Ward trial, 612 patients, six wards

Nursing research poster

A ward based trial of four hourly against two hourly repositioning on high specification foam, laid out as an A0 landscape board in four columns. It reports both outcomes a nursing trial has to report: whether patients were harmed, and how much nursing time the change gives back.

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Two hourly against four hourly repositioning on high specification foam: a ward based trial

D. Fernandes ¹, M. Osborne ¹,², H. Rahman ²

1 Department of Nursing, Riverbend General Hospital · 2 School of Nursing, University of Northwood

Abstract

Two hourly repositioning is standard on our wards and it consumes more nursing time than any other single preventive task. High specification foam mattresses were introduced across the trust in 2023, and the evidence that two hourly turning still adds anything on top of them is thin. We randomised 612 patients at moderate or high risk across six wards to two hourly or four hourly repositioning, all on the same foam mattress. Ulcer incidence at 14 days was 3.8% under four hourly and 4.2% under two hourly, a difference of 0.3 points (95% CI -2.4 to 3.0). Nursing time spent repositioning fell by 51 minutes per patient per day.

Introduction

The two hourly interval is not derived from trial evidence. It comes from mid twentieth century practice on mattresses that no longer exist on our wards, and it has survived into current guidance largely by repetition. High specification foam redistributes pressure continuously, which is the mechanism turning was meant to provide intermittently. If the mattress does that work, the interval can lengthen without harm, and the nursing time released is substantial: on a 28 bed ward, moving from two to four hourly returns roughly the equivalent of one full nursing shift per day. That is a large enough prize to be worth testing directly rather than reasoning about, and small enough in risk to test on a ward, since the comparator is a longer interval and not the removal of repositioning.

REFERENCES

1.Gillespie BM, et al. Cochrane Database Syst Rev 2020;6:CD009958.

2.Moore ZE, Cowman S. Cochrane Database Syst Rev 2015;1:CD006898.

3.Beeckman D, et al. Int J Nurs Stud 2019;97:24-33.

METHODS

Design. Pragmatic randomised trial, six wards, individual allocation, 14 day follow-up.

Participants. 612 adults at moderate or high risk on the Braden scale, expected stay over 3 days.

Arms. Repositioning every two hours or every four hours, day and night, all on the same foam mattress.

Outcome. New pressure ulcer, category 2 or above, assessed daily by a nurse blind to allocation.

Time. Repositioning time recorded by direct observation on 84 randomly sampled shifts.

PARTICIPANT FLOW

Screened

891

Excluded

279

Randomised

612

Two hourly

306

Withdrew or died

Analysed

574

51 min

nursing time saved per patient day

95% CI 44 to 58, direct observation

Four hourly minus two hourly, points

Figure 1. Pressure ulcer incidence at 14 days by arm and by baseline risk category.

Results

Of 612 randomised, 574 were analysed at 14 days. New ulcers of category 2 or above occurred in 11 of 287 under four hourly (3.8%) and 12 of 287 under two hourly (4.2%), a difference of 0.3 percentage points (95% CI -2.4 to 3.0), which excludes the 3 point harm the trial was powered to detect. The result held in both risk strata. Among high risk patients the four hourly arm was 0.9 points worse and among moderate risk 0.4 points better, both well inside the confidence interval and neither close to significance. Direct observation on 84 shifts found repositioning took 51 fewer minutes per patient per day under four hourly (95% CI 44 to 58). Skin inspection was completed on schedule in 96% of four hourly patients against 91% of two hourly, which nursing staff attributed to having time to do it properly rather than in passing. No difference was seen in falls, in length of stay, or in the use of additional pressure relieving equipment, and no serious adverse event was attributed to the interval in either arm.

Discussion

On high specification foam we could not detect a benefit from the shorter interval, and the confidence interval rules out the size of harm that would matter clinically. That is a different claim from proving equivalence, and a larger trial could still find a small effect. The time finding is the one with immediate consequences. Fifty one minutes per patient per day is not saved time in the abstract; on the wards we observed it went into skin inspection and into earlier mobilisation, both of which are themselves preventive. The trial does not speak to patients on standard mattresses, to intensive care, or to anyone unable to be repositioned at all. It also ran on wards where the mattress inventory was audited monthly, so every patient was genuinely on the mattress the protocol assumed, which is not universal and would matter a great deal if it were not true.

Conclusion

On high specification foam, four hourly repositioning matched two hourly on ulcer incidence and returned 51 minutes of nursing time per patient each day, most of which went back into skin inspection and mobilisation.

Incidence 3.8% four hourly against 4.2% two hourly

Difference 0.3 points, 95% CI -2.4 to 3.0

51 minutes per patient day returned to the ward

Skin inspection completed on time more often

Acknowledgements

We thank the nursing teams on the six participating wards, who collected the observation data alongside a full caseload, and the tissue viability service at Riverbend General for the blinded assessments. Funded by the trust research fund. No commercial support was received and no mattress manufacturer had any role.

Block by block

What each block on the board is for, in the order a reader walks it.

Title band and authors: The trial title across the band with the hospital and university affiliations and a QR to the protocol.
Abstract: Why the interval is being questioned, what changed on the wards to make the question live, the trial size and both outcomes.
Introduction: Where the two hourly interval came from, why high specification foam changes the reasoning, and the size of the nursing time at stake on a 28 bed ward.
Methods as a labelled protocol: Design, participants with the risk criterion, the two arms, the blinded outcome assessment, and how repositioning time was observed.
Participant flow: Screened, excluded, randomised, arm allocation, withdrawals and deaths, and the analysed total, all reconciling. The block holds six nodes and one aside, so the 204 who were not eligible and the 75 who declined share a single excluded node at 279; the reasons go in the methods text rather than the diagram.
Time saved and incidence figure: A stat block carrying the 51 minutes with its interval, above a figure showing the incidence difference overall and by baseline risk.
Results: Incidence in both arms with counts, the result by risk stratum, the observed time saving, and the skin inspection completion rates.
Discussion and limits: What the interval rules out, where the released time went, and the four populations the finding does not cover. The three references are invented for this fictional study, because the reference block is required on this layout; on your board, replace them with your sources.
How to adapt this board: Wards go into Participants, with how many and what kind, because ward mix is the first thing another nurse will ask about. The timing of the intervention goes into its own protocol entry, since on a nursing trial the schedule is the intervention. Minutes saved belongs as the second result rather than a closing remark: a change that costs nothing and returns time is a different proposition from one that only avoids harm, and a ward manager reads for that. Keep the confidence interval beside every difference, because a null result without one says nothing at all.

What makes this board work

Time is reported as an outcome

Fifty one minutes per patient per day, measured by direct observation on 84 shifts rather than estimated. In nursing research the resource finding is often the one that changes practice, so it gets a stat block of its own.

It does not overclaim equivalence

The discussion says the interval rules out the size of harm that would matter, and that this is a different claim from proving equivalence. That distinction is what a careful reviewer checks first.

The boundaries are drawn

Not standard mattresses, not intensive care, not patients who cannot be repositioned, and only on wards where the mattress inventory was audited. Each exclusion is one a reader might otherwise assume away.

Questions people ask

What goes on a nursing research poster?

The clinical question in ward terms, the design and allocation, what each arm received, the patient outcome, the resource outcome, and the boundaries of the finding. Nursing time is a legitimate outcome, not a footnote.

How do I report a negative result?

State the difference with its confidence interval and say what size of effect the interval rules out. A difference of 0.3 points with an interval from -2.4 to 3.0 is informative; "no significant difference" on its own is not.

Do I need a flow diagram if it is not a drug trial?

If patients were randomised, yes. This board shows 891 screened, 279 excluded (204 not eligible and 75 who declined), 612 randomised, 38 withdrawn or died and 574 analysed. Every arrow reconciles, which is the first thing a reviewer checks.

Can I fit four columns on one poster?

At A0 landscape, comfortably. The four column layout suits a study with an abstract, methods, results and discussion of roughly equal length.

How do I report a null result honestly?

Print the difference with its interval and say what size of effect the interval rules out. This board shows 0.3 points with an interval from -2.4 to 3.0, which rules out a benefit larger than about three points either way. No significant difference on its own tells the reader nothing.

Do the CONSORT counts have to add up?

Yes, every arrow. Screened minus excluded equals randomised; randomised minus withdrawals equals analysed. Check with a calculator, because a reader will, and a flow that is out by one number undermines every other number on the board.

Can the four columns be resized?

Yes. Every block on the board drags and resizes on its own, and the text refits. A long methods protocol can take more height and the abstract less. What cannot change is the orientation: this layout is landscape only.

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Sources

Written and checked by the OneCraft team. Last checked 30 August 2026.