The Effect of Web-Based Training Given to Nurses on the Prevention of Pressure Injury in Patients Hospitalized in the Anesthesiology and Reanimation Intensive Care Unit: Quasi-experimental Pre-test Post-test Research

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Pressure injury (PI), the importance of which is increasing rapidly as a necessary criterion in the assessment of patient safety and quality of care, affects patient quality of life and results in prolonged hospitalization and increased cost of care.¹ Pressure injuries are common in intensive care units (ICUs)  due to several factors, including limited physical activity and mobilization; extensive use of sedatives, analgesics, and relaxants; frequent use of mechanical ventilation; loss of consciousness; circulatory and respiratory disorders; urinary and fecal incontinence; malnutrition; inflammation; and hypoalbuminemia.¹

According to the National Pressure Injury Advisory Panel (NPIAP) (2019), PI is defined as localized damage to the skin or deep tissues, usually on a bony prominence or in association with a medical or other device.² Demarré et al³ conducted a systematic literature review of articles published in Medline, CINAHL, Web of Science, The Cochrane Library, Embase, and EconLit between 2001 and 2013. They reported that the amount spent per person per day for PI prevention was between €2.65 and €87.57, and the cost of treating PI per person per day ranged from €1.71 to €470.49.³

It is reportedly more expensive to treat PI than to prevent it. Gedamu et al⁴ reported that 71 (16.8%) hospitalized patients in their study developed a PI. The factors significantly associated with the high prevalence of PIs were prolonged hospitalization, reduced sensory perception, and friction and shearing forces. Prospective studies are needed to investigate the incidence of PI and related factors. In a study of 569 patients in Turkey, Gencer and Özkan⁵ reported a PI prevalence rate of 2.5% of hospitalized patients in clinics, PI incidence of 1.9%, and PI prevalence rate in the ICU of 5.9%. Those authors concluded that it is easier to prevent than to treat PI. A study of 46 patients in neurology and neurosurgery ICUs reported that 63% of individuals were at increased risk of developing a PI due to cerebrovascular disease, 41% of patients developed PIs, 71% had injuries on the lower part of the body, and 63% developed injuries between day 2 and day 5 of hospitalization.⁶

It is known that 90% of PIs can be prevented with risk assessment and resulting management and that this is the most effective method of prevention.^7-12 In terms of defining the health of the individual and evaluating the quality of nursing care, it has been established that evidence-based practices and nursing practices such as risk and skin assessment, bed bath, moisturizing the skin with creams, using padding for pressure points, and range of motion exercises greatly reduce the incidence of PI.^4,9,11-13

Evidence-based guidelines have been developed to assist the health care team in the prevention and management of PI.^1,2 Guidelines have also been developed by international PI advisory panels (European Pressure Ulcer Advisory Panel [EPUAP], NPIAP, and Pan Pacific Pressure Injury Alliance).^2,14-16 In Turkey, the Guideline for Prevention and Management of Pressure Injury was established in 2003 by the Wound, Ostomy, and Continence Nurses Society (WOCN).¹⁷ These guidelines note the importance of risk assessment, skin integrity, use of support surfaces to reduce pressure, in-bed mobilization, and periodic re-training, and well as the importance of documenting these procedures.^15,17,18 In Turkey, it is reported that scales for pressure injury risk assessment are not widely used in the clinical field, and preventive care practices are limited.⁷ It is essential for nurses to participate in professional development and, if possible, to conduct their own research to further educate their colleagues.

This quasi-experimental pre-test–post-test research study was conducted to evaluate the effect of web-based training given to nurses on the prevention of PIs in patients hospitalized in the Anaesthesiology and Reanimation Intensive Care Unit (ARICU). Ethics Committee approval was obtained from Okan University Ethics Committee on March 27, 2019, and institutional permission was obtained from Sultan II. Abdulhamid Han Training and Research Hospital (TRH) in Istanbul, Turkey, on April 29, 2019. During the quasi-experimental phase of the study, the nurses and patients were informed about the purpose, plan, and duration of the study. Verbal and written consent were obtained from the participants.

Research hypotheses. The authors proposed 3 hypotheses. Hypothesis 1: The incidence of pressure injury is lower in patients who receive post-training care from nurses working in the Anesthesia and Reanimation Intensive Care Unit (ARICU). Hypothesis 2: The attitudes toward PI prevention of the nurses working in the ARICU are different before and after the training. Hypothesis 3: The rate and stage of PI are lower in patients who receive post-training care from nurses working in the ARICU.

Research variables. The independent variables consist of the demographic characteristics of patients (eg, age, sex, marital status, education level), characteristics associated with the overall condition of the patient (eg, hemoglobin level, plasma albumin level, serum urea nitrogen, creatinine level), and the “Prevention of Pressure Injury in Intensive Care Patients” nurses’ training. The dependent variables consisted of PI rate and stage of ICU patients, the Braden Scale score for predicting PI risk, and the Attitude Towards Pressure Ulcer Prevention instrument score.

Research setting, population, and sample (patient group). The research was conducted with the participation of patients hospitalized in the ARICU of Sultan II. Abdulhamid Han TRH between May 1, 2019, and December 31, 2019, and of nurses working in that unit. The ARICU is a level III ICU with a capacity of 16 beds, and with 22 nurses on duty.

Power analysis was used to determine the minimal sample size of the population. The analysis was performed at 95% CI. A total of 80 patients (40 hospitalized in the ICU before the training program, 40 hospitalized in the ICU after the training) who met the research criteria were included in the study. No additional examinations or tests were performed on the patients who met the research criteria and were accepted to participate in the study; the patient data were obtained from the nurse observation sheet and the patient file.

Inclusion and exclusion criteria. All patients were 18 years or older and deemed high risk for PI according to Braden Scale score (score ≤12). Patient consent was obtained from the patient or their parent or guardian. Patients had no PIs in the sacrum, heel, or trochanters at the time of admission, had not been diagnosed with brain death, and were hospitalized in the ICU for at least 5 days and available for changing positions.

The exclusion criteria were as follows: death, referral, or discharge less than 5 days after inclusion in the study, not at high risk according to Braden Scale score, diagnosis of brain death, or PI in the sacrum, heel, or trochanters that is not amenable to changing positions.

Training phase of the research (nurse) study group population and sample. The research population of the nurse group consisted of 22 nurses working in the ARICU in the Education and Research Hospital of the Ministry of Health in Istanbul. The full population was reached for the sample. The alpha value was set at .05, the effect size had a high effect level, and the power level was 97.63% after maintaining the sample size.

Data collection tools.

Patient Information Form. The Patient Information Form prepared by the researcher (HE) after conducting a literature review^11,12,16,18 consisted of 19 questions about patient demographic characteristics (eg, vital signs, hemoglobin level, plasma albumin level, serum urea nitrogen, creatinine level).

Patient Follow-up Form. The Patient Follow-up Form prepared by the researcher after the literature review^11,12,16,18 consisted of 13 sections, including information obtained from the patient file on vital signs, oxygen therapy, nutrition, pain, use of a urinary catheter, stool frequency and consistency, drugs used, laboratory findings, Glasgow Coma Scale score, PI staging, localization, and Braden risk assessment score.

Braden Scale for risk assessment. The Braden Scale for risk assessment is the most frequently used in the United States and is the most reliable and valid scale that can be used for patient groups with a wide age range. The scale was developed by Barbara Braden and Nancy Bergstrom in 1987,¹⁹ and in 1998, Pinar and Oğuz²⁰ found the reliability and validity of the Norton Scale and Braden Scale to be high.

The Braden Scale has 6 subcategories: sensory perception, moisture, activity, mobility, friction, and shear. Except for friction and shear, which are scored between 1 and 3 points, each variable is scored between 1 and 4 points. The Braden Scale total score ranges between 6 and 23. Lower total scores indicate a higher risk for PI.^11,12,16,18 Scores from the present study were performed by the nurses and recorded in the Patient Follow-up Form by the researcher HE.

Pressure Injury Staging Form. Pressure injury stage was assessed using the Pressure Injury Staging Form. For patients with identified PI, the stage (suspected deep tissue injury, stage 1, stage 2, stage 3, stage 4, unstageable) was recorded in the Patient Follow-up Form; the data were taken from the nurse observation sheet filled out by participating nurses.

Nurse Information Form. The Nurse Information Form prepared by the researcher in line with the literature^11,12,16,18 consisted of 9 questions on the demographic characteristics of the ARICU nurses, such as age, sex, and education level, and on descriptive information, such as any previous training on PI (eg, course, in-service training, seminar) and date of attendance.

Questionnaire Form for Determining Nurses’ Level of Knowledge on the Prevention of Pressure Injury (Pre-test). The Questionnaire Form for Determining Nurses’ Level of Knowledge on the Prevention of Pressure Injury (Pre-test) prepared by the researcher in line with the literature,^12,16,18 and the Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide 2019¹⁵ developed by the EPUAP and the NPIAP, consist of 10 questions with a total of 20 points. The pre-test was prepared to determine nurses’ level of knowledge of the prevention of PI by asking them to mark 1 of the 5 options in the questionnaire.

Questionnaire Form for Determining Nurses’ Level of Knowledge on the Prevention of Pressure Injury (Post-test). The educational video on the Prevention of Pressure Injury in Intensive Care Patients, which consisted of slides with an accompanying audio recording presented by the researcher, was sent to the nurses’ mobile phones as a link so that nurses could watch it at their convenience, play it as many times as they wished, and access it easily. Immediately after the training was completed, the Questionnaire Form for Determining Nurses’ Level of Knowledge on the Prevention of Pressure Injury (Post-test), consisting of 10 questions with a total of 20 points, was applied to determine the effectiveness of the training.^12,16,18

Attitude Towards Pressure Ulcer Prevention instrument. The research instrument used to evaluate nurses’ attitudes toward PI prevention was developed by Beeckman et al²¹ and adapted into Turkish by Üstün.²² The Attitude Towards Pressure Ulcer Prevention instrument consists of 5 dimensions and 13 items related to personal efficacy to prevent PI, effectiveness of prevention, and effect of PI (3 items each), and personal responsibility in PI prevention and confidence in its effectiveness (2 items each). The items are rated using a 4-point Likert scale (“I strongly agree” = 4 points in positively worded items; “I strongly disagree” = 4 points in negatively worded items), with a minimum score of 13 and a maximum score of 52. An increase in the total mean scores indicates a positive attitude. Üstün²² reported a Cronbach α value for the entire tool of 0.714. In the present study, the Cronbach α value for the Attitude Towards Pressure Ulcer Prevention instrument (Pre-Test) was 0.662, and the Cronbach α value for the Attitude Towards Pressure Ulcer Prevention instrument (Post-Test) was 0.682.

Training Evaluation Form. The Training Evaluation Form was prepared in line with the literature and expert opinions. ¹⁸ It consists of 3 sections with 26 items related to (1) planning and implementation of training (11 items), (2) trainer (9 items), and (3) learning outcomes (6 items). Items are rated using a 5-point Likert scale as "completely agree", "agree", "partially agree", "disagree", and "strongly disagree." After the video training, nurses scored the planning and implementation of the training, the trainer, and the learning outcomes using the form.

Research stages. The research had 3 stages.

In stage 1, 40 patients (group 1) received the Braden Scale, Patient Information Form, Patient Follow-Up Form, and Pressure Injury Staging Form. The PI rates and stages were determined based on information from the patient’s file and the nurse observation sheet.

In stage 2, a web-based Prevention of Pressure Injury in Intensive Care Patients training program on the importance, prevalence, pathophysiology, and etiology of PI, common risk factors for PI, and stages and prevention of PI was prepared for the nurses. First, the domain name haticeerdogan.com was purchased. Next, the PowerPoint (Microsoft, Inc) presentation prepared by the authors of the present study was saved as a video file. This file was uploaded to the server to make the educational video easily accessible from mobile phones and computers. This training program used ADDIE (analyze, design, develop, implement, and evaluate) instructional design principles.

Before the training, a link to the Nurse Information Form, Questionnaire Form for Determining Nurses’ Level of Knowledge on the Prevention of Pressure Injury (Pre-test), and Attitude Towards Pressure Ulcer Prevention instrument was sent to the nurses’ mobile phones via e-mail.

The training was carried out with a web-based training program for the prevention of pressure injuries in patients in intensive care. This training consisted of 135 slides and was 40 minutes long. The presentation was sent to the nurses’ mobile phones as a link so they could watch it at a convenient time, play it as many times as they wished, and access it easily. There were no problems with sound and image quality. The web-based training also was printed as a colorful 131-page booklet that was placed on the nurses’ desk. Information leaflets were distributed to all nurses who participated in the training. A colorful poster on the Prevention of Pressure Injury in Intensive Care Patients was hung on the information board in the ARICU.

To assess the effectiveness of the video training, the Questionnaire Form for Determining Nurses’ Level of Knowledge on the Prevention of Pressure Injury (Post-test), Attitude Towards Pressure Ulcer Prevention instrument, and Training Evaluation Form were sent to the nurses’ mobile phones as a link via e-mail.

A waiting period of at least 3 weeks was required in order to evaluate the effectiveness of the training in terms of behavioral change.

In stage 3, 40 patients (group 2) who received care from ARICU nurses who had participated in the video training program on Prevention of Pressure Injury in Intensive Care Patients were evaluated using the Braden Scale, Patient Information Form, Patient Follow-up Form, and Pressure Injury Staging Form. The PI rates and stages were determined based on information from the patient’s file and the nurse observation sheet.

Homogeneity between patients before and after the nurses’ training was ensured by using the Patient Information Form, Patient Follow-up Form, and the Braden Scale for each patient. The video training was sent to nurses’ mobile phones as a link so they could watch it at a convenient time, play it as many times as they wished, and access it easily.

The difference between the nurses’ level of knowledge on the prevention of PI and attitudes toward PI prevention before and after the training was determined by pre- and post-training assessments, and the training itself was evaluated. The changes in nurses’ behaviors were determined by collecting and analyzing data on PI rates, stages, and time of development after hospitalization in patients who received care before (group 1) versus after (group 2) the video training.

Data analysis. The G*power software was used for power analysis.²³The alpha level was set at .05, the effect level was high, the sample size of 22 nurses was achieved, and the power level was 97.63%. The patient population was evaluated to determine the sample size and to perform the analysis at 95% CI. Eighty patients (40 before nurses’ training and 40 after training) were included in the study. Statistical analysis was performed using SPSS v23 (IBM Corp). Descriptive statistics of the variables are expressed as mean ± standard deviation, and categorical variables are expressed as frequency and percentage.

The data distribution was assessed using the Kolmogorov-Smirnov and Shapiro-Wilk normality tests. Skewness and kurtosis values were observed. The chi-square test was used for comparison of categorical data. In the comparison of quantitative data, the independent variable t test was used for the pairwise comparisons, and 1-way analysis of variance (ANOVA) was used for the group comparisons of normally distributed data. The Mann-Whitney U test was used for pairwise comparisons, and the Kruskal-Wallis test was used for the group comparisons of data that did not show a normal distribution.

In the comparison of dependent groups, the paired t test and ANOVA repeated measures were used in the analysis of normally distributed data. Analysis of the data that did not show a normal distribution was performed using the Mann-Whitney U Wilcoxon and Friedman tests.

Depending on the data distribution, the relationship between quantitative data was evaluated with Pearson product-moment and Spearman rank. Frequency analysis data for the Patient Information Form, Patient Follow-up Form, and Nurse Information Form are presented as number and percentage. The paired t test was used for the comparison of Braden Scale score and training pre-test and post-test results. For the pre-test (before the web-based training) and post-test (after the training) Attitude Scale Towards Nurses Preventing Pressure Ulcers, the Mann-Whitney U test was used for the pairwise comparisons, and the Kruskal-Wallis test was used for the comparisons of more than 2 groups. The relationship between the scale subdimensions was analyzed with the Spearman correlation test.

No significant difference was found between group 1 and group 2 in terms of the descriptive characteristics of the patients (P > .05) (Table 1). Neither was there a significant difference between the groups in terms of vital signs or nutrition, use of a urinary catheter, stool frequency, and stool consistency according to data from the Patient Follow-up Form (P > .05). The laboratory results for hemoglobin, albumin, and serum urea nitrogen level were significantly different between groups (P < .05). However, the difference in creatinine level was not significant (P > .05).

The difference in Glasgow Coma Scale scores between groups was significant (P < .05) (Table 2). Braden Scale scores were not significantly different between groups (P > .05) (Table 3).

In both groups, PI stage was evaluated each day for 7 days. In group 1 (before nurse training), 2.5% of patients had stage 1 PI on day 1 (n = 1) and some stage 4 PIs were noted. The number and severity of PI increased over the next 3 days. On day 5, 20% of patients had stage 1 PI (n = 8), 7.5% had stage 2 PI (n = 3), and 5% had stage 4 PI (n = 2). By day 6, PI number and stage had decreased, although 2 stage 4 PIs persisted. On day 7, 7.5% of patients had stage 1 PI (n = 3) and 2.5% had stage 4 PI (n = 1) (Table 4).

In group 2 (after nurse training), 2.5% of patients had stage 1 PI on day 1 (n = 1), and the number and severity of PI increased over the next 3 days. On day 5, 22.5% of patients had stage 1 PI (n = 9) and 5% had stage 2 PI (n = 2). On day 6, PI number and stage had decreased, and on day 7, 2.5% of patients had stage 1 PI (n = 1). Following the training, stage 4 PIs were not seen.

Fifty percent of the nurses included in the study were between the ages of 24 and 28 years, 68% were women, 81.8% had a bachelor’s degree, 45.5% had 0 to 2 years of work experience, and 72.7% had 0 to 2 years of ICU experience. In addition, 86.4% of the nurses had received previous training on PI prevention, and 77.3% had received training within the past 12 months (Table 5).

There was a statistically significant difference in the effect of training on nurses’ level of knowledge on the prevention of PI and attitudes toward PI prevention scores (Table 6). The mean level of knowledge score increased from 61.81 before training to 75.00 after training (P < .001). A statistically significant difference was found when nurses' attitudes towards PI prevention were evaluated before and after the web-based training given to prevent PI in patients hospitalised in intensive care (P = .042). It is seen that the attitude towards PI prevention, which was 44.31 points before the training, increased significantly after the training (48.31 points) (Table 6).

Findings on the descriptive characteristics of patients. The prevalence of PI increases significantly with advancing age. In the 2016 study by Neloska et al²⁴ of 256 patients who developed PI, 86 were male and 170 female, with a mean age of 76.38 years. Katran²⁴ reported a statistically significant relationship between age and PI occurrence in a study of 985 patients. The risk of PI is increased in elderly patients due to epidermal thinning and a decrease in dermal blood vessels.²⁶ Inan²⁷ found no significant relationship between sex and PI. In the present study, when the data of the descriptive characteristics of group 1 patients were evaluated, it was found that groups 1 and 2 shared similar traits in terms of age and sex. Hyun et al²⁸ reported that the incidence of PI was higher in elderly patients who were underweight or with obesity compared with patients with normal weight. In the present study, no statistically significant difference in BMI was found between group 1 and group 2 patients. The findings obtained from the Patient Information Form demonstrated parallelism and homogeneity in the groups before and after training, supporting the reliability of the research.

Findings on patient follow-up. The vital signs of ICU patients were monitored frequently and regularly. The findings were recorded in the nurse observation sheets. Efteli and Güneş²⁹ found no difference between heart rate and blood pressure values in terms of patients’ PI development status. In the present study, the vital signs of the patients in both groups were similar.

In their study on the relationship between mortality and perfusion, Acar et al³⁰ found no relationship between perfusion index measurements and ventilation types. Saghaleini et al³¹ stated that malnutrition is a key risk factor for the development of PI because it reduces collagen synthesis and tensile strength. Sudden weight loss has also been reported to be an important risk factor for PI.³¹ In the present study, 55% of patients in group 1 received parenteral nutrition, whereas 55% of patients in group 2 received enteral nutrition, which indicates a higher risk of PI in group 1. The use of oxygen therapy via mask/nasal cannula was similar in both groups.

In their study of 164 elderly patients (115 females, 49 males), Bale et al³¹ reported urinary incontinence in 70.1% of females and 29.9% of males. In the present study, all patients had a urinary catheter, and stool frequency and consistency were parallel, which indicates similar risks between groups. The study that Kurtuluş Tosun and Bölüktaşı¹⁴ conducted on neurointensive care patients suggested a negative relationship between albumin level and PI stage. Kurtuluş Tosun and Bölüktaşı¹⁴ found no statistically significant relationship between hemoglobin level and PI development. In the 2022 study by Efteli,³³ hemoglobin and albumin levels ​​were statistically significantly lower in patients hospitalized in ICUs who developed PI than in patients hospitalized in ICUs who did not develop PI. In the present study, hemoglobin and albumin levels were low in both study groups; however, the rate was lower in group 2 patients, placing them at increased risk of PI.

The study of Kurtuluş Tosun and Bölükbaşı suggests that level of consciousness affects PI development and that 83% of patients considered comatose according to Glasgow Coma Scale score develop PI.¹⁴ Hug et al³⁴ reported a significant relationship between consciousness/cognitive status disorder and PI development. In the present study, both groups included patients with mild, moderate, or severe neurologic injury based on Glasgow Coma Scale score, with a mild neurologic injury rate of 27.5% in both groups. However, the rate of severe neurologic injury was higher in group 2 patients, indicating a higher risk for PI development. All patients in the present study had a Braden Scale score less than or equal to 12, placing them at high risk for PI. In this regard, the finding suggests homogeneity of the patients in terms of similar group risk scores before and after training of the nurses.

Determining the anatomic location of PI according to PI incidence is important in the selection and implementation of preventive measures. Kurtuluş Tosun and Bölüktaşı¹⁴ reported a total of 156 PIs in 73 patients. Most of these injuries occurred in the sacral area (35.9%) and the heel (28%). Studies have shown the sacral area to be at highest risk for PI development, with the heel at second-highest risk for PI.^14,31 Evaluation of PI stage of group 1 patients in the present study showed that PIs developed mostly on the sacrum. This finding supports the literature. The authors of the present study believe that the increased incidence of sacral PI results from prolonged lying in the semi-Fowler, Fowler, and supine positions in the ICU. In the present study, the authors were pleased to note that the overall PI rate decreased by 10% in the post-training group. Because PIs mainly developed on the sacral area in group 1 patients, and on the greater/lesser trochanter and heel in group 2 patients, it was concluded that the right-left lateral position changes emphasized in the training were taken into consideration but were not sufficient. The authors of the present study believe that position changes should be applied every 2 hours in patients who are available for changing positions, and that it would be beneficial to emphasize this in all in-service training.

Avşar³⁵ reported that PIs developed on the sacrum in 57% of patients and on the heels and sacrum in 19%, with a mean development time of 5.6 days ± 3.7 standard deviation. Latimer et al³⁶ reported that PIs developed in 10.8% of patients in the first 36 hours after hospitalization. In their study of 569 patients, Gencer and Özkan⁵ reported that 70% of the ICU patients developed stage 2 and stage 3 PI, that 15% of patients developed PI on the first day of hospitalization, and that 59% developed PI between 2 days and 10 days. Gencer and Özkan⁵ stated in their study that the PI rate of 15 percent on the first day of hospitalization indicates the number of patients coming from home or from outside the hospital with PI. The onset of PI between day 2 and day 10 suggests nosocomial origin. The fact that the number of patients who develop PIs is high between 2 and 10 days is expressed as important in terms of developing protective-preventive activities.²⁵ In the present study, stage 1 injury occurred in 2.5% of patients on day 1 in both groups. In group 1, stage 2 injury was observed on day 2, and stage 4 injury was observed on day 3, while in group 2, stage 2 injury was detected on day 4. In addition, lower hemoglobin and albumin values ​​in group 2 were important in terms of PI risk. Considering over the 7-day study period, fewer patients in group 2 than in group 1 developed PI. Further, the lack of stage 4 PI in group 2 shows the effectiveness of the training provided within the study, in addition to existing in-hospital treatment for PI. This result confirms hypothesis 3, that is, the rate and stage of PI was lower in patients who received post-training care from nurses working in the ARICU.

Findings on Nurses’ Descriptive Characteristics. Nurses should regularly evaluate the risks of PI and initiate practices to prevent the development of PI immediately after hospitalization.^8-11 Many PI risk assessment scales and care guidelines have been developed in an effort to prevent PI. However, studies consistently indicate that the application of these guidelines is insufficient among nurses working in the field.^8-11  

In a study of 48 intensive care nurses, Doğu³⁷ reported that they were between the ages of 20 years and 55 years and that 91.7% were female, 64.6% were single, and 62.5% had a bachelor’s degree. Celik et al³⁸ reported that 87.4% of the 523 nurses in their study were female, 50.5% were between the ages of 29 years and 38 years, 64.2% had a bachelor’s degree, 39.2% had been working as a nurse for 0 to 5 years, 74.4% had received in-service training on the prevention and treatment of PI, and 29.4% stated that they had not received training in more than 2 years. Most of the nurses in the present study were young females with a bachelor’s degree and 0 to 2 years of work experience in an ICU. The majority of the nurses had received prior training on PI and had received it within the prior 1-year period. The authors of the present study believe that young, newly graduated nurses or nurses who recently started working in a hospital setting are generally assigned to the ICU and that several experienced nurses are on duty in this unit to assist them. The authors attribute the lower number of male nurses in the ICU to the fact that males are newer to the nursing profession. Because training on the prevention of PI is included in hospitals’ annual training plans, it is thought that the majority of the nurses receive training within 1 year of starting work at any hospital.

Findings on the knowledge of nurses on the prevention of PI. In his study titled "Evaluation of Applications,” Doğu³⁷ reported a significant increase and difference after the training. Although the patients in a study by Tel et al⁷ were at high risk for the development of PI, the rate of preventive practices was low due to the attending nurses’ lack of knowledge. In the present study, it was found that nurses' knowledge scores after the web-based training on preventing pressure injuries in intensive care patients were higher than their PI knowledge scores before the training. This finding supports the hypothesis that there is a difference in the knowledge levels of the nurses working in the ARICU before and after the video training. In addition, the literature emphasizes the need for the acquisition and development of knowledge, experience, and practices by participating in continuing education programs, attending scientific activities such as congresses and symposiums, and reading professional publications after completing basic nursing education and achieving graduation.^7,38

Findings on Nurses’ Attitudes Towards the Prevention of Pressure Injury. Kagıtçıbaşı³⁹ defined attitude as the tendency that regularly generates the individual’s feelings, thoughts, and behaviors related to a psychological object. In addition, attitude is the regular and continuous coordination of motivation, excitement, comprehension, and learning processes oriented to the individual’s perception of the world.⁴⁰ In other words, attitudes are learned through experiences, they are not temporary, they continue for a certain time, and people have the same thought at certain periods in their lives.⁴⁰

In the present study, nurses' attitudes towards preventing PI increased significantly after web-based training on preventing pressure injuries given to intensive care patients. It was observed that the nurses were aware of the prevention of PI after the training and had a positive attitude, and their attitude scores increased after the training.

This finding supports the hypothesis that there is a difference in the attitudes of nurses working in the ARICU before and after the web-based training towards the prevention of pressure injuries in intensive care patients. Web-based training on the prevention of pressure injuries in intensive care patients increased nurses' awareness about preventing pressure injuries.

The authors of the present study believe that nurses are not sufficiently trained in the prevention of PI and that their common belief that it is difficult to prevent PIs stems from their young age and lack of work experience in the ICU. This finding suggests that nurses should receive continuing education and work with experienced nurses.

Nurses working in intensive care units need to update their knowledge and skills so that they can use all devices and materials and manage the crisis in emergency situations. Computers and smartphones facilitate instant and easy access to information from anywhere at any time. Because nurses working in specialized units such as ICUs are young and newly graduated, they benefit from technology better and prefer it more.⁴¹ Currently, distance training is preferred in hospitals for in-service training. Such training has led to an increase in training participation rates, as well as increased hospital and employee satisfaction.⁴²

The authors of the present study presume that with the development of technology, the widespread use of computers and smartphones will support education, and that the training provided will contribute to equal opportunities, effective time management, easy access to education, and review of the training, resulting in increased training participation. This is invaluable at busy hospitals and in the setting of staff shortages and time problems. Providing ICU nurses with web-based education on PI, including its definition, risk factors, consequences, and preventive measures, has the potential to significantly improve patient care by reducing the frequency of PI.

Limitations of this study are that web-based training on the prevention of pressure injuries in intensive care patients was conducted with nurses working in the ARICU and was conducted in a single institution.

It was observed that the web-based training given to nurses on the prevention of PI in patients hospitalized in ARICU was effective in improving nurses' knowledge, attitudes, and behaviors towards the prevention of PI. In this study, PI stage and rate were lower in patients who received post-training care from nurses working in the ARICU. The authors recommend that nurses be trained on the prevention of PIs, that this training be provided continuously, and that additional studies be carried out on the prevention of PIs.

Acknowledgments: Ethics committee approval was obtained from the University Ethics Committee (05.08.2021/B.10.1.TKH.4.34.H.G.P.0.01/226).

Authors: Hatice Erdoğan, PhD¹; and Nevin Kanan, PhD²

Affiliations: ¹Maltepe University, High School of Nursing, Istanbul, Turkey; ²Nursing Department, Istanbul Haliç University, Faculty of Health Sciences, Istanbul, Turkey

Disclosure: The authors disclose no financial or other conflicts of interest.

Correspondence: Hatice Erdoğan, Maltepe University School of Nursing, Marmara Education Village, Büyükbakkalköy, 34857 Maltepe, İstanbul, Turkey; haticeerdogan@maltepe.edu.tr

ORCID: Erdoğan, 0000-0001-6376-0267

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