Prevention of Pressure Injuries and Nursing Interventions in Critical Care Settings: a Synthesis Without Meta-Analysis (SWiM)

Purpose: This review aims to update the evidence regarding optimal nursing interventions for mitigating pressure injuries in critical care patients. Method: A synthesis without a meta-analysis design was used. A systematic review was performed on several databases such as PubMed, SCOPUS, CINAHL, MEDLINE, and Web of Science to find nursing research publications related to pressure injury prevention interventions between January 2007 and May 2023. Data were extracted for each study regarding study aim, study characteristics, intervention details, and finding. Result: In our comprehensive review, we examined twenty studies encompassing 305,149 patients that investigated nursing interventions for pressure injuries. These studies were categorized into four main groups: (a) the implementation of pressure injury prevention bundles, (b) regular repositioning with supportive surfaces, (c) strategies targeting the prevention of pressure injuries associated with medical devices, and (d) facilitating access to specialized expertise. All the studies demonstrated a reduction in pressure injuries attributed to the implemented interventions. It is crucial to acknowledge, however, that the strength of the evidence varied across the studies, with ratings ranging from moderate to very low. Despite the potential challenges in translating these findings into practice, the consistent trend observed from 2007 to 2023 suggests that adherence to evidence-based nursing care is pivotal. Efforts must be directed towards ensuring the integration of these recommendations into practical healthcare settings. Conclusion: Nurses have the necessary expertise to prevent pressure injuries in critical care units. Every critically ill patient requires interventions to prevent pressure injuries, which makes prevention a complex process. Nurses are responsible for developing and implementing care plans based on evidence to prevent all types of pressure injuries, including those caused by medical devices. The importance of education and training programs for nurses in pressure injury prevention cannot be overstated.


Introduction
The European Pressure Ulcer Advisory Panel defines pressure injury (PI) 1 as localized skin or underlying tissue damage caused by pressure, pressure combined with shear, or the use of medical devices.The clinical practice guidelines categorize these injuries into stages I, II, III, IV, unstageable, and deep tissue injury (EPUAP, 2019).These stages help clinicians understand the severity and nature of the injuries.A comprehensive skin assessment conducted by nursing professionals is the basis of the diagnostic framework. 2However, the international guidelines list several interventions and practice recommendations for PI prevention (EPUAP, 2019).Based on the five levels of evidence in the guideline, which range from A (more than one high-quality study) to GPS (good practice statement), the strength of evidence regarding nursing interventions related to PI (pressure injury) prevention in critical care shows an absence of any A level of evidence.Most of the evidence ranges from B2 to C levels, with a good amount of GPS level of evidence.
Therefore, additional support and recommendations are needed to strengthen the evidence for preventing pressure injury formation in critically ill patients who were in higher risk for developing PI due to the complex nature of their health conditions. 2 Factors such as limited mobility, using ventilators and vasopressor agents, and invasive medical devices have been identified as contributing to PI development in critical care settings. 3Moreover, PIs give rise to serious complications, including severe pain, infections, prolonged hospital stays, psychological distress, delayed recovery, and even mortality (Lin  et al, 2020).So, patients with PI in critical care significantly impact comorbidities and negatively affect patient outcomes. 4his comprehensive perspective enlightens healthcare practitioners, researchers, and policymakers, fostering a collective understanding crucial for effectively managing and preventing pressure injuries in clinical settings.
Critically ill patients commonly experience pressure injuries due to the complex nature of their health conditions. 2 Factors such as limited mobility, using ventilators and vasopressor agents, and invasive medical devices have been identified as contributing to PI development in critical care settings. 3Moreover, PIs give rise to serious complications, including severe pain, infections, prolonged hospital stays, psychological distress, delayed recovery, and even mortality (Lin et al, 2020).So, patients with PI in critical care significantly impact comorbidities and negatively affect patient outcomes. 4Nurses face a substantial challenge in preventing pressure injuries (PIs) while caring for critically ill patients. 5To mitigate pressure injuries (PIs), nurses must employ evidence-based interventions, possess a comprehensive understanding of PI prevention, adopt a structured yet personalized approach to address individual patient care requirements, and involve the multidisciplinary team in collaborative efforts toward PI prevention. 6uccessive editions of international clinical practice guidelines on preventing and treating pressure injuries (PIs) were published in 2009, 2014, and 2019. 7However, research has shown that the mere availability of guidelines does not guarantee the implementation of best practices in care settings, 8 as these guidelines often need more specific strategies for improving care. 6,9Also, presenting the policies is not associated with staff compliance with the required interventions. 10o enhance the care provided to critically ill patients, various PI prevention programs incorporating multiple interventions, commonly called bundles, have been developed. 4Nonetheless, disparities and variations in nursing interventions within these PI prevention bundles and across different practice settings pose challenges to PI prevention efforts. 11ence, this review aimed to identify and critique the most effective nursing interventions for preventing PIs in critical care unit patients.

Methods
Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA), 12 and Synthesis without meta-analysis (SWiM) guidelines, 13 this systematic review has been conducted.

Eligibility Criteria and Study Selection
The inclusion criteria were utilized to determine which studies would be incorporated into this review; (a) adult patients (≥18 age), (b) studies reported nursing interventions, nurses' knowledge, nursing skills, attitudes towards PI prevention, (c) critical care/intensive care unit settings, (d) studies reporting nursing interventions randomize contorted trials (RCTs), Quasi-Experimental Studies, cohort (either prospective, retrospective), case-control, Case Series, and cross-sectional, (e) English report publication.The following exclusion criteria were applied: (a) duplicate reports, including repetitive patient information; (b) insufficient data; and (c) reviews and reports.
Three authors, AA, MRW, and HM independently assessed the full texts of the articles and applied the inclusion criteria for filtering by EndNote© X9 software.In cases of disagreement, discussions were held with senior authors ARA until a consensus was reached.

Quality Assessment
Two reviewers (AM and ARA) conducted the quality assessment of the included studies independently, and any discrepancies were resolved through mutual agreement.Various critical appraisal tools, such as the Joanna Briggs Institute (JBI) tools for Quasi-Experimental Studies, Randomized Controlled Trials (RCTs), Cross-Sectional Studies, and Case Series were employed to assess the quality of the studies.Each item was assessed and assigned a score of 1 for "yes" or 0 for "no" or "unclear".The total score for each study was then converted into a percentage.Based on the JBI critical appraisal tools guidance, [14][15][16] the authors categorized studies as high (>80% quality score), moderate (50%-80% quality score), or low (<50% quality score).No studies were classified as low-quality (Table 1), and consequently, no studies were excluded based on methodological quality.• Use of special devices and technology Positioning.
• In Phase 1: repositioning compliance was 55%, and the mean repositioning interval was 3.8 hours.• Skin assessment within 4 hours of admission.
• Use of a skin barrier.
• Prophylactic dressings: Five-layer silicone- bordered foam dressings for the heels and sacrum.
• Work unit guideline for pressure injury prevention.
• The use of multiple staff-focused and patient-level strategies to successfully reduce PI prevalence rates.Use of special devices and technology: - • Use of urinary catheters.
• Use of Fecal management system • Overall low prevalence of skin breakdown combined with high prevalence of liquid and semi-liquid stools may be explained by the fact that many patients did not have stools, many had urinary catheters, stoma and fecal management systems avoiding that urine and/or feces affected the skin.
• High prevalence of urinary catheters together with fecal management systems, avoiding urine and feces contact with the skin, may also explain the low prevalence of skin breakdown.

85%
Cao, S. et al, 2022 19 Pre & postquasi 131 China To examine the effectiveness of implementing the evidence in preventing medical device-related pressure injury (MDRPI) in intensive care patients.
Provide Training and increase knowledge • Nurses' knowledge scores and evidence compliance significantly improved.• Control group (2-hour repositioning com- bined with a powered air pressure redistribution mattress).
• Participants received their respective proto- cols until they were discharged, died, or for at least 7 days.
• Thirteen patients had single new stage 2 or worse PIs.
• Difference between the groups' Braden Scale score median during the intervention was not significant (13 vs 13.5 • Compliance to routine repositioning was reported at lower levels between 67% and 84%, respectively.
• Heel elevation was reported for over 60% of the patients with severe HAPIs while 31.9% did not receive heel elevation, only 6% were reported as not needing elevation.
• The of patients had HOB greater than the 30° at the time of the data collection; compliance with minimizing linen layers (≤3) was reported in 76% or more.
• Moisture strategies were reportedly used in more than 71% of all patients and 89% for patients with severe HAPIs.
• Nutrition support was used for 55% to 82% of the patients and only documented as contraindicated in fewer than 2% of all groups.

88%
Anderson, M. et al 2015 22 Quasiexperimental, pre-and postintervention study 327 USA To investigate the effectiveness of the universal PI prevention bundle along with the semi-weekly nurse round Bundle (SAFER) bundle: • Skin emollients • The study intervention led to a significant decrease in the PIs incidence rate from 15.5% to 2.1% (p = 0.001).
• The bundle implementation improved the continuity of staff training.
• Multidisciplinary approach for the early detection of MDRPIs is effective.
• One of the approaches to MDRPI prevention was to standardize securing medical devices.
• The impact of the SAFER bundle separate from the semi-weekly rounds was difficult to quantify.
• A challenge as to whether semi-weekly rounds caused a change, or the actual impact was begun after applying the bundle.
• The severity of PIs decreased in control group including PI stages 3, 4 and unstageable.
• Intervention group outcomes were PIs stage 2 and 3 only Intervention led to increased awareness of possible occiput.• Turning frequency schedule.
• InSPiRE bundle led to a decline in PI incidence (p = 0.04).
• The total number of PI was lower in the intervention group (n = 24) compared to control group (n = 64) (p ≤.001).
• Total number of patients with PI was lower in the intervention group (n = 9) compared to the control group (n = 24).
• Patient repositioning every 3 hr in the intervention group resulted in significant finding (p < 0.001).
• The nurses should position ICU patients according to this sequence: • Supine then left side-lying, then right.
-Placing pillows under and between bony prominence areas.
-Changing the turning frequency for critically ill patients from 5 hourly to 3 hourlies.5-Care included involved other interventions such as: • Applying prophylactic dressing to sacrum and heel • The turning protocol led to a decrease in PI inci- dence and was significantly different between groups (p = 0.028).
• The number of PI occurring in recumbent positions were higher in pre-intervention group [36 vs 8 PIs in recumbent positions (p < 0.001)].
• Risk adjustment based on the APACHE III score, age and intubation duration were carried out and the findings were: • Significant reduction noted in risk of developing PIs by 49% (p = 0.041).
• • 43% in the baseline, 37% in the 2nd period, 28% in the 3rd period • The PI free time increased after the intervention from 12 to 19 days (p = 0.01).
• Staff use of equipment changed during the interven- tion.Frequency of using PI mattresses increased to 40% in the 2nd period and 60% in the 3rd period (p = 0.003)

96%
Gray-Siracusa and Schrier 2011 27 Quasiexperimental, pre-and postintervention study 1199 USA To design an evidence-based PI prevention bundle based and determine its effectiveness on reducing PI.
• Minimal head of bed elevation.
• Nutrition assessment on admission and daily nutritional assessment.
• Skin health and assessment 7/Sacral area cleansing and moisturizing  • Several adverse events occurred more in the inter- vention group but were not statistically significant.• Change of position.
• Application of hydrocolloid dressing on the sacral region.
• Use of emollients for skin hydration.
• External hygiene of perineum area.
• Dry and clean perineum.
• Observation of positioning and fixation of orotracheal catheter • Bed headboard raised to 30°• Some nursing actions were associated with preventing PIs • Repositioning (p = 0.005).
• Several actions have not been carried out by nursing staff and resulted in PI development.
• Application of hydrocolloid dressing on the sacral region (p < 0.001).
• Observation of positioning and fixation of the oro- tracheal catheter (p < 0.001).
• Bed headboard raised to 30° (p = 0.043) Hypothermia (p = 0.029) and oedema (p = 0.012) were found to be significant risk factors for developing PIs.75% Otero, D. et al, 2017 30 RCT 152 Spain To evaluate four methods for prevention of facial PI related to the use of noninvasive mechanical ventilation techniques critical care.
The patients were allocated into four groups to receive different therapeutic strategies as the following: • Group A: Direct mask.
• Group B: Adhesive thin dressing.
• Group C: Adhesive foam dressing.• Position changes every 3 hrs.for those at moderate or high risk.
• Placing patient in sitting position early morn- ing and afternoon.
• Using neutral soap during skin wash in the morning and urea cream for hydration in the evening.
•  • Risk assessment: Prevention measures to be applied when Braden score is ≤16.
• Daily skin assessment and frequent position- ing changing.
• 30-degree head of the bed elevation.
• Nutritional support (especially if Braden score is equal or lower than 11).
• During and after bath: Avoid using hot water and excessive friction.
• Avoid using tape on fragile skin.
• Use a skin protector.
• Do not massage areas with hyperemia.
• Avoid massage on bony prominences.
• Avoid using Donut ring pads.
• Use pressure reducing cushion on seating chair.
• Observe weight distribution, postural align- ment, and stability if a wheelchair is used.
• Pressure relief every 15 min for wheelchair users.

• Patient and family education
The procedure led to a 23% decrease in the ICU incidence of PIs the areas affected were calcaneus (42.1%), sacral region (36.8%),buttocks (15.8%) and trochanter (10.5%)The most-reported stage was stage II (64%) Moisture, sensorial perception and mobility have been found the most crucial influences that increase ordecrease PIs development 98% Swafford, N. et al 2016 33 RCT 1458 USA To reduce the incidence of hospitalacquired pressure ulcers in an intensive care unit.
• Applying a skincare protocol.
• The use of silicone gel adhesive dressings and dressing underneath cervical collars.
• Skin assessment must be within 4 hrs of admission and then every 8 hr.
• Daily bed bath with pH balanced cleaning agent and skin moisturizer.
• A three hourly turning schedule using a 'turn clock'.
• 20-degree elevation for the end of the bed.
• Daily mobility if not contraindicated.
• Transfer and lift patients using draw sheets.
• Documentation of position.
• Frequent training on Braden scale and pre- vention bundle elements.RCT 120 Turkey To determine the impact of an algorithm on preventing PI.
The study has four phases: • Pre-algorithm data collection.
• Training program initiated in critical care units includes distribution of booklets and establishes practicing the algorithm.
• Frequent monitoring by researchers on the progress of applying the algorithm, required documentation.Tool evaluating carried out by nurses after 3 months of starting the algorithm.
• Comparing the incidence rate pre-and -post the algorithm, and then, algorithm evaluation.stayed in the ICU for less than 48 hours, 19 and one study included patients with an expected length of stay of at least 7 days and excluded those with pressure injuries upon admission. 20

Primary Outcomes
The primary outcome measure in all the included studies was the development of pressure injuries (PIs).Of the 20 studies, 18 directly reported a reduction in the incidence of PIs [21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36] , while one study demonstrated an indirect improvement by enhancing compliance with nursing interventions. 1734,35 Additionally, two studies provided training on measuring outcomes related to pressure injuries.In 7 studies, the assessments focused on identifying the initial presence of a pressure injury within 48 hours of admission.This included one study that assessed for pressure injuries at the time of admission, 22 two studies that conducted assessments within 4 hours, 20,24 one study within 8 hours, 35 and three studies that assessed during the first 48 hours of admission. 26,32,36n four studies, 21,22,25,31 data regarding the presence of a pressure injury was extracted from electronic datasets.However, none of the studies provided information on how the presence of a pressure injury at or following discharge from the critical care unit was assessed.

Secondary Outcomes
Several included studies utilized various risk assessment tools to identify patients at a higher risk of developing pressure injuries.][28][29][32][33][34][35] Additionally, alongside the risk assessment tools, some studies collected data on the severity of illness.The Sequential Organ Failure Assessment (SOFA) score was used in two studies, 24,34 while the Acute Physiology and Chronic Health Evaluation (APACHE III) score was employed in one study. 25Two studies incorporated the SOFA and APACHE III scores, and another two utilized a combination of the SOFA and APACHE II scores. 36

Use of Comprehensive PI Prevention Strategy
[33][34][35][36] The interventions in these 11 studies were comprehensive, with certain interventions being commonly implemented among the strategies.These included skin assessment, risk and nutrition assessment, skin hygiene and moisturizing, heel elevation, repositioning, and nursing education and training.Furthermore, additional interventions were included in some studies as part of their comprehensive strategies.These interventions encompassed the application of prophylactic dressing and support surface, minimizing linen layers, head elevation, change of orotracheal catheter and/or nasoenteral catheter fixation device, rotation of pulse-oximeter sensor, temperature monitoring, use of fluidized positioners and application of gel adhesive dressings.Two studies listed multiple interventions but did not describe them as PI prevention "bundles". 31,32Although both studies reported decreased incidence of PIs related to their interventions, they did not provide statistical analysis or a rationale for their chosen interventions.Among these comprehensive strategies and bundles, the interventions could be categorized into the following categories: (a) training and education, (b) assessment prevention and protection against pressure forces.Two studies explicitly framed their interventions within these categories, 24,27 reporting decreased incidence of PIs.

Repositioning
In addition to being included as part of a comprehensive bundle and strategy in multiple studies, [20][21][22]24,26,27,29,[33][34][35][36] one study focused specifically on the repositioning intervention as the main intervention. This study aimed o assess the impact of different repositioning intervals on reducing the incidence and occurrence of PIs.
The study compared a repositioning interval of every 2 hours in the intervention group with a 4-hour interval in the control group.Although no statistically significant difference was observed, the study found that the incidence of PIs was higher in the control group (13.4%) compared to the intervention group (10.3%). 28

Use of Special Devices and Technology
A total of 8 studies acknowledged the utilization of various technologies and devices as part of interventions to prevent pressure injuries (PIs). 17,18,20,23,25,28,30,36One study specifically incorporated alternating-pressure air mattresses as an element of their inclusion criteria. 28Additionally, two studies integrated special devices and technology within their bundle of interventions to prevent PIs.These included prophylactic dressings such as five-layer silicone-bordered foam dressings for the heels and sacrum, 25,36 as well as the implementation of pressure-relieving mattresses. 25Furthermore, one study indirectly mentioned the beneficial impact of special devices, such as Foley catheters and fecal management systems, on preventing PIs in critical care patients, which could explain the low prevalence of skin breakdown observed. 18inally, four studies highlighted the utilization of special technology and devices as primary interventions in their respective research papers. 17,20,23,30These interventions included the use of wearable sensors to prompt critical care patient repositioning, 17 the implementation of pressure-redistribution mattresses with different intervals, 20 the use of a fluidized positioner to reduce occipital pressure injuries, 23 and the application of hyper-oxygenated fatty acids (HOFA) to prevent facial pressure injuries in non-invasive mechanical ventilation patients. 308]31,32,34,35 Additionally, two studies offered training specifically related to measuring outcomes associated with pressure injuries. 22,24ive studies emphasized the crucial role of knowledgeable and highly skilled nurses in preventing pressure injuries, highlighting them as expert practitioners in implementing nursing interventions for PI prevention. 22,25,26,35,36One study explicitly reported a significant improvement in nurses' knowledge scores and compliance, resulting in a substantial decrease in device-related pressure injuries from 24.39% to 4.26%.
Furthermore, the findings of the remaining four papers 22,25,26,35 suggest that having trained and knowledgeable nurses to provide assistance and guidance in practice contributes to lower incidences of pressure injuries.Some PI preventive strategies mentioned in the literature involved the active involvement of highly skilled nurses and the provision of specialized training, which facilitated the implementation of effective nursing interventions. 25

Discussion
This systematic revise of various studies focused on preventing pressure injuries (PIs) in critical care patients to determine the most effective PIs prevention.The results provide valuable insights into PI prevention.From the United States in the west to China in the east, passing through Australia, Spain, Brazil, and so on, nurses over the globe report their concerns about the need for pressure injury prevention.Also, the review shows general agreements on the interventions for pressure injury prevention during their stay in critical care units, including skin assessment, offloading, repositioning, and skin care.However, these studies also have different representations for these interventions; in some reports, the researchers adopt the term "Bundle" to refer to the set of interventions and create an acronym to refer to these interventions, [20][21][22]24,26,27,29,[33][34][35][36] while others stick to the direct terminology of these each intervention. The review shows  general agreement about how PIs prevention had to occur and the importance of these interventions with different levels of the significant impact of these interventions on PI prevention.
On the other hand, the reports show wide variations in how these interventions had been followed, monitored, measured, or assured.For instance, assessing skin conditions formulates a general agreement between the studies.However, there must be a standard on when this must be done, whether immediately, after four hours, 21 eight hours 35 or 48 hours. 26,32,36This was also observed among the tool adopted for skin risk assessment; Braden was the most utilized assessment tool, [19][20][21][22][27][28][29][32][33][34][35] but other tools also adopted for evaluating the general patient's conditions such as Sequential Organ Failure Assessment (SOFA), 24,34 or Acute Physiology and Chronic Health Evaluation (APACHE III) which both initially created for other than PIs purpose 23 but formulated in the review as actual applications, which refers for disagreements between experts about the best assessment tool.
Furthermore, the literature shows that time is essential to PI development.PIs occur during the long duration of pressure on the organs.So, prevention strategies must be monitored over time to prevent injury.However, there were no agreements on the aspects of time in offloading the pressure.For instance, the frequency of conducting the repositioning appears as a disagreement point.The studies report a variation in performing the repositioning from two, three, or even every five hours. 17,28Although the results did not show statistically significant differences in PI incidence with the changes in the repositioning frequencies, studies indicated a trend toward reduced PIs with more frequent repositioning intervals.Therefore, this suggests further research to establish agreeable tools for evaluating the complaint and standardize the measurements of nursing performance for repositioning after assessing the significant impact of these changes on PIs incidences.However, the challenges of repositioning continued time; instead, they also manifested in the term applied.Repositioning appears as not having the same reflection term between the studies; even though majorities adopt the term repositioning, other studies use the positioning, turn, or turning with a lack of assurance if these terms refer to the same actions performed by nurses or a different set of actions.
Expert practitioners' involvement and specialized training provision were associated with lower incidences of PIs.This systematic review provides valuable insights into the continuous need of nurses (all over the globe) to receive education and training in Pi prevention, and this is common among all varieties of nurses in different cultures.However, the studies need more comprehensive descriptions of what these educational programs include and what learning theories are applied to these changes.This makes comparing these educational activities as one "thing" inapplicable.
It is essential to note a gap in the literature about pressure injury prevention interventions.While the studies have explained the immediate impacts of these interventions, they have yet to explore their long-term effects and sustained compliance.The scope of these studies mainly covers the aftermath of the interventions, leaving the long-term impact and adherence to these preventive measures unexplored.For instance, studies have been about repositioning to prevent patient pressure injuries.These studies have shown how vital repositioning can be, but researchers may need to look at the bigger picture of how nurses approach pressure injury prevention in general.It is essential to understand how long these changes in behavior will last beyond just the initial implementation of the intervention.Although some studies have shown how vital repositioning is for critically ill patients-something widely accepted by the scientific community-there are still issues with low compliance.The initial studies showed low compliance with repositioning, but there has yet to be much analysis on why this is the case.Other studies from the same country, conducted a few years later, still reported low to moderate compliance.This suggests that more work needs to be done to improve compliance with pressure injury prevention methods like repositioning.This is the required intervention in the future among the scientific community.
The question arises about how to ensure sustained compliance among healthcare practitioners.While the efficacy of pressure injury prevention interventions is acknowledged, there needs to be more insight into the dynamics governing the enduring adherence to these measures across diverse healthcare settings.It is crucial to ensure compliance for a comprehensive understanding of the landscape of pressure injury prevention.It was observed that the studies had a common initial condition regarding their country of origin.They all had low-quality adoption of interventions, which improved after specific recommendations were given.However, subsequently, they reverted to the initial condition of low quality, which is an indication of the inability of these studies to find their way into the actual nursing practice.For example, the studies conducted in the USA, Anderson 2015 and Edsberg 2022 are related to nursing care for PI management.The authors note the initial conditions in the nursing units were similar.That means the recommendation from Anderson's study after seven years did not find a practical application for nursing care, which makes Edsberg's study conduct the study and document that the stays of nursing care could be more satisfactory.This means that despite similarities in the initial conditions, the recommendations from different studies did not impact nursing care, which needs further exploration on the nature of the compliance of the PI management and its applicability in the actual clinical conditions for a long-term practice.
Pressure injury prevention is multifaceted, and it is necessary to consider not only how these interventions occur but also how they endure over time within the healthcare facilities.Future research must transcend the temporal constraints of existing studies and delve into the intricate fabric of sustained compliance and the pragmatic shifts in nurses' approaches to pressure injury prevention beyond the immediate implementation phase.Such holistic exploration is essential for refining evidencebased practices and fortifying the resilience of pressure injury prevention protocols across diverse healthcare contexts.
In summary, the studies add valuable information about the PIs prevention adopted in critical care: assessing the skin condition at regular intervals, providing regular offloading for the pressure over the patient's body tissues, and dressing for prevention.However, there is a need to build a more substantial consensus among experts in PIs prevention strategies in evaluating the benefits of these interventions and ensuring compliance with the performance.The current review concludes with scattered information about the impact of these interventions with difficulties in comparing these results due to differences in the measurements applied for the prevention applications and changes in the methods of evaluating its effect on pressure injury prevention.A pressure injury panel of experts and stakeholders is asked to organize these efforts toward unifying the ways of PIs prevention evaluation in a similar way of creating a PI staging system.At that time, nurses can detect the impact of these interventions and methods of evaluating the Pi prevention performance.

Strength and Limitation
Nurses equipped with appropriate knowledge and skills can prevent pressure injuries (PIs) in critically ill patients.PI prevention strategies must be grounded in evidence and empower nurses to utilize their decision-making abilities.To enhance the efficiency of care, intervention bundles should be designed within a framework that prioritizes evidence-based practices.
Continuing education plays a vital role in enabling nurses to identify strengths and weaknesses in their practice and promote compliance with best practices.
It is important to note that the studies included in this review displayed varying levels of methodological quality, particularly concerning their sampling methods, measurement validity, and statistical analyses.As a result of the heterogeneity observed in the interventions and study designs, conducting a meta-analysis was not feasible.These considerations should be considered when interpreting the results of the review.Secondly, it is worth mentioning that a few studies were omitted from our analyses due to insufficient or ambiguous information.Additionally, it is important to recognize that the search and inclusion process focused on the most current and up-to-date evidence available in the published literature.

Conclusion
This systematic review encompasses all nursing interventions documented in the literature for preventing pressure injuries (PIs) in critical care settings.Our study offers valuable guidance regarding the utilization of evidence-based PI prevention bundles, regular repositioning, the prevention of medical device-related pressure injuries (MDRPIs), and the role of education in enhancing PI outcomes.It is crucial to incorporate basic PI prevention interventions into the routine care schedule for critically ill patients, with a specific emphasis on mitigating MDRPIs.The implementation of PI prevention interventions resulted in a notable decrease in both the frequency and severity of PIs across all the studies included in this review.To enhance the outcomes of critically ill patients, it is imperative to adopt evidence-based PI prevention bundles.Furthermore, nurses must receive comprehensive education, clinical practice and fully comprehend their pivotal role in PI prevention.
Applying heel protectors in the intervention group showed positive outcomes (p = 0

Table 1
Characteristics of Included Studies and Results