Incorporation of the pressure injury protocol in care management: grounded theory

Rhea Silvia de Avila Soares1, Suzinara Beatriz Soares de Lima2, Thaís Dresch Eberhardt2, Marciane Kessler3, Dienifer Fortes da Fonseca2, Simone Kroll Rabelo2

1Polytechnic College of the Federal University of Santa Maria, Federal University of Santa Maria
2Federal University of Santa Maria
3Federal University of Pelotas


Aim: Understand the significance of the incorporation of the pressure injury protocol in the care management performed by nurses. Method: Qualitative research using a methodological framework based on the Grounded Theory. Data were collected through a semi-structured interview, with 22 nurses from a university hospital, from July to September 2014. Results: The central phenomenon "Making the Pressure Injury Protocol meaningful as a Nursing Qualification Tool for Managerial Care", composed of the category "Qualifying the professionals for the management of care" and its four subcategories, which are: "Perceiving the professional qualification from the protocol", "Considering the protocol a teaching tool", "Perceiving the protocol as an instrument of education in service", and "Evidencing the importance of protocols in patient safety". Conclusion: The study showed that the protocol is a tool of care, as well as an instrument of education in service, which makes management of care safer and also promotes professional qualification.

Descriptors: Nursing; Quality of Health Care; Protocols; Pressure Ulcer; Grounded Theory.


Nursing management is a complex nursing assignment, since it involves cause and effect relationships through scientific analysis of its managerial practice(1). Nurses are responsible for the development of nursing care in all areas of health care, which requires skills linked to the management/administration of care. In addition, nursing management and care are fundamental functions in the daily life of these professionals and aim at the quality of care in health and illness situations(2,3).

Historically, nursing presents a division in the work done by Florence Nightingale. Considered the first hospital administrator, she divided the nursing activities between nurses and ladies nurses, who develop, respectively, managerial (indirect) and assistance (direct) activities(4). Today we see an approximation between managing and assisting, when these concepts complement each other and the management of care becomes understood from a dialectical relationship between the know-how of care and management(5).

The management delineation of care must be considered in the daily work of nurses. The management delineation of care must be considered in the daily work of nurses. These professionals, who manage know-how in a differentiated and complex way, need to be prepared for the administration of risk situations, which implies in the immediate decision making, both in the coordination of the team, and in the care given to patients in critical conditions(6).

Nurses, through management, implement important strategies in order to build adequate forms of care, based on the main trends and demands of their work process. These strategies are supported by important tools, including care protocols that promote care planning, which are considered theoretical and practical support tools that contribute to the quality of patient care, since they allow the systematization and standardization of nursing practice(6).

In this context, we highlight the management of care for patients at risk of developing pressure injury (PI). These lesions represent a public health problem that has an impact on the person, family and society, as well as they are indicators of healthcare quality(7).

PIs are defined as localized damage to the patient's underlying skin and/or soft tissue, which often occur on a bone prominence or are related to medical equipment or other device type. They are characterized as an injury to the intact skin or as an open ulcer and its development is due to the intensity or time of the pressure associated with shear. They may be affected by microclimate, nutrition, perfusion and associated diseases(8).

The innovation of the managerial process of nurses, with regard to the articulation of the management and assistance, from the establishment of strategies that imply in an integral and humanized care of the patient in the prevention and treatment of PI is increasingly instigated. In this sense, it is recommended to use protocols that, as instruments of organization and implementation of care that are part of the management of the care process, qualify the actions performed by the professionals, supported by the best scientific evidence.

However, it is noticed that nurses do not understand the protocols as an instrument of care management. A review study evaluating the Brazilian production of PI prevention and treatment protocols has identified that this tool reduces PI incidence and qualifies care. However, the articles do not present articulations and protocol relationships as tools in the management of care(9), thus justifying this research.

Based on this perspective, we have the following question: what is the meaning attributed by nurses, based on a care protocol, on the management of PI care? The objective was: to understand the significance of the incorporation of the PI protocol in the care management performed by nurses.


This is a qualitative research that had the methodological support of the Grounded Theory (GT), from the Straussian perspective, a method that seeks to understand, from the data extracted from the empirical realities, through the relations and interactions experienced by the subjects, the meaning that determined context or object for the person, generating knowledge, increasing understanding and providing a meaningful guide to action(10).

The study scenario was a university hospital, located in the South of Brazil. The data collection was by individual interview, semi-structured, recorded in a digital medium, performed in the institution itself, starting with scheduling with the nurses, from July to September, 2014. The interviews lasted, on average, 40 minutes. The following guiding question was used for its conduction: what is the significance of incorporating the PI protocol into care management? The selection of participants was intentional, based on the objective of the study, and had as inclusion criteria: all nurses filled out in the Intensive Care Unit (ICU) of adults, in the Medical Clinic II and in the Intensive Cardiac Unit (ICU), independently of their service time. The exclusion criteria adopted were: licensed professionals, of any nature, at the time of data collection. Thus, the study had the participation of 22 nurses.

The interviews were immediately transcribed and analyzed after their completion. This process took place in three interdependent and complementary stages: open coding, axial coding and, finally, selective coding, which allowed the refinement of the categories and subcategories to define the central phenomenon(10).

The category "Qualifying the professionals for the management of the care" is represented as a consequence of the paradigmatic model proposed by the method. This model is an analytical framework that allows for the systematic gathering and ordering of data, so that the structure and process are integrated to reveal the central phenomenon of the study(10). It establishes the interrelationship between subcategories and categories, through the following components: phenomenon, context, causal and intervening conditions, strategies and consequences(10).

It should be emphasized that the research complied with the ethical aspects of Resolution 466/12 of the National Health Council, and the project was approved by the Ethics Committee in Research with Human Subjects under the Certificate of Presentation for Ethical Assessment (CAAE) 30531314.7.0000.5346 and Opinion No. 667 777. In order to guarantee the anonymity of the participants, their names were replaced by a code consisting of the letter "N" followed by the interview order number (N1, N2, N3... N22).


From the phenomenon "Making the Pressure Injury Protocol meaningful as an instrument for the qualification of nurses for managerial care",(12) the consequences of the category "Qualifying professionals for care management" and its four subcategories will be presented: "Perceiving the professional qualification from the protocol", "Considering the protocol as a teaching tool", "Perceiving the protocol as an instrument of education in service", and "Highlighting the importance of protocols in patient safety". The diagram representing the category and its subcategories is represented in Figure 1.

Figure 1 – Diagram representing the component "consequence" of the phenomenon "Signing the pressure injury protocol as instrument of qualification of the nurse for the managerial care"

Figure 1

Source: Master's Dissertation: Signifying the pressure ulcer protocol as a qualification instrument for nurse's managerial care, 2015, Santa Maria(11).


The nurses attributed to the protocol the development of quality care management, since its use implies better practices in the work process.

Thus, an innovative and systematized care is guaranteed, with theoretical foundations for health promotion, as well as reducing the variability of actions. This observation can be observed through the following excerpts from the interviews with the nurses:

Quality improved with the protocol, not only of pressure injury, but of other care processes. It is not only the intuitive care that there was before, but a systematized care that now exists, through the use of LP protocols, then the patient is evaluated and the process is continued in the other shifts. (N7)

I relate the protocol with quality of care, safety and standardization. I think it allows for all legal grounds. You do not do things according to your head. Things are set out for your conduct, for you to have a basis in terms of what to do. This will allow quality improvement because there will be uniformity, that is, continuity of care so that you make an evaluation later. (N18)

The protocol is an innovation, opens the horizons, brings knowledge on how to treat the patient with PI. (N9)

Another important aspect revealed by the professionals in this subcategory is that they perceived the protocol as an instrument for updating knowledge and improving health care practices, facilitating decision making, as can be seen in the following sections:

The protocol serves to guide me, so that I can speak the same language of others, so in case of doubts, I have a place to turn to and to update myself. For example, these days a colleague was in doubt, I told her to see the protocol. (N9)

To make decisions you need knowledge and protocol gives you this knowledge. As new professionals come, you do not have to say how to do it, you tell them to read the protocol. The protocol is well explained and well punctuated. The new professional who arrives can see and understand how it is done here, how PI can be prevented. Everything is in the protocol; every step, everything you need to do, is in the literature. (N14)


The nurses recognize the importance of academic nursing students in the hospital context, so they considered the protocol a teaching tool that should be used to guide and qualify the practical activities developed by the students in the hospital, strengthening their knowledge.

We have students from the Federal University, but also from other universities. So I should have a plan for these students to be guided about the protocols. The goal would be to instrumentalize for professional life, because we know that, out there, everything is different, the reality is different. (N3)

I also urge the nursing students to access the protocol; I encourage them and I use the protocol as a teaching tool. They start with a lot of interest in knowing the protocol's scope, so I always introduce it to them, even as a form of study. They get very interested; they like it; I really like it because it's well explained. (N9)


The implementation and maintenance, including the phases of application and evaluation, of new processes to be used in the practice of health professionals, especially nursing protocols, should be organized with a view to sensitize them constantly.

In this sense, actions must be systematized so that the incorporation of protocol employment can be achieved in the routine work of the nurse practitioner. For this, continuous activities of permanent education are necessary, aiming to keep the professionals updated for the qualification of the care and, also, keep them sensitized for the continuation of these actions.

In general, nurses expressed in their statements that the knowledge acquired from the protocols qualifies care and that strategies are needed to keep them stimulated for their use in care management. Thus, permanent education is important for the maintenance of professionals' knowledge in their daily practices.

I think this protocol issue should be further strengthened because we have the protocol, and I think that, from time to time, this should be resumed, because no matter how much we train, it should be reinforced every six months as a permanent education. Regarding the issue of passing in the units, I think the group of injuries already did this. I think it has to come to pass on one shift, then another; show the protocol on the Internet, and call the staff to see it. (N1)

Everything that is inserted again is difficult to be implemented, but I believe that calling the staff, doing training on a daily basis, during the shift, in the unit, coming here to talk, to demonstrate, to remember, because otherwise it ends up falling into the routine, falling into oblivion . So, I think it's important, especially now that we're going to get a lot of new colleagues, that the staff bring information. (N11)

I think that all institutions lack the time to update for the study. I think the protocol needs to be worked on a monthly basis, that is, daily. (N12)

When we started the training, we apprehended a little more. We began to see that there are a number of issues surrounding the onset of the ulcer and it gave me great relief because it showed me that there are other factors that lead to the injury, not just the lack of interest, not just the decubitus, and not just the humidity. I think it has improved with the protocol because we started talking more. (N20)


The safety of patients and professionals in the care provided in the prevention and treatment of PI, from the use of the protocol, was described by nurses as an activity that adds quality to care, since it guides the actions. They realized that the use of protocols ensures greater probability of safe and qualified care.

The protocol is supposed to standardize our actions, so that everyone uses the same language. For me, it's not just about the PI protocol, but I like to follow all the other protocols, since standardization is very important for patient safety. For me, it serves for all nurses in all sectors to try to speak the same language. (N9)

Working with a protocol means more security because I have something written that guides me and the other employees who work in the unit. (N11)

The protocol gives us confidence to make decisions, to look at a wound and to make a decision as to which treatment is best for that wound.

This means safety for professionals and patients, of course, because they get totally connected because, if there is a protocol and they follow it, they have the knowledge and, thus, provide safe care for patients in order to avoid PI. One of the items in terms of patient safety is to avoid injuries, so we need to be careful. (N14)


The study showed that nurses perceive the PI prevention and treatment protocol as a tool for professional qualification, teaching, education in service, and evaluation, and is of fundamental importance for patient safety. In this sense, one has as a consequence of its implementation, the professional qualification of the nursing team for the management of PI care.

From the above, it can be stated that the use of protocols by nurses is a managerial tool that promotes the quality of care provided and patient safety(12,13). It is believed that ensuring and guaranteeing the management of care using scientific evidence-based and quality-based protocols are important goals for health institutions that seek the excellence of their services(14).

It is worth emphasizing that nurses, in the attribution of their functions, need adequate and up-to-date scientific knowledge, practical skills, clinical and managerial skills, among other characteristics relevant to the practice of the profession(13,15,16).

Therefore, health institutions should value the quality of services provided, considered as a necessary factor for competitiveness in the labor market, for this it is necessary permanent education with a view to professional qualification and improvement of the service provided(17).

Nurses have employed, in their managerial activities, high ethical and professional standards of care and treatment, with the objective of maintaining quality and efficiency(18). The participants of this study highlighted in their testimonies the interaction between quality of care and patient safety as themes that must permeate care. It is important to highlight that the incidence of PI has been considered as one of the main indicators for the evaluation of nursing care quality(19).

Nurses also demonstrated that they understand protocol as a tool for updating knowledge, which cannot be reduced to a simplistic instrument alone, but rather establishes dynamic and complex relationships and interactions that qualify care through constant review, evaluation, and update.

The completeness perceived by nurses in relation to this instrument stands out when the management of care through it goes beyond clinical care, and is also seen as a practice of in-service education and as a teaching instrument. Regarding the acquisition of clinical competences, a study(15) showed that learning occurs mainly in the context of practice(15), highlighting the use of protocols as a tool for acquiring and developing these skills.

In this sense, it is important to highlight the importance of permanent education activities that use the protocols as a facilitator of the process, since they make it possible to update the knowledge of the nursing team and of the nursing students who carry out their practical stages in scenarios analogous to that studied. Academic nursing students, inserted in the hospital context, are encouraged to exercise and mature their professional role by articulating theoretical knowledge with practice. In addition, ongoing education activities facilitate the management of care units, since nurses are the facilitators of these actions(14).

The limitations of this study are related to the context in which the research was developed, since protocol-based nursing management is a new practice in the institution.


In this research, the theme provided a space for nurses to reflect on the PI prevention and treatment protocol and the implications of its use in daily practice, highlighting it as a care management tool that allows updating, teaching and reflecting on the work process with a view to qualification.

It is concluded that nurses made the nurse-patient-protocol relationship meaningful in their clinical application, revealing a complex network of interactions that integrate the daily routine of nurses, care management, education in service and education, and, especially, the assurance of safety and quality of patient care.


  1. Mororó DD, Enders BC, Lira AL, Braz da Silva CM, Menezes RM Concept analysis of nursing care management in the hospital context. Acta Paul Enferm. 2017; 30(3):323-32.
  2. Lorenzetti J, Oro J, Matos E, Gelbcke FL. Work organization in hospital nursing: literature review approach. Texto & contexto enferm. [Internet]. 2014 [Cited 2016 maio 05];23(4):1104-12. Available from: http://www.scielo.br/pdf/tce/v23n4/0104-0707-tce-23-04-01104.pdf
  3. Soares RSA, Lima SBS, Kessler M, Eberhardt TD, Rorato ARS, Dias CC. Coding and analyzing data from the perspective of the theory based on data: case report . J Nurs UFPE on line. [Internet]. 2015 [Cited 2016 maio 1];9(8):8919-22. Available from:http://www.revista.ufpe.br/revistaenfermagem/index.php/revista/article/view/7894
  4. Santos JLG, Pestana AL, Guerrero P, Meirelles BSH, Erdmann ALl. Práticas de enfermeiros na gerência do cuidado em enfermagem e saúde: revisão integrativa. Rev bras enferm. [Internet]. 2013 [cited 2016 abr 10]; 66(2):257-63. Available from: http://www.scielo.br/pdf/reben/v66n2/16.pdf.
  5. Senna MH, Drago LC, Kirchner AR, Santos JL, Erdmann AL, Andrade SR. Meanings of care management built throughout nurses’ professional education. Rev Rene. 2014; 15(2):196-205.
  6. Paes GO, Mello ECP, Leite JL, Mesquita MGR, Oliveira FT, Carvalho SM. Care protocol for clients with respiratory disorder: tool for decision making in nursing. Esc Anna Nery Rev Enferm. 2014;18(2):303-10.
  7. Amir Y, Lohrmann C, Halfens RJ, Schols JM. Pressure ulcers in four Indonesian hospitals: prevalence, patient characteristics, ulcer characteristics, prevention and treatment. Int Wound J. [Internet]. 2017[29 cited mai 2018];14(1):184-193. Available from: https://onlinelibrary.wiley.com/doi/epdf/10.1111/iwj.12580
  8. National Pressure Ulcer Advisory Panel. National Pressure Ulcer Advisory Panel (NPUAP) announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury [Internet]. 2016 [cited 2016 Out 9]. Available from: http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/
  9. Soares RSA, Lima SBS, Eberhardt TD, Kessler M, Fonseca GGP, Saul AMR et al. Protocolos de prevenção e tratamento de úlceras por pressão: análise da produção brasileira. Saúde (Santa Maria). 2016;42:63-72.
  10. Corbin J, Strauss A. Basics of qualitative research: techniques and procedures for developing Grounded Theory. 4th ed. Los Angeles (CA): SAGE; 2015
  11. Soares RSA. Significando o protocolo de úlcera por pressão como instrumento de qualificação para o cuidado gerencial do enfermeiro. [dissertação]. Santa Maria (RS): Universidade Federal de Santa Maria; 2015.
  12. Sales CB, Bernardes A, Gabriel CS, Brito MFP, Moura AA, Zanetti ACB. Standard Operational Protocols in professional nursing practice: use, weaknesses and potentialities. Rev Bras Enferm [Internet]. 2018 Fev [cited 2018 May 28];71(1):126-34. Available from: http://www.scielo.br/pdf/reben/v71n1/0034-7167-reben-71-01-0126.pdf
  13. Siman AG, Brito MJM. Changes in nursing practice to improve patient safety. Rev Gaúcha Enferm [Internet]. 2016 [cited 2018 May 28];37(spe):e68271. Available from: http://www.scielo.br/pdf/rgenf/v37nspe/en_0102-6933-rgenf-1983-14472016esp68271.pdf
  14. Moura EC, Luz MHBA, Cavalcante TB, Queiroz AAFLN, Furtado LB, Monte BKS. Updating pf the assistance protocol for pressure ulcer prevention: evidence based practice. Rev enferm UFPE on line [Internet]. 2016 [cited 2018 May 29];10(Supl):1498-506. Available from: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/11091/12542
  15. Aued GK, Bernardino E, Peres AM, Lacerda MR, Dallaire C, Ribas EN. Clinical competences of nursing assistants: a strategy for people management. Rev Bras Enferm. [Internet]. 2016 Feb [cited 2018 May 29];69(1):142-9. Available from: http://www.scielo.br/pdf/reben/v69n1/en_0034-7167-reben-69-01-0142.pdf
  16. Melnyk BM, Gallagher-Ford L, Long LE, Fineout-Overholt E. The establishment of evidence-based practice competencies for practicing registered nurses and advanced practice nurses in real-world clinical settings: proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. Worldviews Evid Based Nurs. 2014 Feb;11(1):5-15.
  17. Velho JM, Treviso P. Implantação de programa de qualidade e acreditação: contribuições para a segurança do paciente e do trabalhador. Rev adm saúde [Internet]. 2013 Jul-Set [cited 2018 May 29];15(60):90-4. Available from: http://cqh.org.br/portal/pag/anexos/baixar.php?p_ndoc=935&p_nanexo=480
  18. Orvik A, Vagen SR, Axelsson SB, Axelsson R. Quality, efficiency and integrity: value squeezes in management of hospital wards. J nurs manag. 2015;23:65–74.
  19. Pinto VRS, Ferreira SCM. Indicators for the assessment of the quality of nursing care: a descriptive-exploratory study. Online braz j nurs [internet]. 2017 Mar [cited 2018 May 29];16(1):140-51. Available from: http://www.objnursing.uff.br/index. php/nursing/article/view/5481
  20. Sade PMC, Peres AM. Development of nursing management competencies: guidelines for continuous education services. Rev Esc Enferm USP. [internet] 2015 [cited 2016 May 20];49(6):991-8. Available from: http://www.scielo.br/pdf/reeusp/v49n6/0080-6234-reeusp-49-06-0991.pdf

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