Abstract
Turning and repositioning is considered one of the strategies to reduce the incidence of pressure injuries (PIs) among hospitalized patients, as it helps to redistribute and minimize direct pressure on the targeted skin and enhance blood perfusion in the affected areas. The frequency of turning and repositioning is generally uniform across clinical settings, with most clinical guidelines recommending a substantial change in a patient’s position according to their health status. Notably, the optimal time interval between the position changes has not yet been established. Therefore, this study aimed to review the current literature in relation to the frequency of turning and repositioning adult patients to prevent PIs. The author used a systematic review following Whittemore and Knafl’s review strategy. The author used the following databases: CINAHL, Scopus, PubMed, ProQuest, Ovid, MedLine, Web of Science, and Google Scholar. During the search, Boolean logic operators, MeSH terms, and keywords were utilized. The researcher followed the Johns Hopkins Nursing Evidence-based Practice Grading Scale to evaluate the quality of selected studies. The search yielded 723 articles, of which 10 were included in this review. These 10 articles revealed several frequency intervals for comparison purposes: 2-hourly, 3-hourly, 4-hourly, and 6-hourly depending on the healthcare setting, with a combination of supine, 30° tilt, or 90° tilt. This review shows that the optimal frequency of turning and repositioning to prevent PIs remains unclear and further investigation is necessary. Considering the varying nature of clinical settings, there is a lack of clarity regarding a golden standard for the same. Therefore, patients’ health conditions should be considered when choosing the proper frequency to prevent PIs.
PIs are adverse events that require serious attention from healthcare providers, particularly nurses. Nurses play a crucial role in preventing PIs by using different prevention measures such as repositioning patients.
This review provides an overview of the ideal frequency of turning and repositioning in different healthcare settings. This could help policymakers update their policies related to the same.
Identifying the optimal frequency of turning/repositioning is fundamental for preventing PI in healthcare settings. Additionally, nursing researchers should be encouraged to undertake further research to investigate the factors that influence the effectiveness of turning frequencies on the development of PIs.
Introduction
In 2017, the National Pressure Ulcer Advisory Panel (NPUAP) attempted to phase out the term pressure ulcer, recommending that pressure injury (PI) be used in its place. In contrast to the term pressure ulcer, PI encompasses both intact and ulcerated skin. 1 A PI is defined as any destruction of the skin layers in certain areas due to malnutrition or the application of physical pressure for prolonged periods, especially continuous pressure on bony prominences or areas beneath medical devices, such as ventilators and nasogastric tubes. 1 This process of skin destruction undergoes 6 stages (1, 2, 3, 4, unstageable, deep tissue, and mucosal membrane pressure injury stages), depending upon the severity of the destruction. 1 PIs are a serious health issue that affect patients’ overall prognosis. PIs are often used as a quality care indicator.2,3 PIs can lead to a number of complications and have been a factor in increasing the risk of death, specifically among the elderly. 3 Globally, the PI prevalence rate was 12.8% and the incidence rate was 8.4% among hospitalized patients. 4 In addition, PIs increase patients’ experience of pain, result in extended hospitalization, and increase the risk of secondary infections.5,6 Therefore, PIs increase the total treatment cost and are a burden on the health care system budget. In the US, PIs usually cost approximately $11 billion annually. 7
Pressure injuries are typically considered avoidable and may develop when the healthcare provider neglects to adequately evaluate the patient’s illness and PI risk factors. 2 Failing such timely evaluation, the health care provider is unlikely to plan and implement appropriate interventions, oversee and evaluate the effectiveness of interventions, or change interventions as appropriate. 9 Nonetheless, PIs may develop despite the best efforts of the healthcare provider. 9 In these cases, accurate evaluation and monitoring of the patient, from the moment of their admission, may help to predict the patient’s risk of developing a PI, thus allowing appropriate care to be implemented early on.2,8,9
Several strategies can be used to prevent or reduce PIs in patients with immobility or movement difficulties. One of the more popular strategies involves frequent turning and repositioning of patients. This helps to reduce and redistribute direct pressure on the targeted skin and enhance blood perfusion in the affected area. 10 The frequency of turning and repositioning is generally uniform across clinical settings, with most clinical guidelines recommending a substantial change in the patient’s position every 2 h. 10 However, questions have been raised regarding the effectiveness of 2-hourly turning in terms of reducing or preventing the occurrence of PIs. Consequently, the literature has explored the efficacy of alternate turning and repositioning schedules, including 3-hourly, 4-hourly, and 6-hourly schedules. Much of the research on turning and repositioning has explored the effects of using different positioning angles.
The preferred position for distributing pressure equally underneath patients is the flat position, which helps to minimize shearing and prevent sacrum/coccyx PI. 11 However, patients cannot be placed in a flat position if they are on mechanical ventilation or a nasogastric tube. As a result, elevating the head of the bed in certain conditions helps to prevent ventilator-associated pneumonia or aspiration with enteral feeding. 11 In such a condition, one recommendation is to elevate the head of the bed by 30° or less, which may play an important role in decreasing the risk of developing a PI. 11 This degree of elevation is also considered good for preventing aspiration, especially among critically ill patients. While a combination of turning, repositioning, and bed head elevation is widely used for the prevention of PIs, a debate rages about what constitutes the best turning and repositioning frequency, especially in the presence of pressure-relieving devices.8,12 Therefore, this study aimed to review the current literature in relation to the frequency of turning and repositioning adult patients to prevent PIs in different healthcare settings.
Method
A systematic review was undertaken to evaluate the existing literature on the optimal frequency of repositioning in relation to preventing pressure injuries among adult patients. The researcher followed Whittemore and Knafl’s 13 review strategy, which is divided into 5 stages: formulating the problem, searching the literature, evaluating the data, analyzing the data, and presenting the data. 13
Source of Information
From December 2022 to February 2023, the researcher searched the following databases: CINAHL, Scopus, PubMed, ProQuest, Ovid, MedLine, Web of Science, and Google Scholar. The Boolean logic operators (AND, OR, NOT) were employed for this search. In addition, the researcher specified MeSH terms and keywords as the following: pressure ulcer, pressure injury, turning, repositioning, frequency, and nursing.
Inclusion and Exclusion Criteria
All studies included in this review were published in English, with no date limit. These included randomized controlled studies, cohort studies, retrospective studies, observational studies, and pilot studies. In addition, the selected studies target adult patients older than 18 years at any risk level of PI. The excluded studies were reports, qualitative, opinions, written in non-English language, and systematic reviews and meta-analyses.
Process of Data Selection and Extraction
The PRISMA flow chart presented in Figure 1 shows the selection process. This chart reveals the number of studies included or excluded. After identifying the initial revealed studies, the researcher skimmed and scanned them to remove the unrelated/non-illegible studies. Then, the researcher checked for duplications for the remaining studies by using the Zotaro software. The remaining studies were checked by reading the titles and abstracts. Afterward, the researcher read the full texts, which led to the exclusion of illegible studies. Then, the researcher re-read the full texts of the final remaining studies. The researcher used Microsoft Word to create a table displaying the studies’ characteristics such as author, year, title, aim, design, population, setting, country, intervention, and results (Table 1).
PRISMA flow chart of studies that are eligible for meta-analysis.
Characteristics of the Nine Studies Involved in the Meta-Analysis.
Quality of Evidence
Measuring the quality of evidence is important to examine the match between studies’ methodology and inferences. 22 For this systematic review, the researcher utilized the Johns Hopkins Nursing Evidence-based Practice Grading Scale to evaluate the quality of selected studies. This scale has 5 main domains: sufficiency of the sample size, reliability and validity of the used tools, generalizability of the findings; and constancy between literature reviews, methods, results, recommendations, and conclusions. 22 In this scale, the quality level is divided into 3 levels: level A studies were indicated as high-quality studies; level B studies were indicated as good-quality studies; and level C studies were indicated as low-quality studies (Table 1).
Findings
A preliminary search yielded 723 articles. The exclusion criteria were as follows: 629 articles did not meet the inclusion criteria, 77 were duplications, 4 were systematic reviews, 2 were not empirical studies, and one targeted a healthy adult. As a result, 10 articles that met the purpose of this systematic review were identified (See Figure 1).
After conducting a comprehensive search, the 10 selected articles were investigated and summarized, as shown in the literature matrix (Table 1). The 10 articles employed a combined or pooled sample of 4489 patients, and were published between 2004 and 2022. The 10 studies discussed in this review were conducted over a range of settings, including 6 nursing homes (NHs), 2 intensive care units (ICUs), and 2 medical-surgical units. In addition, the selected studies were conducted in 6 countries: the US,12,16,17,19 Canada, 12 Belgium,14,18 Spain, 21 Ireland, 15 and Wales. 20 The 10 articles differed somewhat in terms of research design. Seven were randomized controlled trials (RCTs), and 3 were observational studies (2 prospective designs, one before and one after design). The Braden Scale for Predicting Pressure Sore Risk was the most frequently used PI risk assessment instrument among the 10 studies.12,14 -19 Other assessment tools used in the reviewed studies included the Water-Law Risk Assessment Scale, 20 APACHE II, 21 Norton Pressure Sore Risk-Assessment Scale, 14 and an unspecified risk assessment. 22
The turning and repositioning of patients is essential for alleviating localized pressure on certain skin areas and for increasing blood flow to those areas.12,14 -21,23 Guidelines from the Wound, Ostomy & Continence Nurses Society indicate that the frequency of repositioning should be determined by the individual’s tissue tolerance, level of activity and mobility, skin condition, overall medical condition, treatment goals, type of pressure redistribution surface in use, and comfort of the patient. 24 Despite these recommendations, the incidence of PI remains exceptionally high across most healthcare organizations. Therefore, the authors of the 10 selected studies investigated one or more of the 4 main turning and repositioning frequencies: 2-hourly, 3-hourly, 4-hourly, or 6-hourly. These frequencies were combined with one or more of the 3 positions: supine, 30° tilt, or 90° tilt.12,14 -21,23 Each of these studies attempted to draw a clear conclusion about what constitutes the best frequency for the prevention of PIs in 3 healthcare settings: nursing homes (NHs), intensive care units (ICUs), and medical and surgical units.
The 3 healthcare settings were extracted as 3 themes. The reason behind identifying themes according to healthcare settings is that severity of illnesses and quantity of administered medications are different among settings. Those 2 conditions may play an important role in influencing patients’ skin integrity and tolerance. As a result, nurses should select appropriate PI prevention measures such as frequency of turning and repositioning. In addition, the technology used in each healthcare setting varies, such as the availability of standard and foam mattresses. 14 Furthermore, the diversity of nursing workload in each healthcare setting should be considered when deciding the frequency of turning and repositioning.
Nursing Homes
Six studies were conducted in different NHs.12,14,15,18,19,23 NHs are a logical choice of setting for PI studies because residents stay longer in these facilities than they do in hospitals.12,14,18,19,24 A multi-site RCT was conducted with a sample of 942 residents across 20 NHs in the US and 7 in Canada. 12 Residents identified as moderate or high risk for PI development based on Braden scores were distributed across 3 turning interval groups (ie, 2-hourly, 3-hourly, and 4-hourly). All residents were placed on foam mattresses, and residents with a history of PI were excluded. 12 This RCT failed to produce any statistically significant results between the 3 intervals with respect to the incidence of PIs, regardless of risk level or length of stay. 12 Twenty-one PIs were found in 19 residents, with PIs varying from Stage I to Stage II. 12 Of 19 residents, 8 were turned every 2 h, 2 were turned every 3 h, and 9 were turned every 4 h. 12
Defloor et al. 14 conducted an RCT trial of 761 NH residents (intervention group, n = 250; control group, n = 511) over 11 NHs. The intervention groups were divided into 4 cohorts: the first cohort used standard mattresses with 2-hourly turning; the second cohort used standard mattresses with 3-hourly turning; the third cohort used pressure-reducing viscoelastic foam mattresses with 4-hourly turning; and the fourth cohort used pressure-reducing viscoelastic foam mattresses with 6-hourly turning. All of those cohorts were compared with the control group, which received standard preventative care. Forty-one (65.1%) of 63 residents who were placed in the first cohort developed Stages 1 (30), 2 (7), and 2 (2) PIs. 14 Forty (67%) of 58 residents who were assigned to the second cohort developed Stages 1 (26), 2 (12), 3 (1), and 4 (1) PIs. 14 Interestingly, 30 (54.5%) of 66 residents placed in the third cohort developed Stages 1 (28) and 2 (2) PIs only. 14 Among the 63 residents assigned to the fourth cohort, 39 (62%) developed Stages 1 (29), 2 (8), and 4 (2) PIs. 14 However, among the control group, 220 (43.1%) residents developed Stage 1 PIs; 73 (14.3%) residents developed Stage 2 PIs; 25 (4.9%) residents developed Stage 3 PIs; and 4 (0.8%) residents developed Stage 4 PIs. 14 This RCT did not detect any significant differences in the development of Stage I PIs across the intervention and control groups. 14
An RCT involving a sample of 213 elderly patients in a long-care unit compared the efficacy of 3-hourly and 6-hourly turning to prevent PI. 15 The intervention group (n = 99) was turned every 3 h at night using a 30° tilt, and the control group (n = 114) was turned every 6 h at night with a 90° tilt. 15 In total, 16 patients developed Grade 1 or 2 PIs with a statistically significant difference between the groups, with only 3 patients in the intervention group and 13 in the control group. 15
Another RCT was conducted on 235 NH patients with Stage I PI. All residents in this study were already using a foam mattress. 18 The intervention group was turned using unequal intervals according to the following schedule: 2 h on lateral 30°, and 4 h on semi-Fowler at 30°. 18 The control group was simply turned using equal intervals on a 4-hourly basis using the same positions as the intervention group. 18 It was found that 20 (16.4%) of 122 patients in the intervention group developed Stage 2 (17) PIs, and 3 developed Stage 3 or 4. Among 113 patients in the control group, 24 (21.2%) developed Stages 2 (22) and 3 and 4 (2) PIs. 18 The incidence, severity, location, and time for developing PIs were not statistically significant between the intervention and control groups.
A pilot study of 9 NH residents was conducted to examine variations in transcutaneous oxygen (tcO2), skin temperature, and hyperemic response while turning patients. Turning the patients was achieved in the following steps: lateral pre-load position for 30 min, turning supine with the head of the bed elevated 30°, and sacrum and heels on the bed for 2 h, followed by positioning lateral again for 2 h. 19 The results of this study reflected that 6 out of 9 people had a hyperemic reaction when the position was moved from supine to a lateral position. Only a third of the people had sacral tcO2 of 40 mmHg or higher at the end of 2 h of lateral positioning. The tcO2 for both heels went down in the first 30 min after loading. 19 Prolonged supine position for 2 h decreased sacral oxygenation (tcO2) to below 40 mmHg in some subjects, irrespective of preload tcO2. Lateral repositioning after 2 h of supine placement did not result in tcO2 returning to preload levels. 19
A recent RCT 23 was conducted on 992 nursing home residents from 9 NHs in 34 states. In this study, 3 intervals (2, 3, and 4) were used for repositioning. The 9 NHs were randomly assigned to one of these intervals. 23 In each NH, the residents were attached to sensors that provided signals for the nurses regarding residents’ repositioning. 23 Yap et al. 23 found that after implementing the TEAM-UP intervention, the PI incidence rate was 0% compared to the baseline, which was 5.24%.
The results of the 6 studies showed variations in the PI incidence rates regardless of the frequency used. Several studies found that 2-hourly turning with a combination of standard or foam mattresses did not prevent PIs.12,14,15,18 During 2-hourly turning intervals, patients developed PIs staged between 1, 2, and 4.12,14,15,18 These results confirmed that 2-hourly turning is not enough to allow blood flow to nourish the affected area. 19 In addition, 2 studies found that the 3-hourly turning interval did not prevent the development of PIs among nursing home residents.12,14 However, the 4-hourly turning interval with a combination of foam mattresses showed a significant reduction in the incidence of PIs staged between 3 and 4, compared with more frequent turning on the standard mattress or less frequent turning on the foam mattress.14,18,23
Intensive Care Units
Two studies were conducted in ICU settings to determine appropriate turning intervals.17,21 Still et al. evaluated the effectiveness of a turn team in preventing PIs. 17 Using data from point prevalence surveys, the authors compared hospital-acquired pressure injury rates before and after the implementation of designated turn teams. The intervention involved turning patients using 2-h intervals with a combination of pressure relief mattresses. 17 Baseline data showed 42 (15.11%) PIs among 278 patients, including 34 Stage 1-2 cases and eight higher stages cases. Following the implementation of the turn team, 12 (5.24%) PIs were identified in 229 patients (P < .0001), with seven Stage 1-2 and five higher stages cases.
Manzano et al. 21 conducted an RCT of 329 ventilated patients in 2 ICUs where alternative pressure air mattresses were used as support surfaces. These patients were randomly assigned to either the intervention group (n = 165) with 2-hourly repositioning, or the control group (n = 164) with 4-hourly repositioning. 21 In both groups, repositioning followed by the following sequence: left side with a 30°-tilt, supine with a 30°-elevation of the bed head and the foot end of the bed, and right side with a 30°-tilt. 21 Eventually, both intervention and control groups in the RCT developed Stage 2 and higher PIs. 20 PIs developed in 17 (10.3%) patients in the intervention group, 21 22 (13.4%) patients in the control group; however, the results showed no statistically significant difference between both groups. Measurements of daily nursing workload between the groups were statistically significant, with median minutes per day devoted to turning 21 min/patient in the intervention group compared to 11 min/patient in the control group. 21
Those 2 studies used 2-hourly turning frequency combined with support surfaces such as air mattresses as PI preventive measures.17,21 Also, they found that using unspecified frequency 17 and 4-hourly frequency 21 did not help to prevent or reduce the incidence of PIs among ICU patients.
Medical and Surgical Units
Three studies investigated the turning intervals among patients in medical and surgical units. These studies included one RCT 20 and prospective studies. 16 Young 20 conducted an RCT in 46 medical patients to compare a 30°-tilt position with a 90°-tilt and a supine position to reduce the incidence of PIs. In this RCT, the intervention group (n = 23) was placed in a 30° tilt and supine position within 2 to 3 h. The control group (n = 23) was placed in a 90° tilt and supine position within 2 to 3 h. 20 However, 7 of the 46 patients could not adhere to the study guidelines for the whole night, leaving only 39 participants. 20 Five of the 39 patients who completed the study developed non-blanchable erythema (3 from the experimental group and 2 from the control group). There was no significant difference between the 2 groups. 20 An evaluation of the feasibility of the 30° side-lying position revealed that 78% of the participants had difficulty achieving or maintaining their position. 20
A prospective study was conducted to examine the association between the incidence of PI and 2-hourly turning. 16 The findings of this study are based on data collected from 269 elderly bed-bound patients (aged > 65 years) following hip surgery. 16 Of 269, 134 patients were repositioned after at least every 2 h, and 130 patients were repositioned less frequently. 16 Among the 134 patients repositioned every 2 h, 10 (7.46%) developed PIs greater than Stage 1. 16 However, 12 of the remaining 130 patients developed PIs greater than Stage 1. 16
Discussion
The purpose of this systematic review was to review the current literature in relation to the frequency of turning and repositioning adult patients to prevent PIs in different healthcare settings. After reviewing the findings of the 10 studies, it is clear that PIs, especially Stages I and II, were detected in all 10 studies.12,14 -21,23 This implies that no intervention is capable of completely preventing PIs. However, there are discrepancies in the findings of these studies with respect to the frequency of turning and repositioning. These discrepancies make it difficult to identify the optimal frequency of turning and repositioning to prevent PIs.
Three of the NH studies tested turning/repositioning at 2-hourly, 3-hourly, 4-hourly, and 6-hourly intervals. There was consensus with respect to 4-hourly turning and repositioning with the use of foam mattresses.12,14,18,23 This combined approach appears important in the prevention of PI Stages II and IV, which are considered adverse events.12,14,18,23 However, Stage I and II PIs were present in participants who received 2-hourly turning/repositioning.12,14,15,18,23 Therefore, one study indicated that 2-hourly turning and repositioning is not an optimal practice because the area is subjected to high pressure,15,19 thus resulting in insufficient blood perfusion, and tcO2. 19 The controversy between studies supports the Wound, Ostomy & Continence Nurses Society guidelines, which recommend turning patients according to their needs and situations as standard care. 23 These conclusions might be influenced by several factors; firstly, the NHs in these studies were located in the US,12,19 Canada, 12 Belgium, and Ireland.14,15,18 Therefore, the nature of NHs services in each country may vary. The second factor is that NH residents are typically aged ≥ 65 years. Moreover, NH residents typically experience several health issues simultaneously, making PIs more difficult to prevent. Third, in most NHs, turning and repositioning are activities primarily performed by nursing assistants. These nurse staff often have limited knowledge with respect to the pathology of PIs, nor do they necessarily appreciate the importance of turning and repositioning; therefore, nursing assistants should be provided with additional training sessions to ensure that they have a more comprehensive understanding of the importance of turning and repositioning.12,14,18 These differences between registered nurses and nursing assistants also mean there may be some discrepancies in terms of reporting or documenting the status of PIs.
The ICU setting is also a critical location where patients are seldom well enough to move independently given the seriousness of their illness. Two studies in this review investigated 2-hourly turning and repositioning in ICU patients.17,21 In both studies, the patients still developed PIs despite this 2-hourly intervention.17,21 However, Manzano et al. 21 neglected to identify the stage of PIs in relation to frequency; Still et al., 17 on the other hand, did report the PI stages. From these outcomes, it seems that the special circumstances of ICU patients may lead to PIs. Neither of these studies recommended an optimal turning/repositioning schedule for patients in the ICU. Nevertheless, both studies17,21 suggested the benefit of 2-hourly repositioning. Although through designated turn teams to ensure more consistent repositioning, Manzano demonstrated a slight decrease with 2-hourly turning versus 4-hourly turning, the effect was not statistically significant; this study may be performed on a larger sample.
Patients in medical and surgical units may develop PIs if they are required to remain hospitalized and have limited mobility for long periods. In the prospective cohort study, 16 the authors had no control over the confounding variables because they relied on data extracted from the electronic medical record. One RCT studies 20 were also conducted with patients in medical units. This RCT confirmed that 3-hourly turning/repositioning with a 30° tilt could be effective in reducing the incidence of PIs. 20 However, this RCT observed participants for only a single day in a single hospital unit. 20 As such, the results of these studies do little to shed light upon the ideal frequency for turning/repositioning patients to prevent PI.
In summation, 2-hourly turning/repositioning does not seem to be the optimal frequency. At this frequency level, the demand for nurses’ workload increases, and the outcome in terms of the incidence of PI remains largely unchanged. Therefore, considering patients’ health status and then determining the frequency of turning and repositioning them is the best way to prevent PIs. 1 In addition, this review did not find any discernible differences between care settings. This suggests that several factors should be considered when determining the ideal frequency.
Nursing Implications
PI is a sentinel event in a patient’s healthcare journey, thus healthcare providers expend considerable resources to prevent PIs. Several strategies have been proposed to prevent the occurrence of PI, including frequent turning and repositioning of the patients. This review synthesized the literature to identify the optimal frequency of turning/repositioning to prevent PI; however, it failed to do so. Nonetheless, healthcare providers may benefit from this review by thinking about what constitutes the best turning frequency to help their patients avoid PIs. Additionally, nursing researchers should be encouraged to undertake further research to investigate the factors that influence the effectiveness of turning frequencies on the development of PIs. Moreover, these factors could be related to patients’ or health practitioners’ ability to appropriately use the proper turning frequency.
Limitations
This review had 2 main limitations. First, there was limited literary evidence, thus limiting this review to only 3 healthcare settings. It should involve the operating rooms, palliative care units, and emergency departments. Second, this review included just a single pilot study that had a sample size too small to be reliable. However, most of the studies in this review were RCTs, and the search was comprehensive. Third, most of the studies were published before 2015, although one study published in 2022 was added. Fourth, this review focused on studies written in English only. Fifth, only one author wrote this review, albeit the author put significant effort into minimizing bias.
Conclusion
Turning and repositioning immobile patients is an essential nursing practice that is irreplaceable, even with the introduction of support surfaces. However, there is no gold standard for the frequency of turning and repositioning followed by healthcare providers. Therefore, based on a review of published studies, this systematic literature review concluded that it is difficult to determine the optimal frequency of turning and repositioning to prevent the onset of PIs. In particular, more RCT studies are needed in ICU settings to provide a clearer set of recommendations and guidelines to inform nurses of the optimal turning and repositioning frequency for this high-risk group. Moreover, efforts should be made to recruit a sufficiently large sample to ensure the validity and generalizability of any results concerning the effectiveness of turning/repositioning scheduled to prevent PIs.
Supplemental Material
sj-doc-1-inq-10.1177_00469580231215209 – Supplemental material for Turning and Repositioning Frequency to Prevent Hospital-Acquired Pressure Injuries Among Adult Patients: Systematic Review
Supplemental material, sj-doc-1-inq-10.1177_00469580231215209 for Turning and Repositioning Frequency to Prevent Hospital-Acquired Pressure Injuries Among Adult Patients: Systematic Review by Saeed Asiri in INQUIRY: The Journal of Health Care Organization, Provision, and Financing
Footnotes
Acknowledgements
The authors would like to express their appreciation to the Deanship of Scientific Research, College of Nursing Research Center at King Saud University for supporting this research project.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethics Declaration
This study did not require ethical board approval because our study is a systematic review.
Informed Consent
The informed consent is required because it is a systematic review.
Supplemental Material
Supplemental material for this article is available online.
References
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