ABSTRACT
Nurses' knowledge levels, clinical skills, self‐efficacy, and practices play a decisive role in the prevention and management of pressure ulcers. The study aimed to evaluate intensive care nurses in a Turkish university hospital, evidence‐based practices and self‐efficacy levels in the prevention and treatment of pressure ulcers and to determine factors influencing self‐efficacy. This descriptive and cross‐sectional study was conducted with 134 nurses working in intensive care units of a university hospital. Data were collected using the Pressure Ulcer Management Self‐Efficacy Scale and an Evidence‐Based Clinical Practice Assessment Form. The mean pressure ulcer self‐efficacy score was 57.07 ± 19.28, with the highest in assessment and the lowest in planning. The self‐efficacy level was significantly positively correlated with age and the number of patients receiving pressure ulcer care per week. The self‐efficacy levels of nurses who had not received training on pressure ulcers and who perceived their knowledge and skills as insufficient were significantly lower. The Braden Scale was widely used, whereas the use of wound assessment scales and modern dressing methods was limited. Nurses' self‐efficacy regarding the management of pressure ulcers was above the average level and was affected by age, experience, and education level. Risk assessment was widely practiced, whereas individualised care and advanced treatment methods were insufficient. Regular evidence‐based training and hands‐on workshops for intensive care nurses may enhance self‐efficacy and improve care quality.
Keywords: critical care nursing, evidence‐based practice, pressure ulcer, self efficacy
Key Points
Intensive care nurses demonstrated above‐average self‐efficacy in pressure ulcer management.
Older age, greater pressure ulcer care experience, and education were associated with higher self‐efficacy.
The Braden Scale was widely used, whereas wound assessment scales were used less frequently.
Modern dressings and advanced wound care methods were underutilized despite evidence‐based recommendations.
Regular education and greater adherence to evidence‐based practices may improve nurses’ self‐efficacy and the quality of pressure ulcer care.
1. Introduction
Pressure ulcers (PUs) are a significant health problem frequently encountered among intensive care patients and can have serious consequences [1]. It is defined as localised injuries of the skin and/or underlying tissue on a bony prominence due to pressure and/or shear forces [2]. Worldwide, the prevalence of PUs in adult inpatients is 12.8%, and the incidence of hospital‐acquired PUs is 8.4% [3, 4]. In Turkey, the prevalence of PUs has been reported as 14.4% across all hospital settings, with a hospital‐acquired prevalence of 8.9% [5]. PUs can cause serious clinical consequences such as infection, pain, disability, and prolonged hospitalisation, which are associated with increased morbidity, mortality, and costs [6, 7, 8].
Prevention and treatment of PUs is critical for patient safety and is considered one of the main responsibilities of nurses [1]. Although PU management requires a multidisciplinary approach, it is widely recognised as an important indicator of nursing care quality [9, 10]. Nurses play an active role not only in the prevention of PUs but also in the effective treatment of existing injuries [11]. Evidence‐based nursing practices include preventive interventions such as risk assessment, monitoring of skin integrity, position change, use of support surfaces, nutritional support, appropriate dressing for the wound stage, maintaining moisture balance, infection control, and advanced wound care techniques when necessary [2].
In this context, nurses' self‐efficacy levels play a decisive role in their effective use of evidence‐based practices related to both prevention and treatment. Nurses' self‐efficacy has been associated with clinical practices that may influence pressure ulcer‐related outcomes [12]. Within the context of Bandura's social cognitive theory, self‐efficacy refers to one's belief that he/she can successfully perform a certain task, directly affecting behaviour and performance [13]. Individuals with high self‐efficacy tend to set more challenging goals, engage in complex tasks, and exert greater effort to achieve desired outcomes [13]. In nursing, self‐efficacy is recognised as a fundamental factor that shapes decision‐making processes, clinical practice, and adherence to care guidelines [14]. Because self‐efficacy reflects nurses' belief in their ability to successfully implement clinical practices and achieve desired outcomes, low self‐confidence may result in lower adherence to evidence‐based practice guidelines [14, 15]. Nurses' confidence levels in PU related patient assessment, prevention, treatment, and information processes reflect their self‐efficacy in this field [12, 15].
Studies have shown that self‐efficacy is effective on both knowledge and behaviour and that the implementation of nursing plans is positively influenced by this belief [12]. In a study, it was reported that nurses' knowledge of PU was inadequate and their self‐efficacy was low [15], while in another study, it was found that the self‐efficacy of intensive care nurses was slightly above average [16].
Self‐efficacy may also influence nurses' adherence to evidence‐based clinical practice guidelines. A previous study reported that both knowledge/attitudes and self‐efficacy significantly enhanced nurses' adherence to infection control standard precautions and clinical protocols [17]. Given that pressure ulcer prevention and treatment require the implementation of multiple evidence‐based interventions and clinical decision‐making processes, understanding nurses' self‐efficacy in this area may provide valuable insights into factors associated with evidence‐based practice. Therefore, examining self‐efficacy together with evidence‐based pressure ulcer prevention and treatment practices may provide a better understanding of factors affecting the quality and consistency of care delivered by intensive care nurses.
Although there are many studies in the literature in which the knowledge, attitudes, and practices of intensive care nurses regarding the prevention of PUs have been evaluated, studies on treatment‐related practices and self‐efficacy levels are limited. Nurses should not only implement preventive interventions, but also should apply effective, evidence‐based methods for the treatment of existing wounds. Tallier et al. (2017) emphasised that most nurses perform risk assessment and apply preventive strategies; however, only a few plan and treat existing PUs [4]. This demonstrates that nurses' knowledge and practice levels regarding modern care methods, which have been proven to be effective in the treatment of PUs, have low cost, and reduce the risk of complications, should be improved.
This study aimed to assess the evidence‐based practices and self‐efficacy levels of intensive care nurses in a Turkish university hospital regarding the prevention and treatment of PUs. The findings of the study are expected to contribute to the improvement of nurses' professional competencies, the establishment of effective training programs on the management of PUs, and the development of practices to increase patient safety.
Research Questions:
The study sought to answer the following research questions:
What are the self‐efficacy levels of intensive care nurses in a Turkish university hospital regarding pressure ulcer prevention and management?
To what extent do intensive care nurses in a Turkish university hospital adhere to evidence‐based clinical practice guidelines for the prevention and treatment of pressure ulcers?
Which evidence‐based pressure ulcer prevention and treatment practices are most and least frequently implemented by intensive care nurses in a Turkish university hospital?
Which sociodemographic, professional, and educational factors are associated with nurses' self‐efficacy regarding pressure ulcer management?
2. Materials and Methods
2.1. Design
This study was designed as a descriptive and cross‐sectional study.
2.2. Setting and Sample
This study was carried out in the adult intensive care units (ICUs) of a university hospital in western Türkiye between May and August 2024. The ICUs included the Anaesthesiology and Reanimation ICU, Internal Medicine ICU, Surgical ICU, Neurology ICU, and Coronary ICU.
The study population comprised all nurses (N = 163) working in these ICUs during the study period. Given that the population was fully accessible and relatively small, a census sampling approach was used, and all eligible nurses were invited to participate. Eligibility criteria included being a registered ICU nurse during the data collection period, voluntary participation, and completion of the questionnaire.
An a priori power analysis was conducted using G*Power 3.1 to determine the minimum required sample size for multiple linear regression analysis. The analysis was based on a medium effect size (f 2 = 0.15), a significance level of 0.05, a statistical power of 0.80, and 11 independent variables. The results indicated that a minimum sample size of 123 participants was required. A total of 134 nurses participated in the study and completed the questionnaire.
2.3. Data Collection Tools
The Nurse Description Form, developed by the researchers, comprises 11 items addressing sociodemographic and professional variables, including work experience, training, clinical practices, frequency of encounters, self‐perceived competence, and professional engagement related to PUs.
The Pressure Ulcer Management Self‐Efficacy Scale (PUM‐SES) was developed by Dellafiore et al. (2019) to measure nurses' general self‐efficacy level in pressure ulcer management and adapted into Turkish by Utli and Dinç (2022) [12, 18]. The scale consists of 10 items that are scored between 1 (not at all competent) and 5 (completely competent). The total score obtainable from the scale is between 0 and 100. The scale has four subscales: assessment, planning, supervision, and decision‐making. The scale does not include reverse items. The Cronbach Alpha of the scale was reported as 0.838. In this study, the Cronbach Alpha value was calculated as 0.943.
The Evidence‐Based Clinical Practice Assessment Form for Pressure Ulcer Management was prepared based on the International Clinical Practice Guidelines published in 2019 [2]. The form consists of 43 questions aimed at assessing the compliance of nurses' clinical practices regarding the prevention and treatment of pressure ulcers with the relevant guidelines.
The items were designed to assess specific clinical practices and were analysed individually; therefore, no total score was calculated. Accordingly, score interpretation and internal consistency reliability analyses were not applicable. The form consisted of dichotomous items (e.g., Yes/No) and questions assessing the frequency, type, and methods of pressure ulcer prevention and treatment practices. In order to ensure the content validity of the form, opinions of a total of six experts (two in Nursing Fundamentals, one in Surgical Nursing, one in Internal Medicine Nursing, and two experienced intensive care nurses) in the field of nursing were obtained. The experts evaluated each item in the form using a 4‐point Likert‐type scale based on the Davis Technique, and necessary revisions were made accordingly. The Content Validity Index (CVI) was calculated as 0.94, indicating excellent content validity. The finalised form consists of 43 questions (see File S1).
2.4. Data Collection
The study data were collected through face‐to‐face interviews with intensive care nurses in a Turkish university hospital after obtaining the necessary institutional approvals. Intensive care nurses in a Turkish university hospital were informed about the purpose of the study, procedures, and participant rights. Then, their verbal and written consent was taken. Completion of the data form took an average of 15–20 min.
2.5. Ethical Consideration
The ethics committee approval of the Non‐Interventional Clinical Research Ethics Committee of Pamukkale University (date 2 April 2024, number E‐60116787‐020‐512 962) and Pamukkale University Faculty of Health Sciences institution permissions (date 18 April 2024, number 516275) were obtained from where the study was conducted. The study conformed to the principles of the Declaration of Helsinki. The nurses included in the study were selected on a voluntary basis, and their written consent was obtained after they were informed about the purpose and scope of the research and participant rights. The necessary permissions to use the scales were received from the authors who performed the Turkish adaptation of the scales.
2.6. Data Analysis
Statistical analyses were conducted using IBM Statistical Package for the Social Sciences (SPSS) for Windows, Version 27.0 (IBM Corp., Armonk, NY, USA). For descriptive statistics, mean ± standard deviation was used for numerical variables and number (n) and percentage (%) values were calculated for categorical variables. Normality of the data was first tested with the Kolmogorov–Smirnov test. Multiple linear regression analysis was employed to determine the factors affecting nurses' PUM‐SES levels. Prior to the multiple linear regression analysis, the data set was evaluated for multicollinearity. The correlation coefficients, tolerance values, and variance inflation factor (VIF) values were examined to assess whether there was a multicollinearity problem among the independent variables included in the multiple linear regression analysis. It was determined that all tolerance values were above 0.10 and all VIF values were below 10. These findings indicate that there is no serious multicollinearity problem among the independent variables and that the dataset is suitable for multiple linear regression analysis. Correlation coefficient, variance inflation factor (VIF), and tolerance values of independent variables were analysed. Furthermore, data on pressure ulcer risk assessment and treatment practices were presented as frequency (n) and percentage (%). In all analyses, p < 0.05 was considered statistically significant.
3. Results
The mean age of the nurses participating in the study was 31.12 ± 6.59 and 85.1% of them were female. The nurses' education, work experience, clinical practices, professional responsibilities, and self‐perceived competence regarding PUs are summarised in Table 1.
TABLE 1.
Sociodemographic and professional characteristics of intensive care nurses and their involvement in pressure ulcer care (n = 134).
| Sociodemographic characteristics | Mean ± SD |
|---|---|
| Age | 31.12 ± 6.59 |
| Work experience (months) | 101.69 ± 81.63 |
| Work experience in ICU (months) | 71.32 ± 55.77 |
| Weekly PU care (number of patients) | 2.70 ± 1.29 |
| Variable | Number (%) | |
|---|---|---|
| Gender | ||
| Female | 114 (85.1) | |
| Male | 20 (14.9) | |
| Participation in pressure ulcer ‐related education | ||
| Yes | 36 (26.9) | |
| No | 98 (73.1) | |
| Assessment of interventions for PU prevention | ||
| Sufficient | 87 (64.9) | |
| Insufficient | 47 (35.1) | |
| PU treatment under nurse's responsibility | ||
| Agree | 108 (80.6) | |
| Disagree | 26 (19.4) | |
| Often see PUs | ||
| Yes | 111 (82.8) | |
| No | 23 (17.2) | |
| Self‐perceived adequacy in PU treatment | ||
| Sufficient | 77 (55.5) | |
| Insufficient | 57 (42.5) | |
| Participation in conferences or reading articles on PUs | ||
| Yes | 53 (39.6) | |
| No | 81 (60.4) | |
The mean total score of the PUM‐SES scale was 57.07 ± 19.28, indicating that their self‐efficacy was above the moderate level. The mean scores on the subscales were 59.14 ± 22.22 for assessment, 55.41 ± 22.91 for planning, 56.62 ± 21.60 for supervision, and 57.08 ± 20.21 for decision‐making.
Multiple linear regression analysis was performed to determine the factors affecting nurses' self‐efficacy levels regarding PU management. The model was found significant (F = 23.597, p < 0.001), and the predictive level of the model was high (R = 0.825, R 2 = 0.680). This finding indicated that the independent variables explained 68% of the nurses' self‐efficacy levels regarding PU management.
According to the analysis results, age (β = 0.293, p = 0.012) and the number of PU care per week (β = 0.804, p = 0.021) had a significant positive effect on nurses' self‐efficacy scores. Self‐efficacy scores of nurses who did not participate in pressure ulcer‐related education were significantly lower than the scores of those who received education (β = −2.720, p = 0.011). Similarly, nurses who considered interventions for pressure ulcer prevention inadequate (β = −4.188, p < 0.001) and those who considered themselves inadequate in PU treatment (β = −7.720, p < 0.001) also had lower self‐efficacy scores. In addition, nurses who did not participate in conferences or read articles on PU had significantly lower self‐efficacy levels (β = −2.774, p = 0.003) (Table 2).
TABLE 2.
Multiple linear regression analysis of factors influencing nurses' self‐efficacy in pressure ulcer management (PUM‐SES).
| Variables | PUM‐SES | ||||
|---|---|---|---|---|---|
| B | SE | ß | p | ||
| Constant | 49.082 | 4.138 | < 0.001 | ||
| Age | 0.293 | 0.115 | 0.251 | 0.012 | |
| Work experience (month) | −0.021 | 0.013 | −0.222 | 0.112 | |
| Work experience in ICU (month) | 0.015 | 0.013 | 0.106 | 0.278 | |
| Weekly PU care (number of patients) | 0.804 | 0.343 | 0.135 | 0.021 | |
| Gender | |||||
| Female | Ref | 0.840 | |||
| Male | 0.233 | 1.153 | 0.011 | ||
| Participation in pressure ulcer ‐related education | |||||
| Yes | Ref | 0.011 | |||
| No | −2.720 | 1.054 | −0.157 | ||
| Assessment of interventions for PU prevention | |||||
| Sufficient | Ref | < 0.001 | |||
| Insufficient | −4.188 | 1.068 | −0.260 | ||
| PU treatment under nurse's responsibility | |||||
| Agree | Ref | 0.289 | |||
| Disagree | 1.100 | 1.033 | 0.57 | ||
| Often see PUs | |||||
| Yes | Ref | ||||
| No | −1.910 | 1.131 | −0.094 | 0.094 | |
| Self‐perceived adequacy in PU treatment | |||||
| Sufficient | Ref | < 0.001 | |||
| Insufficient | −7.720 | 1.038 | −0.497 | ||
| Participation in conferences or reading articles on PUs | |||||
| Yes | Ref | 0.003 | |||
| No | −2.774 | 0.921 | −0.177 | ||
Note: R = 0.825, R 2 = 0.680, F = 23.597, Bold values indicate statistical significance (p < 0.05).
Abbreviations: ß, beta; SE, standard error.
In this study, the participants, 95.5% performed PU risk assessment and used the Braden scale. The frequency of risk assessment was usually once a day (78.4%). Factors such as skin changes, pain, circulatory disorders, oxygen deficiency, moist skin, and older age were taken into account at almost 100%. Barrier products (93.3%) were the most frequently used preventive skin care method. Nutritional screening and individualised nutritional plan were practiced at around 57%. Pressure‐redistributing support surfaces were used by 48.5%, and the most commonly preferred type of support surface was alternating pressure air mattresses (44.8%). PU classification system was used by 76.1%, pain assessment was performed by 59.7%, and debridement was practiced by 70.1%.
Of the nurses, 44.8% stated that they regularly measure the size of the PU, and 40.3% stated that they used a scale to assess PUs. Accordingly, 32.8% of the nurses used the Pressure Ulcer Scale for Healing (PUSH) and 7.5% used the Bates‐Jensen Wound Assessment Tool (BWAT), whereas 59.7% did not use any assessment tool (Table 3).
TABLE 3.
Frequency of nurses' clinical practices for the prevention and treatment of Pressure Ulcer (PU).
| Variable | Options | n (Yes) | % |
|---|---|---|---|
| 1. PU risk assessment status | 128 | 95.5 | |
| 2. Type of risk assessment scale used | |||
| Braden Scale | 128 | 95.5 | |
| No scale is used | 6 | 4.5 | |
| 3. Frequency of risk assessment | |||
| Once a day | 105 | 78.4 | |
| Twice a day | 29 | 21.6 | |
| 4. Assessment of skin changes over pressure points | 134 | 100 | |
| 5. Consideration of pain in risk evaluation | 130 | 97 | |
| 6. Consideration of diabetes mellitus | 84 | 62.7 | |
| 7. Consideration of circulatory disorders | 134 | 100 | |
| 8. Consideration of oxygenation deficiency | 131 | 97.8 | |
| 9. Consideration of nutritional status | 126 | 94 | |
| 10. Consideration of moist skin | 134 | 100 | |
| 11. Consideration of increased body temperature | 122 | 91 | |
| 12. Consideration of older age | 131 | 97.8 | |
| 13. Consideration of impaired sensory perception | 104 | 77.6 | |
| 14. Consideration of laboratory test results | 90 | 67.2 | |
| 15. Consideration of general and mental health status | 96 | 71.6 | |
| 16. Performance of comprehensive skin and tissue assessment | 123 | 91.8 | |
| 17. Frequency of comprehensive skin and tissue assessment | |||
| Once a day | 65 | 48.5 | |
| Twice a day | 50 | 37.3 | |
| Three times a day | 13 | 9.7 | |
| Every two days | 6 | 4.5 | |
| 18. Assessment of skin and soft tissue temperature | 128 | 95.5 | |
| 19. Assessment of tissue consistency (e.g., edema) | 128 | 95.5 | |
| 20. Use of colour scale to evaluate skin colour | 94 | 70.1 | |
| 21. Preventive skin care practices applied a | |||
| Alkaline soap or cleanser | 29 | 21.6 | |
| Barrier products | 125 | 93.3 | |
| Low‐friction textile products | 26 | 19.4 | |
| Soft silicone multi‐layer foam dressing | 12 | 9 | |
| 22. Performance of nutritional screening | 77 | 57.5 | |
| 23. Implementation of individualised nutrition care plan | 76 | 56.7 | |
| 24. Repositioning frequency for at‐risk individuals | |||
| Every hour | 2 | 1.5 | |
| Every 2 h | 115 | 85.8 | |
| Every 3 h | 10 | 7.5 | |
| Every 4 h | 7 | 5.2 | |
| 25. Repositioning frequency for individuals with existing PU | |||
| Every hour | 15 | 11.2 | |
| Every 2 h | 116 | 86.6 | |
| Every 3 h | 3 | 2.2 | |
| 26. Use of equipment to reduce friction and shearing | 100 | 74.6 | |
| 27. Encouragement of sitting out of bed | 46 | 34.3 | |
| 28. Assessment of lower extremity circulation | 134 | 100 | |
| 29. Use of special products/devices for heel injuries | 73 | 54.5 | |
| 30. Use of pressure‐redistributing support surfaces | 65 | 48.5 | |
| 31. Type of support surface used a | |||
| Gel‐filled mattresses | 19 | 14.2 | |
| Alternating pressure air mattress | 60 | 44.8 | |
| 32. Use of PU classification system | 102 | 76.1 | |
| 33. Frequency of skin assessment for individuals with PU | |||
| Once a day | 39 | 29.1 | |
| Twice a day | 83 | 61.9 | |
| Three times a day | 9 | 6.7 | |
| Every other day | 3 | 2.2 | |
| 34. Measurement of PU size | 60 | 44.8 | |
| 35. Use of PU assessment scale | 54 | 40.3 | |
| 36. Type of assessment scale used | |||
| Bates‐Jensen Wound Assessment Tool (BWAT) | 10 | 7.5 | |
| Pressure Ulcer Scale for Healing (PUSH) | 44 | 32.8 | |
| No scale used | 80 | 59.7 | |
| 37. Pain assessment performed | 80 | 59.7 | |
| 40. Application of debridement to necrotic tissue | 94 | 70.1 |
Participants could select more than one option.
When the treatment practices of the nurses according to the pressure ulcer stage were examined, it was observed that the frequency of dressing change was mostly twice a day. The frequency of three times a day was more common in Stage IV (20.1%) and unstageable ulcers (20.1%). The most commonly used antiseptic solution in all stages was saline solution, with use rates ranging between 76.9% and 81.3%. When the types of dressings used according to the pressure ulcer stage were evaluated, it was seen that moist gauze dressings were most commonly preferred in all stages. Hydrocolloid and calcium alginate dressings were used at similar rates in all stages, with 6% for Stages I and III and 7.5% for Stage IV and unstageable ulcers. Growth factor administration was limited, and only platelet‐rich plasma (3.7%) and platelet‐derived growth factor (2.2%) were used in Stage III and IV ulcers. Among biophysical agents, negative pressure wound therapy was used only in Stage III (12.7%) and Stage IV (16.4%) PUs. Nurses did not report the use of any type of dressing for suspected deep tissue ulcers (Table 4).
TABLE 4.
Treatment methods applied according to the stage of pressure ulcer (PU) (n = 134).
| PU treatment methods | Stage of PU | |||||
|---|---|---|---|---|---|---|
| Stage I | Stage II | Stage III | Stage IV | Unstageable | ||
| 38. Most common dressing change frequency | ||||||
| Once a day | 44 (32.8) | 20 (14.9) | 16 (11.9) | 18 (13.4) | 18 (13.4) | |
| Twice a day | 80 (59.7) | 104 (77.6) | 94 (70.1) | 89 (66.4) | 89 (66.4) | |
| Three times a day | 10 (7.5) | 10 (7.5) | 24 (17.9) | 27 (20.1) | 27 (20.1) | |
| 39. Most used antiseptic solution a | ||||||
| Saline solution | 103 (76.9) | 107 (79.9) | 107 (79.9) | 109 (81.3) | 109 (81.3) | |
| Rivanol | 4 (3) | 6 (4.5) | 9 (6.7) | 9 (6.7) | 9 (6.7) | |
| Povidone‐iodine solution | 0 | 8 (6) | 8 (6) | 9 (6.7) | 9 (6.7) | |
| Chlorhexidine gluconate | 7 (5.2) | 11 (8.2) | 14 (10.4) | 15 (11.2) | 15 (11.2) | |
| Glucose solutions | 8 (6) | 14 (10.4) | 15 (11.2) | 16 (11.9) | 16 (11.9) | |
| 41. Dressings used according to the stage of PU a | ||||||
| Moist Gauze Dressings | 91 (67.9) | 107 (79.9) | 107 (79.9) | 94 (70.1) | 94 (70.1) | |
| Hydrocolloid Dressings | 8 (6) | 8 (6) | 8 (6) | 10 (7.5) | 10 (7.5) | |
| Calcium Alginate Dressings | 6 (4.5) | 8 (6) | 8 (6) | 10 (7.5) | 10 (7.5) | |
| Foam Dressings (including Hydropolymers) | 1 (0.7) | 4 (3) | 4 (3) | 4 (3) | 4 (3) | |
| 42. Growth factors used in PU | ||||||
| Platelet‐rich plasma | 0 | 0 | 5 (3.7) | 5 (3.7) | 0 | |
| Platelet‐derived growth factor | 0 | 0 | 3 (2.2) | 3 (2.2) | 0 | |
| 43. Biophysical agents used in PU | ||||||
| Negative pressure wound therapy | 0 | 0 | 17 (12.7) | 22 (16.4) | 0 | |
Participants could select more than one option.
4. Discussion
Nurses' self‐efficacy, which reflects their confidence and belief in their skills to prevent and manage PUs, is an important factor that influences their individual performance in preventive nursing practices [12]. The findings revealed that nurses had an above‐moderate self‐efficacy perception in PU management. This result is consistent with the findings of previous studies in which it has been reported that nurses' self‐efficacy in pressure ulcer management is at a moderate level or above [1, 16, 19]. On the other hand, in a study conducted with nurses working in surgical clinics, it was reported that nurses' self‐efficacy perceptions regarding pressure ulcer care were at lower levels [20]. Similarly, in a study conducted with nurses, most of whom worked in wards in China, it was found that nurses' self‐efficacy levels regarding pressure ulcer care were relatively low [15]. In the study of Yurdagül (2025), it was determined that nurses working in intensive care clinics had a higher level of practice in pressure ulcer management than nurses working in other clinics [19]. This suggests that the experience gained in specialised areas such as intensive care may increase nurses' self‐efficacy perceptions.
According to the study findings, it was determined that nurses received the highest self‐efficacy score in the ‘assessment’ subscale and the lowest score in the ‘planning’ subscale. This finding showed that nurses had a more systematic approach and experience in the assessment of PUs; however, they needed more support in the processes of creating and implementing individualised care plans. In addition, it was determined in the study that pressure ulcer classification systems, which are part of the assessment process, were widely utilised by nurses. This finding is important as it shows that nurses act in accordance with certain standards in their knowledge and practices regarding pressure ulcer assessment.
Especially in the ‘planning’ subscale, nurses' self‐efficacy perceptions regarding early mobilisation practices in pressure ulcer management were evaluated. In Turkey, decisions regarding patient mobilisation are generally made by physicians, which limits the direct involvement of nurses in decision‐making responsibility in this process. This may lead to low self‐efficacy perceptions regarding planning. Indeed, in previous studies, it has been emphasised that the level of nurses' involvement in clinical decision‐making processes in Turkey is limited [21]. In their study, Etafa et al. (2018) reported that one of the biggest barriers to pressure ulcer prevention by most nurses was the lack of cooperation with other health professionals [22].
According to the multiple linear regression analysis, age and the number of pressure sore care per week had a significant positive effect on nurses' self‐efficacy levels. This finding demonstrated that clinical experience and frequency of practice increased nurses' self‐esteem and perception of efficacy. In various studies, a positive relationship has been reported between age and pressure ulcer assessment efficacy [11, 19] and between the number of pressure ulcer care and practices [23]. This finding supports Bandura's self‐efficacy model based on social cognitive theory. The acquisition of skills through experience has a direct positive effect on self‐efficacy perception [24].
The multiple linear regression analysis demonstrated that lack of pressure ulcer‐related education and not participating in conferences or reading scientific articles on pressure ulcers were associated with lower self‐efficacy levels. The positive effect of educational activities on self‐efficacy has been highlighted in many studies [25, 26]. According to the findings of a systematic review, personnel education is important in pressure ulcer prevention [27]. These results reveal once again the importance of the continuity of in‐service education programs and the expansion of evidence‐based practices.
An additional point to consider when interpreting the regression findings is the conceptual proximity between some significant predictors and the dependent variable (PUM‐SES). Specifically, nurses' perceptions of the adequacy of pressure ulcer prevention interventions and their self‐perceived adequacy in pressure ulcer treatment are conceptually related to self‐efficacy. Although these variables represent distinct aspects of clinical practice, their conceptual overlap with self‐efficacy may have contributed to the relatively high explanatory power of the regression model (R 2 = 0.68). Therefore, the findings should be interpreted with this consideration in mind.
The majority of nurses stated that they performed pressure ulcer risk assessment and commonly used the Braden Scale. Although this rate was quite high, it was observed that nurses also considered risk factors such as skin changes and circulatory disorders extensively. This may be associated with the overlap of some pressure ulcer prevention strategies with routine nursing practices that include the assessment of parameters such as circulation, oxygenation deficiency, and nutrition. In studies, it has been demonstrated that nurses consider risk assessment as a priority step when planning and implementing interventions for pressure ulcer prevention [28, 29]. In their study, Khojastehfar et al. (2020) showed that nurses' practices on pressure ulcer prevention were relatively desirable, similar to this study [11]. On the other hand, in a meta‐analysis, it was found that the total score on the Braden Scale was an effective indicator in predicting the development of PUs [29]. This finding suggests that additional motivational factors should be provided to encourage nurses to use the Braden Scale more frequently and systematically [30].
In this study, it was determined that nurses mostly adopted risk assessment practices for pressure ulcer prevention; however, the rate of implementing preventive strategies such as the creation of an individualised nutrition plan and the use of pressure‐redistributing support surfaces was lower. This finding is consistent with previous research, which also reported that risk assessment was the most commonly used and perceived as the most effective preventive measure among nurses [31]. In the study of Adıbelli and Korkmaz (2022), nurses thought that physicians and dietitians had the primary responsibility for the nutritional issues of patients [32]. Furthermore, not considering the patient's nutritional status as a part of the nursing assessment may lead to the neglect of nutrition‐related problems without being recognised [33]. Similarly, previous research has demonstrated a substantial gap between reported pressure injury prevention protocols and actual clinical practice. Although nurse managers reported that malnutrition risk screening was implemented in most units, only a small proportion of patients were actually screened, and screening was not systematically performed for all patients at risk of pressure injuries or with impaired mobility [34]. This suggests that nurses perceive their role as limited in the multidisciplinary care process and do not take an active role in preventive care activities such as nutrition.
Although nurses had standardised practices in positioning, the lack of use of support surfaces was noteworthy. Positioning is recognised as a basic practice in the prevention of PUs, and nurses have standardised and comprehensive care practices in this field. However, it has been reported that frequent position changes may reduce patient comfort and increase the workload of nurses. Therefore, Huang et al. (2023) recommended the effective use of support surfaces to reduce the frequency of changes [35]. In a study examining the clinical use of support surfaces, Jiang et al. reported that only 61.81% of patients at risk of pressure ulcers used support surfaces, with a single type of support surface (electric inflatable mattress) being predominantly preferred. Furthermore, support surface selection was not tailored according to the stage or anatomical location of the pressure ulcer [36]. Yarad et al. (2021) reported that 70% of ICU relied on guidelines in the selection of the support surface and that the nurse leader and available beds usually played a role in the selection [37]. In addition, active support surfaces are used in patients who develop PUs, and mattresses are changed according to risk assessment.
In this study, it was determined that more than half of the nurses did not use a scale for the assessment of PUs. This rate demonstrates that there are still significant deficiencies in ensuring standardisation in clinical assessments. In fact, adopting a systematic approach in the monitoring of PUs is critical to objectively follow the wound healing process [38]. In the study, PUSH was found to be the most frequently used scale. In a review of scales used in wound and skin assessments, the PUSH was reported to be the most frequently used tool for wound healing [39]. PUSH can be incorporated into routine clinical practice more easily than other wound assessment tools because it has fewer elements, requires less time and effort to complete, and does not require intensive user instruction [40].
Findings regarding treatment practices have shown that there are differences between Stages I‐IV in terms of dressing frequency, antiseptic solutions used, and dressing types. In this study, the most frequently preferred dressing type in clinical practice at all stages was moist gauze dressings soaked with saline. However, in the literature, this method has limited effectiveness in terms of wound healing [41, 42] and has lower healing rates compared to moist dressings (hydrocolloid, silver ion, etc.) [43]. In particular, foam and hydrocolloid dressings have been reported to provide shorter healing time and require fewer dressing changes [43]. However, in the study, it was found that these effective dressings were used at very low rates. This demonstrates that clinical practices are not consistent with current evidence‐based approaches and that nurses' knowledge and practice skills regarding effective dressings in wound care need to be improved. The continued widespread use of moist gauze dressings, despite strong evidence supporting the effectiveness of modern dressings, represents a critical quality improvement target [44]. This practice gap may contribute to delayed wound healing and increased patient suffering.
In this study, it was observed that growth factor applications were used to a limited extent and preferred only in advanced stage (Stage III and IV) PUs. Similarly, it was found that negative pressure wound therapy, one of the biophysical agents, was administered only in these stages. However, it has been stated in the literature that advanced methods such as platelet‐rich plasma and negative pressure wound therapy can accelerate the healing process, especially in the treatment of advanced‐stage PUs [45, 46]. It has been reported that the limited use of such treatments is mostly due to high costs, lack of technical equipment, and lack of knowledge and skills of health professionals in this field [29, 47, 48]. These findings address the need to make advanced wound care technologies more accessible and widespread in clinical practices.
4.1. Limitations
This study has some limitations. Primarily, the cross‐sectional design of the study complicates establishing causal relationships between variables. Despite this, factors affecting self‐efficacy were identified using multiple linear regression analysis, providing important insights into clinical practice. Secondly, since the study was conducted only with intensive care nurses in a Turkish university hospital, the findings may not be generalizable to intensive care nurses working in different healthcare settings, organisational structures, or cultural contexts. Therefore, replication of this study in different hospitals and countries is needed to confirm and extend the findings.
5. Conclusion
This study revealed that nurses generally had a self‐efficacy perception above the moderate level and had the highest self‐efficacy scores in the ‘assessment’ subscale. Lower scores in the ‘planning’ subscale indicated that nurses need more support in developing an individualised care plan. The self‐efficacy scores of nurses who participated in education programs and conferences on PUs or followed scientific articles were found to be significantly higher. On the other hand, nurses who evaluated their knowledge and skills as inadequate had low self‐efficacy levels. This suggests that self‐efficacy perception is closely associated with both clinical experience and knowledge level.
When clinical practices were examined, it was observed that nurses mostly adopted the risk assessment process; however, there were inadequacies in the use of wound assessment scales and the preference for modern, evidence‐based dressing products. In particular, the widespread use of traditional methods such as moist gauze revealed that effective wound care approaches recommended in the current literature are not sufficiently implemented.
In this context, continuous professional education programs should be planned to improve competence in pressure ulcer management, evidence‐based practices disseminated, and multidisciplinary collaboration strengthened. Strategies to enhance knowledge and skills in individualised care planning, use of assessment scales, effective dressing products, and advanced treatments are essential. Structural and educational interventions to be made in this regard will strengthen nurses' self‐efficacy perceptions and improve the quality of care in the prevention and management of PUs.
Funding
The authors have nothing to report.
Ethics Statement
Ethics committee approval (dated 04/02/2024, no. E‐60116787‐020‐512 962) and institutional permissions (dated 04/18/2024, no. 516275) were obtained from the relevant University where the study was conducted. The study conformed to the principles of the Declaration of Helsinki.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Data S1: STROBE Statement—checklist of items that should be included in reports of observational studies.
File S1: Clinical practices based on guidelines for the prevention and treatment of pressure ulcers/injuries in patients.
Acknowledgements
We would like to thank Pervin Kaçtı Ertaş, Nurse at the Education Coordination Unit of Denizli State Hospital, for her valuable support and contributions to this study.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author but cannot be used for purposes other than data confirmation. The data are not publicly available because of privacy or ethical restrictions.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data S1: STROBE Statement—checklist of items that should be included in reports of observational studies.
File S1: Clinical practices based on guidelines for the prevention and treatment of pressure ulcers/injuries in patients.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author but cannot be used for purposes other than data confirmation. The data are not publicly available because of privacy or ethical restrictions.