Nurses under pressure: do risk assessment tools help prevent pressure ulcers?

Tools to help assess a patient’s risk of developing a pressure ulcer have been in use for half a century, but do they actually result in fewer pressure ulcers, or do they take up nurses’ time which could be better spent with the patient? An updated Cochrane review gives us the current state of the evidence.

Barts nurses 1983

Barts student nurses learning the ‘Australian lift’ in 1983

Looking back on my nurse training in the 1980s, it seems that efforts to prevent pressure ulcers were a really basic, and essential, part of caring for our patients. Any new reddening of the skin was like a mark of shame for the nurse looking after the bearer of it. I remember sheepskin booties, creams, sorbo rings, a variety of mattresses and, for those particularly at risk, soft pink and white squares, a quirky item which was probably peculiar to Barts Hospital and had a cutesy name (‘pink fluffy’?) which none of us can now recall. We made sure our patients were hydrated and nourished; most of all, we didn’t leave them in one position for a long time. A combination of careful observation and practical measures helped reduce the incidence of pressure ulcers and this is a constant, applying equally today, while pressure-relieving aids are subject to change and moving patients doesn’t look the same now as it did thirty years ago, when manual handling was the norm and lifting techniques learnt in the first days of training.

Nurse taking patient's history

Credit: Libby Welch, Wellcome Images

Then there are the assessment tools used to assess a patient’s risk of developing a pressure ulcer. Back then, it was the Norton Scale, whilst now, for hospital patients in the UK at least, the Waterlow Scale prevails, though around forty different tools are currently in use. The tools list factors believed to contribute to the development of pressure ulcers and award them a numerical value. Assessors choose an option from each parameter (relating to mobility, continence and so on) and calculate a final score. In theory, this helps staff make a baseline assessment of the patient’s condition and their level of risk on admission and helps them plan their care and implement preventive or management strategies from the outset.

Structured pressure ulcer risk assessment tools are recommended in many international guidelines and completing the Waterlow score is a requirement for nurses in NHS hospitals on admitting a patient. But do they actually reduce the number of patients who develop pressure ulcers, compared with no structured risk assessment or clinical judgement alone? A Cochrane review addressing this question has now been updated and one high quality randomised controlled trial (RCT) has been added to the one small cluster RCT which was in the original review.

Here’s what they found:

  • A small RCT conducted in 2009 in a military hospital compared use of the Braden Scale and training, unstructured pressure ulcer risk assessment and training, and unstructured risk assessment only. The trial had methodological problems and is at high risk of bias. There was no difference in pressure ulcer incidence between groups
  • A large RCT in an Australian teaching hospital (internal medicine or cancer wards) compared the Waterlow and Ramstadius assessment tools and clinical judgement alone. This was a high quality trial at low risk of bias. There was no difference in pressure ulcer incidence between groups
  • No reliable evidence to suggest that the use of structured, systematic pressure ulcer risk assessment tools reduces the incidence of pressure ulcers

A workman may only be as good as his tools, but nurses are better than theirs!

Eileen Shepherd (@eileenshepherd), Clinical Editor of the Nursing Times, tweeted the point that a tool is there to support clinical judgement and is only as good as the person using it, and certainly the importance of clinical judgement should not be underestimated. It’s worth bearing in mind, when considering the findings of this review, that information gathered in an unstructured way may closely match that required by a risk assessment tool, because the skilled practitioner will know to look for these things anyway, in which case we perhaps wouldn’t see a reduction in pressure sore incidence with use of the tool. On the other hand, as Tissue Viability Nurse Joy Bell points out in her article for Wounds UK, such tools may be really helpful for new practitioners who lack extensive clinical judgement skills, as long as they (as all staff) are trained to use them properly.

What’s more, the most brilliant risk assessment tool isn’t going to make any difference to the patient’s skin integrity if the assessment isn’t followed up with appropriate action. I asked nurses on Twitter what are the most important things they do to prevent their patients developing pressure ulcers and they told me education (themselves, patients, carers), prioritising continence and nutrition and, of course, repositioning (the jury is out, I think, on intentional rounding). No-one mentioned risk assessment actually!

Drawing by Virginia Powell, ca. 1995. Credit: Wellcome Library, London

Drawing by Virginia Powell, ca. 1995. Credit: Wellcome Library, London

‘What does this mean for patients in our care?’

This is an important question asked by Nurse Ellie (@EllieBean40) in response to my tweet about this review and the current state of the evidence. I’ll be interested to hear your thoughts on this. Joy Bell concludes that structured risk assessment tools do have the potential to enhance patient care whilst acknowledging the lack of robust research. This review highlights that resources are currently being allocated to a practice for which there is no high quality evidence of benefit, in terms of preventing pressure ulcers. But more, excellent, research is needed to determine whether or not it is of value and for which patients or clinical settings.

You can follow us on Twitter @ukcochranecentr. I also tweet as @SarahChapman30


Moore ZEH, Cowman S. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD006471. DOI: 10.1002/14651858.CD006471.pub3.

Cochrane summary of this review

Bell J. Are pressure ulcer grading & risk assessment tools useful? Wounds UK 2005; 1(2):62-9. Available from:

6 thoughts on “Nurses under pressure: do risk assessment tools help prevent pressure ulcers?

  1. Great blog. My memories of nurse training in the 1980s (Liverpool) are very similar to yours although our uniforms were not as nice. It was drummed into us that looking out for, and preserving, skin integrity was one of the most important things you could do. Risk assessment scales/tools (well Norton) were also around but I don’t recall them being slavishly completed and anyway two hourly skin checks and changes of position were so high on our to-do list for patients at risk that it didn’t really matter.
    What is surprising about the findings of this review is that there have been so few randomized evaluations of structured risk assessment (there have been two). What have we nurses been researching if not these aspects of care that are so fundamentally “nursey” and important? What is definitely true is that most of the risk assessment tools in use are not based on fundamental epidemiological research (from cohort studies) about factors prognostic or predictive of pressure ulcer development. Most tools have been dreamt up and are filled with factors that people perceive as important; they are clinical judgement presented as a tool and therefore it is not surprising that they do not out-perform clinical judgement. What matters, as Sarah Chapman says, is what we do in response to identified risk. We need a much more robust evidence base for prevention and that includes better epidemiological research to understand risk but in the meantime there is some observational evidence that making pressure ulcer prevention a top priority can itself help to reduce them.

    • Thank you, and for taking time to leave this thoughtful response. Like you, I don’t remember the Norton score being completed for all, but that ‘pressure area care’, encompassing both assessment (through clinical judgement) and action to prevent our patients’ skin breaking down was a really fundamental part of nursing care.
      You make a really good point that these tools are not based on evidence but on perceptions and it seems extraordinary that this is still the case. We certainly need high quality research, as you have highlighted.

  2. One thing I have often wondered is whether the arrival of high-spec pressure-relieving mattresses has reduced the amount of nursing care patients receive. Although these mattresses have, I am sure, contributed vastly to reductions in numbers and severity of pressure sores, they have also spelled the end of the traditional two-hourly ‘back round’ when at-risk patients were turned and made comfortable and their skin was inspected. Now, with a ‘no need to turn them’ mentality, patients may well be deprived of other benefits of interacting with nurses. In part, this explains the vogue for intentional rounding.

    • This is interesting and I hope some nurses currently in practice will respond with their thoughts on this. You are right, of course, that ‘pressure area care’ provides opportunities for interaction between nurses and patients which may have other benefits.

      We are hoping to have a Twitter discussion with @WeNurses relating to this updated Cochrane review and seeing how much nurses on Twitter have had to say already I hope lots of people will join in.

      Sarah Chapman

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