

2224 © 2014 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd.
JAN: DISCUSSION PAPER Proposal of a new PU conceptual framework

Table 1 Glossary of biomechanical terms based on NPUAP/EP- as a direct result of the release of harmful oxygen free
UAP (2009) clinical practice guidelines and Oomens, Loerakker radicals (Peirce et al. 2000, Unal et al. 2001, Tsuji et al.
and Bader (2010). 2005)
External Mechanical Load: comprises of all modes of external • Impaired lymphatic drainage: Occlusion of lymph ves-
loading applied to a person’s skin as a result of contact between sels in soft tissues caused by external loading is associ-
the skin and a support surface (including air-filled or water-filled
ated with an accumulation of waste products and an
devices that provide support) or contact between the skin of two
body surfaces. The loading can be resolved into:
increase in interstitial fluid contributing to pressure ulcer
Normal force: perpendicular to the skin surface; or development (Miller & Seale 1981, Reddy et al. 1981).
Shear force: parallel to the skin surface • Deformation: recent studies involving, animal, engi-
Pressure: normal force per unit surface area neered muscle tissue and finite element modelling have
In a clinical situation, shear forces require actual contact between focused on the role of deformation in pressure ulcer
the skin and the support surface, associated with normal forces,
development. These studies revealed that strains of suf-
so that the skin will be exposed to a combination of both normal
and shear forces. ficient magnitude have the potential to cause cell death
Normal forces are distributed over the contact area, which over very short periods of time (Gefen et al. 2008).
necessitates use of the term pressure, namely normal force divided Gawlitta et al. (2007) considered the differences in
by the contact area. Shear forces are also distributed over the influence of deformation and ischaemia, using tissue
contact area and create external shear stresses.
engineered muscle and found that deformation per se
Friction: technically, this describes all phenomena that relate to
interface properties and sliding of surfaces with respect to each
had an immediate effect, whereas hypoxia reduced cell
other (e.g. a person’s skin over clothing or bed sheets). In PU viability over prolonged loading periods. Furthermore,
literature, the term ‘friction’ has often been defined as the contact animal experiments involving 2 hours of muscle com-
force parallel to the skin surface in case of ‘sliding’ (i.e. sliding of pression showed that while a complete area of muscle
surfaces along each other). was ischaemic, damage occurred in specific regions
Mechanical Boundary Condition: the mechanical load that is
where high shear strain values were observed (Stekelen-
applied to the skin at the interface with the supporting surface
represents a boundary condition. burg et al. 2007). Subsequent work using finite element
Non-uniform Force: localized to a specific area of the skin surface simulations revealed that the areas of tissue damage
for which the magnitude of force may be variable. coincided with those where the predicted strains
Deformation: change in dimension (shape) as a result of applied exceeded a critical threshold (Ceelen et al. 2008). Once
loading.
the critical threshold has been exceeded, the length of
Strain: a measure of the relative deformation.
Stress: force transferred per unit area. Pressure represents a special
the exposure determined the extent of tissue damage,
type of stress where the forces are all normal to the area over (Loerakker et al. 2010). Loerakker further examined
which they act. the additional effects of reperfusion (Loerakker 2011).
Morphology: size and shape of the different tissue layers. The results indicated that over short periods of loading
Mechanical Properties of the Tissue: refers to the stiffness and exposure, the level of deformation was the most impor-
strength of the tissue material.
tant factor in the damage process for muscle tissue,
Transport Properties: refers to the rate of transport of
biomolecules into/out of tissues, which may be either passive or while ischaemia and reperfusion gradually become
active in nature. Active transport, which is sometimes called dominant over prolonged exposure periods. These bio-
convection, involves metabolite transport by flow in blood engineering studies have provided important new
and/or lymph vessels. insights into the damage thresholds for muscle tissue,
but skin and fat are also implicated in pressure ulcer
• Localized ischaemia: conventionally, ischaemia was development.
thought to be the dominant aetiological factor associ-
An early pathological study identified two pathways for
ated with pressure ulcer development. Obstruction or
pressure ulcer development. This included ulcers presenting
occlusion of the blood vessels in soft tissues caused by
as superficial loss of the epidermis that progresses to deeper
external loading results in ischaemia, reduced supply of
tissues if the pressure remains unrelieved and deep tissue
nutrients to cells and elimination of metabolites (and
injury with necrosis of muscle and fat before destruction of
associated change in pH) from localized areas eventu-
the superficial layers and the appearance of a deep ulcer
ally leading to tissue damage (Kosiak 1961, Dinsdale
(Barton & Barton 1981). Bouten et al. (2003) suggest that
1974, Bader et al. 1986, Gawlitta et al. 2007).
the type of ulcer (superficial verses deep ulcer) depends on
• Reperfusion injury: during the unloading reperfusion
the nature of the surface loading. Superficial pressure ulcers
phase, damage caused by ischaemia may be exacerbated

© 2014 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd. 2225
S. Coleman et al.

are mainly caused by shear stresses in the skin layers, systematic review methods recommended for questions of
whereas deep ulcers are mainly caused by sustained com- effectiveness and adapted for risk factor studies (Cochrane
pression of the tissues. 2009, CRD 2009). A full account of the method and results
At the present time, there is insufficient evidence to pro- are reported by Coleman et al. (2013). Briefly, the search
vide definitive numerical values for the duration of pressure incorporated 14 electronic databases (from inception to
or damage thresholds for pressure ulcer development in a March 2010), grey literature, contact with experts and a
human population. The original Reswick and Rogers (Res- citation search. The search strategy was designed with guid-
wick & Rogers 1976) curve has been revised, as illustrated ance from the collaborative team and includes pressure
in the NPUAP/EPUAP clinical practice guideline (2009), to ulcer search terms (Cullum et al. 2001), OVID maximum
more accurately reflect the risk of tissue damage at the sensitivity filters for Prognosis and Aetiology or Harm and
extremes of the loading periods (i.e. at very short and very OVID maximum sensitivity filter for RCTs (CRD 2009).
long loading times). This indicates that the magnitude of No language restriction was applied. Each included study
pressure to induce tissue damage in the short-term is less underwent quality assessment and all factors entered into
than originally predicted by Reswick and Rogers (Linder- multivariable modelling and those which emerged as signifi-
Ganz et al. 2006, Stekelenburg et al. 2007). cant were identified. Risk factors were categorized into 15
Furthermore, there is inherent variability in both individ- risk factor domains and 46 sub-domains and a narrative
ual susceptibility and local tolerance to loading parameters synthesis was undertaken. Evidence tables were generated
associated with factors including morphology and the for each sub-domain showing the studies where the related
mechanical properties of the intervening tissues. These, in variable emerged as significant and those that did not.
turn, are affected by the patients’ characteristics, health sta- The review included 54 eligible studies that had under-
tus and exposure to specific risk factors. However, consider- taken multivariable analyses and the narrative synthesis
ation of the epidemiological literature and linking of patient identified three primary risk factor domains of immobility,
risk factors to the conceptual framework (NPUAP/EPUAP skin/pressure ulcer status and perfusion (including diabetes),
2009) is not clearly articulated in the existing framework. which emerged most consistently in multivariable model-
This important omission will be addressed in this paper, to ling. Important but less consistently emerging risk factor
facilitate the translation of physiological and biomechanical domains included nutrition, moisture, age, haematological
elements to characteristics that nurses can observe in their measures, general health status, sensory perception and
patients. This has the potential to increase understanding mental status. Only a small number of studies included
and could influence risk assessment guidance and practice. body temperature and immunity and these factors require
further research. Finally, there is equivocal evidence that
race or gender is important to pressure ulcer development
Data sources
(Coleman et al. 2013).
Three sources of data were used to inform this paper. The Identifying the risk factors independently associated with
first two sources included a systematic review of pressure pressure ulcer development, the systematic review (Coleman
ulcer risk factors (Coleman et al. 2013) and a consensus et al. 2013) provides a clearer understanding of the critical
study (Coleman et al. in press). These provided the founda- pressure ulcer risk factors (recognizing that some ‘important
tion for the development and validation of a new evidence- factors’ may still be lacking in confirmatory evidence due to
based Risk Assessment Framework (underpinned by a risk the lack of research rather than the effect of the variable). It
factor Minimum Data Set) for clinical practice. They were should also be noted that being ‘independent’ is a statistical
undertaken as part of a programme of work funded by the concept and does not imply causality (Brotman et al. 2005).
National Institute for Health Research (NIHR) regarding Although the review evidence provides good insight into the
pressure ulcer prevention (PURPOSE: RP-PG-0407-10056). risk factors associated with pressure ulcer development at a
In addition, data from an expert group meeting to consider population level, it does not fully explain the underlying
the pressure ulcer conceptual framework were also used to pathology of pressure ulcer development. Limitations are also
inform this paper. acknowledged. The primary studies of the review mainly
observed superficial rather than severe pressure ulcers. In
general, pressure ulcer risk factors were inconsistently repre-
Systematic review
sented in the modelling of the primary studies and a large
The systematic review aimed to identify the factors most number of potential risk factors (over 250 named
predictive of pressure ulcers. The approach was based on variables) were used, with lack of comparable data fields for

2226 © 2014 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd.
JAN: DISCUSSION PAPER Proposal of a new PU conceptual framework

measurement of the same construct. This limited interpreta- • Factors with weak or limited epidemiological/wider sci-
tion and prevented meta-analysis to identify an item pool for entific evidence and/or clinical resonance, which could
a risk stratification tool. A key recommendation of the review be important at an individual patient level (age, medi-
was the development of a Minimum Data Set (MDS) for cation, pitting oedema, chronic wound, infection, acute
pressure ulcer research and institutional cohorts to facilitate illness and raised body temperature).
future large-scale multivariable analyses and meta-analysis. • Factors with contradictory epidemiological evidence
This would underpin the development of an evidence-based (race and gender) or those considered to be a surrogate
pressure ulcer Risk Assessment Framework (RAF). measure of other key risk factors (mental health, hae-
moglobin).

Consensus study By bringing together the relevant and up-to-date fields of

enquiry and clarifying key risk factors for pressure ulcer
In light of the systematic review findings and limitations, a
development, the consensus study highlighted the need to
consensus study was undertaken to agree the risk factor
undertake an additional piece of work to review and
MDS that would underpin the development of the RAF. It
enhance the pressure ulcer conceptual framework (NPUAP/
would identify the risk factors and assessment items
EPUAP 2009).
important for summarizing patient risk. The consensus
study was undertaken between December 2010–December
2011. A full account of the methods and results is Expert group meeting
reported elsewhere (Coleman et al. in press). In summary,
the study used a modified nominal group technique based Aim
on the Research and Development/University of California
To consider the critical determinants of pressure ulcer
in Los Angeles (RAND/UCLA) appropriateness method. It
development to propose a new conceptual framework. The
incorporated an international expert group comprising 17
objectives were to:
clinical and academic leaders including nurses (academic
and clinical nurse specialists), doctors (diabetologist, vascu- • Review and update the biomechanical elements of the
lar surgeon, elderly care medicine and public health), conceptual framework (NPUAP/EPUAP 2009).
bioengineers, epidemiologist and individuals with organiza- • Propose a theoretical causal pathway for pressure ulcer
tional development and clinical decision-making expertise. development.
To agree the risk factors to be included in the MDS and • Map risk factors identified in the consensus study to
RAF, the expert group considered the evidence of the sys- the updated conceptual framework.
tematic review (Coleman et al. 2013), wider scientific evi-
dence drawn from the expertise of the group and clinical
Data collection
resonance (i.e. its considered importance to clinical prac-
tice). In addition, the views of a patient and public involve- The expert group of the consensus study reconvened in
ment (PPI) service user group (Pressure Ulcer Research December 2011 to address the aim and objectives detailed
Service User Network: PURSUN) were also considered in above. The meeting was led by two experienced facilita-
relation to the acceptability of proposed assessment ele- tors and the discussions were audio-recorded and tran-
ments. During the consensus process, four levels of risk fac- scribed, allowing key themes to be identified. The meeting
tors were identified as follows: was planned, so that members had access to the outcomes
of the consensus study (Coleman et al. in press), evidence
• Factors with strong epidemiological/wider scientific evi-
of the systematic review (Coleman et al. 2013) and causal
dence and clinical resonance that increase the probabil-
factor terminology prior to the face-to-face meeting.
ity of pressure ulcer development (immobility, skin/PU
Familiarity with the causal factor terminology allowed us
status and perfusion).
to explore the role of the risk factors in the pressure ulcer
• Factors with good epidemiological/wider scientific evi-
causal pathway. This was facilitated by consideration of
dence and/or good clinical resonance, but showing
definitions suggested by Brotman et al. (2005):
some inconsistency in their statistical association with
pressure ulcer development (albumin, sensory percep- • Risk factor – a variable with a significant statistical
tion, diabetes, nutrition and moisture). association with a clinical outcome.

© 2014 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd. 2227
S. Coleman et al.

• Independent risk factor – a risk factor that retains its the validity of consensus judgements at the time the judge-
statistical association with the outcome when other ments are made (Black et al. 1999), the consensus study
established risk factors for the outcome are included in applied principles of good practice in the planning and
a statistical model. delivery of the consensus process as previously reported
• Non-independent risk factor – a risk factor that loses (Coleman et al. in press). This included the involvement of
its statistical association with the outcome when other a mixed-speciality expert group (Hutchings & Raine 2006)
established risk factors for the outcome are included in and consideration of relevant evidence throughout the pro-
a statistical model. cess. Following analysis of the conceptual framework meet-
ing, the researcher (SC) drafted the new proposed pressure
Brotman et al. (2005) suggests that a causal factor is a ulcer conceptual framework and theoretical causal pathway
risk factor that has a causal relationship with a clinical out- and circulated this to the expert group via email to ensure
come and is defined experimentally (known to affect out- content validity. This led to minor revisions of the work.
come) rather than statistically. He makes a distinction
between direct and indirect causal factors:
Results
• Direct causal factor – directly impacts the outcome (or
the likelihood of the outcome). Revised NPUAP/EPUAP conceptual framework (2009)
• Indirect causal factor – impacts the outcome (or affects
its likelihood of occurrence) by changing a direct causal The in-depth discussions of the expert group led to amend-
factor. If the direct causal factor is prevented from ments to the existing NPUAP/EPUAP conceptual framework
changing, then changes in the outcome will not be pro- (2009), as detailed in Figure 1. Most notably, it was recog-
duced. nized that while mechanical properties of the tissues and
geometry (morphology) of the tissues and underlying bones
In our work, we further categorized indirect causal fac- have an impact on the internal strains and stresses (as an
tors into key indirect causal factors (where the epidemiolog- example, subjects who are either very emaciated or very
ical/wider scientific evidence and/or clinical resonance was obese will have enhanced strains and stresses in the soft tis-
stronger) and other indirect causal factors. sues), its impact was considered to be more relevant to the
susceptibility of the individual, i.e. having an impact on the
damage threshold and so was moved as detailed in Fig-
Ethical considerations
ure 1. Furthermore, transport (perfusion and lymphatic
No formal ethical scrutiny was required or undertaken for drainage) also has an impact on the damage threshold of
the conceptual framework expert group meeting. the individual and this would be affected by temperature in
terms of vasodilation/vasoconstriction, thereby affecting tis-
sue perfusion. The underlying physiology of an individual
Data analysis
will also have an impact on their repair capacity and this
The findings of the consensus study (Coleman et al. in was an important consideration that was captured in the
press), which identified the pressure ulcer risk factors con- amended conceptual framework (Figure 1). The amended
sidered important for summarizing patient risk, provided conceptual framework and its key components provided the
the initial framework to address the study aims. In addi- foundation on which to link to the epidemiological
tion, the researcher (SC) listened to the audio-tapes of the evidence.
conceptual framework expert group meeting discussions
and read the associated transcripts in total to ensure com-
Theoretical causal pathway
pleteness. The analysis provided the basis for the new pro-
posed pressure ulcer conceptual framework and theoretical The proposed causal pathway for pressure ulcer develop-
causal pathway. ment detailing the direct, key indirect and other potential
indirect causal factors is illustrated in a theoretical schema
(Figure 2). Table 2 shows the mapping of the direct causal
Validity and reliability
factors and key indirect causal factors against the key
Validity and reliability issues relating to this study are components of the enhanced NPUAP/EPUAP (2009) con-
linked to the preceding consensus study (Coleman et al. in ceptual framework. Although it was recognized that the
press). While it is acknowledged that it is difficult to assess presence and weighting of specific risk factors may vary in

2228 © 2014 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd.
JAN: DISCUSSION PAPER Proposal of a new PU conceptual framework

Mechanical boundary conditions

Internal strains
Magnitude of mechanical load
Stresses
Time duration of the mechanical load
Type of loading (shear, pressure, friction)

Risk factors
Pressure
ulcer?

Susceptibility and tolerance of the individual

Individual mechanical properties of the tissue
Individual geometry (morphology) of the tissues and
bones Damage threshold
Individual physiology& repair
Individual transport and thermal properties

Figure 1 Enhancement of NPUAP/EPUAP (2009) factors that influence susceptibility for pressure ulcer development.

Other Potential Indirect Causal Key Indirect Causal Factors Direct Causal Factors
Factors

Immobility
Older age Poor Sensory
perception &
response

Medication Diabetes

Pitting oedema Skin/PU Status Outcome

Pressure Ulcer

Chronic wound Moisture

Poor nutrition
Infection
Acute illness Low Albumin Poor perfusion
Raised body
temperature

Figure 2 Theoretical schema of proposed causal pathway for pressure ulcer development. The solid arrows show the causal relationship
between the key indirect causal factors and direct causal factors and the outcome. Interrupted arrows show the causal relationship between
other potential indirect causal factors and key indirect causal factors and between direct causal factors. Interrupted arrows also demonstrate
interrelationships between direct causal factors and indirect causal factors.

relation to the anatomical site of the pressure ulcer, it was (incorporating existing and previous pressure ulcer and
not possible to delineate the evidence to skin site level risk general skin status) and perfusion. Immobility is a neces-
factors. sary condition for pressure ulcer development and,
through its affect on mechanical boundary conditions
(Table 2), has a direct impact on the outcome (or the like-
Direct causal factors
lihood of the outcome). It is, therefore, considered a direct
Three characteristics were classified as direct causal causal factor (Figure 2). Of note is that friction and shear
factors including immobility, skin/pressure ulcer status is not specified as a patient characteristic, rather it is a

© 2014 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd. 2229
S. Coleman et al.

Table 2 Mapping of direct causal and key indirect causal factors to the conceptual framework.
Mechanical Boundary
Conditions: Type of
loading (shear, pressure,
friction) & magnitude Individual Geometry Individual Individual
& duration of (Morphology) of the Individual Mechanical Transport & Physiology
Risk Factor mechanical load tissue & bones Property of the Tissues Thermal Properties & Repair

Immobility X

Skin/PU Status X X X X

Poor Perfusion X X

Poor Nutrition (x) in extreme cases (x) in extreme cases X X

Moisture X X

Poor Sensory Perception (x) through immobility

& Response

Diabetes (x) through sensory (x) through perfusion

perception

Low Albumin (x) through perfusion

characteristic of the mechanical boundary condition healthy tissues. Other factors such as the delivery of nutri-
(Table 2). ents and waste removal were also considered important,
Identifying whether skin/pressure ulcer status and poor although at present, it is difficult to ascertain the most cru-
perfusion represent direct or indirect risk factors is less cial factors relating to perfusion. Further confirmatory
straight-forward. It could be assumed that they are indirect research is needed to more clearly ascertain the aetiological
factors as without some degree of immobility, a pressure mechanisms of importance.
ulcer would not develop. However, this is not in keeping
with the definitions of causal factors detailed above. Fur-
Key indirect causal factors
thermore, it oversimplifies the complex interplay of factors
required to lead to tissue damage. There is strong epidemio- Moisture, sensory perception, diabetes, low albumin and
logical/wider scientific evidence that poor perfusion and poor nutrition were considered key indirect causal factors, as
skin/pressure ulcer status reduce patients’ tolerance to pres- they have an impact on the outcome (or affect its likelihood
sure and increase the likelihood of pressure ulcer develop- of occurrence) by changing a direct causal factor (Figure 2).
ment. This suggests that they are direct causal factors and
may explain why some immobile patients develop pressure
Other potential causal factors
ulcers while others do not.
Further insight was gained by mapping skin/pressure The theoretical conceptual schema (Figure 2) was further
ulcer status and poor perfusion to the conceptual frame- developed to include other indirect causal factors to illus-
work and it was apparent that they were clearly implicated trate the potential relationships and impact of diverse fac-
in the susceptibility and tolerance aspect of the framework tors that may be involved in the causal pathway. However,
(Table 2). Skin/pressure ulcer status mapped to the individ- it is recognized that the interrelationships among potential
ual geometry (morphology) of the tissue and bones, the and key indirect causal factors are complex and require fur-
mechanical property of the tissues, the transport and ther- ther elucidation. Other indirect causal factors include those
mal properties and the physiology and repair aspects of the with weak or limited epidemiological/wider scientific evi-
framework. Perfusion mapped to the individual transport dence, but are thought to have an impact on key indirect
and thermal properties and the physiology and repair ele- and direct causal factors. They include age, medication,
ment of the framework and is related to factors that impair pitting oedema and other factors relating to general health
circulation. In the expert group, it was recognized that the status including infection, acute illness, raised body temper-
oxygen-carrying capacity was important in maintaining ature and chronic wound.

2230 © 2014 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd.
JAN: DISCUSSION PAPER Proposal of a new PU conceptual framework

paper only considers a one-directional relationship between

New proposed pressure ulcer conceptual framework
risk factors but, in reality, bi-directional relationships exist
Following consideration of the causal pathway for pressure and causal factors may have multiple roles in a pathway
ulcer development (Figure 2) and mapping of direct and (e.g. moisture has an impact on the vulnerability of the skin
key indirect causal factors for pressure ulcer development and may also effect the impact of immobility by increasing
against the components of the enhanced conceptual the likelihood of friction and shear).
framework (Table 2), a new conceptual framework (Fig- It should be noted that the new conceptual framework
ure 3) is proposed. This enables the epidemiological evi- does not consider varying parameters of risk factors (e.g.
dence to be linked to the physiological and biomechanical patients have varying levels of mobility, nutrition, moisture,
elements of the conceptual framework. The new framework etc.) in the causal pathway and how these have an impact
proposes the relationship between the mechanical boundary on pressure ulcer outcome. Furthermore, it does not explain
conditions and the susceptibility and tolerance of the indi- how varying combinations of risk factors increase the likeli-
vidual. The risk factors that have an impact on the mechan- hood of pressure ulcer development. The importance of
ical boundary conditions and the susceptibility and individual risk factors may also vary in relation to body
tolerance of the individual are detailed in the framework site, for example a patient with peripheral vascular disease
and are based on the direct causal factors including immo- may have reduced tolerance to pressure to their heels, but
bility, skin/pressure ulcer status and poor perfusion, as well not to their trunk areas. Patients may also have conditions
as the key indirect causal factors of poor sensory perception such as contractures, which may increase their risk of pres-
and response, diabetes, poor nutrition, moisture and low sure ulcers at less commonly encountered body sites. In
albumin. For simplicity, the risk factors are represented addition, the new conceptual framework does not clearly
under the elements they are thought to predominantly affect articulate the aetiological mechanisms of importance for
(either mechanical boundary conditions or susceptibility risk factors, for example there is still uncertainty about the
and tolerance of the individual). However, the interrupted specific mechanisms of importance relating to perfusion.
line running under the risk factors indicates that some risk Limitations of the approach relate to the uncertainties
factors may have an effect on both sides of the framework, associated with the primary research considered in the con-
which is more clearly articulated in the theoretical schema sensus study (Coleman et al. in press) and in the proposal
(Figure 2) and risk factor mapping (Table 2). The absence of the new conceptual framework. The bioengineering
of risk factors on either the individual susceptibility and tol- research is limited due to its development in animal or tis-
erance or the mechanical boundary conditions side of the sue-engineered muscle models as opposed to human sub-
framework would affect the likelihood of pressure ulcer jects. The evidence of the systematic review is limited by
development, i.e. a patient with good perfusion may be able poor reporting, heterogeneity of patient populations, incon-
to tolerate higher levels of immobility (without developing sistent inclusion of pressure ulcer domains, inconsistent
a pressure ulcer) than someone with poor perfusion. measurement of risk factor variables, the use of different
outcomes and lack of differentiation between pressure ulcer
sites. Furthermore, the primary studies of the systematic
Discussion
review mainly observed superficial pressure ulcers, while
This new proposed pressure ulcer conceptual framework much of physiological and bioengineering research relates
incorporates key physiological and biomechanical compo- to muscle tissue and it could be argued that the associated
nents and their impact on internal strains, stresses and aetiological mechanisms differ. However, there is no evi-
damage thresholds. Direct and key indirect causal factors dence that the key direct causal factors for superficial or
suggested in a theoretical causal pathway are mapped to deep pressure ulcers are different, rather it is the nature of
the physiological and biomechanical components of the surface loading that influences the type of pressure ulcer
framework. Agreeing the proposed elements of the new that develops (i.e. initially developing superficially or in
conceptual framework proved challenging as while the muscle tissue) (Bouten et al. 2003).
physiological and bioengineering research, the systematic
review and the outcomes of the consensus study (Coleman
Implications for nursing
et al. in press) provide a good starting point, there are still
many gaps in the evidence base. In addition, the proposal The new conceptual framework and theoretical causal path-
of a causal pathway for any condition/disease is a compli- way together propose clearer linkage between the physio-
cated process. For simplicity, the pathway detailed in this logical and biomechanical determinants of pressure ulcer

© 2014 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd. 2231
S. Coleman et al.

Individual Susceptibility
& Tolerance
Physiology & repair
Transport & thermal properties

Individual damage Mechanical properties of the

threshold exceeded tissue e.g. stiffness, strength
Geometry (morphology: size
Mechanical Boundary
& shape of different tissue
Conditions
layers) of the tissue & bones
Magnitude and duration
of mechanical load
Type of load: pressure, Risk Factors
shear & friction
Skin / PU status
Poor perfusion
Risk Factors PU Conceptual Poor nutrition
Immobility Framework to show
Diabetes
the balance for PU
Poor sensory perception development Moisture
& response
Low albumin

Figure 3 New pressure ulcer conceptual framework.

development and patient risk factors. They provide a frame- ation and enhancement of the NPUAP/EPUAP (2009) con-
work for understanding the critical determinants of pressure ceptual framework, the proposal of a theoretical causal
ulcer development and facilitate the translation of physio- pathway for pressure ulcer development and mapping of risk
logical and biomechanical elements to characteristics that factors to the conceptual framework. The new conceptual
nurses can observe in their patients. They could lead to framework and theoretical causal pathway propose the
increased understanding and have the potential to influence critical determinants of pressure ulcer development and
risk assessment guidance and practice. could influence risk assessment guidance and practice. They
The proposed conceptual framework and theoretical cau- could also be used to underpin and guide future pressure
sal pathway also have implications for research. They pro- ulcer research, to further explore the relationship between
vide an up-to-date account of how existing evidence can be risk factors and increase our understanding of pressure ulcer
used to develop theory and help to identify gaps in our development.
knowledge base. These could be used to underpin and guide
future research, building on the evidence and enabling us to
more clearly define the role of individual pressure ulcer risk
Funding
factors conceptually and operationally. This publication presents independent research funded by
the National Institute for Health Research (NIHR) under
its Programme Grants for Applied Research Programme
Conclusion (RP-PG-0407-10056). The views expressed in this publica-
This paper describes work undertaken by an international tion are those of the author(s) and not necessarily those of
expert group and the proposal of a new pressure ulcer con- the NHS, the NIHR or the Department of Health.
ceptual framework. The approach incorporated consider-
ation of physiological, biomechanical and epidemiological
Conflict of interest
evidence, as well as the outcomes of a consensus study and
the views of an expert panel. This was enabled by consider- No conflict of interest has been declared by the author(s).

2232 © 2014 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd.
JAN: DISCUSSION PAPER Proposal of a new PU conceptual framework

Coleman S., Nelson E.A., Keen J., Wilson L., McGinnis E., Dealey
Author Contributions
C., Stubbs N., Muir D., Farrin A., Dowding D., Schols
The authors have confirmed that all authors meet the IC- J.M.G.A., Cuddigan J., Berlowitz D., Jude E., Vowden P., Bader
D.L., Gefen A., Oomens C.W.J., Schoonhoven L. & Nixon J. (In
MJE criteria for authorship credit (www.icmje.org/ethi-
press) Developing a pressure ulcer risk factor minimum data set
cal_1author.html), as follows:
and risk assessment framework. Journal of Advanced Nursing.

• substantial contributions to conception and design of, or CRD (2009) Systematic Reviews: Centre for Reviews and
Disemminations Guidance for Undertaking Reviews in Health
acquisition of data or analysis and interpretation of data,
Care. University of York. Retrieved from http://www.york.ac.uk/
• drafting the article or revising it critically for important inst/crd/index_guidance.htm on January 2012.
intellectual content, and Cullum N., Nelson E.A., Flemming K. & Sheldon T. (2001)
• final approval of the version to be published. Systematic reviews of wound care management: (5) beds; (6)
compression; (7) laser therapy, therapeutic ultrasound,
electrotherapy and electromagnetic therapy. Health Technology
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