Table of Contents
Type: Dissertation proposal | Subject: Nursing | Level: Undergraduate | Word Count: ~2,100 words
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Overview: A model undergraduate nursing dissertation proposal that sets out a quantitative, pre-test/post-test evaluation of a structured risk-assessment and repositioning bundle designed to reduce hospital-acquired pressure ulcers on two UK acute wards. It demonstrates how to build a focused PICO question, justify a quasi-experimental design in an NHS setting, and plan ethics, data collection and analysis to an academically rigorous standard.
Hospital-acquired pressure ulcers (HAPUs) remain one of the most frequently reported patient-safety incidents on acute wards within the United Kingdom’s National Health Service. A pressure ulcer is localised damage to the skin and underlying soft tissue, usually over a bony prominence, caused by sustained pressure, shear or a combination of the two. Although they are widely regarded as largely preventable, pressure ulcers continue to cause avoidable pain, delayed recovery and prolonged length of stay, and they are associated with a considerable burden of wound care across the NHS (Guest et al., 2020). For older adults and those with reduced mobility on acute medical and surgical wards, the risk is especially pronounced, because immobility, comorbidity and periods of acute illness combine to compromise skin integrity at precisely the time when patients are least able to protect themselves.
National guidance recommends that every adult admitted to secondary care receives a documented pressure-ulcer risk assessment within six hours of admission, followed by proportionate preventive measures such as repositioning, skin inspection and the provision of pressure-redistributing equipment (National Institute for Health and Care Excellence, 2014). Despite this, local clinical-governance data and routine ward audits frequently reveal inconsistent risk-assessment documentation and variable adherence to repositioning schedules. This proposal sets out a plan for an undergraduate dissertation that evaluates whether a structured, bundled risk-assessment intervention can reduce the incidence of HAPUs on two acute wards at a single NHS trust. The study is framed as a quantitative, pre-test/post-test evaluation grounded in established prevention frameworks and current clinical guidelines.
The central problem addressed by this proposal is the persistence of avoidable pressure damage on acute wards despite the availability of clear preventive guidance. Risk-assessment tools such as the Braden Scale are well validated, yet the evidence suggests that tools alone do not reliably change outcomes unless they are embedded within a consistent, team-based care process (Moore and Cowman, 2014). The rationale for this study is therefore twofold. First, pressure ulcers represent a clear nursing-sensitive outcome, meaning that the quality and consistency of nursing care directly influence their occurrence; this makes them an appropriate focus for a nursing dissertation. Second, a bundled approach that combines structured assessment, scheduled repositioning, skin inspection and brief staff education offers a plausible mechanism for translating guideline recommendations into measurable improvement at ward level. Establishing whether such a bundle reduces incidence in a local acute setting would provide useful evidence to inform ward practice and to shape future quality-improvement work.
The aim of this study is to evaluate the effect of a structured risk-assessment and repositioning bundle on the incidence of hospital-acquired pressure ulcers among adult inpatients on two UK acute wards. The specific objectives are:
The study is guided by a focused clinical question structured using the PICO framework, which supports a clear quantitative design and keeps the methodology aligned with a single, measurable outcome.
| Element | Definition for This Study |
|---|---|
| P — Population | Adult inpatients on UK acute medical and surgical wards |
| I — Intervention | A structured risk-assessment and repositioning bundle |
| C — Comparison | Standard care delivered during the pre-intervention period |
| O — Outcome | Incidence of category 2 or higher hospital-acquired pressure ulcers |
The resulting research question is: among adult inpatients on UK acute wards, does the implementation of a structured risk-assessment and repositioning bundle, compared with standard care, reduce the incidence of category 2 or higher hospital-acquired pressure ulcers?
A preliminary review of the literature establishes both the scale of the problem and the rationale for a bundled intervention. Pressure ulcers are conceptualised as the product of interacting mechanical and physiological factors, including the intensity and duration of pressure, tissue tolerance, mobility, perfusion and skin condition (Coleman et al., 2014). This conceptual understanding supports interventions that address several risk pathways at once rather than relying on any single measure, and it frames the present study’s emphasis on a multi-component bundle.
Risk-assessment tools occupy a central place in prevention guidance. The Braden Scale, which rates sensory perception, moisture, activity, mobility, nutrition, and friction and shear, is among the most widely used and validated instruments internationally (Bergstrom et al., 1987). However, a Cochrane review found limited high-quality evidence that the use of structured risk-assessment tools, in isolation, reduces pressure-ulcer incidence (Moore and Cowman, 2014). This apparent paradox is often explained by variation in how assessment results are acted upon; a documented score has little value unless it reliably triggers timely and proportionate preventive care.
Repositioning is a core preventive intervention, and a further Cochrane review concluded that, although repositioning is widely recommended, the optimal frequency and position remain uncertain and the supporting trial evidence is of modest quality (Gillespie et al., 2020). International clinical guidance nonetheless endorses individualised repositioning alongside skin assessment and appropriate support-surface selection as part of a comprehensive prevention strategy (European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance, 2019). Staff education and nutritional assessment are commonly cited as further components that strengthen a prevention programme, and economic analyses consistently indicate that prevention is less costly than treatment, which strengthens the case for reliable preventive practice (Demarré et al., 2015).
Taken together, the literature suggests that the individual components of prevention are well established, but that their combined and consistent delivery is where everyday practice frequently falls short. This supports the present study’s focus on a bundled intervention and on process measures as well as outcomes. It also reveals a gap: much of the existing evidence derives from controlled trials and systematic reviews, with comparatively few pragmatic evaluations of bundled interventions delivered under ordinary UK acute-ward conditions. The proposed study is designed to address that gap at a local level.
A quantitative, quasi-experimental pre-test/post-test design will be used. This before-and-after approach is appropriate for evaluating a service-level intervention where randomisation of individual patients is impractical, because it compares outcomes on the same wards before and after the bundle is introduced. A quantitative design aligns with the research question, which concerns measurable incidence, and with the positivist assumption that pressure-ulcer rates can be objectively observed and counted (Polit and Beck, 2021). The absence of a concurrent control group is acknowledged as a limitation and is addressed later in this proposal.
The study will be conducted on two acute adult wards, one medical and one surgical, within a single NHS trust. Consecutive sampling will be used, meaning that all eligible adult patients admitted during the pre- and post-intervention periods will be included. Eligibility criteria are age eighteen or over and an expected stay of at least twenty-four hours. Patients admitted with an existing pressure ulcer will be recorded but excluded from the incidence calculation, so that only hospital-acquired damage is counted. An illustrative sample-size estimate, assuming a baseline incidence of approximately eight category 2 or higher HAPUs per one thousand patient-bed-days and a clinically meaningful relative reduction of around one third, indicates that each period should encompass roughly three months of ward activity; a formal power calculation will be confirmed with a statistician before data collection begins.
The intervention is a structured prevention bundle comprising four linked elements. First, a Braden Scale risk assessment will be completed within six hours of admission and repeated at defined intervals and after any change in condition. Second, patients will follow an individualised repositioning schedule, with a default minimum frequency informed by their risk level and documented on a bedside chart. Third, a structured skin-inspection routine will be carried out at each repositioning point, with early signs of damage escalated promptly to the tissue-viability team. Fourth, ward nursing staff will receive brief, standardised education on the bundle and its rationale before the post-intervention period begins. The bundle is intentionally designed to be deliverable within existing staffing and resources, which improves the likelihood that any observed effect would be transferable to comparable wards.
Data will be collected prospectively during both periods using a standardised audit tool. The primary outcome, incidence of category 2 or higher HAPUs, will be drawn from routine skin-inspection records and the trust’s incident-reporting system, with ulcers staged according to the international classification system. Process measures, namely the proportion of patients with a timely documented risk assessment and the proportion of scheduled repositionings recorded as completed, will be captured through weekly ward audits. Denominator data on patient-bed-days will be obtained from ward activity records. Using the same definitions, instruments and data sources in both periods is essential to the validity of the before-and-after comparison.
Data will be analysed using descriptive and inferential statistics within appropriate statistical software. Incidence will be expressed as the number of category 2 or higher HAPUs per one thousand patient-bed-days for each period, with ninety-five per cent confidence intervals. The pre- and post-intervention rates will be compared using an incidence rate ratio, and proportions for the process measures will be compared using the chi-square test, or Fisher’s exact test where expected counts are small. A p-value below 0.05 will be treated as statistically significant. Analysis will be guided throughout by the principle that statistical significance must be interpreted alongside clinical significance, so that any change is judged by whether it is meaningful for patients as well as whether it is unlikely to be due to chance.
The study is planned to run over twelve months, as summarised below.
| Phase | Months | Key Activities |
|---|---|---|
| 1. Preparation | 1–2 | Finalise protocol, refine audit tool, confirm power calculation |
| 2. Approvals | 2–3 | Obtain ethics and research-and-development approvals |
| 3. Baseline | 4–6 | Collect pre-intervention incidence and process data |
| 4. Implementation | 7 | Deliver staff education and introduce the bundle |
| 5. Post-intervention | 8–10 | Collect post-intervention incidence and process data |
| 6. Analysis and write-up | 11–12 | Analyse data, interpret findings and disseminate |
Ethical approval will be sought in line with the UK Policy Framework for Health and Social Care Research before any data are collected (Health Research Authority, 2020). Because the project evaluates a quality-improvement intervention using largely routine data, early discussion with the trust’s research-and-development department will determine whether it is classified as research requiring Research Ethics Committee review or as a service evaluation; the appropriate approvals will be obtained for whichever classification applies. Where individual consent is indicated, patients will receive clear information and the opportunity to decline without any effect on their care, consistent with the principle of autonomy and the professional duty of informed, person-centred practice set out in the professional code (Nursing and Midwifery Council, 2018).
All data will be handled in accordance with the Data Protection Act 2018 and the principles of confidentiality. Patient-level information will be anonymised at the point of collection, stored securely on trust-approved systems, and accessed only by the research team. The intervention itself reflects recommended good practice and is not expected to introduce additional risk; its purpose is to strengthen preventive care. The study will be framed throughout as an evaluation intended to benefit patients and to inform safe, evidence-based nursing practice.
Several limitations are acknowledged. The pre-test/post-test design without a concurrent control group means that observed changes cannot be attributed to the intervention with certainty, because secular trends or seasonal variation may also influence incidence. Conducting the study on two wards within a single trust limits generalisability, and consecutive sampling may introduce case-mix differences between the two periods. The Hawthorne effect is also relevant, because staff awareness of audit may improve documentation and care independently of the bundle. These limitations will be considered transparently when interpreting the findings, and the use of standardised definitions and process measures is intended to reduce their impact as far as is practicable.
Findings will be shared with the participating wards and the trust’s tissue-viability and clinical-governance teams, and summarised in a format suitable for ward-based learning and future quality-improvement work. In conclusion, this proposal outlines a feasible quantitative evaluation of a structured prevention bundle that addresses a persistent and largely avoidable harm on UK acute wards. By measuring both outcomes and the processes that drive them, the study aims to contribute practical, locally relevant evidence to support consistent, guideline-based pressure-ulcer prevention.
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