Intensive Care Unit, Cardiac Care Unit, and Emergency Department Nurses’ Perceptions of Medical Device-Related Pressure Injuries

A Cross-Sectional Study

Pressure injury (PI) is a serious health care problem globally.^1-3 In hospital settings, medical devices are sometimes a necessary component of therapeutic care for patients.⁴ However, the use of medical devices, such as oxygen masks, endotracheal tubes, nasogastric tubes and pulse oximeters, can cause PIs in some patients. This type of PI is called medical device­–related pressure injury (MDRPI).^5-8 In acute care wards, critically ill patients are at greater risk of MDRPIs.⁹ In this regard, the results of one study in Iran in 2020 showed that approximately 20% of patients admitted to intensive care units (ICUs), cardiac care units (CCUs), and emergency departments experience varying degrees of MDRPIs.⁶ Similarly, the results of another study in Turkey in 2021 showed that about 49% of patients admitted to ICUs suffer from MDRPIs.⁹ One systematic review in 2019 reported the incidence of such injuries in acute care wards to range from 0.9% to 41.2%.¹⁰

Proper prevention and care of MDRPIs are essential. During the outbreak of the COVID-19 pandemic, the number of patients connected to such medical devices as oxygen face masks, nasal masks, pulse oximeters, and cardiac monitors increased, and the issue of this associated risk became even more important. In addition, many COVID-19 patients had a serious clinical condition that made them more susceptible to MDRPIs.^11-13

In prevention of all types of PIs, including MDRPIs, nurses play a significant role.^14-16 Their performance in this regard is influenced by several factors, including their attitudes.¹⁷ The authors’ previous study, which was conducted among critical care nurses in Iran, showed that those nurses who had a positive attitude toward PIs demonstrated better clinical performance regarding the prevention and care of this type of injury in clinical settings.¹⁷ In another study, Khojastehfar et al examined critical care nurses’ attitudes and practices when caring for patients with PIs and found a direct relationship between their attitude and practice in clinical settings.¹⁸

By taking these findings into consideration, one might hypothesize that nurses’ attitudes toward MDRPIs are likely to affect their performance when caring for patients who are at risk of such injuries. Therefore, it is essential to determine nurses’ attitudes towards MDRPIs. The authors’ literature review revealed limited studies in this regard, and most research examining care of patients with PIs were related to non-MDRPIs. These types of injuries are significantly different from MDRPIs. For example, non-MDRPIs are more common in immobile and bedridden patients, while MDRPIs can occur in both types of patients as long as a medical device is connected. Due to the lack of studies as well as the importance of nurses’ attitudes towards MDRPIs, the current study was designed and conducted to examine ICU, CCU, and emergency department nurses’ attitudes toward prevention and care of MDRPIs.

This cross-sectional study was conducted in Iran in 2021. All nurses (N = 310) working in ICUs, CCUs, and emergency departments of 4 general hospitals of Iran were invited to participate in the study.

Inclusion criteria. Nurses whose experience included working in an ICU, CCU, or emergency department for at least 6 months were invited to participate. Participants were also required to have obtained a bachelor’s degree in nursing in Iran, which stipulates 4 years of education at a nursing school. Access to a mobile phone with an active WhatsApp, Telegram, or email service was required to receive the electronic questionnaire.

Exclusion criteria. Nurses were excluded only if they had an illness that caused them to leave the study.

Data collection method. Given the outbreak of the COVID-19 pandemic at the time of this study, the researchers elected to distribute the data collection tool to potential participants electronically. To meet this end, the hospital managers provided the authors with a list of nurses working in their ICUs, CCUs, and emergency departments. All eligible nurses were then contacted by two of the researchers (LS and MJ) via mobile phone and asked to participate in the study. During this contact, the researchers provided details regarding the study objective, methods, and data collection tool. If the nurse agreed to participate, an informed consent form was sent to them with the data collection tool via WhatsApp, Telegram, or email according to the nurse’s preferences. Nurses were instructed to first complete and return the informed consent form within 24 to 48 hours and before accessing the data collection tool. No reward or incentive was offered for participation. For developing the electronic tool, the authors used the services of Porsline website (https://survey.porsline.ir). Completion of the consent form and use of the data collection tool was done anonymously. Data collection took about 3 to 5 weeks.

Data collection tools

Demographic data. Participants were asked to complete a researcher-made demographic checklist. The demographic variables were age (reported numerically), sex, years of work experience, workplace setting, participation in workshops on MDRPIs prevention and care during the last year (yes or no answer), and completed trainings on MDRPI prevention and care at a nursing school (yes or no answer).

Attitude toward MDRPIs questionnaire. This questionnaire was first developed by Fereidouni et al in Iran in 2020 to assess nurses’ and nursing students’ attitudes toward MDRPIs.¹⁹ The questionnaire was divided into 2 sections: prevention of MDRPIs (6 items) and care for patients with MDRPIs (5 items). Respondents rated each item on a 5-point Likert scale, ranging from strongly agree (1) to strongly disagree (5). The total score was the sum score of all 11 items, with a potential score ranging from 11 to 55. A higher score indicated more positive attitudes toward proper prevention of MDRPIs and care for individuals with such injuries. A score of 11 to 25 indicated a negative attitude, a score of 26 to 40 indicated a neutral attitude, and a score >40 indicated a positive attitude.¹⁹

In their study, Fereidouni et al reported a Cronbach’s alpha of 0.77, intraclass correlation coefficient of 0.75, and Pearson’s correlation coefficient of 0.86 at P < .005 for their questionnaire.¹⁹ In the current study, 3 methods (Cronbach’s alpha, split-half, and intraclass correlation) were used to determine the reliability of this questionnaire among nurses in ICUs, CCUs, and emergency departments. The Cronbach’s alpha for the whole questionnaire was estimated to be 0.793. Also, the reliability and stability of the questionnaire were examined by splitting the items into two sections, and then, calculating the correlation coefficient between the scores of each one; the correlation coefficient between the two halves (r) was estimated to be 0.826. Finally, the intraclass correlation was estimated to be 0.73 (95% confidence interval, 0.808–0.637).

Ethical considerations. This study received the approval of the Ethics in Research Committee of Bam University of Medical Science (ethic code: IR.MUBAM.REC.1399.075). The authors considered the ethical principles of medical research throughout all stages of the study, including writing the initial proposal, sampling, collecting data, analyzing data, and writing the article. All nurses who participated in this study signed the electronic informed consent form, which was developed by Bam University of Medical Science and sent via a web link, before they accessed the data collection tool.

Statistical analysis. Raw data were first entered into SPSS v23 and then analyzed using mean, frequency, Pearson correlation (to determine the relationship between the mean score of attitude and mean age and work experience), independent t test (to determine the differences in mean score of attitude between men and women and between those who participated in workshops and those who did not). It should be noted that the total scores of nurses’ attitudes followed a normal distribution according to Kolmogorov-Smirnov test.

Of 310 nurses who were invited, a total of 260 participated in the study (response rate, 83.8%). The participants’ mean age was 33.4 ± 6.8 years, and mean work experience was 10.3 ± 4.3 years. Of the 260 participants, 151 stated they had not received any formal trainings on MDRPIs at nursing school during their education, and 212 nurses stated they had not participated in any scientific workshops on MDRPI prevention and care. In addition, 167 nurses reported having insufficient knowledge about the prevention and care of MDRPIs (Table 1).

Attitude toward MDRPIs. The mean total score of attitude towards MDRPIs was 41.7 ± 6.1. The participants gave the highest scores (indicating a more positive attitude) to the items “MDRPIs do not need any treatment and heal on their own” and “There is no need for recording and reporting the MDRPIs in the patient’s medical record.” Yet, the participants gave the lowest scores (indicating a more negative attitude) to the items “It is more difficult to prevent MDRPIs than conventional PIs, such as those that occur in the patient’s sacrum due to lying on the bed for long periods” and “In many cases, it is not possible to prevent MDRPIs.” Table 2 presents more information about the responses of nurses differentiated by work unit.

No significant relationship was observed between the total score of nurses’ attitude and their demographic variables (P > .05). There was no significant relationship between the total mean score of attitude and nurses’ work experience (P = .555; r = -0.37) as well as their age (P = .493; r = -0.04). Also, no significant differences were observed among nurses working in ICUs, CCUs, and emergency departments with regard to the total mean score of attitude towards MDRPIs (P = .08). However, nurses working in ICUs (mean score, 42.3 ± 2.3) showed a more positive attitude toward prevention and care of MDRPIs than those working in CCUs (mean score, 41.5 ± 7.1) and emergency departments (mean score, 40.4 ± 3.7) (Table 2). The mean scores of attitude toward MDRPIs in nurses who had participated in workshops and those who had not were 42.5 and 41.2, respectively; this difference was not statistically significant (P = .113). The mean scores of attitude toward MDRPIs in nurse who had received education at nursing schools and those who had not were 42.5 and 41.5, respectively; this difference was also not statistically significant (P = .360).

This study aimed to investigate ICU, CCU, and emergency department nurses’ attitudes toward proper prevention of MDRPIs and care for individuals at risk such injuries. The total mean score showed that nurses had a positive attitude toward MDRPI prevention and care (mean score >40 indicated a positive attitude towards prevention and care of MDRPIs). The results also showed that more than half of the nurses (61.2%) had not received formal training on MDRPI care during their education. Moreover, nearly 82% of the nurses had not participated in any workshops on MDRPIs. In addition, 65% of the participants indicated that they have insufficient knowledge about the prevention and care of this type of injury.

Nurses play a significant role in prevention and care of MDRPIs in ICUs, CCUs, and emergency departments. The results of the current study showed that these specialty nurses have a positive attitude toward proper prevention of these injuries and care for individuals at increased risk. Previous surveys of experienced nurses regarding this issue are very limited, but, similar to the findings of the current study, the results of one recent study in China showed that nurses have a positive attitude toward MDRPI prevention and care.²⁰ An important finding in the current study related to the items that received a lower score. ICU, CCU, and emergency department nurses believed that the prevention of MDRPIs is more complicated than that of non-MDRPIs, and in many cases, such injuries cannot be prevented. These findings should be considered by nursing managers and educators when teaching acute care strategies and PI management to nursing students. MDRPIs can, in fact, be prevented by taking the following measures: selecting a device of the correct size for the patient; connecting the device correctly to the patient; repeatedly evaluating the skin under the device; disconnecting the device early, if possible; and using preventive dressings under the equipment. The key time to examine the skin under a medical device is whenever the patient is repositioned.

A notable finding in the current study was that a significant proportion of nurses stated they had not received any formal training on MDRPIs, either during their education in nursing school or after they were employed in a hospital. One study conducted in Iran in 2020 reported similar results. In that study, Behnammoghadam et al examined the attitudes of 187 nursing students toward MDRPIs using a similar questionnaire. In that study, nearly 42% of the students stated that they had not received any trainings on MDRPIs during their education at nursing schools. In addition, students who had received education often noted that the education was insufficient.²¹ One study on nursing education curriculum also showed that little attention is paid to the education and empowerment of nursing students about PIs, indicating a significant training gap at nursing schools.²² Similar to the present study’s findings, one 2022 study of 355 nurses in Turkey found that nurses do not have enough knowledge about MDRPI care.²³ In China, Zhang et al reported that nurses did have good knowledge about MDRPIs, which is in contrast with the findings of the current study.²⁰ While some of these differences can be attributed to variations in the questionnaires used in the studies, the dissimilar outcomes are likely related to differences in the methods of nursing education between China and Iran. ²⁰

It should be noted that using an electronic self-report approach to examine nurses’ attitudes is associated with some limitations, such as the possibility of participants not understanding the main concepts as well as the content of the items. In addition, by using this method of data collection, fear of public perception may cause some participants to voluntarily or involuntarily report their attitude as better than their true feelings. Therefore, this should be considered when using the finding of current study.

This cross-sectional study was conducted to examine critical care nurses’ attitudes toward prevention of MDRPIs and care of patients with these injuries. Final results revealed that ICU, CCU, and emergency department nurses do have a positive attitude toward MDRPI prevention and care. However, they feel they have not received adequate training on MDRPI management, either during their academic education or while they were employed at the hospitals. Therefore, revisions in nursing education curriculums are essential. The results of the current study can be used by health care managers, nursing educators, and clinical nurses to develop fuller educational and care plans for MDRPIs prevention and care. The questionnaire used in current study was validated and can also be used by researchers, educational institutions, and health care facilities to gain more understanding of nurses’ attitudes in other settings. Due to the lack of research in this area, the authors recommend that further studies investigate ICU, CCU, and emergency department nurses’ knowledge and practice about MDRPIs.

The authors thank the participants in this study and Bam University of Medical Sciences for its support.

Asra Nassehi, MSc, PhD student^{1, 2}; Mojtaba Jafari, BSN, MSc, PhD²; Franoosh Rashvand, BSN, MSc, PhD³;
Hossein Rafiei, BSN, MSc, PhD³; Fatemeh Hosseinpour⁴; and Lida Shamekhi, RN⁴

¹School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
²School of Nursing and Midwifery, Bam University of Medical Sciences, Bam, Iran
³Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
⁴Student Research Committee, Qazvin University of Medical Sciences, Qazvin, Iran

Address all correspondence to: Hossein Rafiei, BSN, MSc, RN, Social Determinants of Health Research Center, Research Institute for Prevention of
Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran; email: Hosseinr21@gmail.com