A Descriptive Study of Turkish Intensive Care Nurses’ Pressure Ulcer Prevention Knowledge, Attitudes, and Perceived Barriers to Care

Nurses should be highly knowledgeable about and have a positive attitude toward pressure ulcer (PU) prevention. Purpose: This descriptive study was conducted among intensive care unit (ICU) nurses in 6 hospitals in Turkey to identify their PU prevention knowledge, attitudes, and perceptions of barriers to care. Methods: The study was conducted between January 1, 2017, and April 30, 2017, using supervised self-reporting, among nurses working in the ICUs of 3 education and research hospitals, 2 university hospitals, and a private hospital in Ankara, Turkey. Three (3) data collection instruments were used: a participant sociodemographic data collection form, the Pressure Ulcer Prevention Knowledge Assessment Instrument (range 0–26, where higher scores indicate more knowledge), and the Attitude Towards Pressure Ulcer Prevention Instrument (range 13–52; a higher score implies a more positive attitude). Frequencies, t tests, analysis of variance, Pearson correlation analysis, and multiple regression analysis were used to analyze the data. Results: Participants (N = 390) were mostly women (339; 86.9%) who had a bachelor’s degree (283; 72.6%). The mean knowledge score was 11.54 ± 2.91, and the mean attitude score was 42.96 ± 4.06. The most commonly cited barriers to PU prevention were insufficient staff levels (85.6%) and pressure redistribution materials and equipment (82.6%). Regression analysis of attitude scores showed the following variables affected nurses’ attitude toward PU prevention: self-sufficiency in PU risk assessment (β = 0.28), willingness to learn more about preventing PU (β = -0.15), gender (β = -0.15), and knowledge score (β = 0.14). Conclusion: ICU nurses were found to have a low levels of knowledge but positive attitudes toward PU prevention. Policies and procedures should be developed to increase ICU nurse knowledge levels and remove barriers to optimal PU prevention practices.

According to a descriptive study,¹ the development of pressure ulcers (PUs), although an important health issue, is frequently overlooked by health care personnel. A prevalence study² conducted in the United States of 918 621 patients determined that for 2015, overall PU prevalence was 9.3%, facility-acquired prevalence was 3.4%, and acute care prevalence was 9.3%. A prevalence study conducted at 10 hospitals (N = 2326) by Karadağ et al³ determined the overall prevalence of PUs in Turkey was 10.3%.

Patients who develop PUs are at increased risk for pain and infection, they can experience physiological and psychological trauma, and hospitalization for PU treatment may increase, all of which diminishes patient quality of life.⁴ Moreover, issues such as wound care, debridement, and grafting increase hospitalization time add to hospital and patient costs.

PUs have been shown in a white paper⁵ and in practice guidelines⁶ to have a higher prevalence in patients in palliative care, neonatal care, and intensive care units (ICUs). A systematic review⁷ of 7 publications reported a PU prevalence of 4% to 49% and an incidence of 3.8% to 12.4% in ICUs. Prospective descriptive research^8,9 has shown reduced physical activity, being bedbound for a long period of time, changes in consciousness, reduced sensory perception, using medications to treat vascular disease and vasoactive drugs, and mechanical ventilation increase the risk of developing PUs among ICU patients by reducing cardiac output and increasing tissue perfusion. It is the responsibility of the nurses, who care for patients 24 hours a day, to evaluate patients at risk for PUs and perform interventions to prevent PUs, both for ethical and legal reasons.^10,11 However, a systematic review¹² conducted between 1992 and 2014 reported nurses did not use risk assessment tools on a routine basis and offered skin care for patients based on their own knowledge and experience, not on study findings.

A cross-sectional, multisite study¹³ showed that in addition to having sufficient knowledge of PUs, exhibiting a positive attitude is necessary. However, a cross-sectional study¹⁴ has noted a gap between theory and practice; despite having a positive attitude, nurses do not have sufficient knowledge regarding interventions to prevent PU development. Results of cross-sectional studies^14-17 have shown a lack of knowledge, time, nursing staff, and materials thwart PU prevention efforts. In addition to educating nurses, administrative arrangements (eg, insufficient number of nurses, insufficient pressure redistribution materials and equipment) affect PU prevention. Ensuring nurses have a positive attitude regarding prevention, are sufficiently knowledgeable on the subject, and are not met with barriers will contribute to preventing PUs and reducing their incidence rate in ICUs.^14,18

Despite the many studies related to knowledge,^13,19-28 attitude,^{13,14,17,19,26,28} and barriers^{14-17,19,20,29} in hospitals about PU prevention, very few studies have investigated the knowledge level, attitudes, and challenges of ICU nurses concerning PU prevention.^16,30 A descriptive study performed in internal medicine, surgical units, and ICUs in Turkey by Aslan and van Giersbergen³¹ revealed nurses (N = 426) had a positive attitude toward PU prevention, but a descriptive study conducted in Turkey by Özdemir and Karadağ³² found ICU nurses (N = 30) were inconsistent in their application of the interventions recommended for PU prevention. In the ICU, with high prevalence rates of PUs, it is important to assess the knowledge and attitudes of nurses and to understand the barriers they encounter in the prevention of PU together.

The purpose of this descriptive study was to identify the level of knowledge, attitudes, and perceptions of the barriers encountered in the prevention of PU among ICU nurses. Research questions addressed were:

1. What knowledge do ICU nurses have regarding PU prevention?

2. What are the attitudes of ICU nurses toward preventing PUs?

3. What are the opinions of ICU nurses regarding barriers to preventing PUs?

A descriptive study was conducted involving nurses in the ICUs of 3 education and research hospitals, 2 university hospitals, and a private hospital located in Ankara, Turkey, between February 1, 2017, and April 30, 2017. Using convenience sampling methods, all ICU nurses employed at these hospitals were invited to participate. Nurses who agreed to participate and who completed the data collection forms in their entirety were included in the study.

Instruments. Data were collected using a data collection form developed for this study, the Pressure Ulcer Prevention Knowledge Assessment Instrument (PUPKAI-T), and the Attitude Towards Pressure Ulcer Prevention Instrument (APuP).

Data collection form. The data collection form was comprised of 3 sections. The first section was created based on data collection forms used in previous related studies.^33-35 It was comprised of 16 questions that described characteristics of the nurse participants. The questions garnered information on attitudes such as “willingness to receive education on the prevention of PUs,” “following developments related to PUs,” “self-sufficiency levels in PU risk assessments,” “sufficiency level of preventive PU interventions,” “obtaining education after graduating in the prevention of PUs,” and “willingness to engage in scientific activities” (see Table 1).

The second section contained 8 questions related to the status of ICUs with regard to PU prevention, including the presence of a PU prevention protocol, use of risk assessment scales and type of materials used to prevent PUs, and the number of at-risk patients receiving specific preventive nursing interventions.

The third section included a table about the barriers faced by nurses while performing interventions to prevent PU and was based on the literature (see Table 2).^16,19,20

PUPKAI-T. This scale was developed by Beeckman et al,³⁶ and the Turkish version was evaluated in terms of validity and reliability by Tulek et al.³⁷ The PUPKAI-T is comprised of 26 multiple choice questions with 6 sections/themes (see Table 3). The “etiology and causes” section contains 6 questions regarding PU knowledge and includes the effect of PU factors such as malnutrition, body mass index, positioning, and age. Five (5) questions in the “classification and observation” section consider observation and PU staging and address factors such as location, depth, and tissue structure. Under “risk assessment,” 2 questions concern knowledge of when and how risk assessments should be performed and questions about the importance of risk assessments. The “nutrition” section includes a question related to knowledge of the importance of nutrition in the prevention of PU. Under “reduction in the amount of pressure and shear,” 7 questions address knowledge and application of pressure and shear reduction methods. The “reduction in the duration of pressure and shear” section includes 5 questions about the knowledge and application of mobilization, positioning, and support surfaces on the duration of pressure and shear.

Each question has 3 choices and 1 correct answer. The total number of correct answers for each section/theme and each question represents the knowledge level of the participant. The highest possible score is 26, and a mean knowledge score of ≥60% is considered to be satisfactory.¹³ The Cronbach’s alpha value of the scale as developed was 0.77. Tulek et al³⁷ reported that PUPKAI-T has a good overall internal consistency with a Kuder-Richardson Formula 20 value of 0.803.

APuP. This scale was developed by Beeckman et al,³⁸ and the Turkish version was evaluated for validity and reliability by Üstün.³⁹ It is comprised of 5 subdimensions (see Table 4) and has 13 items in total (see Figure), including attitude toward personal competency to prevent PUs (3 items), attitude toward the priority of PU prevention (3 items), attitude toward the impact of PUs (3 items), attitude toward responsibility in PU prevention (2 items), and attitude toward confidence in the effectiveness of prevention (2 items). Six (6) of the items are worded positively and 7 are worded negatively. The scale items are rated with a 4-point Likert-type scale (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree). The lowest possible score is 13 and the highest possible score is 52. A higher total score on the scale implies a more positive attitude. Cronbach’s alpha value of the scale as developed by Beeckman et al³⁸ is 0.79, and the Cronbach’s alpha value of the Turkish version is 0.714.³⁹

Ethical considerations. The Gazi University (Ankara, Turkey) Ethical Board provided consent for this study (number 15, date: December 30, 2016). Written permission was obtained from the studied institutions. The eligible nurses provided informed consent.

Data collection procedure. The nurses in charge (executive nurses) of ICUs were contacted by supervisors regarding their availability to participate. Nurses who volunteered to participate in the study completed the data collection tools in nurses’ rooms using a supervised self-completion method to ensure they did not interact during the questionnaire completion and did not refer to any information sources (internet, textbook) while filling out the forms. On average, the instruments could be completed in 20 minutes.

Statistical collection and analysis. Data were entered directly into the software, checked by 2 researchers, and analyzed using IBM SPSS Statistics, SPSS Statistics Standard Pack 15V, (IBM Inc, Chicago, IL). Frequency, ratio, mean, and standard deviation values were calculated using descriptive statistics. Groups with normal distribution were compared using a t test, and groups with an abnormal distribution were compared using the Mann-Whitney U test.  A one-way analysis of variance (ANOVA) was used to compare the average score when more than 2 groups with normal distribution were assessed, and Tukey’s test was used to determine the group causing the difference. The t test and Mann-Whitney U test were used for independent groups according to the number of groups and samples; the ANOVA and Kruskal-Wallis tests were used for independent groups to compare knowledge and attitude scores for preventing PUs according to independent variables. The correlation between the numeric independent variables and knowledge and attitude scores was evaluated using Pearson correlation and Spearman correlation analyses. Independent variables that had an impact on the knowledge and attitude score were evaluated using multiple regression (backward method) analysis. The significance level was P <.05.

Of the 580 nurses working in the participating hospitals’ ICUs, 390 nurses agreed to participate (participation rate 67.2%). Nurses who were on leave on the date of the study (n = 39), did not consent to participate in the study (n = 128), or did not complete the entire data collection forms (n = 23) were not included in the sample. The average age of the nurses was 28.50 ± 5.42 (range 19–65) years; 339 (86.9%) were women and 283 (72.6%) had a bachelor’s degree. The average time of employment in the ICU was 4.84 ± 4.42 (range 1–30) years; 216 (55.4%) had received additional education about PU prevention after graduation, 209 (53.6%) followed developments about PU prevention, 55 (14.1%) attended scientific activities, and 330 (84.6%) expressed an interest in education about preventing PUs (see Table 1).

Regarding the challenges to preventing PUs, 334 nurses (85.6%) mentioned a shortage of nurses, 322 (82.6%) mentioned a lack of pressure-redistribution materials and equipment, and 310 (79.5%) mentioned a lack of assistive personnel (see Table 2).

The average PU prevention knowledge score was 11.54 ± 2.91 (44.38%; range 3–18; see Table 3). Only 23 nurses (5.9%) provided correct answers to 16 (60%) or more questions, which is the requirement to demonstrate a sufficient level of knowledge. Years of employment, education level, willingness to attend education, and other sociodemographic variables did not affect total knowledge scores (P >.05; see Table 5).

The nurses’ average attitude score was 42.96 ± 4.06 (see Table 4). The total attitude scores were higher in female nurses versus male nurses, in nurses who had a bachelor’s degree or higher versus high school graduates, in nurses who followed developments versus those who did not, and among nurses who were willing to take education versus those who were not; these differences were statistically significant (P <.05; see Table 5).

Regression analysis of attitude scores showed, in order of significance from greatest to least, the following variables affected nurse attitude toward PU prevention: self-sufficiency in PU risk assessment (β = 0.28), willingness to learn more about preventing PUs (β = -0.15), gender (β = -0.15), and knowledge score (β = 0.14). These 4 variables accounted for 13% (R² = 0.13) of the total variation in attitude scores of the nurses.

The total score for the PUPKAI-T and the APuP (r = 0.15; P <.05), including impact (r = 0.18; P <.05) and responsibility (r = 0.20; P <.05) subdimension scores, had a weak but significant positive correlation.

This is the first study to assess ICU nurses’ PU prevention knowledge, attitude, and barriers to care in Turkey. ICU nurses were found to have low levels of PU prevention knowledge; participants scored lowest in questions related to PU etiology and development and scored highest with regard to items related to the importance of nutrition. A descriptive study conducted by Özdemir and Karadağ³² in Turkey determined the behaviors least exhibited by ICU nurses (N = 30) in preventing PUs were applying a skin barrier to damp skin, protecting the skin during patient transfer, repositioning, applying moisturizer to dry skin, and documentation. In the same study, helping the patient eat was the most frequently fulfilled practice by nurses in preventing PU. This confirms nurses are more likely to perform the practices they know about and less likely to perform those they do not know, if at all.

The study by Beeckman et al¹³ among nurses in internal medicine, surgical units, and ICUs in Belgium, using the same PUPKAI-T scale as the current study to measure nurse knowledge levels, reported a low level of knowledge among ICU nurses (N = 68; 12.5/26 questions; 48.2%), which is in agreement with the findings of the current study. Other cross-sectional studies^21-23,40 also have reported medium or low levels of knowledge among ICU nurses in preventing PUs.

A study by Tweed and Tweed²⁴ involving a pretest for an education program offered to ICU nurses (N = 62) in a university hospital in New Zealand, reported high PU knowledge scores (mean score of nurses: 84%), unlike other research cited herein. A descriptive cross-sectional study by Strand and Lindgren¹⁶ of ICU nurses (N = 146) conducted in a university hospital in Sweden reported a high level of knowledge among nurses regarding PU risk factors (46.8% of the nurses answered correctly). A descriptive study by Köse et al⁴¹ (N = 73) conducted in the ICUs of a university hospital in Turkey reported high levels of knowledge among the nurses in preventing PU (34.97 ± 4.43; score range 24–50). A descriptive study by Aydın and Karadağ⁴² (N = 162) conducted in Turkey reported insufficient knowledge levels among the ICU nurses in preventing Stage I PUs and deep tissue damage (mean correct score of nurses: 49.20%). Different countries, hospital types, level and type of education, and priorities of the nurses all could be responsible for the differences in reported knowledge levels.

Another reason for insufficient knowledge levels might be outdated and inadequate content in the basic education provided to nurses. Wilborn et al⁴³ conducted a content analysis of the PU chapters in the textbooks most frequently used in German general and geriatric nursing education that showed only a quarter of the resources used by education programs of 92 schools were compliant with the German Expert Standard of Pressure Ulcer Prevention; the rest of the textbooks used by the nursing students had insufficient content. The same study reported some textbook authors did not refer to available scientific research on preventing PU. In Turkey, a review of the literature reported studies published by nursing researchers are not used by clinical nurses.⁴⁴ The fact that the nurses scored low on the knowledge scale in this study supports previously reported findings.^43,44

A statistically significant correlation was not found between the knowledge levels of nurses and the education program they graduated from or their work experiences (P >.05). A descriptive study by Iranmanesh et al⁴⁰ conducted among ICU nurses (N = 126) in Iran and the study by Tweed and Tweed²⁴ also did not find a significant correlation between nurses’ knowledge levels and work experience. After offering an educational program to 32 ICU nurses in the US about preventing and staging PUs, Miller et al²⁵ did not find any significant correlation between work experience and knowledge levels of the nurses. However, knowledge levels are expected to increase with more work experience, especially if nurses receive postgraduate education about preventing PUs, attend scientific activities such as congresses and symposiums, and follow professional periodicals. A large majority of the nurses in the current study reported they did not attend any scientific activities and half of them said they did not receive any education about preventing PUs after graduation. In agreement with current findings, many studies have reported that the majority of nurses do not receive education about preventing PU after graduation.^14,26,27

An intervention study by McCluskey and Lovarini⁴⁵ demonstrated that continuous education was effective in improving knowledge levels but was insufficient in creating behavioral changes. However, attitude was reported to impact behavioral change.⁴⁶

This study found ICU nurses had a positive attitude toward preventing PUs. These results are similar to other studies conducted in ICUs that determined nurses had positive attitudes in this respect.^{13,16,30,31,47} However, the descriptive study by Beeckman et al¹³ reported the attitudes of ICU nurses toward preventing PUs were below the satisfactory level (75%). A descriptive study by Aslan and van Giersbergen³¹ conducted in Turkey demonstrated ICU nurses had a positive attitude regarding preventing pressure injury. Results of a descriptive, multimethod study in Sweden by Sving et al⁴⁸ showed licensed nurses (N = 9) did not view PU prevention as a care priority and provided fewer preventive interventions.

Individuals with extensive knowledge have been reported to be more flexible and tolerant in their attitudes and behaviors compared to others, and this flexibility increases positive behavior.⁴⁶ The current study found a weak but significant positive correlation between nurses’ attitude scores and knowledge levels regarding PU prevention (P <.05). Similar to the current study, Beeckman et al¹³ determined a weak significant correlation between the knowledge levels and attitudes of nurses (N = 553). In their cross-sectional multicenter study in Belgium (N = 145), Demarre et al²⁸ did not find a significant correlation between knowledge levels and attitudes of nurses and assistant nurses.

The most frequently experienced barriers in preventing PUs by the nurses in the current study were low nurse staffing levels, insufficient pressure-redistribution materials and equipment, and insufficient numbers of assistive personnel. In the descriptive study by Mirshekari et al²⁹ in Iran (N = 88 nurses), the most cited barrier to carrying out PU prevention was inadequate knowledge about PUs (64.8%). In the study by Strand and Lindgren,¹⁶ the most important barrier in preventing PUs was insufficient time (57.8%).

More than half of the nurses in the current study reported a lack of knowledge as a barrier to preventing PUs. At the same time, a large majority of the nurses expressed a willingness to obtain PU prevention education. These findings suggest nurses are aware of their lack of knowledge. However, the information provided in courses should reflect on practice, be up to date, and be reinforced. Otherwise, education cannot be expected to significantly impact knowledge levels.

A review of the literature⁴⁹ has shown preventing PUs requires total team effort. If all members of the team do not contribute fully, the efforts of other members might be insufficient. Staff shortages in all areas can cause extreme stress and overload. It is very difficult to perform the necessary duties to prevent PUs, such as changing the patient’s position, without the required assistive personnel. Having an insufficient number of nurses results in more patients per nurse, which affects nurses both physically and mentally. As a result, the health care offered to patients may not be high quality. Cross-sectional studies^14,50 have shown if a lack of nurses and assistive personnel remains unresolved for a long period of time, preventing PUs is not a high priority.

Because some of the hospitals in Ankara, Turkey stated that they could not participate in the study due to the intensity of work in their ICUs, the study was limited to 6 hospitals. Nurses who were on maternity or sick leave were not included in the study. Because the data collection forms were not suitable for neonatal ICUs, they were excluded from the study.

A descriptive study was conducted among Turkish ICU nurses to identify their knowledge, attitudes, and perceptions of barriers related to PU prevention. The study found nurses had insufficient levels of knowledge but had a positive attitude about preventing PUs. The most commonly cited barriers to PU prevention were nurse, materials, and assistive personnel shortages. Therefore, it is recommended that hospitals provide continuous in-service education programs for PU prevention that include etiology and risk factors, classification and observation, use of risk assessment tools, nutrition, and preventive interventions to reduce the amount and time of pressure, shear, and rupture. Nurses should be required to attend scientific activities such as symposiums and should be supported accordingly. It is important to develop health care protocols for preventing PUs and to encourage nurses to use these protocols as information sources. The number of nurses and assistive personnel should be increased according to ICU standards and the availability of pressure-redistribution equipment carefully examined and optimized. It is hoped this study will contribute to the available scientific information and provide guidance for developing policies to prevent PUs as well as for reviewing and improving in-service training programs, curricula, staffing levels, and supplies. Further follow-up research to determine which methods enhance PU prevention outcomes is warranted.

Mr. Aydoğan is a research assistant, Mehmet Akif Ersoy University Faculty of Health Sciences, Nursing Department, Burdur, Turkey. Dr. Çalışkan is an Associate Professor, Gazi University Faculty of Health Sciences, Nursing Department, Ankara, Turkey.

Please address correspondence to: Sinan Aydoğan, RN, Research Assistant, Gazi Universitesi Sağlık Bilimleri Fakültesi Hemşirelik Bölümü, Emniyet Mah, Muammer Yaşar Bostancı Cad. No: 16, PK: 06500 Beşevler/Ankara, Turkey; email: sinanaydogan@gazi.edu.tr.