Abstract
Aim
This study aims to develop and validate a scientific and reliable set of nursing quality assessment indicators for orthopedic patients with pressure injuries based on the Donabedian model. The Delphi method was adopted for the selection and establishment of the indicators.
Design
Delphi method.
Methods
We developed an evaluation index system using a literature review and semi-structured interviews. Two rounds of Delphi surveys were conducted with 25 international experts to gather insights on indicators for orthopedic pressure injury care quality. The analytic hierarchy process was used to determine indicator weights. Consensus was defined as an average score of at least 3.5 and agreement from 75% of participants. Based on these criteria, we finalized the evaluation framework.
Results
The final evaluation index system for nursing quality in orthopedic pressure injury management comprises 3 first-level indicators—structural quality, process quality, and outcome quality—along with 9 second-level and 26 third-level indicators. Both rounds of expert consultation achieved a 100% effective response rate. The expert authority coefficients were 0.890 for the first round and 0.934 for the second round. In the second consultation round, Kendall’s concordance coefficients for the first, second, and third-level indicators were 0.186, 0.217, and 0.115, respectively (P < 0.05).
Conclusion
The nursing quality evaluation index system for orthopedic pressure injuries developed in this study is scientifically valid and applicable to clinical practice. It provides a standardized reference for assessing nursing quality in managing orthopedic pressure injuries.
Implications for the profession and patient care
The nursing quality evaluation index system for orthopedic pressure injuries, based on the Donabedian model, offers a structured framework for monitoring nursing quality. It standardizes nursing processes and improves resource allocation efficiency. Through outcome-based feedback, the system promotes continuous quality improvement, enhances service standardization, increases patient safety, and completes the quality management cycle.
Reporting method
This study was reported by the Conducting and Reporting of Delphi Studies (CREDES) guidance.
Patient or public contribution
No Patient or Public Contribution.
Clinical trial number
Not applicable.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12912-025-03823-1.
Keywords: Nursing quality, Evaluation indicators, Pressure injury, Pressure ulcer, Orthopedics, Donabedian
Introduction
Pressure injury (PI) is a key indicator of clinical nursing quality. It refers to localized skin and/or subcutaneous tissue damage caused by pressure, alone or combined with shear force [1]. According to the National Pressure Ulcer Advisory Panel (NPUAP) [2], pressure injuries can progress from Stage I (skin erythema) to Stage IV (deep tissue exposure). The system also includes categories for suspected deep tissue damage and unclassified injuries. Global data [3] show that the overall Incidence of Pressure injuries (PIs) among general hospital inpatients is 12.8%. A systematic review and meta-analysis [3, 4] found that among orthopedic patients, the PIs incidence rises to 20.4%, with patients suffering from spine or hip fractures showing a rate of 23.9%—significantly higher than the general inpatient rate. Orthopedic departments are particularly at risk due to the nature of orthopedic conditions and treatment limitations. Many orthopedic patients are elderly and suffer from degenerative bone diseases. These patients often have limited mobility, reduced skin sensation, and may be malnourished—all factors that increase PIs’ risk. Additionally, immobilization devices such as cervical collars, spinal fixation systems, traction equipment, splints, and plaster casts increase the likelihood of pressure injuries during transport, treatment, and rehabilitation. Long-term use of such devices also raises the risk of device-related PI [5].
Once pressure injuries occur, they increase patient discomfort and economic burden, and may lead to serious complications such as infections or sepsis. These complications can cause persistent pain and functional impairment, which compromise patients’ quality of life, recovery, and safety [6]. In addition, pressure injuries prolong hospital stays by an average of 5 to 8 days [4] and significantly increase the workload of healthcare staff in care and treatment [3]. Currently, orthopedic pressure injury care faces three significant challenges [7, 8]: (i) prevention and management strategies are fragmented and inconsistently applied; (ii) there are no specialized nursing guidelines for orthopedic patients; and (iii) a lack of scientific evaluation tools makes it hard to identify weaknesses or support quality improvement. Therefore, developing a specialized quality evaluation system for orthopedic pressure injury care is essential to improve nursing quality and patient outcomes.
Since its introduction in 1966, the Donabedian model has become one of the most influential frameworks for evaluating healthcare quality [9]. It organizes quality assessment into structure, process, and outcome [10]. Structure includes elements like staffing and infrastructure; process covers clinical activities such as patient assessment and interventions; and outcome focuses on results, such as pressure injury incidence and healing rates. This framework has proven effective in explaining healthcare quality and improving outcomes in areas like diabetes care and cardiac surgery. A systematic review found that using the Donabedian model in multidisciplinary diabetic foot care can lower amputation risk by 48% [11]. Applying the model to a cardiac surgery program in Maryland, USA, reduced mortality from 2.2 to 0.3%, with complication rates well below the national average [12]. Most research on pressure injury nursing quality in orthopedics focuses on statistical analyses of dressing use and PI incidence [4]. However, no systematic evaluation index system based on the Donabedian model has been developed. This lack of theoretical guidance leads to fragmented assessments, limiting the identification of key improvement areas.
Additionally, the absence of standardized criteria across institutions hinders evidence-based quality improvement. Significant orthopedic-specific risks—such as compression from traction devices and postoperative immobilization—are missing from current frameworks. Therefore, developing a Donabedian-based evaluation system tailored to orthopedic practice is particularly important.
This study used the Donabedian model to develop a scientific and measurable nursing quality evaluation system for orthopedic pressure injury care. By integrating evidence-based research with clinical practice, the system provides standardized prevention, monitoring, and quality improvement tools, helping reduce pressure injury rates and improve nursing quality. It also offers methodological guidance for future specialized nursing research, supporting more precise and specialized quality management.
Methods
This study used a three-dimensional quality structure model to develop a nursing quality assessment index system. The system was built through a literature review, semi-structured interviews, and expert consultations. The Delphi method was then applied to gather insights from 25 experts on the proposed index system. The study followed the “Consensus-based Reporting and Implementation Guidelines for Delphi Studies” (CREDES) [13].
The construction of the evaluation index system
This research team has five members: two wound care specialists, one orthopedic physician, one nursing management expert, and one nursing graduate student. The wound care specialists conducted literature reviews, performed interviews, developed the item pool, and prepared questionnaires. The graduate student handled data analysis and interpretation. The orthopedic physician and nursing expert jointly oversaw consultant selection and consultation. All members contributed to developing, revising, and refining the evaluation indicators.
The research team first outlined the study’s research questions and objectives. A systematic literature search will be conducted using keywords in both Chinese and English, including the following terms: “Pressure injury OR pressure ulcer OR bedsore AND nursing OR quality of care AND indicators OR management OR evaluation OR safety OR standards AND nurse* OR Care AND Quality Indicators, health OR Standard OR Quality* OR Quality Control OR Quality Improvement OR Quality of Health Care OR Quality Assurance OR Health care OR Index OR Assessment OR Safety " to search in databases such as Wanfang, CNKI, CBM, and VIP, PubMed, Cochrane Library, and Web of Science databases. The search period will cover all available data from the establishment’s database until December 31, 2023. Relevant studies that meet the research topic and inclusion criteria will be selected for further analysis.The inclusion criteria for the literature were as follows: ① Studies focusing on pressure injury care quality indicators, patient outcomes influenced by nursing interventions, nursing strategies for quality improvement, or interventions aimed at maintaining or improving patient outcomes; clinical guidelines and quality standards related to pressure injuries in orthopedic settings from both domestic and international sources; ② Studies involving hospitalized patients; ③ Peer-reviewed articles published in Chinese or English. Exclusion criteria were: ① Studies rated as low methodological quality (grade C); ② Non-research materials such as news, editorials, and conference abstracts; ③ Duplicated or overlapping studies; ④ Full texts inaccessible. Core evaluation indicators were initially identified based on orthopedic patient characteristics, wound care nurse competency standards, and pressure injury management guidelines for high-risk groups. The selected literature’s methodological quality, data sources, and evidence levels were assessed using the JBI appraisal tools to identify high-quality evidence for the indicator system. A total of 1630 documents were retrieved. Seven high-quality documents were selected after removing duplicates and applying the inclusion and exclusion criteria. The Donabedian model and literature findings developed a preliminary framework for an orthopedic pressure injury care quality evaluation system consisting of 3 first-level, 8 second-level, and 24 third-level indicators.
Between February and March 2024, this study selected 16 medical and nursing staff members from orthopedic wards in two tertiary hospitals in Shenzhen. Participants included orthopedic head nurses, wound specialist nurses, orthopedic specialist nurses, and orthopedic physicians.They were selected based on the following criteria: (1) experience in wound care, orthopedic nursing, or nursing management; (2) at least a bachelor’s degree; (3) a minimum of 10 years of professional experience; (4) a mid-level or higher professional title; and (5) voluntary participation and commitment to the consultation process. They were interviewed using a semi-structured format. The interview guide covered seven topics: ①What are the main challenges in preventing and managing pressure injuries in orthopedic departments? ②What factors most affect the quality of pressure injury care, especially regarding staffing, equipment, workflow, and facilities? ③How should pressure injury care quality in orthopedic wards be assessed? Are current indicators comprehensive enough? ④For prevention, which nursing interventions are most important and effective for orthopedic patients, especially those with fractures or who are postoperative? ⑤For treatment, what principles should guide the management of pressure injuries at different stages? ⑥How can collaboration between physicians and nurses be improved in pressure injury management?⑦What other suggestions do you have for improving the current system for evaluating and enhancing orthopedic pressure injury care? Based on interview findings, the original evaluation indicators were revised and expanded. After team discussion, a preliminary evaluation system for orthopedic pressure injury care quality was developed, consisting of 3 first-level, 9 second-level, and 25 third-level indicators.
Invitation to experts for consultation
The Delphi consultation should include 15 to 30 experts to avoid group homogeneity [14]. Between March and April 2024, the research team distributed questionnaires to nursing management, orthopedic nursing, and wound care experts to collect professional insights. Experts were selected based on the following criteria: (1) experience in wound care, orthopedic nursing, or nursing management; (2) at least a bachelor’s degree; (3) a minimum of 10 years of professional experience; (4) a mid-level or higher professional title; and (5) voluntary participation and commitment to the consultation process.
The initial draft of the expert consultation questionnaire
The initial expert consultation questionnaire was developed using findings from literature research and semi-structured interviews. A literature database was established to build a quality index system for orthopedic pressure injury care, based on which the consultation form was designed. The form includes three main sections: (1) Questionnaire instructions outlining the research background, objectives, significance, and completion procedures; (2) A draft of the quality evaluation index system covering structure, process, and outcome indicators. A 5-point Likert scale was used for scoring, ranging from 1 (“not important at all”) to 5 (“extremely important”), along with a section for expert comments to suggest additions, deletions, or modifications; (3) A background information survey collecting details such as name, gender, age, education, title, specialty, years of experience, familiarity with the indicators (rated from most familiar to unfamiliar), and judgment basis (including theoretical analysis, practical experience, literature references, and subjective insights), each with assigned scores (see Tables 1 and 2 for details). Based on the first round of feedback, the questionnaire was revised for the second round.
Table 1.
The score table indicating expert familiarity
| Degree of familiarity | Most Familiar | More familiar | Familiar | Less familiar | Unfamiliar |
|---|---|---|---|---|---|
| Expert self-evaluation | 1.0 | 0.8 | 0.6 | 0.4 | 0.2 |
Table 2.
The expert judgment is grounded on the quantitative
| Basis for making judgments | The extent of the impact on the significance of the items | ||
|---|---|---|---|
| Significant | intermediate | Insignificance | |
| Practical experience in the field | 0.5 | 0.4 | 0.3 |
| theoretical analysis | 0.3 | 0.2 | 0.1 |
| reference documentation | 0.1 | 0.1 | 0.1 |
| presentative judgment | 0.1 | 0.1 | 0.1 |
Two rounds of Delphi method reasoning and expert consultation
In March and April 2024, two rounds of expert consultation were conducted via email. After the first round, the team analyzed expert scores and feedback to develop the second-round questionnaire based on preset screening criteria. The second-round content was reviewed and finalized internally. After the second consultation, expert input was analyzed again. The screening criteria were an importance score above 3.5 and a coefficient of variation below 0.25 [15].
Statistic analysis
This study created a structured Excel 2007 database to input the results of the expert questionnaire survey. Data were analyzed systematically using SPSS 22.0 and YaapH12 statistical software. Count data are presented as percentages, and measurement data as mean ± standard deviation. The questionnaire recovery rate was used to assess expert participation. The consistency of expert scoring across indicators was evaluated using Kendall’s coefficient of concordance (W), where values closer to 1 indicate higher agreement [16]. The study assessed expert consensus using the mean score, standard deviation, and coefficient of variation (CV). A mean score of 3.50 or higher and a CV below 0.25 indicated strong expert agreement [15]. The significance level was set at P < 0.05. Expert authority was evaluated using three factors: familiarity (Cs), judgment (Ca), and authority coefficient (Cr), where Cr = (Cs + Ca) / 2 [17]. Expert judgment was based on literature reviews, practical experience, intuition, and theoretical analysis. A Cr above 0.70 was considered acceptable, and above 0.80 reflected high authority [18]. Indicator weights were calculated using the Analytic Hierarchy Process (AHP), with P < 0.05 considered statistically significant.
Results
General information of experts
The two rounds of expert consultations included 25 participants from hospitals and universities in Shenzhen and Luoyang, China, and Singapore. Participants were aged between 35 and 51, with an average age of 42.24 ± 4.28 years. Their professional experience ranged from 10 to 31 years, averaging 20.44 ± 5.04 years. Further demographic and professional details are provided in Table 3.
Table 3.
The general information of the consulting experts (N = 25)
| Variables | Classification | Number of people |
Percentage |
|---|---|---|---|
| Gender | Male | 3 | 12 |
| Female | 22 | 88 | |
| Age(years) | 30–39 | 9 | 36 |
| 40–49 | 14 | 56 | |
| 50–60 | 2 | 8 | |
| Education level | Bachelor’s degree | 8 | 32 |
| Master’s degree | 12 | 48 | |
| Doctor’s degree | 5 | 20 | |
| Professional title | Intermediate title | 9 | 36 |
| Associate senior | 7 | 28 | |
| Senior | 9 | 36 | |
| Work Field | Clinical Nursing | 2 | 8 |
| Wound Nursing | 20 | 80 | |
|
Nursing Administration |
3 | 12 | |
| Working years | 10–20 | 12 | 48 |
| 21–30 | 12 | 18 | |
| Above 30 | 1 | 4 |
N = number of consulting experts
The enthusiasm of experts
The recovery rate of the expert questionnaire reflects the experts’ enthusiasm. In this study, 25 questionnaires were distributed in two rounds, and all were successfully collected and validated, showing a 100% positive response rate in both rounds. Specifically, 12 experts (44.44%) provided feedback in the first round, and 4 experts (14.8%) in the second. These results demonstrate sustained high engagement throughout the consultation process.
Expert authority coefficient and degree of opinion coordination
In the first round of expert consultation, the judgment, familiarity, and authority coefficients were 0.924, 0.856, and 0.890, respectively. In the second round, these values increased to 0.972, 0.896, and 0.934. Generally, an authority coefficient above 0.7 indicates relatively high credibility. These results are shown in Table 4, which presents the indicator consistency analysis. In the first round, Kendall’s coefficient of concordance for the first, second, and third-level indicators was 0.140, 0.206, and 0.179, respectively. In the second round, the values were 0.186, 0.217, and 0.115. All coefficients were statistically significant (P < 0.05), as summarized in Table 5.
Table 4.
Two rounds of expert authority
| Round | Judgment coefficient | Familiarity coefficient |
Authority coefficient |
|---|---|---|---|
| First round | 0.924 | 0.856 | 0.890 |
| Second round | 0.972 | 0.896 | 0.934 |
Table 5.
Kendall’s harmony coefficient (W) values and hypothesis testing for two rounds of consultations
| Stage | Indicator | Number of Indicators | Kendall’s W |
χ2 | p |
|---|---|---|---|---|---|
| Round 1 | Primary Indicator | 3 | 0.140 | 7.0 | 0.030 |
| Secondary Indicator | 9 | 0.206 | 41.276 | 0.000 | |
| Third-level indicators | 25 | 0.179 | 107.210 | 0.000 | |
| Round 2 | Primary Indicator | 3 | 0.186 | 9.3 | 0.010 |
| Secondary Indicator | 9 | 0.217 | 43.371 | 0.000 | |
| Third-level indicators | 26 | 0.115 | 71.909 | 0.000 |
Delphi expert consultation results
The first round of Delphi
In the first round of expert consultation, the average importance scores of primary indicators ranged from 4.32 to 4.68, with a coefficient of variation between 0.10 and 0.11. Secondary indicators had average importance scores from 4.04 to 4.80 and a coefficient of variation from 0.09 to 0.16. Tertiary indicators scored between 4.04 and 4.92, with a coefficient of variation ranging from 0.06 to 0.20. Experts noted that most orthopedic patients are trauma cases who may experience psychological issues such as fear, anxiety, or depression during treatment. Therefore, nurses should systematically assess patients’ psychological states in nursing practices aimed at preventing pressure injuries to provide more targeted and effective care. After internal team discussions, the tertiary indicator “Assessment of the patient’s psychological state” was added under process quality. The secondary indicators were also updated: “First admission (to the department) and changes in risk factors for pressure injuries” was replaced with “Assessment of patient”, “During hospitalization” was changed to “Technological in Nursing”, and “At discharge” became “The impact of nursing intervention”.
The second round of Delphi
The second round of Delphi expert consultation questionnaires has been completed. The average importance scores for the first-level indicators ranged from 4.24 to 4.68, with a coefficient of variation between 0.10 and 0.11. For second-level indicators, the average scores ranged from 4.00 to 4.76, and the coefficient of variation ranged from 0.07 to 0.16. Third-level indicators had average scores between 4.20 and 4.96, with a coefficient of variation from 0.04 to 0.19. Based on these results, the research team revised the indicators by screening, reorganizing, deleting, merging, and refining the text. It established an evaluation index system for orthopedic pressure injury care quality, consisting of 3 first-level, 9 second-level, and 26 third-level indicators. The Analytic Hierarchy Process (AHP) was used to calculate the weights of each indicator through judgment matrices based on average importance scores. All consistency ratios (CR) were below 0.1, indicating acceptable consistency (see Table 6 for details).
Table 6.
Index and weight of the nursing quality indicator for pressure injury at all levels
| Indicator | Importance assignment (  ±s) |
Coefficient of variation | Weighted value |
|---|---|---|---|
| 1. Structural quality | 4.24 ± 0.44 | 0.10 | 0.1396 |
| 1.1Framework for management | 4.40 ± 0.71 | 0.16 | 0.2684 |
| 1.1.1 Establishing a specialized nursing management team dedicated to pressure injuries in orthopedics. | 4.84 ± 0.47 | 0.10 | 0.0125 |
| 1.1.2 Reframe the responsibilities of the nursing management team in addressing pressure injuries within orthopedic care. | 4.92 ± 0.28 | 0.06 | 0.0250 |
| 1.2 Methodology and framework | 4.00 ± 0.289 | 0.07 | 0.1172 |
| 1.2.1 Reinforce establishing a preventive system for pressure injuries in orthopedics. | 4.96 ± 0.20 | 0.04 | 0.0071 |
| 1.2.2 Establish a comprehensive management system for pressure injuries in orthopedic practice. | 4.20 ± 0.65 | 0.15 | 0.0011 |
| 1.2.3 Reinforce establishing a comprehensive reporting system for pressure injuries in orthopedics. | 4.80 ± 0.50 | 0.10 | 0.0034 |
| 1.2.4 Reinforce establishing a consultative framework for pressure injury management in orthopedics. | 4.92 ± 0.28 | 0.06 | 0.0048 |
| 1.3 Management of personnel and equipment | 4.72 ± 0.54 | 0.11 | 0.6144 |
| 1.3.1 Regularly organize training and assessment sessions for orthopedic nurses to enhance their knowledge and skills in preventing and managing pressure injuries, including medical device-related pressure injuries. | 4.80 ± 0.50 | 0.10 | 0.0423 |
| 1.3.2 Recurrently organize orthopedic nurses to conduct training and assessment on nursing knowledge and the operation of orthopedic-related orthoses or fixed devices, such as casts, neck supports, and external fixation supports. | 4.60 ± 0.87 | 0.19 | 0.0168 |
| 1.3.3 The orthopedic wards should have adequate protective equipment, such as air mattresses, turning pads, and various protective dressings, including foam and skin moisturizers. Additionally, the healthcare professionals working in these wards should receive proper training and assessment on correctly utilizing these resources. | 4.76 ± 0.52 | 0.11 | 0.0267 |
| 2. Process quality | 4.52 ± 0.510 | 0.11 | 0.3325 |
| 2.1 Assessment of the patient | 4.28 ± 0.46 | 0.11 | 0.3108 |
| 2.1.1 The assessment was performed using the Braden Pressure Injury Risk Assessment Tool and accurately reflected the patient’s condition. | 4.88 ± 0.33 | 0.07 | 0.0510 |
| 2.1.2 Assess the patient’s psychological state and understanding of pressure injury information. | 4.80 ± 0.500 | 0.10 | 0.0321 |
| 2.1.3 Record and implement nursing measures according to the risk level. | 4.64 ± 0.49 | 0.11 | 0.0202 |
| 2.2 Technological in Nursing | 4.32 ± 0.48 | 0.11 | 0.4934 |
| 2.2.1 Reinforce health education to patients and caregivers regarding preventing pressure injuries, including device-related pressure injuries. | 4.80 ± 0.50 | 0.10 | 0.0300 |
| 2.2.2 For patients at risk of pressure injury: maintain correct positioning, ensure adequate decompression of the heel and bulge; implement regular repositioning; uphold cleanliness of the bed unit; promote skin hygiene by keeping it clean and dry; and employ appropriate protective equipment or dressings for preventive measures as necessary. | 4.68 ± 0.56 | 0.12 | 0.0158 |
| 2.2.3 For patients wearing a medical device, it is essential to carefully select the device with minimal damage and the appropriate size. Additionally, adequate support for the device can help reduce pressure and shear force. Ensuring proper fixation of the medical device is crucial to prevent displacement. Moreover, avoiding direct contact between the patient’s skin and the device is recommended. Lastly, educating patients and caregivers on proper device usage while monitoring its functionality should be emphasized. | 4.96 ± 0.20 | 0.04 | 0.0564 |
| 2.2.4 Relevant adult nutritional risk assessment forms should be employed to evaluate the nutritional status of patients and implement appropriate interventions. | 4.72 ± 0.61 | 0.13 | 0.0226 |
| 2.2.5 Relevant actions following hospital-acquired pressure injuries include reporting and documenting the incidents, conducting causal analysis, and implementing continuous quality improvement measures. | 4.92 ± 0.28 | 0.06 | 0.0394 |
| 2.3 The impact of nursing intervention | 4.24 ± 0.44 | 0.10 | 0.1958 |
| 2.3.1 Reinforcement of patients’ and caregivers’ adherence to preventive measures for pressure injuries, including device-related pressure injuries. | 4.68 ± 0.557 | 0.12 | 0.0434 |
| 2.3.2 The satisfaction of patients and caregivers regarding the prevention and treatment efficacy of pressure-induced injuries, including device-related pressure injuries, was assessed. | 4.64 ± 0.64 | 0.14 | 0.0217 |
| 3. Results Quality | 4.68 ± 0.48 | 0.10 | 0.5278 |
| 3.1 Rate of risk assessment and Rate of reporting | 4.48 ± 0.51 | 0.11 | 0.2493 |
| 3.1.1 Rate of pressure injury risk assessment. | 4.76 ± 0.60 | 0.13 | 0.0409 |
| 3.1.2 Reporting rates of pressure injuries before and during hospitalization. | 4.84 ± 0.47 | 0.10 | 0.0649 |
| 3.1.3 Rate of skin assessment(including skin assessment rate at brace or traction sites). | 4.72 ± 0.54 | 0.11 | 0.0258 |
| 3.2 Incidence of pressure injury | 4.36 ± 0.57 | 0.13 | 0.1571 |
| 3.2.1. Incidence of stage II and higher pressure injuries during hospitalization. | 4.72 ± 0.54 | 0.11 | 0.0415 |
| 3.2.2 Efficacy of continuous quality improvement in addressing in-hospital pressure injuries. | 4.72 ± 0.54 | 0.11 | 0.0415 |
| 3.3 The awareness rate of pressure injury and device-related pressure injury. | 4.76 ± 0.44 | 0.09 | 0.5936 |
| 3.3.1 Awareness rate of pressure injuries (including device-related pressure injuries) among inpatients and caregivers in the orthopedic ward. | 4.52 ± 0.77 | 0.17 | 0.1044 |
| 3.3.2 The Awareness rate of orthopedic nurses regarding knowledge of pressure injuries, including device-related pressure injuries. | 4.76 ± 0.44 | 0.09 | 0.2089 |
Discussion
5.1 The nursing quality evaluation indicators for orthopedic pressure injury care are reliable and scientifically sound. This study conducted a literature review and used semi-structured interviews to develop a preliminary indicator system based on the Donabedian model. After two rounds of expert consultation, the research team revised the indicators according to the feedback. The Analytic Hierarchy Process (AHP) was then used to determine the weight of each indicator. This systematic, evidence-based approach resulted in a comprehensive, measurable, and scientifically valid evaluation system suitable for practical use. The success of the Delphi method depends on selecting representative, proactive, and authoritative experts. This study involved 25 experts from China and Singapore, ensuring regional diversity. Most have professional backgrounds in wound care, nursing management, and orthopedic care, reflecting relevant expertise. Among them, 18 (72%) hold senior titles, and 52% have over 20 years of experience, indicating strong practical knowledge. In both consultation rounds, all experts participated fully. Twelve and four experts, respectively, provided constructive suggestions, showing high engagement. The average authority coefficient was 0.912 with a variation coefficient of 0.11, indicating consistent and credible expert evaluations.
5.2 The quality evaluation indicators for orthopedic pressure injury care are comprehensive and professionally structured. The system includes three first-level, nine second-level, and twenty-six third-level indicators, covering all key aspects of orthopedic pressure injury care. (1) Outcome quality: With the highest weight of 0.5278, it reflects expert consensus that the value of nursing processes lies in improving patient outcomes. Outcome quality is the most objective criterion for evaluating nursing effectiveness, directly showing the impact of nursing practices on patient safety, care quality, and health benefits. This aligns closely with domestic and international research on nursing quality evaluation systems [19–21]. The secondary outcome quality indicators, including the rates of risk assessment, reporting, and occurrence of pressure injuries, as well as awareness levels regarding pressure injury prevention and device-related pressure injuries, have garnered significant attention. These indicators most directly and quantifiably reflect the weaknesses and overall effectiveness of orthopedic specialized nursing. Centered around the ultimate goal of preventing pressure injuries, these metrics aim to minimize the risk of such occurrences to the greatest extent possible. Outcome quality is regarded as the gold standard for evaluating the efficiency and functionality of the entire nursing care system. It is the most direct and compelling evidence of nursing performance [22]. (2) Process Quality: With a weight of 0.3325, it ranks second to Result Quality. This highlights the importance of standardized and consistent nursing practices for patient safety. Process quality indicators focus on the standardization, timeliness, and completeness of nursing actions, such as position management, skin and psychological assessments, and care of medical device contact areas. These indicators bridge evidence-based guidelines and clinical practice. Their proper execution is essential for achieving good outcomes and supports the effective implementation of pressure injury prevention strategies in orthopedic care [22, 23]. (3) Structural Quality: Weight is 0.1397. As a foundational aspect of quality management, the weight assigned to structural quality reflects a consensus among experts that structural components are essential to effectively implementing nursing practices. Although its influence on overall quality is more indirect when compared to process and outcome measures, structural quality primarily emphasizes the material foundations, procedural systems, and the management of personnel and equipment involved in preventing pressure injuries in orthopedic care. These factors collectively form the physical and organizational environment in which nursing activities are conducted, serving as the institutional framework for standardizing nursing behaviors and facilitating the implementation of evidence-based guidelines [9].In orthopedic wards, patients often face activity restrictions and use medical devices. Ensuring adequate structural and resource support is essential for effective position management, skin care, and preventing device-related pressure injuries. This support also forms the foundation for successfully implementing the multidisciplinary team (MDT) model.
5.3 The evaluation indicators for the quality of pressure injury care in orthopedic settings demonstrate strong clinical relevance. Their practical value stems from their close alignment with real-world clinical scenarios, effectively addressing the challenges in orthopedic care where preventive and management strategies for pressure injuries lack systematic integration and exhibit low implementation rates. The indicator system emphasizes specific risk factors inherent to orthopedic patients, such as prolonged immobilization and the frequent use of multiple medical devices. Indicators tailored to orthopedic contexts—such as “compliance of patients and caregivers with preventive measures for device-related pressure injuries” and “skin assessment rate at brace or traction sites”—have been incorporated into the core framework. This approach ensures that the indicators remain closely connected to clinical practice and provides nursing personnel with actionable and measurable standards for performance evaluation. The《National Nursing Development Plan (2021–2025)》clearly states [24], We should continue promoting high-quality nursing and improving basic care standards. The Incidence of pressure injuries, a key indicator of fundamental care quality, is included in international standards such as “the JCI Hospital Accreditation Standards”, 《the 2022 Edition of Tertiary Hospital Accreditation Criteria》, and《the 2016 Patient Safety Objectives》 [25]. Due to the specific disease characteristics of orthopedic patients, preventing and managing pressure injuries have become critical and challenging aspects of orthopedic nursing. There is an urgent need to transition nursing practices from experience-based approaches to more standardized and refined methodologies. Therefore, the development of a pressure injury care quality evaluation index system that aligns with the actual clinical conditions of orthopedics in China is essential. This system not only responds to national policy directions but also promotes the high-quality development of fundamental nursing practices. It provides a scientific foundation for monitoring and continuously improving the quality of orthopedic pressure injury care, contributes to enhancing nurses’ capabilities in the prevention and management of pressure injuries, and ultimately supports the continuous improvement of patient safety and nursing service quality.
5.4 China has progressively improved its specialized quality indicators for wound ostomy nursing and wound care management evaluation framework [26, 27]. However, although preventing and managing pressure injuries have been identified as key responsibilities in orthopedic nursing, there remains a lack of systematic and specialized quality evaluation standards tailored explicitly for orthopedic pressure injury management. Current evaluation systems predominantly rely on general nursing quality frameworks, which fail to address orthopedic patients’ unique clinical requirements fully and have not established a widely accepted, evidence-based professional indicator system. Therefore, developing a scientific, standardized, and applicable evaluation index system for orthopedic pressure injury care holds significant value for clinical practice and healthcare management. Such a system would provide clear competency benchmarks and assessment references for the training and certification of orthopedic nursing specialists and serve as a structured tool for monitoring and continuously improving the quality of basic nursing care. This, in turn, would effectively guide clinical nursing practice, reduce the Incidence of pressure injuries among orthopedic patients, and further enhance the professional significance of nursing services and the overall quality of patient care.
Limitation
The expert team includes members from China and Singapore, and regional differences may exist. The current evaluation index system for orthopedic pressure injury care needs further large-scale empirical studies and continuous refinement across various regions and medical institutions. Future research will expand validation efforts to improve the system’s scientific rigor, reliability, and clinical applicability.
Conclusion
This study supports the national strategy to improve nursing quality by integrating the unique needs of orthopedic patients in China with pressure injury prevention goals. A nursing quality evaluation system for pressure injury management in orthopedics was developed using the Delphi method and evidence-based approaches. The system is scientifically sound, well-structured, and highly applicable, reflecting the professional nature of orthopedic nursing. It provides a solid foundation for standardized and continuously improved pressure injury care in orthopedic settings.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
The authors extend their sincere gratitude to all the experts involved in the Delphi study and the research team members, whose unwavering dedication and exceptional professional expertise are indispensable for ensuring the precision and reliability of the results. Lastly, we express our profound appreciation to all participants for generously sparing their valuable time amidst their demanding schedules to actively engage in this study. Appreciate Shenzhen Natural Science Foundation General Program for Basic Research Projects (JCYJ20240813144031040). Appreciate the Medical Scientific Research Foundation of Guangdong Province (B2025054).
Author contributions
ZLQ wrote the main manuscript text. SPP distributed questionnaires to experts, analyzed data, and processed. HYF contributed to the writing and revision of the articles. All authors read and approved the final manuscript.
Funding
This research was supported by the Shenzhen Science and Technology Program (JCYJ20240813144031040), the Medical Scientific Research Foundation of Guangdong Province (B2025054).
Data availability
The data supporting this study’s findings are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
This study received approval from the Ethics Committee of South China Hospital of Shenzhen University in compliance with the Declaration of Helsinki. All methods followed the relevant guidelines and regulations—approval number-(Ethical No. 20231229002-XZ01).This study included informed consent from all participants.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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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 Availability Statement
The data supporting this study’s findings are available from the corresponding author upon reasonable request.