Relationship Between Practice and Attitude Regarding Pressure Injury Among Intensive Care Nurses in Iran: A Descriptive, Correlational Study

Nursing practice can be influenced by attitude. Purpose: A study was conducted to evaluate the relationship between critical care nurses’ practice, demographics, and attitude regarding pressure injury. Methods: The descriptive-correlational study was conducted from March 14 to June 21, 2019, among nurses working in 3 intensive care units affiliated with Qazvin University of Medical Sciences in Iran. Using convenience sampling methods, nurses with at least a bachelor’s degree in nursing who are involved in pressure injury care were invited to participate. Demographic information (age, sex, work experience in intensive care unit, education level) and pressure injury education information were collected from participants. Each nurse was observed 3 times by a researcher during his or her full work shift and evaluated using the Quality of Nursing Care Related to Pressure Injury checklist, which consists of 85 items categorized in 6 groups: 1) pressure injury risk factor evaluation (23 items), 2) change of patient position (12 items), 3) patient nutrition (16 items), 4) skin examination (25 items), 5) skin care in high-risk patients (5 items), and 6) use of accessories for pressure injury prevention (4 items). Each item offers 3 response options (ie, applied, not applied, applied but not correct). Correct responses on 70%, 69% to 50%, and less than 50% of items indicate good, relatively good, and poor practice, respectively. The Attitude Towards Pressure Ulcer Questionnaire, used to assess nurses’ attitudes regarding pressure injury prevention, is a paper-and-pencil questionnaire that is completed by the nurse participants and consists of 11 items, with answers based on a 5-response Likert scale that ranges from 1 (totally agree) to 5 (totally disagree). The total score ranges from 11 to 55. A higher score indicates a more positive attitude. Descriptive statistics including mean and standard deviation were used to describe demographic information, and analytical tests including Pearson correlation test were used to determine the correlation between numerical variables. An independent t test was used to evaluate the differences in mean scores of numerical variables between the 2 groups. Significance level was considered as P < .05. Results: The mean quality-of-nursing checklist score was 71.4 ± 13.5, inferring nurses provided good care. The highest and lowest mean scores were related to skin examination (22.8 ± 3.7) and skin care in high-risk patients (4.3 ± 0.8). The mean overall score of nurses’ attitudes toward pressure injury was 27.26 ± 5.1, indicating a positive attitude toward providing pressure injury care and prevention. There was a significant and positive relationship between mean years of practice and the mean attitude score (r = 0.195; P = .041) as well as a significant relationship between quality of practice and attitude score (r = 0.195; P = .041) Conclusion: Ninety percent (90%) of critical care nurses demonstrated a good practice and a relatively positive attitude toward pressure injury. Additionally, the findings suggest that nurses with more years of experience and a more positive attitude have better quality of practice. The results of the present study could be useful for improving pressure injury care in the hospital setting and for educating nurses and nursing students. Further research that includes nurses in other wards is warranted. 

Cross-sectional studies show that the development of a pressure injury in a patient is associated with numerous negative consequences, including reduced quality of life, pain, loss of independence, loss of privacy and dignity, decreased desire to participate in social activities, increased risk of infection, and increased risk of mortality.^1–4 Pressure injury is also considered one of the most costly issues in health care systems throughout the world. The results of a recent incidence study by Zarei et al⁵ in Iran reported that treatment of pressure injury can cost the health care system between $12 000 and $67 000 (U.S. dollars), depending on the stage of the injury. In this regard and by using economic simulation methods, Padula and Delarmente⁶ reported in 2019 that pressure injury costs could exceed $26.8 billion in the United States.

Patients hospitalized in intensive care units are at high risk for pressure injury development.⁷ The incidence of pressure injury among 102 Chinese critically ill adult patients (54 men, 48 women) was 31.4%.⁸ Lucchini et al⁹ examined the incidence and risk factors of pressure injuries among 122 adult critically ill patients in a general intensive care unit in Italy and found the incidence of pressure injury was 33% and that most injuries were stage 2. A systematic review and meta-analysis¹⁰ in Iran found the prevalence of pressure injuries in intensive care units was almost 20%.

According to systematic review and descriptive studies, the occurrence of pressure injuries is thought to reflect poor practice within the health care system¹¹; nurses play a significant role in pressure injury prevention and care.^11-13 In Iran, nurses are responsible for almost 100% of pressure injury management. Given the importance of the nurse’s role in the prevention and care of patients at high risk of developing or currently having a pressure injury, many descriptive and correlational studies have investigated the knowledge, attitudes, and practices of nurses in this regard.^12–18 In a 2017 cross-sectional study in Turkey (N = 101), Ünver et al¹⁷ showed that Turkish nurses working in a surgical ward had a positive attitude toward pressure injury prevention. A cross-sectional study in 2012 by Lawrence et al¹⁹ (N = 827) in Australia found nurses lacked sufficient knowledge of pressure injury. Cox and Schallom²⁰ conducted a descriptive cross-sectional study in 2016 (N = 333) that showed critical care nurses had a positive attitude toward pressure injury prevention. Numerous cross-sectional studies have been conducted regarding the knowledge and attitude of Iranian nurses toward pressure injury; most indicate that Iranian nurses, despite their positive attitude, have insufficient knowledge in this regard.^13,18,21 

Provision of evidence-based care can be influenced by several factors. One of the factors least studied and published in related Iranian literature is the relationship between nurses’ attitudes and the management of patients at high risk of developing, or who currently have, a pressure injury. Therefore, the present study was designed to evaluate critical care nursing practices with regard to patients who have or are at high risk of developing a pressure injury and how care may be affected by their attitudes as well as demographics characteristics. 

The present descriptive, correlational study was conducted in Iran from March 14 to June 21, 2019. The study sample consisted of 120 nurses working in the intensive care units of 3 teaching hospitals affiliated with Qazvin University of Medical Sciences.

Sample size. The study sample was calculated using the sample size formula shown. According to Adeli²² and taking into account the type I error (α = 0.05), the minimum sample size was 96 and a final sample size of 120 was chosen to account for a potential dropout rate of 20%.

Equation 1

Inclusion and exclusion criteria. Inclusion criteria stipulated that participants should have a bachelor’s degree or higher in nursing and be caring, at the time of study enrollment, for at least one patient with a pressure injury. 

Recruitment.

Convenience sampling used for participant recruitment

Variables.  Demographic information. Participant demographic information collected included age, sex, work experience in intensive care unit, education level, and whether they 1) received pressure injury training during their education, 2) believed the training regarding pressure injury they received during their education was sufficient, 3) participated in workshops about pressure injury, and 4) believed there was a need for workshops on the care of pressure injury. This checklist was developed by the researchers and according to the opinions of experts at the Qazvin University of Medical Sciences. This checklist was completed by the nurses after they completed the attitude questionnaire. 

Nursing practice regarding the prevention and care of patients at high risk for developing a pressure injury. Researchers coordinated a schedule to observe each nurse’s practice. The researchers included a clinical registered nurse with a master’s degree in critical care nursing and who was qualified in wound care as well as 3 researchers (2 of whom were wound care specialists) who were faculty members responsible for educating nurses and nursing students in critical care settings. Nurses’ practices regarding pressure injury were evaluated 3 times (based on the sample size of 120, total number of observations 360). Observations occurred during the morning (7:30 AM to 1:30 PM) and evening (1:30 PM to 7:30 PM) shifts and lasted for the entire shift. The nurses were aware of the observers’ presence in the unit but did not know what aspects of practice were recorded and documented in writing. The nurse-to-patient ratio was 1:2; care of both patients was observed. 

The Quality of Nursing Care Related to Pressure Injury, a paper-and-pencil checklist designed by Adeli et al,²² was completed by the researchers to document and assess nurse practices regarding the prevention and care of patients at high risk of developing a pressure injury. The checklist consists of 85 items that are categorized into 6 groups:

1) patient evaluation in terms of risk factors for pressure injury (23 items, possible score range from 0 to 23),

2) change of patient position (12 items, possible score range from 0 to 12),

3) patient nutrition (16 items, possible score range from 0 to 16),

4) skin examination (25 items, possible score range from 0 to 25),

5) skin care in high-risk patients (5 items, possible score range from 0 to 5), and

6) use of accessories in pressure injury prevention by the nurse (4 items, possible score range from 0 to 4).

Each item offers 3 options: applied, not applied, and applied but not correct. Correct behavior by nurses on 70%, 69% to 50%, or less than 50% of items indicates good, relatively good, and poor practice, respectively.^22,23 Content validity of this questionnaire was established by Saifollahi et al for use in the critical care setting, with a reported reliability of 0.86.²³ 

Nurses’ attitude toward pressure injury prevention. The Attitude Towards Pressure Ulcer Questionnaire, designed by Moore and Price,²⁴ was used to assess attitude regarding pressure injury prevention. This paper-and-pencil questionnaire, completed by the nurse participants, consists of 11 items, with answers based on a 5-response Likert scale that ranges from 1 (totally agree) to 5 (totally disagree); some items feature reverse scoring. The total score ranges from 11 to 55. A higher score indicates a more positive attitude toward pressure injury. The face and content validity of this questionnaire was determined by Mortazavi et al²⁵ and showed a Cronbach’s alpha of 0. This questionnaire was distributed among nurses after their performance was observed and recorded 3 times. Researchers were available to participants to address any questions about the questionnaire, which usually took approximately 30 minutes to complete. To ensure anonymity, a code was assigned to each nurse participant to be used on the demographic checklist and attitude questionnaire. 

Data analysis. Data were entered from paper-and-pencil instrument into and analyzed using SPSS, version 16 manufactured by IBM. Descriptive statistics including mean and standard deviation were used to describe demographic information, and analytical tests including Pearson correlation test were used to determine the correlation between numerical variables. An independent t test was used to evaluate the differences in mean scores of numerical variables between the 2 groups. Significance level was considered as P < .05.

Ethical considerations. This study was reviewed and approved as a student research project by the Research Council of Qazvin School of Nursing and Midwifery, Qazvin, Iran (ethical code: IR.QUMS.REC.1397.070). The study was performed under the supervision of a designee of this council. Participation was voluntary and oral consent was obtained. Information collected from nurses participating in the study remained confidential throughout the study. Nurses also were assured that the information collected would be used and reported only for study purposes.

Demographic information. A total of 133 nurses comprised the total sample size of eligible nurses working in these intensive care units. Of the 120 completed questionnaires, 10 were excluded because more than 50% of “Attitude toward pressure injury questionnaire” items were not completed by 10 nurses; 110 valid questionnaires were included in the analysis. Most of the participants were female (N = 103; 94.5%); mean participants’ age was 30.96 ± 7.3 years. All participants had a bachelor’s degree in nursing. The mean intensive care unit work experience of participants was 8.9 ± 6.1 years (Table 1).

Nurses’ prevention practices with patients at high risk of developing a pressure injury. The mean score on Quality of Nursing Care Related to Pressure Injury was 74.4 ± 13.5 (range 32–86). Overall, 99 (90%), 7 (6.4%), and 4 (3.6%) of the participants had good, relatively good, and poor pressure injury practice methods, respectively. The highest and lowest mean scores were related to skin examination (22.8 ± 3.7) and skin care in high-risk patients (4.3 ± 0.8), respectively. The mean score in the subscales patient evaluation in terms of risk factors for pressure injury, change of patient position, patient nutrition, skin examination, skin care in high-risk patients, and use of accessories in pressure injury prevention by the nurse were 19.4 ± 4.4 (range 7–23), 10.3 ± 2.1 (range 4–12), 14.2 ± 3.1 (range 4–17), 22.8 ± 3.7 (range 6–25), 4.3 ± 0.8 (range 2–5) , and 3.2 ± 1.3 (range 0–4), respectively. Results of Pearson correlation test showed significant and direct relationship between nurses age and mean score of practice (r = 0.360; P < .001). Older nurses showed more positive attitudes. The relationship between nurses’ practice score and demographic variables are presented in Table 2. 

Nurses’ attitudes toward pressure injury prevention and care. The mean overall score on the Attitude Towards Pressure Ulcer Questionnaire was 27.26 ± 5.1 (range 19–38). “Continuous assessment of patients will give an accurate account of their pressure injury risk” and “Most pressure ulcers can be avoided” yielded the most positive answers. “My clinical judgment is better than any pressure injury risk assessment tool available to me” and “In comparison with other areas of care, pressure ulcer prevention is a low priority for me” yielded the most negative answers (Table 2). No significant relationship was observed between nurses’ demographic variables and their attitudes toward pressure injury prevention (P > .05).

Relationship between quality of nursing care and nurses’ attitude toward prevention of pressure injury. Using the Pearson correlation test, a significant and direct relationship was noted between pressure injury prevention and care practice mean score and attitude score (r = 0.195; P = .041) (Table 3 and Table 4). 

Pressure injury is one of the most complex and costly issues confronting health care systems, especially in intensive care units. Nurses play a significant role in the prevention, treatment, and rehabilitation of pressure injury. The results of the present study showed that the majority of nurses working in these intensive care units in Iran provided good care and exhibited a relatively positive attitude toward pressure injury. Additionally, in this study, nurses with a more positive attitude demonstrated a better quality of practice.

According to a descriptive study, the role of the nurse in prevention, treatment, and rehabilitation of pressure injury is considered highly important.²⁶ Having a positive attitude in this regard can be helpful. The results of other research on attitudes toward pressure injury among Iranian nurses showed relatively similar results. In a 2016 cross-sectional study, Farzi et al²⁷ reported that nurses had a relatively positive attitude toward pressure injuries, results consistent with the present study. Studies among nurses working in intensive care units in other countries showed similar results. In a 2017 cross-sectional study²⁸ conducted in Turkey that included 390 nurses, researchers found critical care nurses had a positive attitude toward pressure injury. In a 2017 cross-sectional study conducted in Saudi Arabia on 54 nurses, Tayyib et al²⁹ found that nurses working in intensive care units had a positive attitude toward pressure ulcer care. A high percentage of nurses in the study²⁹ believed that all hospitalized patients are at high risk of developing pressure injuries. Similarly, most of the nurses believed that most pressure injuries can be avoided. Despite these sentiments, pressure injury prevention was not their top priority. 

In recent years, the issue of pressure injury has been much discussed in Iran and is considered a priority of the Ministry of Health; many measures have been taken to address this issue. Efforts include setting up a wound nursing working group at the Ministry of Health, establishing a wound working group at the deputy director level of teaching hospitals, setting up a wound unit at teaching hospitals, appointing a wound care nurse at each hospital, training wound care nurses, and collecting and reporting annual statistics on wound incidence. Numerous studies have been undertaken by researchers in this field over the past 10 years. For instance, over the past 4 years, approximately 10 research projects on pressure injury have been approved and conducted at Qazvin School of Nursing and Midwifery. Along with these measures and efforts, changing critical care nurses’ attitude toward pressure injury is very important. In addition, changes in the nursing students’ curriculum appear to be necessary; it appears nursing students receive very limited education on pressure injury, a reality that can make it difficult for them to change their attitudes once they graduate.³⁰ 

A 2017 cross-sectional study³¹ in Japan (N = 48) evaluated the practice of care managers with regard to pressure injury that, unlike the results of the present study, showed poor pressure injury practices. Differences between the results of the 2 studies may be attributed to disparate data collection tools and methods. In the present study, nurses’ practice was observed and evaluated; the Japanese study utilized questionnaires. Furthermore, it should be noted that the population of the present study consisted of nurses working in intensive care units. Because of the high prevalence of pressure injury in this setting, multiple training courses are usually provided; a nurse’s practice is carefully monitored, which can lead to initiatives that can contribute to improving the critical care nurse’s practice. Although the practice among critical care nurses in Iran has improved in recent years, there is still a need for continued improvement measures. An important issue regarding the improvement of nurses’ practices should be demonstrated. 

Nurses should consider all 3 aspects of pressure injury management (ie, prevention, treatment, and rehabilitation), but they seem to be most concerned about treatment as opposed to prevention and rehabilitation.²⁶ One of the basic strategies to ensure that nurses appreciate the importance of prevention and rehabilitation is to employ systematic models at the time of providing care to patients. An example is the Neuman Systems Model. In addition to providing a guide to holistic care for the patient, this approach offers nursing care at 3 levels: primary prevention, secondary prevention (treatment), and tertiary prevention (rehabilitation). Rafiei and Vanaki²⁶ explained the application of this theory as a facilitator in the prevention, treatment, and rehabilitation of patients who were at high risk of developing or currently had or improved from a pressure injury. 

Results of the current study also showed that critical care nurses with a more positive attitude provide a better quality of practice. Similar studies examining this relationship are limited. In a 2020 study conducted in Iran on 308 nurses, Khojastehfar et al³² examined attitude and practice of nurses in the intensive care unit with regard to pressure injury prevention. Similar to current study findings, their results³² showed a positive and significant relationship between a nurse’s attitude and practice. Guttormson et al³³ examined 177 critical care nurses’ attitudes and practices related to sedation in the United States; they reported that nurses’ attitudes significantly affected their practice. 

The relationship between nurses’ attitudes and practice regarding the prevention of pressure injury in the present study can be described based on the theory of planned behavior.³⁴ According to the main concepts of this theory, behavior is based on behavioral intentions, which consist of 3 parts: attitudes toward behavior, subjective norms, and perceived behavioral control. As shown in this study and beyond, a person’s attitude influences behavior. 

The most important limitation of this study was that nurses’ practices may have been affected by the presence of the observer. In addition, although an instrument was used to guide observations, responses by the researchers may have been somewhat subjective.

Results of a descriptive, correlational study conducted among 110 critical care nurses in Iran found that the vast majority demonstrated good practices and a relatively positive attitude toward pressure injuries. Additionally, nurses with a more positive attitude were noted to provide a better quality of practice. In planning to improve pressure injury care in the hospital setting, nursing managers should be aware that critical care nurses’ attitudes about pressure injury affect their practice. Educators can use the results and instruments to educate nurses and nursing students. Because of a lack of available research, further cross-sectional study should be conducted. Studies on the relationship between knowledge and practice as well as knowledge and attitude are also recommended.

The present study is a student research project that was approved by the research Committee of Qazvin University of Medical Sciences (registered code: 28/6/2647). The authors thank all the authorities of Qazvin University of Medical Sciences as well as all the critical care nurses who participated in this study.

Ms. Tayebi Myaneh is a master student in critical  care nursing and a member of the Student Research Committee, Qazvin University of Medical Sciences, Qazvin, Iran; Mr. Rafiei, Dr. Hoseinigolafshani, and Dr. Rashvand are faculty members of the Qazvin School of Nursing and Midwifery as well as the Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran. Please address correspondence to: Farnoosh Rashvand, email: rashvandifar1361@gmail.com.