Associated factors of hope in cancer patients during treatment: A systematic literature review.

AIM: To identify the associated factors of hope during treatment in cancer patients. BACKGROUND: Hope is very important to cancer patients at all stages of the disease process. Hope is seen as an important coping mechanism. Most research about hope in cancer patients considered the end of life or in palliative care. Several and different factors are associated with hope. It is not yet sufficiently clear which factors are associated with hope during the treatment. DESIGN: A systematic literature review of quantitative empirical studies on hope in cancer patients during treatment. DATA SOURCES: Search in MEDLINE (PubMed interface), CINAHL (EBSCO interface), Psychinfo and Cochrane (January 2009-December 2018). REVIEW METHODS: Empirical quantitative studies were included regardless of the disease stage, written in English or Dutch, measuring hope from the perspective of cancer patients. Two authors independently screened all the studies and assessed their quality. RESULTS: Thirty-three studies were included. Positive relationship has been established between hope and quality of life, social support, spiritual and existential well-being. Hope appears to be negatively associated with symptom burden, psychological distress and depression. There appears to be no relationship between hope and demographic and clinical variables. The relationship between anxiety and hope remains unclear. CONCLUSIONS: Hope primarily seems to be a process that takes place in a person's inner being rather than being determined from outside. IMPACT: Health professionals may want to focus on the meaning of hope for cancer patients in relation to the associated factors. A better understanding of the meaning of hope during treatment can be of great value in supporting cancer patients with regard to treatment decisions, psychosocial support, the experienced quality of life and symptom burden and any wishes they may have with regard to advanced care planning.

The influence of team members on nurses' perceptions of transgressive behaviour in care relationships: A qualitative study.

AIM: The aim of this study was to gain insight into the influence of team members in how nurses perceive and address patients' transgressive behaviour. BACKGROUND: Aggression and transgressive behaviour in health care have been a focus of research over the past few decades. Most studies have focused on individual nurses' experiences with aggression and transgressive behaviour. Literature examining group dynamics in nursing teams and team members' interactions in handling patients' transgressive behaviour is scarce. DESIGN: Qualitative interview study. METHODS: Seven focus-group interviews and two individual interviews were carried out in 2014-2016. Twenty-four nurses were drawn from eight wards in three general hospitals. Interviews were analysed using the constant comparative method influenced by the grounded theory approach. FINDINGS: While elaborating how they perceived and addressed transgressive behaviour, nurses disclosed how interactions with team members occurred. Several patterns arose. Nurses talk to one another, excuse one another, fill in for one another, warn one another and protect and safeguard one another. In these patterns in reaction to patients' transgressive behaviour, implicit group norms transpire, causing nursing teams to acquire their specific identity "as a group". Consequently, these informal group norms in nursing teams impinge how nurses feel threatened by patients' potential transgressive behaviour; gain protection from the group of nurses and conform to informal ward rules. CONCLUSION: The findings of this study can support intervention strategies aimed at supporting nurses and nursing teams in managing patient aggression and transgressive behaviour by identifying and explicating these group dynamics and team members' interactions.

Planned change or emergent change implementation approach and nurses' professional clinical autonomy.

BACKGROUND: Nurses' clinical autonomy is considered important for patients' outcome and influenced by the implementation approach of innovations. Emergent change approach with participation in the implementation process is thought to increase clinical autonomy. Planned change approach without this participation is thought not to increase clinical autonomy. Evidence of these effects on clinical autonomy is however limited. AIMS AND OBJECTIVES: To examine the changes in clinical autonomy and in personal norms and values for a planned change and emergent change implementation of an innovation, e.g. intensive insulin therapy. DESIGN: Prospective comparative study with two geographically separated nurses' teams on one intensive care unit (ICU), randomly assigned to the experimental conditions. METHODS: Data were collected from March 2008 to January 2009. Pre-existing differences in perception of team and innovation characteristics were excluded using instruments based on the innovation contingency model. The Nursing Activity Scale was used to measure clinical autonomy. The Personal Values and Norms instrument was used to assess orientation towards nursing activities and the Team Learning Processes instrument to assess learning as a team. RESULTS: Pre-implementation the measurements did not differ. Post-implementation, clinical autonomy was increased in the emergent change team and decreased in the planned change team. The Personal Values and Norms instrument showed in the emergent change team a decreased hierarchic score and increased developmental and rational scores. In the planned change team the hierarchical and group scores were increased. Learning as a team did not differ between the teams. CONCLUSIONS: In both teams there was a change in clinical autonomy and orientation towards nursing activities, in line with the experimental conditions. Emergent change implementation resulted in more clinical autonomy than planned change implementation. RELEVANCE TO CLINICAL PRACTICE: If an innovation requires the nurses to make their own clinical decisions, an emergent change implementation should help to establish this clinical autonomy.

Drug administration via enteral feeding tube in residential care facilities for individuals with intellectual disability: A focus group study on guideline implementation.

People with profound intellectual disabilities often receive medication through enteral feeding tube (EFT). In a previous study, we found that current guidelines concerning medication preparation and administration through EFT are often not followed in residential care facilities (RCFs) for individuals with intellectual disabilities. The present qualitative study aimed to identify barriers and facilitators experienced by RCF staff members to following guidelines on medication administration via EFT, by conducting focus group interviews. Time constraints, lack of knowledge, lack of clear administration instructions, lack of necessary materials, and limited gastric fluid tolerance in certain residents were identified as barriers to following guidelines. Other influencing factors were the number of staff members, residents, and medications; habits; and the residents' comfort and well-being. To optimize care for this vulnerable patient population with EFT, an intervention can be set up focusing on improving staff members' medication-related knowledge and providing clear administration instructions and the necessary materials.

Intensive insulin therapy implementation by means of planned versus emergent change approach.

BACKGROUND: Nurses' participation in decisions about new care procedures and protocols is potentially of benefit for patient outcomes. Whether nurses' participation in decisions is allowed in the implementation of innovations depends on the implementation approach used for the introduction. A planned change implementation approach does not allow it, an emergent change implementation approach does. AIM: To compare a planned change and an emergent change implementation approach to introduce an intensive insulin therapy to an intensive care unit (ICU). DESIGN: A prospective comparative study in an ICU in the Netherlands of two teams of nurses using either implementation approach. METHODS: Pre-introduction of the comparability of the two teams was assessed. The nurse compliance to the protocol was assessed as being nurses' behaviour according to the protocol and leading to acceptable glucose values. The effectiveness of the implementation was assessed by measuring the percentage of patients' glucose values within the target range, the occurrence of hypoglycaemic events and the time to glucose value normalization. Data were collected from December 2007 till January 2009. RESULTS: In the emergent change approach team there was better nurse compliance measurements than in the planned change approach team (83.5% vs 66,8% conform protocol), a better percentage of glucose values in the target range (53,5% vs 52.8%) and a shorter time to glucose value normalization. CONCLUSION: The implementation approach allowing nurse participation was associated with better nurse compliance and patient outcome measurements. The implementation approach did not conflict with introducing an evidence-based innovation. It was also associated with more effective adaptation of the protocol to changing circumstances. RELEVANCE FOR CLINICAL PRACTICE: When a new treatment requires adaptability to changing circumstances to be most effective, nurses' participation in decisions about the implementation of the treatment should be considered.

Informal support needs of cancer patients who are living alone: a qualitative insight.

OBJECTIVE: Staying independent is an important need for cancer patients living alone. Such patients might have specific informal support needs in order to stay independent. We want to explore which informal support patients living alone perceive as helpful along the cancer care continuum. METHODS: A purposeful sample of 32 patients living alone and undergoing cancer treatment were interviewed, using a semi-structured interview guide. Seventeen of them were interviewed a second time, 8 months to 1 year later. Analysis was conducted using grounded theory techniques. RESULTS: The informal support patients received was not experienced unconditionally positive. We found that an equilibrium was necessary between reducing the disadvantages of living alone while not endangering the advantages of living alone, resulting in a need for an equilibrium between distance and proximity with their informal network. The needed equilibrium was influenced by the patients' history of living alone, the perception of helpfulness of the informal network, the acuteness of side-effects and prognosis of the disease. We found that, as treatment progressed, patients tended to favor proximity and needed a greater share of the support to be provided by professionals. CONCLUSIONS: Cancer patients living alone experience informal support as an ambiguous blessing. Such support has to be given in a fine balance in order to be perceived as helpful. Health care providers should educate the informal network of the patient about which support is helpful, and under what circumstances.

Factors influencing the occupational trajectory of patients with systemic sclerosis: a qualitative study.

OBJECTIVES: To describe, from the patient's point of view, the factors influencing the occupational trajectory of patients with systemic sclerosis (SSc). METHODS: This was a qualitative study designed using grounded theory with constant comparison. Data were collected through semi-structured interviews with 14 patients who fulfilled the American College of Rheumatology or Leroy-Medsger criteria for SSc. RESULTS: Based on our interviews, we found that the occupational trajectory of patients with SSc is influenced by the continuous interplay between four groups of factors. The first group concerns the values patients attribute to work, including identity, normality, financial value, social contact, and structure. The meaning of these values and how they relate to each other underlies the desire to work. A second group of factors is those influencing the balance between daily life, work participation, and medical condition (e.g. job content, flexibility in organising work, and the willingness to ask for accommodations at work). The occupational trajectory is also influenced by external factors, including availability of support, know-ledge of the disease, pressure to work, contact with medical professionals, and existing regulations and the patient's knowledge about them. Finally, the occupational trajectory is influenced by personal factors, including socio-demographics, psychological assets, and disease- and work-related personal factors. CONCLUSIONS: The decisions patients with SSc take concerning work depend on an interplay between many factors and, especially, on the patients' personal interpretation of these factors. These need to be taken into account when helping patients with SSc determine their occupational trajectory.

Factors predicting the development of pressure ulcers in an at-risk population who receive standardized preventive care: secondary analyses of a multicentre randomised controlled trial.

AIMS: To identify predictive factors associated with the development of pressure ulcers in patients at risk who receive standardized preventive care. BACKGROUND: Numerous studies have examined factors that predict risk for pressure ulcer development. Only a few studies identified risk factors associated with pressure ulcer development in hospitalized patients receiving standardized preventive care. DESIGN: Secondary analyses of data collected in a multicentre randomized controlled trial. METHODS: The sample consisted of 610 consecutive patients at risk for pressure ulcer development (Braden Score <17) receiving standardized preventive care measures. Patient demographic information, data on skin and risk assessment, medical history and diagnosis were collected during 26 months (December 2007-January 2010). Predictive factors were identified using multivariate statistics. RESULTS: Pressure ulcers in category II-IV were significantly associated with non-blanchable erythema, urogenital disorders and higher body temperature. Predictive factors significantly associated with superficial pressure ulcers were admission to an internal medicine ward, incontinence-associated dermatitis, non-blanchable erythema and a lower Braden score. Superficial sacral pressure ulcers were significantly associated with incontinence-associated dermatitis. CONCLUSIONS: Despite the standardized preventive measures they received, hospitalized patients with non-blanchable erythema, urogenital disorders and a higher body temperature were at increased risk for developing pressure ulcers. RELEVANCE TO CLINICAL PRACTICE: Improved identification of at-risk patients can be achieved by taking into account specific predictive factors. Even if preventive measures are in place, continuous assessment and tailoring of interventions is necessary in all patients at risk. Daily skin observation can be used to continuously monitor the effectiveness of the intervention.

Acting Independently While Living Alone: The Strategies and Struggles of Cancer Patients.

Cancer patients who live alone place specific importance on acting independently during treatment. We want to describe what it means to act independently and which strategies patients use to continue to act independently. We used a qualitative design, based on grounded theory. We interviewed 32 patients, 17 of them a second time. Patients who live alone defined acting independently in two different ways: It meant not only doing things alone but also using the help of others in a controlled way. These two meanings lead to two types of strategies. As treatment evolves, patients needed to change their preferred type of strategies to continue acting independently. Succeeding to change led to a feeling of mastery and success. However, failing to change led to struggling, whereby patients' needs became invisible. Health care providers should anticipate patients' inability to change strategies during cancer treatment, thereby preventing the patient's struggle from only becoming visible during crisis.

Living Alone During Cancer Treatment: An Exploration of Patients' Experiences.

The social environment is an important determinant in the overall experience of having cancer. The purpose of this article is to identify how patients experience living alone during their cancer treatment. Using qualitative methods based on grounded theory techniques, we interviewed a sample of 32 cancer patients. Living alone was an ambiguous experience during cancer treatment: patients experienced both a lack of support as well a gain in privacy, freedom, and know-how. Living alone was also seen as a constitutive element of the patients' identity. Consequently, patients saw living alone as either a threat or as a resource for their adjustment to cancer treatment. These divergent meanings of living alone did share one common attribute, which was that staying independent was their key goal during cancer treatment. Health care providers should be attentive to the heterogeneous aspects of the experience of living alone when critically appraising the independence of patients.

Patients' nursing records revealing opportunities for interprofessional workplace learning in primary care: a chart review study.

BACKGROUND: Working and learning go hand in hand during interprofessional collaborative practice. Patients' nursing records are designed to record patient care and health status. It is not known whether these records are also used to keep track of interprofessional contacts or interprofessional learning between team members. This study explored the usefulness of patients' nursing records in optimising interprofessional workplace learning for general practitioners. METHODS: We utilized a descriptive retrospective chart review. All palliative home care teams of the Dutch speaking part of Belgium were involved. Throughout the year 2010, a representative sample of patient charts was selected. Characteristics of encounters between general practitioners and palliative care nurses were extracted from the charts. RESULTS: Detailed accounts of interprofessional contacts were found in the charts. Palliative care nurses recorded number and type of contacts, topics discussed during contacts and general practitioner's learning activities. DISCUSSION: Palliative care nurses are sensitive and open towards the general practitioners' learning needs. Patients' nursing records provide useful information for interprofessional team discussions on workplace learning. Healthcare professionals should be trained to respond to each other's learning needs.

The effectiveness of three types of alternating pressure air mattresses in the prevention of pressure ulcers in Belgian hospitals.

To compare the effectiveness of multi-stage and one-stage alternating low-pressure air mattresses (ALPAM) and alternating pressure air mattress (APAM) overlays in preventing pressure ulcers among hospitalized patients, data were pooled (N = 617) from a study of patients allocated to multi-stage ALPAM (n = 252) or one-stage ALPAM (n = 264), and another study of patients allocated to APAM overlay (n = 101). Cumulative pressure ulcer incidence was 4.9% (n = 30) over 14 days. Fewer ulcers developed on multi-stage ALPAM compared with APAM overlay (OR = 0.33; 95% CI [0.11, 0.97]), but no difference was found between one-stage ALPAM and APAM overlay (OR = 0.40; 95% CI [0.14, 1.10]). Time to develop ulcers did not differ by mattress type.

Knowledge deficits and information-seeking behavior in leg ulcer patients: an exploratory qualitative study.

PURPOSE: The aim of this study was to explore knowledge deficits and underlying processes in information-seeking behavior in patients with leg ulcers. METHOD: A qualitative approach based on grounded theory methods with constant comparison was used. Semistructured interviews were held with 15 patients with venous leg ulcers in community care settings and wound care clinics between October 2008 and June 2009. Data processing and data analysis occurred via a cyclic process. RESULTS: Patients did not express a clear understanding of the causes of ulcers or their own contribution to enhance leg ulcer healing. They often lacked knowledge about relevant lifestyle advice and its relationship to healing or recurrence. During the leg ulcer trajectory, different leg ulcer perceptions were present: the ulcer as a trifle, the ulcer as a wound not healing on its own and making everyday life impossible, the ulcer as a skin problem, and the ulcer as a chronic condition. These perceptions defined patients' actions in leg ulcer care. CONCLUSION: Leg ulcer patients often have inadequate knowledge of their condition and related lifestyle advice. Patients require greater knowledge about their condition before they can understand their treatment and recognize their role in promoting healing.

Psychometric properties of the Dutch version of the American Nursing Activity Scale in an intensive care unit.

AIM: To report the development and psychometric testing of the Dutch version of the Nursing Activity Scale in a Dutch intensive care unit nursing population. BACKGROUND: The Nursing Activity Scale developed by Schutzenhofer measures professional clinical autonomy, by inquiring about the nurses' intention to exercise their own clinical decisions. This autonomy is increasingly relevant due to the ongoing professionalization, nurses increasingly have to make their own clinical decisions. DESIGN: Instrument development. METHOD: The study was conducted from November 2007-February 2008 and consisted of the following steps: translation, expert panel content validation, reliability testing and further content validation, test-retest stability examination, additional internal consistency, and validity assessment. RESULTS: After the first reliability testing two items seen to describe a situation not applicable to intensive care unit nursing in the Netherlands were deleted from the questionnaire. In the test-retest stability assessment the intra class correlation coefficient was 0·76. The Cronbach's alpha of the final questionnaire was 0·82. The alphas of the subsamples with higher scores were significantly different from those with lower scores, supporting the validity of the weighing of the items. CONCLUSION.: The Dutch version of the nursing activity scale consists of 28 items and provides the opportunity to measure professional clinical autonomy for Dutch intensive care nurses using a well-established method.

Systematic development and validation of a nursing intervention: the case of lifestyle adherence promotion in patients with leg ulcers.

AIMS: To describe and discuss of the added value of systematic development and validation of nursing interventions in nursing care. BACKGROUND: An adherence-promoting intervention for leg ulcer patients was developed in 2008, based on the model of van Meijel. This model requires a systematic development using an analysis of patients' (lived) experiences and professionals' views on (good) care. It employs a cyclical process of trying out, evaluating, revising and reassessing the adapted intervention in patients. The intervention consists of information and counselling sessions carried out by tissue viability nurses and focuses on wearing compression hosiery, practising leg elevation, physical activity and performing leg exercises. DISCUSSION: Exploring patients' and nurses' perspectives during the development of intervention increases the likelihood that the resultant intervention is both feasible and attuned to patients' needs. Various implementation issues were identified during the developmental process. Validation of the intervention through its use in nursing care aids in refining the intervention and in linking the techniques most successful in effecting behavioural change to theoretical constructs. It contributes to the refinement of concepts of behavioural theories by clarifying the processes underlying the intervention's effectiveness. Direct involvement of the researcher in the validation phase has great added value. IMPLICATIONS FOR NURSING: Patient involvement in intervention development is essential, as is the researcher's direct involvement in practical situations in which the intervention is tested. Qualitative (evaluation) approaches are recommended. CONCLUSION: Although the systematic development of nursing interventions is time-consuming, the contribution to the development of nursing practice and nursing science makes it worthwhile.

Adherence to leg ulcer lifestyle advice: qualitative and quantitative outcomes associated with a nurse-led intervention.

AIM AND OBJECTIVES: Examining the (experienced) changes associated with a nursing intervention to enhance adherence to leg ulcer lifestyle advice. BACKGROUND: Few interventions to enhance adherence to leg ulcer treatment are developed and tested. DESIGN: Qualitative evaluation approach and pre-post-test design were used. METHOD: Twenty-six patients with venous ulcers in a community care setting participated. Data were collected by means of interviews and participant observation. Frequency and duration of wearing compression, leg exercising and leg elevation, activity level, pain and ulcer size were registered at baseline, after the end of the intervention and three months later. Inductive content analysis and Wilcoxon signed-rank test were used. RESULTS: Knowledge about leg ulcer advice increased. The education contributed to more consciously following of the advice. The rationale of the advice and its association with healing or recurrence remained often unclear. More patients performed exercises after the intervention and at follow-up. Patients often looked out onto a 'new' perspective where enhancement of quality of life and even healing might be attainable. Some patients regained independence after learning how to apply and remove compression garments themselves. The frequency of exercising and the duration of exercises increased significantly. Step counts had not altered significantly. Patients not elevating the legs at baseline elevated the legs more and for a longer period of time after the intervention. This effect on leg elevation decreased after three months. No significant changes were reported on hours wearing compression. CONCLUSIONS: The perceived changes suggest that the intervention holds a promise for current home care. Combining qualitative and quantitative research assisted to determine the possible effects of the intervention, increasing the potential for a meaningful randomised trial in the future. RELEVANCE TO CLINICAL PRACTICE: Education about leg ulcer advice should be incorporated in nursing practice. Further testing of the intervention is recommended.

Researching lived experience in health care: significance for care ethics.

The aim of this article is to demonstrate the usefulness of qualitative research for studying the ethics of care, bringing to light the lived experience of health care recipients, together with the importance of methods that allow reconstruction of the processes underlying this lived experience. Lived experiences of families being approached for organ donation, parents facing the imminent death of their child and patients being treated using stem cell transplantation are used to illustrate how ethical principles are differentiated, modified or contradicted by the narrative context of persons concerned. The integration of empirical data into ethics will help caregivers in their ethical decision making and may enrich care ethics as a narrative and interpretative field.

How evidence-based is venous leg ulcer care? A survey in community settings.

AIM: This paper is a report of a study to describe venous leg ulcer care regarding compression, pain management and lifestyle advice in community settings and to identify factors that predict the provision of lifestyle advice by nurses. BACKGROUND: Incongruence between evidence and practice in leg ulcer care has been reported. Little is known about predictive factors related to the provision of lifestyle advice. METHOD: Two focus interviews and a Delphi procedure were used to develop a self-administered questionnaire based on the Graham questionnaire. Nurses employed by community healthcare organizations and independent nurses in private practices participated (n = 789). The data were collected in 2006. FINDINGS: Compression was applied in 58.7% of patients with venous ulcers. Pain was present in 82.9%. A third of patients with pain received analgesics, but half of these patients (52.1%) took analgesics as prescribed. Half of the nurses (50.8%) gave lifestyle advice related to the leg ulcer. It was mainly instructions about leg elevation (68.3%), promoting physical activity (39.8%) and optimizing nutrition (16.7%) that were provided. Nurses who perceived themselves to have adequate leg ulcer knowledge and skills were 3.75 times more likely to provide lifestyle advice compared with those lacking such knowledge and skills. Nurses who found leg ulcer care not rewarding, rarely successful or difficult gave statistically significantly less lifestyle advice than those who found it rather rewarding, successful and not difficult. CONCLUSION: Patients with leg ulcers receive less than optimum care and patient education. A particular challenge lies in leg ulcer education programmes and pain management.

A review of why patients with leg ulcers do not adhere to treatment.

AIM: To provide an overview of what is known thus far about reasons for and determinants of non-adherent behaviour. BACKGROUND: Compression, leg exercises and leg elevation are regarded as essential components in leg ulcer treatment and in the prevention of ulcer recurrence. Non-adherence to leg ulcer regimen is a major problem. Reasons for non-adherence are not fully understood. DESIGN: Systematic review. METHOD: Medline, CINAHL and the Cochrane database were explored from 1995 - December 2007. Reference lists of retrieved articles were searched. Studies were eligible if they included patients with venous or mixed leg ulcers, reported reasons or determinants of non-adherence and were published in English, Dutch, French or German. Thirty-one studies were included. RESULTS: Non-adherence is a multidimensional problem. Pain, discomfort and lack of valid lifestyle advice by healthcare professionals were primary reasons for non-adherence from patient's perspective. CONCLUSIONS: Healthcare professionals mainly focus on patient-related factors such as poor motivation, lack of knowledge and understanding and unwillingness. The beliefs that compression was unnecessary, uncomfortable, worthwhile and prevented recurrence significantly determined (non-)adherence. RELEVANCE TO NURSING AND NURSING SCIENCE: Interventions to promote adherence will require a multifaceted approach and a holistic comprehensive assessment. Therapeutic non-judgemental relationships are essential to enhance patient adherence. Effective pain management is recommended and social support by family or significant others could be encouraged. Healthcare professionals should give clear, unambiguous and tailored information. Research can best focus on the factors and processes affecting patient adherence to leg ulcer treatment. Comprehensive adherence-enhancing strategies could be developed and their effectiveness should be tested.

The identification of older nursing home residents vulnerable for deterioration of grade 1 pressure ulcers.

AIMS AND OBJECTIVE: The objective of this study was to identify prognostic factors associated with the development of pressure ulcer lesions (grade 2-4) in nursing home patients with non-blanchable erythema. BACKGROUND: No studies could be found that identify risk factors for further development of pressure ulcer in patients with non-blanchable erythema. For some patients with non-blanchable erythema, standard preventive measures do not suffice to prevent pressure ulcers from deterioration. Identifying these patients beforehand can considerably contribute to the efficiency of pressure ulcer prevention. DESIGN: Secondary data analyses of a previously conducted randomised controlled trial were performed. METHODS: Eighty-four wards of 16 Belgian nursing homes participated in the study. In total, 235 nursing home residents with a grade 1 pressure ulcer (non-blanchable erythema) were included. All the residents received standard preventive care. Potential prognostic factors were collected using a standardised form. The incidence of pressure ulcers was recorded according to the European pressure ulcer classification system. RESULTS: The cumulative pressure ulcer incidence was 18.7% (44/235). Hypotension (relative risk = 3.42, 95% CI = 1.56-7.49), a history of a cerebral vascular accident (relative risk = 1.94, 95% CI = 1.10-3.70) and contractures (relative risk = 2.02, 95% CI 1.03-3.95) were identified as independent predictive factors for developing pressure ulcers. Remarkably, being urinary incontinent decreased the risk of developing a pressure ulcer by 76%. CONCLUSIONS: In nursing home residents with non-blanchable erythema, hypotension, contractures, and a history of cerebral vascular accident were independent risk factors for the development of pressure ulcer lesions. RELEVANCE TO CLINICAL PRACTICE: Patients with non-blanchable erythema who have hypotension, contractures or a history of cerebral vascular accident are in need of more intensive preventive measures. Identifying these patients can contribute considerably to a more efficient pressure ulcer prevention policy, resulting in a lower pressure ulcer lesion incidence and in lower costs.