A survey of knowledge, attitudes, and practices among paediatric intensive care unit nurses for preventing pressure injuries: An analysis of influencing factors

Abstract

To explore the knowledge, attitudes and practice (KAP) status of preventing pressure injury among clinical nurses working in paediatric ICU, and to examine factors affecting nurses' KAP. A questionnaire survey was conducted among 1906 paediatric ICU nurses in 18 children's hospitals by convenience sampling method. The survey tools were self‐designed general data questionnaire, KAP questionnaire for the prevention of pressure injury and the influencing factors were analysed. A total of 1906 valid questionnaires were collected. The scores of overall KPA, knowledge, attitudes, and practice were 101.24 ± 17.22, 20.62 ± 9.63, 54.93 ± 5.81and 25.67 ± 6.76, respectively. The results of multiple linear regression analysis showed that education background, professional title, age and specialist nurse were the main influencing factor of nurses' knowledge of preventing PI; education background and specialist nurse were the main influencing factors of nurses' attitudes of preventing PI; knowledge, attitudes and education background were the main influencing factors of nurses' practice of preventing PI. Paediatric ICU nurses have a positive attitude towards the prevention of PI, but their knowledge and practice need to be improved. According to different characteristics of nurses, nursing managers should carry out training on the knowledge of prevention of PI to establish a positive attitude, so as to drive the change of nursing practice and improve the nursing practice level of ICU nurses to prevent of PI.

1. INTRODUCTION

Pressure injury (PI) refers to the local injury of skin and/or potential subcutaneous soft tissue, typically located at the apophysis, or injury caused by medical devices or other equipment. ¹ The incidence of PI in paediatric general wards ranges from 2% to 35%, whereas the incidence of PI in children in the intensive care unit (ICU) is as high as 44%. ² The prognosis of children can be adversely affected by delayed treatment and nursing, as well as secondary infection, prolonged hospitalization time, and increased treatment costs. ³ Early effective evaluation and targeted nursing interventions are crucial for the prevention and treatment of PI in children. Currently, the content of authoritative guidelines consists primarily of adult PI guidance and recommendations, with less paediatric content. ⁴ , ⁵ Clinical prevention and nursing protocols for paediatric patients have historically been adapted from adult practice guidelines, with limited consideration for the anatomical and physiological distinctions inherent to the paediatric population. ⁶ In recent years, scholars have endeavoured to consolidate nursing evidence pertaining to pressure injuries within the framework of evidence‐based theory. However, the available literature in paediatrics and ICU settings pertaining to paediatric PI prevention remains notably sparse. ⁷ Most of these studies examined the causes of PI, the development and application of risk assessment scales, and the use of dressings. ⁸ , ⁹ , ¹⁰ A limited number of studies have systematically assessed the knowledge, attitudes, and practices of clinical nurses in the context of PI prevention. As a consequence, this study was designed to investigate the knowledge, attitudes, and practices surrounding PI prevention specifically among paediatric ICU nurses in China. The primary objective of this research is to provide valuable insights that can inform the clinical advancement of pertinent training programs, the development of nursing protocols for PI prevention, and the establishment of standards for quality control assessments within this critical healthcare domain.

2. MATERIAL AND METHODS

2.1. Research material

In September 2022, we conducted a questionnaire survey involving 1906 paediatric ICU nurses from 18 tertiary children's hospitals across China. A convenient sampling method was employed for participant selection. Inclusion criteria: (1) Having a nurse professional qualification certificate; (2) Working in paediatric ICU for more than 1 year. Exclusion criteria: (1) Nurses who were not on duty at the time of the survey (sick/maternity leave, advanced studies, etc.); (2) Refresher and rotary nurses. All nurses who participated in the survey provided informed consent and volunteered to participate in this study.

2.2. Survey methods

2.2.1. Demographic profile questionnaire

Self‐designed by the research team, including gender, age, working years, ICU working years, professional title, educational background, hospital level, department category, marital status, whether they are specialist nurses, and whether they have received relevant training.

2.2.2. Knowledge of paediatric ICU nurses and their attitudes and practices on prevention of pressure injury

The research group compiled a questionnaire based on knowledge, attituded, and practices after reviewing relevant literature and evidence summary from domestic and international sources. ⁴ , ⁵ , ⁷ Five experts in the field of paediatric ICU were invited, including two chief nurse practitioners and three co‐chief nurse practitioners who were asked to revise the content of the questionnaire, as experts in the field of paediatric ICU. They held a bachelor's degree or higher and had more than 15 years of paediatric ICU nursing experience. The research group revised the questionnaire after discussion and based on expert opinions. The questionnaire was revised twice, and an expert in scale development methodology was consulted to create the final version. Prior to the formal investigation, 20 paediatric ICU nurses were selected for a preliminary survey. The questionnaire's Cronbach's α coefficient was 0.949, and the Cronbach's α coefficients of knowledge, attitude, and practice dimensions were 0.886, 0.953, and 0.761, respectively. The questionnaire contained 3 dimensions, with a total of 50 entries.

Prevention of PI in: ① In the evaluation of the Knowledge dimension, comprising 18 items encompassing essential aspects such as the fundamental concept of PI, clinical manifestations, contributing factors, and predilection sites, a scoring system was applied. Each correct response garnered 2 points, while incorrect answers received 0 points. As such, the cumulative score for this dimension varied between 0 and 36 points. To calculate the score rate, the actual score was divided by the total possible score. Consequently, a higher score rate signified a more comprehensive and accurate understanding of PI among the participating nurses. ② In the assessment of the attitude dimension, encompassing a total of 14 items that pertained to the perceived importance of PI assessment and prevention, the willingness to actively engage in PI prevention practices, the advocacy for the existence of a practical management plan, and related aspects, a Likert 5‐level scoring method was employed. Responses were categorized into five distinct levels: “highly disagree”, “disagree”, “uncertain”, “agree”, and “highly agree” with each level corresponding to a numerical value ranging from 1 to 5 points. Consequently, the cumulative score for this dimension ranged from 5 to 70 points. It is noteworthy that a higher score signified a stronger inclination among ICU nurses towards the importance of PI prevention. ③ The practice dimension encompassed a total of 18 items, covering aspects such as the utilization of assessment tools and their frequency, methods of conducting skin assessments, the utilization of preventive supplies, and techniques for repositioning patients. Each item was answered by selecting from available options. Correct responses were awarded 2 points, while incorrect responses received 0 points. The primary objective of this survey was to assess the current status of the implementation of clinical PI prevention practices among the surveyed healthcare professionals.

2.3. Survey methods

Electronic questionnaires were used to collect the data, and the Wenjuanxing (WJX) platform was used to generate questionnaire hyperlinks and QR codes. Prior to the survey, the consent and cooperation from the hospital and section heads were obtained, and professional hyperlinks and QR codes were issued. To ensure the quality of the questionnaire, the researchers used the professional version of the WJX platform and randomly processed all the entries and options. The survey was executed in an anonymous fashion, ensuring the privacy of participants. Each IP address was restricted to a single submission, and respondents were required to answer all questions. A standardized guideline was provided within the questionnaire, elucidating the survey's purpose, significance, and the methodology for completing it. Nurses voluntarily filled out and submitted the questionnaire.

Upon collection by the researchers, questionnaires with identical responses and those completed in less than 200 s were excluded, as they were deemed invalid submissions. Out of a total of 1997 questionnaires distributed, 1906 valid questionnaires were returned, resulting in an effective recovery rate of 95.44%.

2.4. Statistical methods

SPSS 25.0 statistical software was used for data analysis. The enumeration data are described in terms of frequency or percentage. The measurement data followed a normal distribution and are characterized as mean ± standard deviation. The t‐test or analysis of variance was used to compare the differences in the scores of knowledge, attitude, and practice of PI prevention among ICU nurses with distinct characteristics. Multivariate analysis was conducted using a multivariate linear regression analysis. The statistical test level was α = 0.05.

3. RESULTS

3.1. Demographic profile of nurses in paediatric ICU

There were 108 nurses over the age of 50 in the paediatric ICU (5.6%), 217 nurses between the ages of 41 to 50 years old (11.4%), 1040 nurses between the ages of 31 to 40 years old (54.6%), and 541 nurses were between the ages of 20 to 30 years old (28.4%). There were 1594 female nurses (83.6%) and 312 male nurses (16.4%). In terms of education, 102 nurses (5.3%) had a master's degree or above, 1414 (74.2%) had a bachelor's degree, and 390 (20.5%) had a specialty degree. There were 2 chief nurse practitioners (0.1%), 121 co‐chief nurse practitioners (6.3%), and 667 supervisor nurse practitioners (35.0%). There were 844 nurse practitioners (44.3%) and 272 nurses (14.3%). In terms of marital status, 669 nurses were single (35.0%) and 1237 were married (65.0%). In terms of work experience, 106 (5.5%) had worked for over 20 years, 222 (11.7%) had worked for 16 to 20 years, 481 (25.3%) had worked for 11 to 15 years, 742 (38.9%) had worked for 6 to 10 years, and 355 (18.6%) had worked for less than 5 years. There were 1328 specialist nurses (69.7%) and 578 non‐specialist nurses (30.3%).

3.2. The knowledge, attitude, and practice score of preventing PI among paediatric ICU nurses

The total score for knowledge, attitude, and practice in preventing PI among 1906 paediatric ICU nurses was 63.032 ± 24.1. The score of the knowledge dimension was 20.623 ± 9.64, and the scoring rate was 57.28%. The score of the attitude dimension was 16.729 ± 10.46, and the scoring rate was 78.47%. The score of the behaviour dimension was 25.679 ± 6.76 points, with a scoring rate of 71.31%. The three entries with the lowest scores in knowledge, attitude, and practice are presented in Table 1.

TABLE 1.

The three entries with the lowest knowledge, attitude, and practice scores regarding the prevention of PI among paediatric ICU nurses (n = 1906).

Dimension	Entry	Scoring rate (%)
Knowledge	39Select the most appropriate method to avoid heel compression.	29.6
	33Pressure redistribution devices can prevent pressure injuries effectively. What do pressure distribution devices consist of?	31.7
	38. Which of the following are high‐risk pressure injury groups?	35.8
	31.You believe that children with local or systemic edema are not at risk for pressure injury and therefore do not require frequent skin examinations.	31.0
Attitude	1.You believe that a comprehensive pain assessment is not necessary for children with pressure injury.	31.8
	26.You believe that pressure injury is the result of restricted motion, high friction, and shear force.	63.2
Practice	25.How often do you turn a child on the ward who has a pressure injury or is at risk for one?	40.8
	29.When you are nursing children with pressure injury, what is the frequency of routine assessment of the Child Stress Injury Risk Factor Assessment Scale?	44.1
	14.What is the pH value of the cleanser you intend to use to prevent dryness, erythema, and irritation?	46.9

Note: PI stands for pressure injury.

3.3. Comparison of knowledge, attitude, and practice scores of paediatric ICU nurses preventing PI based on their demographic characteristics

The demographic profiles of paediatric ICU nurses were used as independent variables to analyse the differences between groups of nurses with different knowledge, attitude, practice, and total scores. The total scores of knowledge, attitude, and practice questionnaire of nurses with different ages, educational backgrounds, professional titles, working years, marital status and whether they were specialist nurses were compared, and the differences were statistically significant (p < 0.05). There were statistically significant differences in the scores of the knowledge component of PI prevention among nurses with different ages, educational backgrounds, professional titles, working years, marital status, and whether they were specialist nurses (p < 0.05). There were statistically significant differences in the scores of attitude dimension of PI prevention among nurses with different educational backgrounds, professional titles, and specialist nurse status (p < 0.05). There were statistically significant differences in the scores of the practice dimension of PI prevention among nurses with different ages, educational backgrounds, years of employment, marital status, and whether they were specialist nurses (p < 0.05) (Table 2).

TABLE 2.

Comparison of KAP scores for preventing stress injury among paediatric ICU nurses with varying characteristics (n = 1906, point(s), $\overline{\mathit{x}}$±s).

Indicator		Knowledge dimension	Attitude dimension	Practice dimension	Total score of knowledge‐attitude‐practice
Gender	Male	22.37 ± 9.24	55.58 ± 4.97	27.12 ± 5.94	105.08 ± 15.44
	Female	20.57 ± 9.64	54.92 ± 5.83	25.64 ± 6.78	101.14 ± 17.25
t value		1.327	0.778	1.501	1.566
p value		0.190	0.437	0.134	0.117
Age (years old)	20 ~ 30	18.87 ± 9.37	55.07 ± 6.04	24.70 ± 6.80	98.65 ± 16.95
	31 ~ 40	21.46 ± 9.67	54.92 ± 5.58	26.18 ± 6.66	102.57 ± 17.10
	41 ~ 50	22.53 ± 9.49	54.94 ± 5.62	26.48 ± 6.86	103.96 ± 17.38
	50 years old and above	22.32 ± 9.57	53.48 ± 6.92	26.83 ± 6.40	102.64 ± 18.29
F value		13.377	1.413	8.168	8.926
p value		0.000	0.232	0.000	0.000
Education	Specialty degree	12.58 ± 4.63	52.36 ± 6.84	20.10 ± 4.42	85.05 ± 10.43
	Bachelor's degree	24.10 ± 9.05	56.14 ± 4.87	28.08 ± 6.04	108.34 ± 14.31
	Master's degree and above	31.37 ± 6.20	55.73 ± 3.13	33.24 ± 4.05	120.35 ± 9.48
F value		480.795	95.313	466.219	692.667
p value		0.000	0.000	0.000	0.000
Title	Nurse	19.48 ± 10.08	54.87 ± 6.07	24.92 ± 7.22	99.28 ± 18.19
	Nurse practitioner	21.02 ± 9.77	54.82 ± 5.61	25.96 ± 6.81	101.81 ± 17.38
	Supervisor nurse practitioner	20.75 ± 9.10	55.32 ± 5.78	25.78 ± 6.29	101.85 ± 16.02
	Co‐chief nurse practitioner	22.57 ± 8.11	54.36 ± 5.33	26.38 ± 6.30	103.32 ± 15.43
	Chief nurse practitioner	15.60 ± 12.11	44.00 ± 12.10	22.40 ± 8.64	82.00 ± 29.63
F value		2.803	5.303	2.225	3.594
p value		0.025	0.000	0.064	0.006
Years of working	5 years and below	18.76 ± 9.31	54.96 ± 6.19	24.52 ± 6.89	98.25 ± 17.16
	6 ~ 10 years	20.78 ± 9.76	55.04 ± 5.27	25.82 ± 6.73	101.65 ± 16.89
	11 ~ 15 years	21.64 ± 9.69	54.88 ± 5.99	26.31 ± 6.61	102.84 ± 17.36
	16 ~ 20 years	22.20 ± 9.35	55.05 ± 5.93	26.40 ± 6.73	103.66 ± 17.45
	20 years and above	22.38 ± 9.24	54.17 ± 6.17	26.85 ± 6.26	103.41 ± 16.78
F value		8.254	0.506	6.196	6.319
p value		0.000	0.732	0.000	0.000
Marital status	Unmarried	18.21 ± 9.23	55.34 ± 6.08	24.08 ± 6.84	97.64 ± 16.46
	Married	20.87 ± 9.64	54.89 ± 5.78	25.84 ± 6.73	101.61 ± 17.25
F value		−3.639	0.973	−3.300	−2.931
p value		0.000	0.331	0.001	0.003
Specialized nurse	No	26.72 ± 7.64	56.73 ± 4.65	30.05 ± 4.62	113.51 ± 10.53
	Yes	19.91 ± 9.59	54.73 ± 5.89	25.17 ± 6.78	99.83 ± 17.28
F value		11.457	5.509	13.183	10.826
p value		0.000	0.000	0.000	0.000

3.4. Multiple linear regression analysis of knowledge, attitude, and practice of paediatric ICU nurses in preventing PI

The statistically significant factors from the single factor analysis were used as independent variables, while the knowledge, attitude, and practice of paediatric ICU nurses in preventing PI were used as dependent variables for multiple linear regression analysis (Table 3). The multiple linear regression analysis of practice increased the scores of knowledge and attitude dimensions (α _in = 0.05, α _out = 0.10) (Table 4).

TABLE 3.

Independent variable assignment table.

Independent variable	Assignment method
Age (years old)	20 ~ 30 = 1, 31 ~ 40 = 2, 41 ~ 50 = 3,>50 = 4
Education	Specialty degree = 1, Bachelor's degree = 2, Master's degree and above = 3
Title	Nurse = 1, Nurse practitioner = 2, Supervisor nurse practitioner = 3, Co‐chief nurse practitioner = 4, Chief nurse practitioner = 5
Years of working (years)	≤5 = 1,6 ~ 10 = 2, 11 ~ 15 = 3, 16 ~ 20 = 4,≥21 = 5
Marital status	Unmarried = 1, Married = 2
Specialized nurse	No = 1, Yes = 2

TABLE 4.

Findings of a multiple linear regression analysis of the knowledge and attitudes of paediatric ICU nurses regarding the prevention of PI.

Dependent variable	Independent variable	B value	Standard error	Β value	t value	p value
Knowledge dimension a	Constant	4.600	1.454	‐	3.163	0.002
	Education	10.735	0.358	0.562	30.028	<0.001
	Age	1.904	0.304	0.146	6.259	<0.001
	Specialized nurse	−1.915	0.515	−0.073	−3.721	<0.001
	Title	−0.962	0.291	−0.080	−3.304	0.001
Attitude dimension b	Constant	51.156	0.861	‐	59.427	<0.001
	Education	3.184	0.256	0.276	12.442	<0.001
	Specialized nurse	−0.867	0.351	−0.055	−2.471	<0.014
Practice dimension c	Constant	9.896	0.823	‐	12.027	<0.001
	Knowledge dimension	0.525	0.011	0.749	48.000	<0.001
	Education	1.748	0.218	0.130	8.035	<0.001
	Attitude dimension	0.036	0.015	0.031	2.320	0.020

Note: PI stands for pressure injury.

^a R ²  = 0.351, Adjusted R ²  = 0.349, F = 256.534, p<0.001.

^b R ²  = 0.084, Adjusted R ²  = 0.083, F = 87.112, p<0.001.

^c R ²  = 0.696, Adjusted R ²  = 0.696, F = 1451.961, p<0.001.

4. DISCUSSIONS

4.1. Paediatric ICU nurses have a positive attitude to prevent PI, but their level of knowledge and behaviour needs to be enhanced

4.1.1. The knowledge of preventing PI among paediatric ICU nurses needs to be enhanced

The score of ICU nurses in the prevention of PI knowledge dimension directly reflects their ability to prevent, recognize, and manage PI, which is closely related to the incidence of PI and the outcome of patients. In this study, the average scoring rate of PI prevention knowledge among paediatric ICU nurses was 57.28%, which was lower than the level of PI nursing knowledge among nurses in China, indicating that paediatric ICU nurses had a generally low level of knowledge, and the overall level of PI prevention nursing knowledge needed improvement. ¹¹ There was a lack of overall strategies for preventive practice, as well as updates and training of related knowledge. ⁷ , ¹² International studies have demonstrated that the incidence of PI is closely related to the mastery of relevant knowledge by nurses. Another study found that nurses who had received stress injury training had a positive attitude towards preventing stress injury, which could affect their nursing behaviour. ¹³ , ¹⁴ In this study, it was discovered that the knowledge structure of paediatric ICU nurses in preventing PI was relatively outdated. The three key aspects of PI prevention knowledge are the high‐risk population for PI, appropriate methods for preventing heel pressure, and the use of pressure redistribution devices. It is evident that ICU nurses have inadequate reserves of prevention knowledge, and this lack of knowledge affects the effective implementation of preventive measures. ICU nurses must identify high‐risk populations and risk factors early in order to provide targeted preventive measures. Therefore, accumulating prevention knowledge, integrating theory with clinical practice, summarizing experience, and promoting it is crucial for preventing PI.

Based on the scores of each entry, it was evident that paediatric ICU nurses lacked knowledge of the identification, prevention measures, and risk factors of PI high‐risk groups, and there were few opportunities for relevant theoretical knowledge training, workshops, and nursing practice training. Therefore, in clinical work, various learning platforms such as theoretical training, lectures, and workshops should be developed to enhance the learning of theoretical knowledge of PI prevention among nurses. Through comprehensive and systematic learning, the cognition of PI should be enhanced among ICU nurses.

4.1.2. Paediatric ICU nurses have a positive attitude towards the prevention of PI

The scoring rate for the attitude to prevent PI was 78.47%, which was lower than the average scoring rate of clinical nurses' attitude to PI nursing in Guangdong Province (86.9%) and the national level (86.25%) among paediatric ICU nurses, indicating that although they had poor knowledge of preventing PI, they had a positive attitude towards preventing PI, which is consistent with the conclusion of knowledge–attitude–practice research related to nursing behaviour. ¹¹ , ¹⁵ The results of this study indicated that paediatric ICU nurses fully comprehended the significance of PI prevention and had a more optimistic outlook and a strong desire to prevent PI. From the three entries with the lowest scores, ICU nurses show a lack of awareness and poor recognition in preventing pressure injuries in children with localized or systemic edema or those who have already suffered pressure injuries. Although their attitude is positive, there is a lack of subjective awareness in implementing measures. Children in the ICU are critically ill, and nurses prioritize monitoring vital indicators such as circulation, respiration, cardiopulmonary function, medication treatment, and the patency of lines and tubes. Secondary attention is given to observing and assessing the skin under pressure areas and medical devices. Nurses do not place emphasis on the increased medical costs, pain to the child, risk of infection, and extended hospital stays that can result from pressure injuries; their primary focus remains on treatment rather than comprehensive care.

It is evident that ICU nurses had a limited understanding of the importance of effective assessment, pain management, and activities to prevent pressure ulcers. In accordance with the findings of Teo et al., nurses were the direct personnel responsible for preventing PI in patients. ¹⁶ Through case analysis, adverse event summary meetings, and workshops, it is suggested that nursing managers should strengthen the training and awareness of nurses, as well as increase enthusiasm and sense of responsibility in the prevention of PI among nurses. In addition, the incidence of PI can be used as a sensitive indicator of care quality and linked to performance evaluation, promotion, and so on to increase the awareness of prevention and execution among nurses.

4.1.3. The practice of paediatric ICU nurses to prevent PI needs to be enhanced

The model of knowledge–attitude–practice is a process of acquiring knowledge, the formation of beliefs, and the formation of practices and habits. The change of preventive behaviour towards PI is predicated on the retention of pertinent theoretical knowledge among nurses. By acquiring knowledge, clinical nurses can provide patients with effective preventive care. ¹⁷ The results of this study revealed that the scoring rate for the PI prevention behaviour dimension among paediatric ICU nurses was only 71.31%, indicating a low rate of implementation of PI prevention among paediatric ICU nurses. This is related to the lack of guidelines and consensus on PI prevention in paediatrics and the lack of evidence‐based prevention strategies, in addition, the lack of awareness of prevention among nurses. In clinical practice, it is recommended to actively engage in evidence‐based practice and multicentre research.

The analysis of the three lowest‐scoring entries in the survey reveals notable deficiencies among ICU nurses. The low scores in items such as the frequency of repositioning and assessment of pressure injuries in children indicate that the implementation of preventive measures by ICU nurses lacks strict adherence, influenced by various factors such as restricted positioning of the child, mechanical ventilation, resuscitation, and heavy workload. ICU nurses are occupied with routine treatments and temporary nursing procedures, failing to establish a work pattern that integrates PI prevention measures such as micro‐repositioning, skin checks, preventive skin protection, and pressure relief with routine treatment and nursing procedures. The focus is primarily on nursing procedures and treatment, with little attention given to protecting the skin at pressure points and resetting the position after treatment. Treating critically ill children is equally important as preventing pressure injuries and can be executed simultaneously.

Firstly, it is evident that there is a deficiency in their capacity to assess and document PI parameters during practical healthcare delivery. Secondly, there is room for improvement in assessing the frequency and effectiveness of patient repositioning practices. Lastly, there is a discernible gap in both knowledge and clinical proficiency regarding the safeguarding and nursing care of the skin in high‐risk paediatric patients.

It is strongly recommended that nursing managers take proactive steps to institute comprehensive and efficient chain management protocols encompassing PI prevention strategies, wound treatment, standardized documentation practices, risk assessment reporting, and rigorous quality control measures. To address these issues effectively, nursing managers should bolster the execution of these protocols and enhance their oversight. Additionally, process management improvements within paediatric ICU nursing units are essential to proactively prevent PI occurrences and, in turn, enhance the overall outcome indicators for paediatric patients. This multifaceted approach can contribute significantly to elevating the quality of care provided in paediatric ICU settings.

4.2. Analysis of influencing factors of knowledge, attitude, and practice of paediatric ICU nurses in preventing PI

4.2.1. Nurses with higher levels of education, advanced professional titles, longer seniority, and specialization in specific areas demonstrate a more comprehensive and proficient understanding of PI prevention

Multiple linear regression analysis revealed that the educational background, professional title, age, and whether nurses were ICU specialists influenced the knowledge dimension of PI prevention. The knowledge level of ICU nurses in tertiary children's hospitals in China to prevent PI was low, especially with respect to updating professional knowledge on PI, and learning channels and resources are relatively insufficient. ICU nursing managers should place a heightened focus on training initiatives that encompass the utilization of new machines and technologies, in addition to emphasizing the importance of daily care and treatment procedures. The evaluation and observation of paediatric patients' skin integrity require particular attention, as it has come to light that there is a deficiency in relevant prevention knowledge, understanding of skin characteristics, and awareness of critical nursing considerations for paediatric patients in ICU settings.

Moreover, it is essential to recognize that ICU paediatric patients often contend with incontinence or dampness‐related factors, which can contribute to the development of incontinence dermatitis or diaper dermatitis in the sacrococcygeal and perineal regions. This occurrence is predominantly attributed to their critical medical condition and limited mobility. Addressing these challenges necessitates tailored training programs and protocols that specifically cater to the unique care needs of critically ill paediatric patients in ICU settings. It is worth noting that there exists a notable deficit in the understanding of PI and incontinence dermatitis (IAD) among the nursing staff, which has led to the potential for confusion between these two conditions. This lack of clarity has implications for the effective implementation of targeted preventative measures, ultimately impeding the recovery process for paediatric patients. ¹⁸

Nursing managers in ICUs should intensify their efforts in providing regular training and conducting assessments to enhance the knowledge and skills of ICU nurses. It is crucial to promote a culture of active learning among nurses, motivating them to pursue ongoing education and professional development. Encouraging ICU nurses to bolster their academic credentials and achieve advanced professional titles through continuous learning initiatives is highly recommended.

To incentivize participation in specialized nursing certification programs, it is proposed that healthcare management authorities at all levels consider the proportion of specialist nurses as a key assessment criterion for nursing wards. This approach can serve as a catalyst for clinical nurses to actively engage in the pursuit of specialist nursing qualifications, thereby enriching the knowledge base of ICU nurses through systematic study and practical experience. Ultimately, these efforts contribute to enhancing the quality of care provided in ICU settings.

4.2.2. Highly educated and specialist nurses maintain a positive attitude towards the prevention of PI

The findings derived from this study shed light on the significant influence of education level and nursing specialization on the attitude dimension pertaining to PI prevention. These results align with the outcomes of previous research in the field, demonstrating a clear pattern where highly educated, extensively qualified, and specialized nurses exhibit a more positive and proactive attitude towards PI prevention. ¹⁹ Nurses with extensive clinical experience possess a valuable skill set that enables them to promptly identify the risk of PI and implement tailored preventive measures. Among highly educated and specialized nurses, there is a notably proactive attitude towards PI prevention compared to their less educated and more general counterparts. These nurses exhibit a heightened capacity for observation, learning, and the consolidation of clinical practice experience. They are accustomed to applying evidence‐based theories in their clinical practice, consistently seeking evidence‐based solutions.

The empirical evidence from relevant studies further supports the importance of nursing specialization in PI prevention. Notably, the research indicates that for every 1% increase in the proportion of ICU specialist nurses, the incidence of PI decreased by 1.539. ²⁰ In our study, only 10.2% of the 1906 ICU nurses were specialists.

Nursing administrators are encouraged to take proactive steps to enhance the allocation and composition of ICU specialist nurses. This entails giving due importance to the training and deployment of specialist nurses within ICU units. It is essential to establish clear admission standards, assessment mechanisms, and well‐defined job responsibilities for specialist nurses, ensuring their roles and contributions are well‐defined and aligned with the specialized needs of critical care. Furthermore, nursing administrators should adopt a dual approach by not only increasing the “quantity” of specialist nurses but also prioritizing the enhancement of their “quality.” ²¹

In addition to specialist nurses in the ICU, healthcare institutions should consider integrating specialist nurses from various fields, including wound care, stoma care, incontinence management, static therapy, nutrition, oncology, and other relevant domains. This strategy aims to augment the overall proportion of specialist and highly skilled nurses within the ICU, thereby standardizing and elevating the quality of care provided. To achieve this goal, it is imperative to establish a framework for the systematic and consistent management of specialist nurses. This framework should encompass authorization processes, performance evaluation criteria, and promotion priority incentives tailored to specialist nurses.

4.2.3. Strong knowledge, positive attitudes, and higher education enhance PI prevention practices among nurses

Consistent with the findings of other studies, we discovered a positive relationship between knowledge, attitude, and practice of PI prevention. ²² Enhancing the knowledge and fostering positive attitudes among nurses towards PI prevention can significantly elevate their clinical proficiency. In the light of this, it is recommended that policymakers and nursing administrators focus on designing training materials and practical exercises centred around the key factors influencing nursing practice. This approach aims to bridge the gap between theoretical understanding and practical application, facilitating the seamless integration of knowledge and hands‐on expertise in the realm of PI prevention. Beyond knowledge and attitude, the educational background of nurses also exerts a significant influence on their behaviour related to PI prevention. Notably, nurses with higher levels of education demonstrate more effective PI prevention practices. This phenomenon may be attributed to several factors, including the enhanced learning capacity typically associated with individuals holding bachelor's degrees or higher qualifications. Additionally, their practice tends to be less influenced by work experience, allowing them to apply a combination of theoretical and practical knowledge.

The study findings underscore this relationship, revealing that out of the 1906 nurses working in the ICU, a substantial percentage—68.7%—held a bachelor's degree or higher, while 31.7% possessed specialized degrees. The data clearly indicate a relatively high proportion of ICU nurses with advanced degrees. However, it's noteworthy that approximately one‐third of the nurses possess specialized degrees or have attained initial degrees from technical secondary schools, subsequently pursuing on‐the‐job specialization. Among this subset of nurses, there may be lower subjective awareness and limited learning capacity. Some may also exhibit reluctance to actively seek out learning opportunities or invest their spare time in academic study and professional training. This hesitancy could be attributed to the substantial life burdens that these nurses bear, which may hinder their pursuit of educational and professional development.

In the light of these observations, nursing managers face a multifaceted challenge. They should not solely advocate for nurses to enhance their academic qualifications and professional expertise but must also engage in a thorough examination and analysis of the factors influencing individual nurses. Subsequently, managers should implement tailored measures to address these factors and motivate nurses to take the initiative in their own self‐improvement.

Effective strategies include providing appropriate theoretical and skill‐based training, fostering a culture of positive practice beliefs, and encouraging conscientious and proactive nursing practices among the staff. Additionally, nursing administrators play a crucial role in monitoring various process indicators related to preventive practices. These indicators may include assessing the frequency of body‐turning implementation, the objectivity of skin risk assessments, and the consistent execution of preventive measures. This proactive approach helps ensure that preventive practices align with best practices and contribute to improved patient care outcomes.

4.3. Limitations

The convenient sampling method was used in this study, and the sample representation may be inadequate. In this study, a self‐assessment method with reporting bias was used for evaluation. Future research should employ more objective methods, such as theoretical knowledge assessment and behaviour observation, to assess the knowledge of nurses and practice of preventing PI in patients who are critically ill.

5. CONCLUSION

Among ICU nurses working in 18 tertiary children's hospitals in China, positive attitudes towards PI prevention were evident. However, there remains room for improvement in both knowledge and practical application of PI prevention strategies. The key factors influencing ICU nurses' knowledge of PI prevention included their educational background, professional title, age, and specialization status. Similarly, educational background and specialization status were primary determinants of the attitude dimension, while knowledge, attitude, and educational background collectively influenced the behaviour dimension.

To enhance healthcare outcomes for paediatric patients, policymakers should consider implementing and closely monitoring process indicators related to PI prevention. This includes assessing the implementation rate and evaluating the effectiveness of PI prevention practices.

Recognizing the diverse characteristics and backgrounds of nurses, nursing administrators should tailor their approach to knowledge training and practical training on pressure injury prevention. This includes addressing the unique learning needs of nurses and fostering a positive coping attitude towards this critical aspect of healthcare. By enhancing knowledge and promoting positive attitudes, nursing administrators can effectively drive changes in nursing practices, ultimately leading to improved nursing care quality for paediatric patients admitted to the ICU and reducing the occurrence of PI.

FUNDING INFORMATION

Nursing fund of Beijing children's hospital, Capital medical university(YHL202010); Nursing research project of Chinese Medical Association Magazine(CMAPH‐NRD2021037).

CONFLICT OF INTEREST STATEMENT

The authors declare that they have no competing interests.

ETHICS STATEMENT

This study was conducted in accordance with the declaration of Helsinki. This study was conducted with approval from the Ethics Committee of Beijing Children's Hospital, Capital Medical University, National Centre for Children's Health. A written informed consent was obtained from all participants.

Song N, Liu W, Zhu R, Wang C, Wang C, Chi W. A survey of knowledge, attitudes, and practices among paediatric intensive care unit nurses for preventing pressure injuries: An analysis of influencing factors. Int Wound J. 2024;21(2):e14710. doi: 10.1111/iwj.14710

DATA AVAILABILITY STATEMENT

Pediatric ICU nurses have a positive attitude towards the prevention of PI, but their knowledge and practice need to be improved. According to different characteristics of nurses, nursing managers should carry out training on the knowledge of prevention of PI to establish a positive attitude,so as to drive the change of nursing practice and improve the nursing practice level of ICU nurses to prevent of PI.