Advances and trends in pressure ulcer care research over the last 20 years: A bibliometric and visual analysis

Abstract

Objective

This study aims to investigate the current status and trends of pressure ulcer care studies over the past two decades using bibliometric and visual analysis, with the objective of providing guidelines for the development of relevant clinical practices or further research.

Methods

We conducted a search on the Web of Science Core Collection database using the subject terms “pressure ulcers” or “pressure injuries” for the period from January 2002 to December 2021. Bibliometric tools such as CiteSpace (version 5.8.R3), VOS viewer (version 1.6.17) and the R software 4.0.3 were used to visualize and analyze annual publications, country, institution, author, keyword and cited literature.

Results

We identified 5102 publications related to pressure ulcers during the 20-year period, including 4034 articles published in 1557 journals. The number of annual publications on the relevant topics has been increasing annually at an annual growth rate of 4.89 %. The keyword cluster analysis of these studies can be divided into four areas: epidemiology, risk assessment, caring intervention and prognostic analysis. Keyword temporal analysis revealed that the “Braden score” was the most commonly used keyword over a long-term span. The dissemination of knowledge and student training on pressure ulcers have become hot topics of research in recent years. Additionally, pressure ulcer care in COVID-19 patients has emerged as another research hotspot due to the pandemic.

Conclusion

Bibliometric analyses have shown that there has been a steady increase in research on pressure ulcer care, with studies related to pressure ulcer risk scores accounting for a large portion of this research. In recent years, education on pressure ulcer-related knowledge and pressure ulcer care in COVID-19 patients have emerged as research hotspots. Future research on pressure ulcer care in the elderly may be a research hotspot as the aging population progresses.

1. Introduction

A pressure ulcer, also known as a pressure injury, is a localized injury to the skin or subcutaneous tissue that occurs at bony prominences due to pressure or a combination of shear and/or frictional forces [1]. According to the National Pressure Ulcer Advisory Committee's 2016 definition, this injury can result in tissue damage ranging from superficial reddening to full-thickness tissue loss [2]. Pressure ulcers have become an increasingly serious complication of chronic disease, particularly as the population ages [3,4]. As a result, there has been a growing interest in researching this area. Although there are many literature reviews being published on pressure ulcer prevention and treatment, it is difficult for readers to quickly identify research trends and hotspots from them and find some key nodes in the research literature.

Bibliometric analysis is an emerging tool that uses statistical methods and visualization to rapidly explore the logical structure and development trends of a particular topic or domain [[5], [6], [7]]. The method extracts valuable information from a large amount of data by identifying nodes that are cross-referenced to the subject literature. Of the many bibliometric analysis software available, CiteSpace and VOS viewer are by far the most frequently used due to their professionalism and aesthetics. CiteSpace is a bibliometric analysis visualization software developed by Professor Chao-Mei Chen of Drexel University using Java language based on the theory of citation analysis [8]. It not only assists the researcher to find all the literature related to the research topic, but also to identify the most relevant literature to the topic from the vast and complex literature available. Thus, helping them to understand the most important and critical effective information in the domain. This helps to clarify the development process of a topic and identify hot research edges and growing trends. VOS viewer is another scientific literature visualization and analysis application developed by Leiden University in the Netherlands, which is used to create visual maps based on literature cross-citation data [9]. The principle of VOS viewer is mainly based on the cluster analysis algorithm to realize the literature knowledge map, and in this way to show the knowledge structure, development trend, mutual cooperation and other relationships in the field. Its outstanding features are strong graphical presentation capabilities, making it suitable for large-scale data.

Therefore, the aim of this study was to find the research trends and hotspots in recent years on this topic by bibliometric analyses of studies related to pressure ulcer care published in the last 20 years.

2. Methods

We conducted a bibliometric analysis of pressure ulcer care studies over the last 20 years using data retrieved from the Web of Science Core Collection (WoSCC) on December 1, 2022. To avoid potential bias due to database updates, we chose this specific date to collect the data. We used “pressure ulcers” or “pressure injuries” as our subject search terms and limited the literature type to English-language articles published between 2002 and 2021. We performed the search using WoSCC, which is the most commonly used database for bibliometric analysis [7]. The search and analysis process are detailed in Fig. 1.

Fig. 1.

Flow chart for literature screening and analysis.

To analyze the data, we used the bibliometrix package of R software (version 4.0.3) to determine the overall characteristics of the literature, the number of publications per year, collaborations between countries, and relevant information such as authors and keywords. We have performed manual statistics on the data generated by the bibliometrics software and visualized and mapped the data on countries/regions, institutions, authors and journals using Origin 2022. Further, we used the VOS viewer (version 1.6.17) to visualize and analyze the relationships among the literature based on their citation relationships, including mutual cooperation among countries/regions, citations among keywords, and co-citation clustering of keywords. In the visualizations, different colors represent clusters, and the connecting lines indicate collaboration or co-citation. Finally, we used CiteSpace (version 5.8.R3) to identify the most cited keywords, as well as their cross-referencing relationships, based on the literature citation nodes.

3. Results

3.1. General characteristics and annual analysis

From 2002 to 2021, a total of 5102 papers were published on the topic of “pressure ulcers” or “pressure injuries,” which includes 4034 articles (Fig. 2A). These articles were published in 1550 journals and written by 15204 authors, with an average of 4.75 co-authors per article. Of these authors, 221 were independent authors, and 15.27 % of the articles were international co-authored. A total of 86,584 references were cited in these articles, with an average of 21.89 references per article.

Fig. 2.

General characteristics of pressure ulcer care research and related annual and national analyses. (A) General characteristics of pressure ulcer care research; (B) Annual and national analysis of pressure ulcer care research; (C,D) International cooperation in pressure ulcer care research.

Over the past 20 years, the literature on pressure ulcer care has seen a steady increase year by year, with two notable peaks in 2008–2009 and 2014–2015 (Fig. 2B). Additionally, since 2017, more than 200 pressure ulcer-related literature reports have been published annually, suggesting that pressure ulcer care is gaining increasing attention from clinical practitioners and researchers.

3.2. Analysis of the influence of countries/regions and cooperation

According to our analysis, the top five countries in terms of the number of publications related to pressure ulcer care are the United States, China, the United Kingdom, Japan, and Germany (Fig. 2B). Notably, the United States has published significantly more articles than any other country. While different countries cite each other's literature, only a few countries are frequently cited. The collaboration between issuing countries is concentrated in the United States, China, and European countries, indicating a close cooperation relationship (Fig. 2C).

3.3. Analysis of institutions, authors, and journals

An analysis of the published journals revealed that the top five journals with the highest number of published articles all had over 50 articles, namely ANNALS OF PLASTIC SURGERY (n = 70), JOURNAL OF WOUND OSTOMY AND CONTINENCE NURSING (n = 63), SPINAL CORD (n = 63), PLASTIC AND RECONSTRUCTIVE SURGERY (n = 60), and JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY (n = 50) (Fig. 3A). The results serve as a guide for pressure ulcer caregivers for literature study and paper submission to alternative journals. In general, the number of journal publications and their impact have the same trend, but some journals are exceptions. For example, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION has only 36 publications, but it has high impact indexes, especially the h and g indexes. Indicates that relevant articles in the journal have had a greater impact on the field and have been cited more often.

Fig. 3.

Journal and author analysis of pressure ulcer care studies. (A) The top 20 journals with the most relevant articles and their impact; (B) The top 20 authors with the most relevant articles and their citations; (C) the distribution of the top 20 authors by year of publication.

Regarding author publications, the top 20 authors have all published more than 10 articles, with Professor Lars Arendt-Nielsen from the University of Aalborg, USA having the most publications (Fig. 3B). Fig. 3C shows the distribution of the top 20 authors by year of publication.

3.4. Keyword clustering and trending analysis

The analysis of keywords in the articles revealed that certain keywords were cited more frequently than others, and these were plotted in a word cloud (Fig. 4A). The word cloud indicated that “scoring,” “management,” and “prevention” were the most commonly used keywords, indicating that scoring, prevention, and management of pressure ulcer care were the most common research topics in these studies. Among these, “Braden score” was the most commonly used keyword, highlighting that “Braden score” is frequently used in pressure ulcer prevention and management.

Fig. 4.

Keyword clustering and trending analysis of pressure ulcer care studies. (A) The word cloud of the 50 most commonly used keywords; (B) Cluster analysis results for keywords; (C) Trending analysis results for keywords.

To further explore the relationships between the keywords, we conducted a cluster analysis (Fig. 4B) and identified four main directions of research: status and epidemiology of pressure ulcers (red), risk assessment of pressure ulcers (blue), prevention and care of pressure ulcers (yellow), and pressure ulcer outcomes and influencing factors (green). These directions are interconnected, and the keywords within each direction are related to one another.

We also conducted a temporal analysis of the keywords (Fig. 4C) and found that “pressure ulcer” and “Braden score” were the most commonly used keywords in the early years, with the latter having the longest timespan. In recent years, “Turkish nursing student knowledge” has become a new research topic in pressure ulcer care, indicating a growing attention to caregivers’ education. Additionally, due to the outbreak of COVID-19 in 2019, pressure ulcer care associated with this disease has become another research hotspot.

4. Discussion

Based on the bibliometric analysis conducted in this study over the past 20 years, we can make the following observations: (i) There has been a steady increase in the number of pressure ulcer-related studies, and this issue has gained attention from various countries with close collaboration among them. (ii) Several scholars and journals have focused on pressure ulcer research and achieved significant results and impact, but their influence is not entirely consistent with the total number of articles published. (iii) Early studies primarily focused on the Braden score and risk assessment, whereas recent research has explored new areas, such as pressure ulcer caregivers’ education and COVID-19-related pressure ulcer care.

Pressure ulcers, also known as bedsores, are a significant global health issue affecting millions of patients worldwide [10]. The incidence of pressure ulcers varies widely between countries, with a global incidence ranging from 5 % to 30 % [[11], [12], [13]]. According to the World Health Organization, pressure ulcers contribute to more than 2 million deaths annually, making the prevention and treatment of this condition a crucial healthcare topic [14]. The incidence and distribution of pressure ulcers vary by region, healthcare facility, and patient population. Epidemiological data show that populations with a high incidence of pressure ulcers include the elderly, disabled individuals, bedridden patients, and surgical patients [15,16].This study's analysis of the annual volume of relevant literature highlights that pressure ulcer care has emerged as a global healthcare issue, and clinical practitioners are becoming increasingly aware of the problem. However, raising awareness is only the first step towards addressing this issue, and we must continue to learn from our clinical and research experiences to improve our skills and treatment strategies.

Pressure ulcer care has been a popular research topic that has received attention from numerous scholars and journals. These scholars and journals cover a wide range of specialties. For example, three of the five journals that included the most publications were in the plastic surgery specialty, and the other two were in the spine and anesthesia specialties respectively. This may be due to the fact that the diseases covered in these specialties are strongly associated with pressure ulcers. For example, the spine specialty contains a large number of paraplegic patients who are bedridden for long periods of time, which may cause patients to develop pressure sores [17]. In addition, the large number of pressure ulcer care studies published in plastic speciality journals is likely to be due to the fact that these studies have been designed to treat pressure ulcers relevant to the plastic specialty.

Keyword analysis revealed that pressure ulcer prevention was the most common of these studies related to pressure ulcer care. Early identification of high-risk patients is crucial in the prevention and management of pressure ulcers. In clinical practice, several methods and scores are utilized for assessing pressure ulcer risk, including the Braden scale [18], Waterlaw scale [19], Norton scale [20], Munro scale [21], and Scott triggers tool [22]. Among these, the Braden scoring system is one of the most commonly used risk assessment tools [18]. This system includes six indicators, namely Sensory Perception, Moisture, Activity, Mobility, Nutrition, and Friction/Shear, each of which is assigned a score, resulting in a total score of 23. A lower score indicates a higher risk for pressure ulcers [18]. In practice, healthcare professionals, particularly nurses, need to assess each patient on a case-by-case basis using these tools and take appropriate preventive and therapeutic measures.

The temporal analysis of the keywords found that “nursing student knowledge” has become a new research topic in pressure ulcer care, indicating a growing attention to caregivers’ education [[23], [24], [25]]. These results indicate a growing body of research that emphasizes the development of knowledge in nursing students. Additionally, pressure ulcer care associated with COVID-19 has become another research hotspot. Undoubtedly, this trend has arisen because the epidemics of COVID-19 over the past few years have prompted an increased focus by researchers on the care of pressure ulcers in the patients involved.

With the continuous evolution of medical technology, new technologies are increasingly used in pressure sore prevention and treatment. For instance, electronic pressure sore prediction systems can anticipate pressure sore risk by monitoring factors such as patient position, movement, and pressure [26,27]. This helps caregivers take appropriate preventive measures. Additionally, new treatment techniques have been developed, such as photobiomodulation, which promotes wound healing and reduces patient pain and discomfort [28]. New biological dressings also aid in wound healing, reduce infection risk, and alleviate patient discomfort [[29], [30], [31]]. Studies demonstrate that negative pressure closed drainage techniques can significantly reduce the incidence of wound sepsis and promote wound healing, particularly for complex pressure ulcer and deeper skin soft tissue wounds, leading to shorter healing times.

With the progress of population aging, studies related to pressure ulcer care for the elderly may be a research hotspot in the future. In addition, as technology advances and develops, various new types of pressure ulcer treatments will emerge, and research related to pressure ulcer treatment may be another research trend.

4.1. Limitations

There are some unavoidable limitations to this paper. Firstly, although WoSCC is currently the most commonly used database for bibliometrics, it inevitably results in the loss of some of the literature, which may bias the results to some extent. Also, this study did not set strict screening criteria, which may also bias the results somewhat. Secondly, bibliometric analyses are given to literature citation node relationships, and inappropriate citation of literature sites in some studies may lead to errors in the analyses. Finally, keywords in the literature are subjective and the number of times they are used does not fully represent their importance. Therefore, beginners should conduct in-depth literature reading based on the findings of this article to further and more accurately grasp the current state of research and trends in pressure ulcer care.

5. Recommendations for future research

The use of keywords should be standardized in future pressure ulcer care studies to increase the reliability of similar bibliometric findings.

5.1. Clinical implications for health managers and policymakers

The bibliometric findings of this study on pressure ulcer nursing research can be used as a basic guide for instructing nursing students when they are first contacted with pressure ulcers. For example, the results serve as a guide for pressure ulcer caregivers for literature study and paper submission to alternative journals.

6. Conclusion

Over the past 20 years, pressure ulcer care has received increasing attention from researchers and the number of related studies has gradually increased. Studies related to pressure ulcer risk scores make up a large portion of this segment. In addition, education about pressure ulcers and pressure ulcer care for patients with COVID-19 have become research hotspots.

Data availability

The data generated in this article are available from the corresponding author, Prof Qin Hu.

CRediT authorship contribution statement

Guo Li: Writing – review & editing, Writing – original draft, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Hong Chen: Writing – review & editing, Visualization, Resources, Methodology, Investigation. Jing Yang: Writing – review & editing, Visualization, Resources, Methodology, Investigation, Data curation. Mufeng Peng: Writing – review & editing, Visualization, Formal analysis, Data curation. Pu Cheng: Writing – review & editing, Visualization, Formal analysis, Data curation. Yuankun Cai: Writing – review & editing, Visualization, Supervision, Software, Conceptualization. Qin Hu: Writing – review & editing, Project administration, Investigation, Funding acquisition, Conceptualization.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.