ABSTRACT
Aim
To systematically explore research on nurses' clinical decision‐making and factors influencing pressure injury prevention in hospitalised patients.
Design
Scoping review.
Data Sources
Medline full text, Cumulative Index to Nursing and Allied Health Literature Plus with full text, and Scopus.
Methods
Arksey and O'Malley's five‐step framework guided this scoping review. Studies published prior to 11 July 2024 were included.
Results
Thirty‐eight studies were included. The factors influencing nurses' decision‐making in pressure injury prevention included: ‘support systems’, ‘knowledge and attitudes’, ‘barriers to implementing prevention practices’ and ‘risk assessment tools and clinical judgement’. Limited research was conducted on nurses' clinical decision‐making about implementation of pressure injury prevention interventions.
Conclusion
More research on nurses' clinical decision‐making related to pressure injury prevention is needed to enhance education, support effective care and reduce the incidence of pressure injuries.
Impact
Nurses recognise the importance of preventing pressure injuries, however implementation of pressure injury prevention interventions are inconsistent, and pressure injuries remain common in hospitals. Limited research exists on the processes nurses use to make clinical decisions about pressure injury prevention for hospitalised adults at risk of pressure injury.
Reporting Method
This scoping review adhered to the PRISMA Extension for Scoping Reviews (PRISMA‐ScR) checklist.
Patient or Public Contribution
No patient or public contribution.
Keywords: clinical decision making, nurses, pressure injury, pressure injury prevention, pressure ulcer
Summary.
- Impact statement
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○Pressure injuries are a global problem occurring frequently in hospitalised patients.
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○Pressure injuries are largely preventable.
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○Nurses are responsible for implementation of pressure injury preventative practices.
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○This paper identified four factors that influence nurses' decision‐making about pressure injury prevention. However, no studies that explicitly explored nurses' clinical decision making processes on implementation of pressure injury prevention activities were identified. This scoping review has highlighted a significant gap in the literature.
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○Understanding nurses' decision making processes related to pressure injury prevention may reduce the incidence of pressure injuries and can inform nursing education, practice, and the development of policies and guidelines.
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- What does this paper contribute to the wider global clinical community?
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○Nurses are responsible for making decisions about implementation of pressure injury prevention interventions for patients in acute hospital settings.
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○This research has identified the factors that influence nurses' clinical decision making when implementing pressure injury prevention interventions, however, no studies were identified that explicitly examined the clinical decision making processes used by nurses.
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○More research is needed on what influences nurses' decision making so that pressure injuries can be prevented.
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1. Introduction
The international clinical practice guidelines on the prevention and treatment of pressure injuries defines a pressure injury (PI) as ‘localised injury to the skin and/or underlying tissue as a result of pressure, or pressure in combination with shear’ European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, & Pan Pacific Pressure Injury Alliance [EPUAP, NPIAP, & PPPIA] (EPUAP 2019. 194). PIs occur frequently among hospitalised patients (Rodgers, Sim, and Clifton 2020) and develop because of friction, shear or pressure from body weight or medical devices related to the magnitude and/or duration of this mechanical load (EPUAP 2019). Pressure injuries are a global problem and profoundly affect patients, resulting in extended length of stay, pain, invasive procedures, psychological distress, increased risk of infection and mortality (Lin et al. 2020). Pressure injuries also negatively impact patient well‐being and contribute to substantial annual costs in Australia of $9.11 billion AUD (Nghiem et al. 2022) and $26.8 billion USD in the USA (Padula and Delarmente 2019).
Pressure injuries are also referred to as pressure ulcers, decubitus ulcers or bedsores (Ousey et al. 2022). Preventing PIs is a key component of the nursing role and hospital‐acquired PIs (HAPI) are considered preventable for all patients except those at end‐of‐life (Lin et al. 2020; Rodgers, Sim, and Clifton 2020). Pressure injuries are also used as a measure of the quality of nursing care (Sim et al. 2019; Stotts et al. 2013). Despite the development of international clinical practice guidelines and patient safety initiatives, PIs continue to pose a significant challenge in hospital settings globally (Li et al. 2020). Validated risk assessment tools like the Braden and Waterlow scale identify patients at risk of PIs (Moore and Patton 2019). Preventative practices such as using reactive surface supports, mandatory turning schedules, prophylactic dressings, providing appropriate skin care and addressing nutrition needs are recommended for patients at risk of PI (EPUAP 2019). Studies have identified a number of barriers that hinder the implementation of PI prevention practices, including lack of time, inadequate resources, nurse staffing levels and heavy workloads (Berihu et al. 2020; Chaboyer et al. 2024; Tayyib, Coyer, and Lewis 2016). The implementation of clinical decision support systems and PI prevention bundles have shown positive outcomes in reducing HAPIs in some settings (Chaboyer et al. 2024; Huang et al. 2020; Renganathan et al. 2019). However, PIs remain a global problem and further research is needed to understand nurse's clinical decision‐making in implementing appropriate interventions.
Nurses make everyday decisions about what to do, or not do, regarding PI prevention. These decisions are influenced by many factors and competing demands. An examination of nurse's clinical decision making about PI prevention may help provide an understanding of the choices nurses make when providing care to patients. Within the nursing literature, the concept of clinical decision‐making is used interchangeably with clinical judgement, clinical reasoning and critical thinking to describe how nurses collect and process data to plan patient care (Connor et al. 2022). Nurses' clinical decision‐making has been described as a complex process, and involves making quick decisions in uncertain circumstances using subjective and objective data (Connor et al. 2022; Johansen and O'Brien 2016). Clinical judgement is a reflective clinical reasoning process where nurses arrive at a conclusion based on their extensive knowledge (Connor et al. 2022). Both clinical decision‐making and clinical judgement rely on critical thinking, which is described as a cognitive process that resolves problems and informs decisions (Ali‐Abadi, Babamohamadi, and Nobahar 2020). Before designing interventions to address the high rate of PI in at risk populations, there is an urgent need to understand how nurses make clinical decisions when caring for these patients. This review uses the term clinical decision‐making to encompass the critical thinking nurses perform to make clinical judgements and decisions about PI prevention activities.
2. The Review
3. Aim
This scoping review aims to explore research on nurse's clinical decision‐making about PI prevention, and the factors which influence that decision making, when providing care to hospitalised patients at risk of developing a PI. Understanding the decision making processes of nurses can help to reduce the incidence of PIs by improving how evidence‐based PI prevention interventions are implemented in hospital settings.
4. Methods/Methodology
4.1. Design
A scoping review was undertaken because this method enabled a comprehensive summary of the research, was flexible enough to allow identification and exploration of the complex factors which influence nurses' clinical decision‐making related to PI prevention practices, and facilitated identification of knowledge gaps (Levac, Colquhoun, and O'Brien 2010). Arksey and O'Malley's (2005) framework was used to provide a systematic structure for the review. The framework consists of five stages: (1) identifying the research question/s; (2) identifying relevant studies; (3) study selection; (4) charting the data; and (5) collating, summarising and reporting the results. The PRISMA Extensions for Scoping reviews was used to guide reporting of the study (Tricco et al. 2018).
This review sought to explore nurses' clinical decision‐making on PI prevention with the specific question, ‘How does nurses' clinical decision‐making about pressure injury prevention impact pressure injury development for hospitalised patients?’
4.2. Search Methods
The search was conducted in February 2023 and updated on 11 July 2024. No date restrictions were applied. Three databases were searched: Medline with full text, Cumulative Index to Nursing and Allied Health Literature (CINHAHL) plus with full text, and Scopus. The search terms for all databases included: (“pressure injur*” OR “pressure ulcer*” OR “bed sore*” OR “decubitus ulcer*”) AND (“clinical decision making” OR “clinical decision*” OR “clinical judgement” OR “clinical reasoning” OR “decision making” OR “critical thinking”) AND (nurs*) AND (hospital OR “acute care” OR inpatient). A health librarian provided input into the search strategy to improve its effectiveness.
4.3. Inclusion and/or Exclusion Criteria
Studies published in English were included if the study: (a) included participants 18 years or older; (b) examined care provided by nurses to hospitalised patients; (c) explored PI prevention and (d) explored or reported on decision making/clinical judgement of nurses. Only primary or secondary research was included. Studies were excluded if the population of the study were not adults (≥ 18 years of age), the patients received care in community, nursing homes or non‐hospitalised settings, and if data were collected in multiple settings and the data for hospitalised patients could not be separated from other settings. The aim of this review was to explore nurses' clinical decision‐making regarding PI prevention in hospitalised patients. The study was therefore limited to hospitalised adults, as including other settings and paediatric populations would introduce varying care requirements and influencing factors.
4.4. Search Outcome
Studies were identified and downloaded into EndNote 21 (The EndNote Team 2013) and then imported into Covidence (Covidence systematic review software 2024) to manage the screening process. A total of 2894 studies were identified. Duplicates were removed (n = 69) and 2825 studies were subjected to title and abstract screening by one researcher (JC). Full text screening was undertaken on 121 studies by two researchers (JC and KR). If consensus was not achieved, a third team member (JS) independently assessed the study against the inclusion and exclusion criteria. The reasons for excluding studies are in Figure 1. Thirty‐eight studies were included in the final review. The PRISMA flow diagram illustrates the search outcomes (see Figure 1).
FIGURE 1.
PRISMA flow diagram.
4.5. Quality Appraisal
The methodological quality of the studies was assessed using the Mixed Methods Appraisal Tool (MMAT) for qualitative, quantitative and mixed methods studies, and the Critical Appraisal Skills Programme (CASP) checklist for systematic reviews. When using the MMAT, studies were scored out of five with higher scores reflecting higher quality studies. The CASP Checklist for systematic reviews was scored out of 10. Two researchers (JC and KR) independently completed quality appraisal and met to discuss any differences. Any discrepancies were resolved by consultation with a third researcher (JS).
4.6. Data Abstraction
Data on each study were extracted into a data extraction form in Covidence. Data included the citation, country where the study was conducted, aim, research design, research methods, study population, sample size, instruments used, interventions implemented, primary outcomes, secondary outcomes and key findings. Any other findings directly related to the scoping review question were also extracted and summarised narratively.
4.7. Synthesis
After the data were extracted and compiled into a summary table it was synthesised. A number of concepts related to nurses' clinical decision‐making were identified and the relevant information associated with each concept, was collated and explored for similarities and patterns. All authors were involved in the identification of the key findings and group meetings were used to develop, refine and summarise each theme.
5. Results
A total of 2894 studies were identified. There were 8 systematic reviews, 23 quantitative studies, 6 qualitative studies and 1 mixed methods study included in the final review. The focus of the included studies covered five key areas. Two studies investigated the impact of education and training on PI prevention (Kim, Park, and Kim 2020; Porter‐Armstrong et al. 2015). Two systematic reviews and a quantitative study explored the use of risk assessment tools (Fulbrook et al. 2024; Lovegrove, Miles, and Fulbrook 2018; Lovegrove et al. 2021). One systematic review examined the link between risk assessment and PI prevention interventions (Lovegrove et al. 2021). Four studies examined the effects of using clinical support systems and digital applications (Araujo, Sousa, and Dutra 2020; Chuang et al. 2022; Huang et al. 2020; Kim, Ryu, and Choi 2023). Six studies explored the implementation of a Sub‐Epidermal Moisture scanner (SEM) on PI prevention (Avsar et al. 2024; Musa et al. 2021; Nightingale and Musa 2021; Ousey and Fletcher 2011; Ousey et al. 2022; Raine 2021). Eleven studies explored specific interventions and/or bundles for PI prevention (Chaboyer and Gillespie 2014; Cobos‐Vargas et al. 2022; Greenwood et al. 2024; Latimer, Chaboyer, and Gillespie 2016; Meyer, Hecke, and Verhaeghe, and Beeckman 2019; Moya‐Suárez et al. 2018; Renganathan et al. 2019; Sving et al. 2017, 2016; Yilmazer and Bullut 2017; Yilmazer and Bulut 2018). Finally, the perceptions, beliefs and attitudes of nurses were examined in 12 studies (Balzer et al. 2014; Berihu et al. 2020; Choi et al. 2016; De Meyer et al. 2019; Gaspar et al. 2022; Hafedh Ahmed et al. 2024; Kaba et al. 2017; Kim et al. 2019; Li et al. 2022; Tayyib, Coyer, and Lewis 2016; Wan et al. 2023; Wu et al. 2023). A summary of the findings from included studies are reported in Table 1.
TABLE 1.
Summary table.
| Systematic Reviews | |||||||
|---|---|---|---|---|---|---|---|
| Citation, country | Aim | Years and included countries | Review type included studies | PICO elements | Key findings from the study | Implications for nurses' decision making | Quality score |
|
Araujo, Sousa, and Dutra (2020) Portugal |
To identify the effects of nurses using clinical decision support systems on clinical decision‐making for PI management |
1995–2017 US, Italy, Canada, Norway, South Korea, Belgium and Singapore. |
Systematic review
Qualitative, quantitative, and mixed‐method studies. |
P: Nurses I: Clinical decision support systems C: Nil O: The effect on clinical decision‐making for PI prevention |
|
|
10/10 |
|
Avsar et al. (2024) Ireland |
To describe changes in clinical decision‐making in the delivery of PI/PU care pathways as a direct result of detecting an abnormality by SEM scanner |
2017–2022 UK, Ireland, Belgium, Spain, Australia and Canada |
Systematic review
Quantitative studies. |
P‐ Adults at risk PI I: Assessment using SEM C: Nil O: Changes in clinical practice and care delivery pathway for PI prevention |
|
|
10/10 |
|
Lovegrove et al. (2021) Australia |
To identify differences in PI risk assessment outcomes when using a structured risk assessment tool compared to clinical judgement alone |
2010–2220. Germany, Australia and the United States |
Systematic review
Qualitative, quantitative, and mixed‐method studies. |
P: Adults greater than 18 years in acute care hospitals I: Assessment of PI risk using risk assessment tool C: Assessment of PI risk using clinical judgement O: PI risk score, level or category, selection of PI preventive intervention |
|
|
7/10 |
|
Lovegrove, Miles, and Fulbrook (2018) Australia |
To evaluate primary research that links pressure ulcer risk assessment with prescription and implementation of preventative interventions for hospitalised adults |
2007–2017 Holland, Indonesia, Belgium, Sweden, Jordan, Germany |
Systematic review
Quantitative studies. |
P: Adults in hospital or acute care I: PI risk assessment C: Prescription and implementation of PU preventative interventions O: Linkage between risk assessment, prescription and intervention |
|
‐ Risk assessment is widely used, though prescription and preventative interventions do not always follow with an overall lack of prescription.—Preventative implementation is often lower than the risk assessment scale indicates. ‐The lack of prescription is an influencing factor in inadequate PI prevention |
10/10 |
|
Kim, Park, and Kim (2020) Korea |
To conduct a meta‐analysis of the literature on training programs that aimed to improve nurses' pressure injury management skills |
No specific time limits were set. UK, US, Netherlands, Turkey, Belgium, Norway, Sweden, Korea, India, Egypt, Canada, New Zealand |
Quantitative studies. |
P: Nursing staff I: Training C: Nil O: Training can improve knowledge, nurse's visual discrimination and clinical judgement Studies published in English or Korean. |
|
‐Training programs increase knowledge of PI and prevention. The groups that received training showed a statically significant increase in clinical judgement (p < 0.001). | 7/10 |
|
Porter‐Armstrong et al. (2015) UK |
To assess the effects of educational interventions for healthcare professionals on pressure ulcer prevention. |
No time limit restrictions Norway, UK, USA, Netherlands |
RCT and Cluster RCT |
P: Types of participants: All Healthcare staff, including allied in all settings, including home care, including nursing homes I: Education C: Change in healthcare professionals' knowledge and behaviour O: Inconclusive as to whether education changes practice. |
|
|
6/10 |
|
Wan et al. (2023) Australia |
To synthesise quantitative and qualitative evidence on the perceptions and experiences of hospital clinicians and inpatients regarding evidence‐based PI practices. To identify the barriers and facilitators to implementing these guidelines in acute care settings |
Studies published between 2009 and August 2022. Australia, USA, and Sweden |
Quantitative, qualitative and mixed‐methods studies |
P: Hospital clinicians and inpatients in acute care settings I: Perceptions and experience related to PI prevention. C: Nil O: Factors influencing PI prevention and use of guidelines in acute care |
Nurses perceived barriers.
|
|
9/10 |
|
Wu et al. (2023) China |
To systematically synthesise research evidence on barriers and facilitators to PI prevention in hospital settings |
2008–2022 Turkey, Iran, Ethiopia, Sweden, Jordan, Australia, China, Nigeria, Brazil, Saudi Arabia, Singapore, Belgium, the USA, Canada, Finland, Korea, the UK, Cyprus, Egypt, India, Slovakia, South Africa, Spain, Portugal, and Uganda |
Quantitative, Qualitative and Mixed Methods |
P: Nurses and healthcare professional I: Identification of barriers and facilitators of PI prevention C: Nil O: Identified barriers and facilitators. Theoretical Domains Framework was used to categorise and understand the influence of various factors influence PI prevention. |
Knowledge, attitudes, shortage of resources, support from leaders and multidisciplinary teams
Education/training, adequate knowledge, positive attitudes, access to resources |
|
9/10 |
| Qualitative | |||||||
|
Chaboyer and Gillespie (2014) Australia |
To explore nurses' views of the barriers and facilitators to the use of a newly devised patient‐centred pressure ulcer prevention care bundle |
Qualitative descriptive study |
|
|
|
|
5/5 |
|
Gaspar et al. (2022) Portugal |
To understand the perceptions of Portuguese nurses' stakeholders regarding PI prevention practice and reality in the hospital setting |
Qualitative descriptive study |
11 Nurses involved in PI prevention and/or patient safety | Semi‐structured interview and focus group. |
|
|
5/5 |
|
Greenwood et al. (2024) England |
To explore how, when, and why heel offloading devices are used (or not used) for prevention of heel PIs in patients in a hospital setting. | Ethnographic study |
32 patients 19 staff 3 ward managers The professional qualifications of staff were not described but it was assumed they were nurses. |
Observation Interviews |
|
|
5/5 |
|
Kaba et al. (2017) Greece |
To explore Greek nurses' perceptions about the barriers involved and to identify the factors that influence care planning in PI treatment. |
Grounded theory study |
Seven nurses | Semi‐structured interviews |
|
|
5/5 |
|
Li et al. (2022) China |
To describe Registered Nurses' (RN) approaches to PI prevention, including how nurses perceive their roles in PI prevention, how they prioritise PI prevention and factors influencing PI prevention. |
Qualitative descriptive study |
27 Registered Nurses |
Semi‐ structured interviews |
|
|
5/5 |
|
Sving et al. (2017) Sweden |
To describe registered nurses', assistant nurses' and first‐line managers' experiences and perceptions of a multifaceted hospital setting intervention focused on implementing evidence‐based PI prevention. |
Qualitative descriptive study |
RN, AIN and first‐line managers
|
Five focus interviews with RN and AIN Five individual nurse manager interviews Interventions.
|
Bedside support, feedback
|
|
4/5 |
| Quantitative | |||||||
|
Berihu et al. (2020) Ethiopia |
To assess practices towards PI prevention among nurses in the Central Zone of Tigray, Ethiopia | Cross‐sectional study | 122 Nurses working in three public hospitals in Ethiopia | Self‐administered structured questionnaire |
|
|
4/5 |
|
Choi et al. (2016) USA |
To examine PI prevention by nurses in a critical care setting for improvement of care quality using a behavioural approach |
Quality improvement study |
15 RNs in a 10‐bed cardiovascular ICU. |
|
|
|
3/5 |
|
Chuang et al. (2022) Taiwan |
The purpose of this study was to determine whether a PI E‐book app would improve nurses' PI‐related knowledge, attitudes, and care confidence |
RCT |
164 Nurses |
|
A comparison of the three variables showed:
|
|
4/5 |
|
Cobos‐Vargas et al. (2022) Spain |
To analyse the degree of compliance with the preventive measures for PI reported by an International Study Group in a cohort of adult critically ill patients. |
Observational study |
|
Observation of preventative measures Specific measures for each level of risk identified, based on the COMHON index risk scale (consciousness, mobility, hemodynamics, oxygenation and nutrition). |
|
|
4/4 |
|
Fulbrook et al. (2024) Australia |
To compare the outcomes of nurses' PI risk assessments for hospitalised adult patients using a structured PI risk assessment tool versus clinical judgement | Interrater agreement study |
681 bed tertiary Hospital Participants Nurses were assessors and patients' participants |
Waterlow risk assessment tool and clinical judgement |
|
|
5/5 |
|
Guerrero et al. (2023) Saudi Arabia |
To evaluate the level of knowledge of ICU nurses concerning PU prevention in tertiary hospitals in Saudi Arabia | Cross sectional study |
General ICU in four tertiary hospitals 320 ICU nurses |
Questionnaire |
|
|
3/5 |
|
Hafedh Ahmed et al. (2024) Iraq |
To evaluate the knowledge, attitude, and practice of intensive care unit nurses in Iraq regarding the prevention of pressure ulcers | Cross sectional study | 231 ICU nurses working across 8 hospitals in Iraq |
Five questionnaires Demographics
|
|
|
4/5 |
| Kim, Ryu, and Choi (2023) Korea | To develop and evaluate the effectiveness of a clinical decision support system for pressure ulcer prevention on clinical (performance, visual discrimination ability, and decision‐making ability) and cognitive (knowledge and attitude) workflow. | Quasi‐experimental study | 49 ICU RNs from 7 tertiary and 5 secondary hospitals
|
|
Pre and post test
|
|
4/5 |
|
Meyer, Hecke, and Verhaeghe, and Beeckman (2019) Belgium |
To study the effectiveness of tailored repositioning and a turning and repositioning system. | RCT. |
227 patients at risk of PI development 29 wards in 16 hospitals in Belgium |
A multi‐centre, cluster, three‐arm, randomised, controlled pragmatic trial of three groups. Two groups were given two separate interventions; 1 was the control. |
Overall, there was a significant decline in repositioning patients seated. |
|
3/5 |
|
De Meyer et al. (2019) Belgium |
To gain insight into the knowledge of nurses and nursing assistants about pressure ulcer prevention. |
Cross‐sectional study |
474 Nurses and nursing assistants 29 wards in 16 Belgium hospitals |
Completion of Pressure Ulcer Knowledge Assessment Tool (PUKAT) 2.0, a valid and reliable questionnaire consisting of 28 multiple‐choice items. |
|
|
4/5 |
|
Huang et al. (2020) Taiwan |
To evaluate the outcomes of implementation of decision support functions into the preventive care system as regards nurses' acceptance of technology, documentation completeness, and incidence of HAPI | Before and after study |
Regional Northern Taiwan Hospital |
|
|
|
4/5 |
|
Kim et al. (2019) Korea |
To determine clinical nurses' perceived importance and performance towards medical device‐related PI prevention. | Cross‐sectional study |
620 nurses Seven Korean hospitals |
Questionnaire |
|
|
4/5 |
| Latimer, Chaboyer, and Gillespie (2016) Australia | To describe five planned and implemented PI prevention strategies (risk assessment, management plan, support surface, repositioning, and education), and determine if a relationship existed between the planning and implementation of support surfaces and regular repositioning |
Observational study |
165 participants from Hospital A; 76 from Hospital B. Australian hospitals |
Chart audits and semi‐structured observations. |
|
|
4/5 |
|
Moya‐Suárez et al. (2018) Spain |
To analyse the adherence by clinical nurses to recommendations for decision‐making for prevention of PI. | Cross‐sectional study |
168 nurses All wards in a Spanish hospital |
Questionnaire
|
|
Context influences nurses' decision making on PI prevention | 4/5 |
|
Musa et al. (2021) UK |
The aim of the study was to evaluate the clinical impact of a sub‐epidermal moisture (SEM) scanner in the early identification of increased risk of tissue damage and the reduction of HAPI across multiple sites. | Before and after study |
1478 patients, 15 participating sites |
Implemented SEM scanner as part of routine skin assessment. Training was provided |
|
|
3/5 |
|
Nightingale and Musa et al. (2021) UK |
To measure the impact of adding scanning technology to the prevailing standard of care pathway on the incidence of category 2–4 hospital‐acquired PI. | Cross–sectional study |
697 patients 2 UK hospitals |
|
|
|
3/5 |
|
Ousey et al. (2022) UK |
This study assesses the patient‐level impact of SEM assessment technology when used as a diagnostic tool in the prevention of PI in hospital patients | Quantitative descriptive study |
995 patients across different wards in different hospitals |
Implementation of SEM scanner in routine care
|
|
|
3/5 |
|
Raine (2021) UK |
To assess the feasibility of preventing PI using SEM technology as an adjunct to routine care in a 22‐bed inpatient hospice. | Quantitative descriptive study |
146 patients UK Hospice |
SEM was the new intervention introduced along with Waterlow, SKINN and clinical judgement. |
|
|
3/5 |
|
Renganathan et al. (2019) India |
To develop and evaluate the usefulness of a continuous patient position monitoring system to assist nurses in improving turn protocol compliance. | Multi‐centre cohort study |
40 Patients In 2 ICU in India |
The intervention was a wearable sensor.
|
|
|
4/5 |
|
Sving et al. (2016) Sweden |
To evaluate whether a multi‐faceted, unit‐tailored intervention using evidenced‐based PI prevention affects the performance, knowledge and prevalence of PI | Before and after study |
Patients‐ Pretest 251 Post‐test 255 Nurses‐ Pretest 145 Posttest130 5 hospital units in a 344 bed hospital |
The intervention was training and quality measure feedback once per month. The patient's skin was assessed, and Waterlow risk assessment was performed. Pre and post‐questionnaire, Knowledge assessment tool (PUKAT) and Attitudes towards Pressure Ulcer (APuP) was used. |
|
|
5/5 |
|
Tayyib, Coyer, and Lewis (2016) Saudi Arabia |
To examine attitudes towards PI prevention strategies in a group of critical care nurses practicing in Saudi Arabia |
Cross‐sectional study |
56 Nurses ICU in Saudi hospital |
Survey 4 sections; demographics potential barriers and facilitators to skincare and RN attitudes towards PI care using the Attitudes towards PI Prevention instrument.t |
Similarly, the mean priority subscale was low (μ = 8.28/12; 69%).
|
|
5/5 |
|
Yilmazer and Bulut (2018) Turkey |
To evaluate the effect of a PI prevention algorithm on pressure injury prevention. | Pre‐ post‐ intervention study |
15 Nurses 80 patients in anaesthesiology and ICU Training and research hospital |
PI prevention algorithm The study was performed in four phases: evaluation of PI incidence in the pre algorithm period, development of a PI prevention algorithm, education of ICU nurses on PI prevention and the use of the algorithm, and provision of care based on the algorithm in the postal algorithm period. |
|
|
4/5 |
|
Yilmazer and Bullut (2017) Turkey |
To examine the content validity of the PI prevention algorithm incorporating a combination of the preventive care stages and using a larger sample size of intensive care nurses | Cross‐sectional study |
81 Registered Nurses Turkey Training and Research Hospital |
Algorithm |
|
|
5/5 |
| Mixed Methods | |||||||
|
Balzer et al. (2014) Germany |
To explore which patient characteristics nurses, employ when assessing PI risk without use of a risk assessment scale. | Mixed methods |
Quantitative: 106 patients Qualitative: 16 nurses 2 trauma wards German University Hospital |
|
Qualitative:
Quantitative:
|
|
3/5 |
5.1. Themes
Four themes were identified and included: ‘support systems’, ‘knowledge and attitudes’, ‘barriers to implementing prevention practices’ and ‘risk assessment tools and clinical judgement’.
5.1.1. Support Systems
Support systems encompassed the use of clinical decision support systems at point of care and the use of new technological aids to support decision making about PI prevention. Clinical decision support systems (CDSS) were examined in four studies and had a positive influence on nurses' decision making and PI prevention practices and outcomes (De Meyer et al. 2019, Renganathan et al. 2019, Huang et al. 2020, Yilmazer and Bulut 2018). An RCT conducted by DeMeyer, Hecke, and Verhaeghe, and Beeckman (2019) examined the effectiveness of a tailored repositioning program on nurses' compliance with repositioning protocols. This multi‐centre RCT included 227 patients at risk of PI across 16 Belgian hospitals and compliance was evaluated over an eight‐day period using observation. In the experimental group, compliance increased by 84.9%, compared to the control group (71.4%). Renganathan et al. (2019) evaluated the effect of a continuous patient position monitoring system on improving repositioning compliance in two intensive care units in India and found that visual alerts improved compliance in repositioning patients. The compliance with the repositioning protocol was significantly higher in Phase II, 80.15% (SD = 8.97%), than in Phase I, with a compliance rate of 24.36% (SD = 12.67%) (p < 0.001). The use of support systems was also shown to decrease the incidence of PI in two quasi‐experimental studies. Huang et al. (2020) implemented a ‘PI Prevention and Care Information System’ in a 350‐bed hospital in Northern Taiwan where acceptance, compliance with documentation and PI incidence were evaluated before and after the implementation of the CDSS. The study found that HAPI incidence decreased from 0.057% (pre‐test: 5 events per 8728 bed days) to 0.021% (post‐test: 2 events per 9492 bed days) with a concomitant increase in documentation. Yilmazer and Bulut (2018) implemented a PI prevention algorithm in a Turkish hospital and examined its content validity on risk assessment, skin evaluation and care management. The study found the use of the algorithm significantly decreased PI incidence from 46.10 per 1000 bed days during the pre‐intervention period, to 9.21 per 1000 bed days in the post‐algorithm period.
Most studies did not examine the ease of use of the support system, but it was likely to be a major factor in nurses' compliance with CDSSs. Huang et al. (2020) explored this phenomenon and found that the perceived ease of usefulness of the CDSS influenced nurses' intention to use the system and their attitudes towards the system (β = 0.799, p < 0.001). Perceived the ease of use also had a significant association with nurse perceptions of usefulness and a positive effect on nurses' attitudes (β = 0.505, p < 0.001).
Sub‐epidermal moisture scanners (SEM) were also evaluated as a support system as they are a tool used to detect oedema in the skin surfaces before visible signs of tissue damage can be detected with routine skin assessment (Musa et al. 2021). Six studies examined the use of sub‐epidermal moisture scanners and found that use of a SEM scanner influenced nurses' decision making on preventative care interventions (Avsar et al. 2024; Musa et al. 2021; Nightingale and Musa 2021; Ousey and Fletcher 2011; Ousey et al. 2022; Raine 2021). Avsar et al.'s (2024) systematic review identified that a positive SEM reading led to a change to care planning and PI prevention activities in seven out of nine included studies. Musa et al. (2021) enrolled 1478 patients across 15 UK hospitals in a pre and post study to evaluate baseline HAPI rates, outcome data (including daily SEM readings), tissue health observations and HAPI diagnosis. The results of this study found that the use of the data from the SEM assessment led to a change in clinical decision‐making in 82% of participants whose patients were otherwise not perceived to be at risk of a PI (n = 14/17). A positive SEM delta without visible skin damage led to a 64.9% increased chance of nursing interventions being implemented in a quantitative descriptive study by Ousey (2022) and colleagues. A positive SEM delta and the visible presence of localised skin damage led to implementation of nursing interventions in 48.8% of cases (Ousey et al. 2022). Another quantitative descriptive study examined the implementation of the SEM scanner into a 22‐bed inpatient hospice in the United Kingdom, which led to a 47% reduction in PI incidence over 6 months (Raine 2021). This was attributed to the additional nursing interventions being implemented such as repositioning and surface support in 40% of patients (Raine 2021).
Despite positive findings in some studies, not all included studies found that support systems influenced nurses' decision‐making. Araujo, Sousa, and Dutra's (2020) systematic review found insufficient evidence to support the effectiveness of CDSS on PI incidence or nurses' knowledge about PI management and prevention (Araujo, Sousa, and Dutra 2020). A quasi‐experimental study conducted by Kim, Ryu, and Choi (2023) found that although CDSS improved attitudes, there was no significant differences between nurses' clinical decisions in the control and intervention groups. The mixed findings may have occurred for a variety of reasons including the research design, as most studies were observational or pre and post design. Before recommending CDSS, further high‐quality research that incorporates confounding factors is needed. Whilst CDSS may positively impact PI prevention practices by increasing compliance with protocols and implementing additional interventions, the CDSS's influence on nurses' decision‐making is not yet understood, as none of the included studies explored this aspect.
5.1.2. Knowledge and Attitudes
Seven studies explored how education and training influence nurses' decision‐making related to PI prevention. A systematic review and meta‐analysis of training programs conducted by Kim, Park, and Kim (2020) included three RCTs and 20 observational studies. Seventeen of these studies investigated changes in knowledge; five focused on visual discrimination, and 10 on clinical judgement. Groups who received training had significantly higher knowledge scores in both the RCT and observational studies (OR, 1.52; 95% CI, 1.46–1.57; p < 0.001) (Kim, Park, and Kim 2020). This systematic review also found that education programs that focused on clinical judgement were more effective than those that only provided knowledge on PI prevention and management however experimental research is needed as most of these had an observational design. De Meyer et al. (2019) conducted a multi‐centre cross sectional study, using the Pressure Ulcer Knowledge Assessment Tool (PUKAT) to evaluate nurses' knowledge of PI prevention practices. Findings identified that nurses who had previously received training on PI prevention had higher total PUKAT scores than those who had not received such training (61.0% vs. 50.2%, p = 0.004). Prevention sub‐scale scores were also higher for those who had received additional training (54.2% vs. 42.3%, p = 0.021). Sving et al. (2016) undertook a pre‐ and post‐study in five units of a 344‐bed hospital in Sweden to evaluate an evidence‐based training intervention and found that nurses' knowledge of PI prevention increased significantly (Pre: 57%, Post: 63%, p = < 0.001). A cross sectional study of 231 ICU nurses working across eight government hospitals in two Iraqi cities found that education increased knowledge on PI prevention and identified a positive relationship between knowledge of PI prevention with previous training (p = 0.021) (Hafedh Ahmed et al. 2024). Although cross sectional surveys are useful in assessing current attitudes and knowledge, most of these studies have geographical limitations. Guerrero et al. (2023) conducted a cross sectional study of 320 Saudi Arabian ICU nurses from four different hospitals and identified that nurses had low levels of knowledge on PI prevention (39.55%) which impacted implementation of PI prevention interventions. This study was conducted in four different hospitals; however, the sample size is relatively small which may have affected the generalisability of these results. Kim et al. (2019) undertook a descriptive cross‐sectional survey of 682 nurses attending an educational seminar. They examined the differences between nurses' perceptions of the importance of PI prevention activities and their actual performance in preventing medical device‐related PI (MDRPI). The findings identified that perceived importance didn't change even with protocols for PI management and prevention in place, however, a significant difference in participant's actual performance in PI prevention was observed (p = 0.008) (Kim et al. 2019).
Knowledge and education were also found to influence attitudes towards PI prevention. An RCT conducted by Chuang et al. (2022) evaluated the effectiveness of a digital intervention on nurses' knowledge, attitudes, and confidence in PI prevention. This RCT involved 164 nurses randomly assigned to a conventional education program or education using a digital intervention. Using the digital intervention led to a statistically significant increase in knowledge (p < 0.001), attitudes (p < 0.001) and confidence (p < 0.001) towards PI prevention. Although this study focused on a digital intervention, the results showed that a positive attitude towards PI prevention triggered the implementation of prevention practices. Because this study was conducted in one Taiwanese hospital further research is needed across a broader variety of settings to determine if the results could be transferred into clinical practice. A qualitative study of seven nurses in Greece conducted by Kaba et al. (2017) found that nurses' attitudes were influenced by their level of knowledge, and this was influential in the actions nurses took when preventing PIs. Yilmazer and Bulut (2018) conducted a pre‐ and post‐intervention study and found that education increased nurses' knowledge of PI prevention, but that regular education may be needed as knowledge decreased 3 months following the intervention. Although most primary studies found an association between education and training on PI prevention, a systematic review on the effects of educational interventions on PI prevention did not produce conclusive findings due to the low‐quality of included evidence (Porter‐Armstrong et al. 2015).
Four studies found that positive attitudes influenced nurses decision making on PI prevention which had the potential to overcome barriers such as heavy workloads and lack of teamwork (Chaboyer and Gillespie 2014; Chuang et al. 2022; Kaba et al. 2017; Sving et al. 2016). Kaba et al. (2017) qualitative study on nurses' experience in PI prevention also highlighted that nurses were more able to overcome barriers to PI prevention if they had positive attitudes. Chaboyer and Gillespie's (2014) qualitative study and Huang et al.'s (2020) quasi–experimental study both found that the implementation of CDSS and care bundles relies on nurses having a positive attitude towards these systems for them to be utilised to prevent PIs.
Most studies examining nurses' knowledge and attitudes highlighted a link between education/training and nurses' clinical decision making for PI prevention. Before recommendations can be given on the content, structure and approach to education programs on PI prevention, the impact of these educational programs needs to be measured multiple times across various geographical locations. Exploration of how knowledge/training and positive attitudes influences nurses' decision making about PI prevention practices is warranted. This information is needed to ensure that targeted, evidence‐based programs can be developed and implemented.
5.1.3. Barriers to Implementing Prevention Practices
Heavy workloads were the most common nurse‐reported barrier to PI prevention (Berihu et al. 2020; Choi et al. 2016; Li et al. 2022; Tayyib, Coyer, and Lewis 2016). Two systematic reviews focussed on barriers and facilitators to PI prevention. Wan et al. (2023) included 55 studies (29 quantitative, 22 qualitative and 4 mixed methods). Wu et al. (2023) included 78 studies (65 quantitative, 11 qualitative and 2 mixed methods). The most common barriers identified were knowledge (Wu et al. 2023; Wan et al. 2023), lack of training (Wu et al. 2023), and insufficient resources (Wan et al. 2023). Berihu et al. (2020) conducted a cross‐sectional study in three hospitals in Ethiopia and found that heavy workloads were associated with an increased risk of PI (OR 2.59, CI 0.126–0.933). Li et al. (2022) conducted semi‐structured interviews with 27 nurses in a Chinese hospital and identified heavy workloads as the most significant barrier, resulting in PI prevention being conducted by families. Further research is required to gather data from a larger number of nurses over different settings to help validate these findings. Choi et al. (2016) used a root cause analysis approach involving 15 RNs in a 10‐bed cardiovascular ICU to evaluate the cause of PIs in critical care settings. They found heavy workloads, lack of time and lack of staff were consistent barriers to implementing PI prevention interventions. A cross‐sectional study conducted in a Saudi Arabian ICU setting found that time constraints were the most significant barrier to PI prevention (Tayyib, Coyer, and Lewis 2016).
Lack of training and guidelines for nurses were also identified as additional barriers to PI prevention (Berihu et al. 2020). PI prevention interventions were not always implemented when required due to nurses' knowledge and a lack of guidance about decision‐making. Li et al.'s (2022) qualitative study also found that shortages of equipment such as prophylactic dressings, led to nurses needing to prioritise patients at risk of PIs based on their perceptions of risk and severity of need.
5.1.4. Risk Assessment Tools and Clinical Judgement
Risk assessment tools are used to identify patients at risk of developing PI so that appropriate PI prevention activities can be implemented. PI prevention interventions, however, are not always implemented following the identification of risk (Latimer, Chaboyer, and Gillespie 2016). This finding suggests that nurses do not always base their decision to implement PI prevention interventions based solely on the scores given by a validated risk assessment tool (e.g., Braden and Waterlow). Several studies found risk assessment tools are used in combination with clinical judgement when implementing PI prevention interventions (Li et al. 2022; Lovegrove et al. 2021; Moya‐Suárez et al. 2018). Li et al. (2022) reported that risk assessments and clinical judgement were required to provide prevention interventions related to nutrition and hydration and skin cleansing.
Lovegrove, Miles, and Fulbrook's (2018) systematic review examined the link between PI risk assessment processes (including clinical judgement) and the prescription and implementation of preventative practices. The findings suggest a misalignment between risk assessment scores and the implementation of PI prevention, with preventative practices often not being implemented as indicated by the risk scores. Cobos‐Vargas et al. (2022) observational study involving 73 ICU nurses in one setting evaluated the use of the Conscious level, Mobility, Haemodynamic, Oxygenation and Nutrition (COMHON) risk assessment tool designed specifically for ICU patients. Their findings suggest that even with a population specific tool, not all PI prevention recommendations were implemented and/or adapted at an individual level. Fulbrook et al. (2024) compared the use of risk assessment tools and clinical judgement in one hospital setting, and identified significant variability in how risk is perceived and categorised. Over two‐thirds of patients were considered high risk when using the structured risk‐assessment tool, however they were considered a lower risk level when using clinical judgement. Clinical judgement was explored in Greenwood et al. (2024) ethnographic study on how, when, and why nurses implement heel offloading devices. Clinical judgement and experience were found to influence decisions on which offloading device to use when there were no protocols or guidelines available (Greenwood et al. 2024). A mixed methods study by Balzer et al. (2014) explored which patient characteristics nurses associated with an increased risk of PI in two wards in one hospital and found that nurses used patient dependency and the extent to which a person can be involved in their own care as the key drivers for PI prevention activities. These strategies do not align with either risk assessment scores or recommendations of clinical practice guidelines. These results suggest that nurses do not rely on risk assessment scores when planning and implementing PI prevention in isolation from their clinical judgement.
6. Discussion
This scoping review has identified several factors that influence nurses' clinical decision‐making about the implementation of PI prevention activities for patients in hospital settings. Four themes were identified: the use of clinical decision support systems, nurses' knowledge and attitudes, perceived barriers, along with risk assessment tools and clinical judgement. Although the factors influencing nurses' decision making were identified, there was limited research into how nurses make decisions about what PI prevention interventions they implement, and the processes they use to plan and implement that care. A scoping review enabled available research to be comprehensively summarised and facilitated exploration of the complex factors which influence nurses' clinical decision making about PI prevention. The scoping review methodology enabled a gap in knowledge to be identified.
Clinical decision support systems, including care bundles, computer programmes, algorithms, and the use of technical devices such as SEM scanners, had positive impact on nurses' implementation of PI prevention practices (Avsar et al. 2024; De Meyer et al. 2019; Huang et al. 2020; Renganathan et al. 2019; Yilmazer and Bulut 2018). A SEM scanner can detect oedema and sub‐epidermal tissue damage before any visible signs of skin damage are apparent (Musa et al. 2021), and therefore this device has great potential to be used as an adjunct to support nurses' clinical decision making. The technology prompts nurses to implement PI prevention interventions prior to skin damage being visible if a positive SEM Delta is detected. Currently, SEM scanners are not yet widely available, are costly, and a nurse still needs to decide when to use the device to assess for possible tissue damage. SEM scanners are also only validated for assessment of heel and sacral PIs (McLaren‐Kennedy et al. 2023). Clinical decision support systems also show promise. The digitalisation of electronic records and the use of point of care technology may revolutionise the way patient care is delivered. However, CDSS are only available to nurses in some settings, uptake is sub optimal (Araujo, Sousa, and Dutra 2020) and ease of use has been identified as a major factor influencing nurses' intention to use these systems (Huang et al. 2020). Findings from this review have identified that support systems may influence nurses PI prevention practices, and this is reflected in increased compliance with turning regimes and/or prompting implementation of PI interventions. Research into why nurses make the decisions to utilise these support systems, or not, is essential for developing strategies that can improve adoption in the clinical setting.
The findings from this review have identified that whilst education is important, the intervention needs to directly target clinical judgement and decision making for it to be most effective. Effective decision making to prevent PIs is contingent on a nurse having foundational knowledge including aetiology and prevention of PIs. Many studies have identified that education/training on PI prevention increases nurse's knowledge, and also has a positive effect on attitudes towards PI prevention (Chuang et al. 2022; De Meyer et al. 2019; Kim, Park, and Kim 2020). Although the link between education and positive attitudes towards PI prevention has been a common finding influencing the implementation of PI prevention (Chuang et al. 2022; Kim, Park, and Kim 2020; Sving et al. 2016), none of the included studies researched the thought processes behind the clinical decisions nurses make.
Validated risk assessment tools such as the Braden scale and the Waterlow score are used internationally to determine an individual patient's risk of developing a PI. These risk assessment tools should aid the planning of PI prevention interventions. However, risk assessments tools also require nurses to use their clinical judgement in order for them to be effective (Fulbrook et al. 2024; Li et al. 2022; Lovegrove et al. 2021; Moya‐Suárez et al. 2018). There is criticism of the sensitivity of some PI risk assessment tools and therefore they can be viewed in some settings as a ‘tick box’ activity focused on compliance, rather than a useful tool to assess PI risk and guide PI prevention strategies (Barakat‐Johnson et al. 2019). Nurses' clinical judgement about an individual patient's risk of developing a PI is used alongside validated risk assessment tools to prevent PIs. These findings suggest that clinical judgement needs to be included when using validated risk assessment tools. Further research is needed to examine how nurses use risk assessment tools in combination with their clinical judgement to make decisions about the implementation of PI prevention strategies.
Barriers to implementing PI prevention interventions in hospital settings persist and include heavy workloads, staffing and skill‐mix, and lack of equipment. Other studies have also identified similar barriers (Barakat‐Johnson et al. 2019; Coyer et al. 2019; Song et al. 2024; Tallier et al. 2017; Taylor, Mulligan, and McGraw 2021). A lack of equipment can lead to nurses having to ration care and make decisions about which patients receive PI interventions (Li et al. 2022). High acuity patients can be perceived to be at higher risk of developing PIs due to the critical nature of their illness, however, nurses' clinical decision making processes related to acuity have not been adequately explored (Choi et al. 2016; Coyer et al. 2019). Recent initiatives to improve care include providing education to nurses to prioritise PI prevention (Suva et al. 2018), integrating nursing care bundles (Lin et al. 2020), and having expert nurses available to guide care (Anderson et al. 2015). These strategies have had some success in reducing PI incidence, however, the process by which nurses make clinical decisions about the implementation of PI prevention has not been explored. The results from these studies highlight common barriers nurses face. To fully address these barriers, research is needed to identify when and how barriers to PI prevention impact on the clinical decision‐making process of nurses. This knowledge will help us to understand why nurses make the decisions they make when implementing PI prevention activities.
7. Strengths and Limitations
This scoping review used Arksey and O'Malley (2005) framework and the PRISMA Extensions for Scoping reviews guideline to guide reporting of the study (Arksey and O'Malley 2005). Quality appraisal of the included studies was conducted which improved the rigour of the findings. A comprehensive search was conducted and no research that explicitly examined nurses' clinical decision‐making regarding PI prevention for hospitalised patients was identified. Only studies published in the English language were included and this may have excluded relevant studies in other languages. A limitation of this study was seen in the types of studies included. Many studies were observational, or pre‐ and post‐ designs, that did not allow consideration of confounding factors such as workloads, staffing levels, resource availability and organisational factors including PI prevention policies. In addition, most of the studies included in this review were limited to one setting or geographical location. Further high‐quality research with larger participant numbers in many different geographical locations is required before firm recommendations for change can be made.
8. Conclusion
This scoping review provides a comprehensive summary of the current literature on nurses' clinical decision making related to the prevention of PIs for hospitalised patients. By synthesising the evidence from the included studies, key themes were identified to examine the factors influencing nurses' clinical decision making on PI prevention. These factors include support systems, knowledge and attitudes, barriers, risk assessments and clinical judgement. Further research into these themes using high quality research is needed. This should include longitudinal studies that follow a cohort of nurses over a period of time and/or mixed methods studies to explore nurses thought processes about whether to implement PI prevention interventions. High quality research is needed to validate the findings from this scoping review so that changes can be made to support nurses to provide appropriate PI prevention interventions.
A significant gap in the literature has been identified in this study. Nurses' clinical decision making about PI prevention has not been adequately explored and this has implications for nurses, nursing care and patient safety. Further research is urgently needed to help us understand the thought processes behind why nurses choose to implement PI prevention, or not, for patients at risk of developing PIs. The findings of future research on this topic have the potential to directly inform nursing practice, the development of policies and guidelines and interventions such as educational programs, and support systems targeted to the enhancing nurses' clinical decision‐making processes for PI prevention.
Author Contributions
All authors have agreed on the final version and meet at least one of the following criteria (recommended by the ICMJE*): (1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content. Joanne Cordina, Jenny Sim, Kaye Rolls made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data. Joanne Cordina, Jenny Sim, Kaye Rolls involved in drafting the manuscript or revising it critically for important intellectual content. Joanne Cordina, Kaye Rolls, Jenny Sim given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content. Joanne Cordina, Jenny Sim, Kaye Rolls agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Ethics Statement
The authors have nothing to report.
Consent
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Peer Review
The peer review history for this article is available at https://www.webofscience.com/api/gateway/wos/peer‐review/10.1111/jan.16776.
Supporting information
Data S1.
Acknowledgements
This study was undertaken as part of a Higher Degree Research study with RTP scholarship from the Australian government. Open access publishing facilitated by University of Wollongong, as part of the Wiley ‐ University of Wollongong agreement via the Council of Australian University Librarians.
Funding: The authors received no specific funding for this work.
Data Availability Statement
All data generated or analysed during this study are included in this article.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data S1.
Data Availability Statement
All data generated or analysed during this study are included in this article.