ReviewEvidence supporting the use of two-hourly turning for pressure ulcer prevention
Introduction
Pressure relief is essential for pressure ulcer prevention. In order to accomplish complete pressure relief, changing position is traditionally taught in nursing education and employed in nursing practice. Although the interval for turning was not specified by Nightingale, “two-hourly turning” is routinely recommended in nursing textbooks and is widely accepted in clinical practice setting.
The origin of the two-hourly turning regimen: who initiated this frequency of turning and any evidence-base to support the practice, still remains unclear.
In this paper an attempt is made to explore the origin of the regimen of “two-hourly turning”.
Section snippets
Methods
Articles describing the turning interval or frequency for pressure ulcer prevention were searched through secondary sources mainly in nursing and rehabilitation texts up to 1978 since most basic studies on pressure vs. duration for pressure ulcer prevention using animals and humans were conducted by that time. However, some of them are not accessible at present because they are too fragile to handle.
“Notes on Nursing”, “Nurses, Training of, and Nursing the Sick” by Nightingale [1,2] (1860, 1882)
It is reported that “anecdotally the two-hourly interval is attributed to the length of time taken for nurses in the Crimean War Hospitals to work their way down one side of a ward and up the other” [3]. Nightingale did make a statement about pressure ulcers “to manage the position of such cases; to prevent or to dress bed-sores;” in Nurses, Training of, and Nursing the Sick [2], but did not specify a certain frequency of turning or turning intervals. She also emphasized the importance of
Discussion
In early nursing books there are descriptions of the importance of turning for pressure ulcer prevention. The recommendation “turning frequently – changed every hour” [7], [8], [9], [10] is often seen in the US nursing textbooks, however, it has not been possible to find the original evidence for how the turning interval was determined. The practice may be the result of extensive clinical experiences for long periods of time.
In the 1940s, Guttmann's articles [18], [19], [20], [21], [22], [23],
Conclusion
The evidence supporting “two-hourly turning” regimen was not clearly identified, but one possible explanation may be that it came from Guttmann's articles of spinal cord injured in the UK. Another explanation may be that it came from the results of animal experiments by Husain and Kosiak. However, no strong scientific support could be found to explain why two-hourly turning is optimal in humans to prevent pressure ulcer development following old literature search.
Conflict of interest
The authors have no conflict of interest.
Acknowledgements
We would like to express our grateful thanks to Ms. Kazuko Kodama (renowned Nightingale historian) and Dr. Mary R. Bliss (well-known pressure ulcer researcher) for providing invaluable information in the preparation of this article.
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