Abstract
Aim
This study aimed to assess the knowledge and attitudes of nurses working in an intensive care unit regarding the prevention of pressure injuries.
Materials and methods
The study utilized a descriptive cross-sectional design and was conducted among nurses working in the intensive care unit of a university hospital. Participants’ knowledge and attitudes regarding pressure injury prevention were measured using validated scales. The findings were compared with individual characteristics and statistically analyzed.
Results
Inferential analyses demonstrated that higher knowledge scores were significantly associated with advanced age (F = 26.5, p < 0.001), postgraduate education (F = 5.37, p = 0.02), and prolonged professional experience (F = 6.97, p < 0.001). Similarly, professional attitude scores were significantly higher in more experienced cohorts (F = 22.41, p < 0.001), whereas formal educational attainment exerted no statistically significant influence (F = 1.29, p = 0.28). Although the overall variance across age groups was statistically significant (F = 3.29, p = 0.04), post-hoc pairwise comparisons demonstrated that no individual age-group comparison reached statistical significance. Furthermore, a weak but statistically significant positive linear correlation was identified between total knowledge and professional attitude metrics (r = 0.237, p = 0.032).
Conclusion
ICU nurses’ knowledge levels regarding pressure injury prevention were found to be insufficient, particularly in relation to specific prevention-related knowledge areas. Although nurses demonstrated generally positive attitudes toward pressure injury prevention, the findings should be interpreted within the scope of the measured knowledge and attitude variables. The study did not directly assess bedside clinical performance, adherence to preventive measures, or patient-level pressure injury outcomes.
Keywords: Pressure injury, Attitude, Knowledge, Prevention, Intensive care, Nursing
Introduction
Pressure injury is defined as localized damage to the skin and/or underlying soft tissue, usually occurring over a bony prominence or related to the use of a medical or other device, and is caused by pressure or pressure in combination with shear [1]. Pressure injuries remain an important patient safety problem because they are associated with increased morbidity, prolonged hospitalization, higher healthcare costs, and reduced quality of life [2–4].
Patients in intensive care units are particularly vulnerable to pressure injuries due to the presence of multiple intrinsic and extrinsic risk factors. Hemodynamic instability, impaired tissue perfusion, mechanical ventilation, sedation, vasopressor use, immobility, altered consciousness, malnutrition, edema, moisture caused by sweating or incontinence, and the prolonged use of medical devices may reduce tissue tolerance and compromise skin integrity [1, 5]. The international EPUAP/NPIAP/PPPIA guideline emphasizes that pressure injury risk assessment should include not only mobility and activity limitations but also perfusion, oxygenation, skin condition, moisture, nutrition, shear, and medical device use [1, 5]. These risk domains are highly relevant for critically ill patients, who often experience several of these conditions simultaneously.
The complexity of intensive care may also make pressure injury prevention more difficult. Sedated or mechanically ventilated patients may be unable to report discomfort or pain, while repositioning may be restricted by hemodynamic instability, invasive lines, drains, monitoring equipment, or prone positioning [5, 6]. In addition, medical devices such as endotracheal tubes, oxygen masks, non-invasive ventilation interfaces, urinary catheters, cervical collars, and monitoring probes can exert localized pressure and contribute to medical device-related pressure injuries [6–9]. Therefore, pressure injury prevention in intensive care requires systematic risk assessment, regular skin and tissue evaluation, moisture management, individualized repositioning when clinically feasible, appropriate support surfaces, and careful monitoring of device-related pressure points [1, 5].
The incidence and prevalence of pressure injuries in intensive care settings vary widely across studies. This variation may be related to differences in patient characteristics, case mix, study design, follow-up duration, assessment methods, and institutional prevention protocols [10–12]. Despite these differences, existing evidence consistently indicates that critically ill patients constitute a high-risk population for pressure injury development [10–12]. For this reason, identifying modifiable factors related to prevention remains an important issue for intensive care nursing.
Nurses have a central role in pressure injury prevention because they are responsible for continuous patient observation, skin assessment, risk identification, documentation, and coordination of preventive care [13–17]. However, the ability to recognize pressure injury risk and understand evidence-based prevention principles may be influenced by nurses’ knowledge, attitudes, educational background, clinical experience, and previous training [13, 14, 16]. Previous studies have reported that nurses may have insufficient knowledge regarding pressure injury classification, risk assessment, nutrition, prevention strategies, and care of specific patient groups, even when their attitudes toward prevention are generally positive [16–20]. This suggests that knowledge and attitude should be evaluated together, particularly in high-risk settings such as intensive care units.
Studies conducted in different countries have examined nurses’ knowledge and attitudes toward pressure injury prevention; however, findings vary across clinical settings and healthcare contexts [16, 18, 19]. Similar evidence has also been reported among intensive care nurses in Turkey [17]. Therefore, further research focusing on intensive care nurses is needed to better understand knowledge gaps, attitude patterns, and educational needs in high-risk clinical settings.
Based on this background, this study aimed to determine the knowledge levels and attitudes of intensive care nurses regarding pressure injury prevention and to examine the relationship between these variables and selected demographic and professional characteristics.
Materials and methods
Research type
A descriptive, cross-sectional study.
Research universe and sample
The research was conducted between September and November 2024 at the Kocaeli University Research and Practice Hospital. The study setting was a 22-bed General (Mixed) Intensive Care Unit, which accommodates adult patients across both medical and surgical critical care specialties. The aim was to reach the entire population (n = 88) without selecting a sample. Eighty-two nurses who met the inclusion criteria and volunteered to participate were included in the study. The nurse staffing structure in the unit was based on a primary nursing care model, utilizing a 12-hour rotating day and night shift system, with an average nurse-to-patient ratio ranging from 1:2 to 1:3 depending on patient acuity. Regarding institutional quality protocols, evidence-based pressure injury prevention and risk assessment guidelines (utilizing the Braden scale) were already formally implemented in the unit before the study, requiring routine documentation for every patient upon admission and during shifts. While specific in-service training on pressure injury prevention was periodically offered by the hospital’s clinical education department, attendance at these sessions was optional rather than mandatory. By reaching 82 out of the total 88 nurses, the study achieved a high response rate of 93.1%. Because a complete enumeration (census) approach was used and almost the entire target population was included, typical sampling procedures and subsequent power analyses were not performed. Out of the target population, two nurses were excluded due to being on active maternity leave, and four nurses declined to participate, resulting in a final analytical sample of 82 intensive care nurses.
Inclusion criteria
Having worked in an intensive care unit for at least one full year (12 months),
Being a graduate of a nursing program,
Voluntarily participating in the study.
To ensure methodological clarity and prevent statistical overlap in categorical analyses, professional experience was structured into mutually exclusive strata (1–5 years, 6–10 years, and 11 years and over).
Exclusion criteria
Not actively working due to maternity leave, long-term sick leave, etc., at the time of the study.
Data collection
For data collection, surveys were administered face-to-face by the researcher. Researchers visited the intensive care unit work environments two to four times weekly, and surveys were administered to nurses who met the inclusion criteria. The survey took 25 min to complete with each nurse. The data collection tools aimed to determine nurses’ knowledge of pressure injury diagnosis, pressure injury staging, and their attitudes toward risk assessment and prevention. A Personal Information Form, the Pressure Injury Knowledge Level Assessment Tool 2.0-Updated Version (PUKAT 2.0-T), and the Attitudes Towards Pressure Injury Prevention (APuP) scale were used to collect data.
Personal information form
The form was prepared by the researchers after reviewing similar studies in the literature [14–16, 21, 22] and consisted of 15 questions, including nurses’ demographic characteristics (age, gender, marital status, years of working in intensive care, and level of education) and information about pressure injuries, such as whether they had received training, the type of training received, and where the training was obtained.
Pressure injury knowledge level assessment tool 2.0-updated version (PUKAT 2.0-T)
The PUKAT 2.0 was developed by Manderlier et al. (2017) to assess nurses’ knowledge of pressure injury prevention [23]. The Turkish validity and reliability study of the instrument was conducted by Dallı et al. (2022) [6]. The test addresses knowledge about pressure injuries within the framework of six themes and contains a total of 25 questions. The maximum possible scores for each specific sub-dimension are as follows: “Etiology and development” (6 points), “Classification and observation” (4 points), “Risk assessment” (2 points), “Nutrition” (3 points), “Prevention” (8 points), and “Specific patient groups” (2 points). Each correct answer is worth 1 point, yielding a total score range of 0 to 25. In accordance with the original psychometric validation by the instrument’s developers, a cut-off threshold of 60% (corresponding to a minimum of 15 correct responses out of 25) was utilized to define ‘adequate knowledge,’ while scores below this parameter were categorized as insufficient knowledge. The Cronbach’s alpha value for our study was 0.70.
Attitudes towards pressure injury prevention scale (APuP)
The APuP scale was developed by Beeckman et al. (2010) [24]. The instrument evaluates professional attitudes toward pressure injury prevention across 13 items and five sub-dimensions using a 4-point Likert scale (1 = strongly disagree to 4 = strongly agree), with total scores ranging from 13 to 52. The maximum possible scores for the sub-dimensions are 12 points for Competence, 12 points for Priority, 12 points for Impact, 8 points for Responsibility, and 8 points for Prevention Effectiveness. Because the original APuP framework does not possess a psychometrically validated, rigid cut-off point to dichotomize scores into ‘positive’ or ‘negative,’ total scores were converted into percentages using linear transformation [\text{Percentage} = (\text{Observed Score} / \text{Maximum Score}) \times 100] to facilitate standard comparative reporting. In line with established critical care nursing literature utilizing this instrument, a transformed percentage score exceeding 75–80% was interpreted as a generally high or favorable attitude level toward prevention practices. The Turkish adaptation of the scale was made by Üstün [13]. The internal consistency of the scale was 0.714 (Cronbach’s alpha). In our study, the Cronbach’s alpha value for the APuP Scale was found to be 0.84.
Ethical aspects of the study
Ethical approval, institutional permission, and participant consent procedures were obtained in accordance with ethical research standards. Full details are provided in the Declarations section.
Data analysis
The study data were analyzed using SPSS for Windows, version 25.0. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were calculated to summarize demographic characteristics and scale scores. Data screening showed no missing values, as completion of all questionnaire items was mandatory for submission. The normality of data distribution was evaluated using the Kolmogorov-Smirnov test, confirming that the continuous variables followed a normal distribution (p > 0.05). Homogeneity of variance was assessed using Levene’s test. Since parametric assumptions were fully satisfied, the Independent Samples t-test was utilized to compare the means of two independent groups. For comparisons involving more than two groups, the One-Way ANOVA test was applied. Following a significant ANOVA, the Tukey HSD post-hoc test was performed to conduct pairwise multiple comparisons and pinpoint specific group differences, controlling for Type I error inflation. Bivariate relationships between the continuous scale variables specifically the PUKAT and APuP total scores were modeled utilizing Pearson’s product-moment correlation analysis (r) [25]. The use of parametric tests was justified as the data demonstrated a normal bivariate distribution (p > 0.05). Additionally, to facilitate a standardized comparison between the two primary tools in the descriptive tables, percentage metrics were computed using distinct mathematical logic: the Pressure Ulcer Knowledge Assessment Tool (PUKAT) percentage indicates the exact mean proportion of correct responses, whereas the Attitude towards Pressure Ulcer Prevention (APuP) percentage represents a linear transformation converting raw Likert scale scores into a standardized 0-100% operational index.
Results
Of the participants, 51.2% were between 27 and 33 years old, 57.3% were married, and 70.7% had a bachelor’s degree. 45.1% of the nurses had worked in intensive care for 1–5 years, and 92.7% worked rotating day and night shifts. Regarding clinical exposure characteristics within the critical care environment, 76.8% (n = 63) of the participating nurses reported that they frequently encountered patients with pressure injuries in their daily clinical practice, whereas 22.0% (n = 18) and 1.2% (n = 1) reported encountering them “sometimes” and “rarely,” respectively. Furthermore, the entire nursing cohort (100%, n = 82) stated that they were actively responsible for executing pressure injury wound dressings within their respective units. When examined in terms of clinical exposure, 86.6% reported performing too many pressure injury dressings to accurately recall. Additionally, 58.5% (n = 48) of the sample had received specific pressure injury training; among these individuals, 95.8% (n = 46) obtained this education through in-service training, while 4.2% (n = 2) attended external congresses or seminars. Of these nurses, 83.3% (n = 40) stated that they fully reflected this training in their care, 12.5% (n = 6) partially reflected it, and 4.2% (n = 2) did not reflect it in care. Finally, 67.1% of the total sample stated that the pressure injury prevention measures taken in the clinic were partially adequate (Table 1).
Table 1.
Analysis of participants’ demographic data (n = 82)
| Variables | Number (n) | Percentage (%) | |||
|---|---|---|---|---|---|
| Marital Status | |||||
| Married | 47 | 57.3 | |||
| Single | 35 | 42.7 | |||
| Age | |||||
| 20–26 years (1) | 33 | 40.2 | |||
| 27–33 years (2) | 42 | 51.2 | |||
| 34 years and older (3) | 7 | 8.5 | |||
| Education Level | |||||
| High School (1) | 15 | 18.3 | |||
| Bachelor’s Degree (2) | 58 | 70.7 | |||
| Master’s Degree (3) | 9 | 11 | |||
| Work Type | |||||
| Daytime | 6 | 7.3 | |||
| Day + Night Shift | 76 | 92.7 | |||
| Work Duration (years) | |||||
| 1–5 years | 37 | 45.1 | |||
| 6–10 years | 29 | 35.4 | |||
| 11 years and above | 16 | 19.5 | |||
| How Often Do You Encounter Pressure Injuries in Your Clinic? | |||||
| Rarely | 1 | 1.2 | |||
| Sometimes | 18 | 22 | |||
| Frequently | 63 | 76.8 | |||
| Who Performs Pressure Injury Dressings in Your Clinic? | |||||
| Nurse | 82 | 100 | |||
| Number of Pressure Injury Dressings You’ve Done So Far | |||||
| Less than 10 | 2 | 2.4 | |||
| 10–50 | 9 | 11 | |||
| Too many to remember | 71 | 86.6 | |||
| Previous Pressure Injury Training | |||||
| Yes | 48 | 58.5 | |||
| No | 34 | 41.5 | |||
| Where Did You Receive Pressure Injury Training? ( n = 48) | |||||
| In-Service Training | 46 | 95.8 | |||
| Congress/Seminar | 2 | 4.2 | |||
| Do you think you reflect your education on your caregiving? ( n = 48) | |||||
| Yes | 40 | 83.3 | |||
| Partially | 6 | 12.5 | |||
| No | 2 | 4.2 | |||
| Are Pressure Injury Prevention Measures Adequate in Your Clinic? | |||||
| Adequate | 22 | 26.8 | |||
| Partially Adequate | 55 | 67.1 | |||
| Inadequate | 5 | 6.1 | |||
*Note: Data are expressed as numbers (n) and frequencies (%) based on the total sample (n = 82), except for variables regarding the source of training and the application of training to care, which were calculated using the sub-sample of nurses who had received prior pressure injury training (n = 48) as the denominator
Participants’ PUKAT and APuP scale scores are examined in Table 2. The PUKAT subscale mean scores were found to be etiology and development 2.3 ± 1.2, classification and observation 2.5 ± 1, risk assessment 1.4 ± 1, nutrition 1.7 ± 1, prevention 2.7 ± 1.5, special patient groups 1 ± 1, and a total mean score of 11.7 ± 3.7. The maximum score that can be obtained from the scale is 25, and the scores obtained in the study were also calculated as percentages. As a result of this calculation, the etiology and development score was 38.4%, classification and observation 62.5%, risk assessment 70%, nutrition 56.7%, prevention 33.8%, special patient groups 50%, and the PUKAT total score 46.8%.
Table 2.
Analysis of participants’ PUKAT and APuP scores
| Variables | No. Items | Mean ± SD | Standardized Metric (%) |
|---|---|---|---|
| Theme 1. Etiology and development | 6 | 2.3 ± 1.2 | 38.4 |
| Theme 2. Classification and observation | 4 | 2.5 ± 1 | 62.5 |
| Theme 3. Risk assessment | 2 | 1.4 ± 1 | 70 |
| Theme 4. Nutrition | 3 | 1.7 ± 1 | 56.7 |
| Theme 5. Prevention | 8 | 2.7 ± 1.5 | 33.8 |
| Theme 6. Specific patient groups | 2 | 1 ± 1 | 50 |
| PUKAT Scale Total Score | 25 | 11.7 ± 3.7 | 46.8 |
| Competence Dimension | 3 | 8.7 ± 1.4 | 72.5 |
| Priority Dimension | 3 | 10 ± 1.3 | 83.3 |
| Impact Dimension | 3 | 10.7 ± 1.3 | 89.1 |
| Responsibility Dimension | 2 | 6.3 ± 0.86 | 78.8 |
| Prevention Effectiveness Dimension | 2 | 6.5 ± 0.81 | 81.3 |
| APuP Scale Total Score | 13 | 42.3 ± 4 | 81.3 |
*The reported percentages reflect fundamentally different mathematical calculations: PUKAT percentages express the true mean proportion of correct conceptual answers, whereas APuP percentages represent a linear transformation converting raw Likert scores into a standardized 0–100% scale value
For the APuP scale, the mean sub-dimension scores were 8.7 ± 1.4 for competence, 10.0 ± 1.3 for priority, 10.7 ± 1.3 for impact, 6.3 ± 0.86 for responsibility, and 6.5 ± 0.81 for prevention effectiveness. The total APuP score was 42.3 ± 4.0 out of a possible score range of 13–52. When converted into percentages, the competence, priority, impact, responsibility, and prevention effectiveness scores were 72.5%, 83.3%, 89.1%, 78.8%, and 81.3%, respectively. The total APuP percentage score was 81.3% (Table 2).
The relationship between the participants’ PUKAT scale mean scores and demographic characteristics was examined. A statistically significant relationship was found between age groups and mean scale scores; participants aged 34 and over had higher mean scores (19.3 ± 2.4) than participants aged 27–33 (11 ± 2.7) and 20–26 (10.8 ± 3.2) (F = 26.5, p < 0.001). Post-hoc pairwise comparisons using the Tukey HSD test demonstrated that participants aged 34 and over scored significantly higher than those aged 20–26 (p < 0.001) and 27–33 (p < 0.001), whereas no statistically significant difference was found between the 20–26 and 27–33 age groups (p = 0.942). Post-hoc pairwise comparisons utilizing the Tukey HSD test revealed that educational level had a statistically significant effect on participants’ mean scores (F = 5.37, p = 0.02). Post-hoc pairwise comparisons using the Tukey HSD test showed that participants with a master’s degree had significantly higher PUKAT scores than high school graduates (p = 0.041). However, no statistically significant differences were found between master’s degree and bachelor’s degree graduates (p = 0.124) or between bachelor’s degree and high school graduates (p = 0.761). Post-hoc analysis indicated that this significance was primarily due to the difference between master’s degree and high school graduates (p = 0.041), with no other significant variations found between the remaining education levels. Furthermore, a statistically significant relationship was found between the duration of employment and mean scale scores (F = 6.97, p < 0.001). Tukey HSD post-hoc testing indicated that participants who had worked for 11 years or more (14 ± 4.5) scored significantly higher than those with 1–5 years of experience (9.9 ± 3.3) (p < 0.001), and those with 6–10 years of experience (13 ± 2.7) also scored significantly higher than the 1–5 years cohort (p = 0.003). Additionally, the difference between the 11 years or more group and the 6–10 years group was statistically significant (p = 0.046), indicating a clear progressive increase in knowledge scores. Lastly, a statistically significant difference was found according to previous pressure injury training status. The Independent Samples t-test showed that the mean score of participants who had received training (13.4 ± 3.2) was significantly higher than the mean score of those who had not (9.2 ± 3.9) (t = 5.91, p < 0.001) (Table 3).
Table 3.
Analysis of the relationship between participants’ PUKAT scale score average and demographic characteristics
| Variables | PUKAT Scale Score | |||||||
|---|---|---|---|---|---|---|---|---|
| Number (n) | Mean ± SD | Statistical analysis* | Post-Hoc Pairwise Comparisons (p-value) |
|||||
| Age Groups | ||||||||
| 20–26 years (1) | 33 | 10.8 ± 3.2 | F = 26.5, p < 0.001b |
3 vs. 1 (p < 0.001); 3 vs. 2 (p < 0.001); 1 vs. 2 (p = 0.942) |
||||
| 27–33 years (2) | 42 | 11 ± 2.7 | ||||||
| 34 years and older (3) | 7 | 19.3 ± 2.4 | ||||||
| Education Level | ||||||||
| High School (1) | 15 | 10.8 ± 1.9 | F = 5.37, p < 0.02b |
3 vs. 1 (p = 0.041); 3 vs. 2 (p = 0.124); 1 vs. 2 (p = 0.761) |
||||
| Bachelor’s Degree (2) | 58 | 11.5 ± 3.8 | ||||||
| Master’s Degree (3) | 9 | 14.3 ± 4.6 | ||||||
| Working Time | ||||||||
| 1–5 years (1) | 37 | 9.9 ± 3.3 | F = 6.97, p < 0.001b |
3 vs. 1 (p < 0.001); 2 vs. 1 (p = 0.003); 3 vs. 2 (p = 0.046) |
||||
| 6–10 years (2) | 29 | 13 ± 2.7 | ||||||
| 11 years and above (3) | 16 | 14 ± 4.5 | ||||||
|
Previous Pressure Injury Training Yes (1) No (2) |
48 34 |
13.4 ± 3.2 9.2 ± 3.9 |
t = 5.91, p < 0.001b | 1 vs. 2 (p < 0.001) | ||||
* A independent Samples t-test (t-value), bOne-Way ANOVA test (F-value). Note: Pairwise comparisons were evaluated utilizing Tukey’s Honestly Significant Difference (HSD) post-hoc test
The relationship between participants’ APuP scale mean scores and demographic characteristics was also evaluated. A statistically significant relationship was found between age groups and mean attitude scores (F = 3.29, p = 0.04). However, subsequent pairwise comparisons utilizing the Tukey HSD post-hoc test revealed no statistically significant differences between individual age cohorts (p = 0.183 for 20–26 vs. 27–33; p = 0.191 for 20–26 vs. ≥34; p = 0.824 for 27–33 vs. ≥34), an outcome primarily driven by the limited sample size within the oldest stratum (n = 7). Consequently, no clear directional trend could be established across the individual age groups. No statistically significant relationship was found between the level of education and mean APuP scale scores (F = 1.29, p = 0.28). However, a statistically significant relationship emerged between the length of service and mean scale scores (F = 22.41, p < 0.001). Post-hoc pairwise comparisons confirmed a significant progressive trend across all categories: participants with 11 years and above of experience scored significantly higher than those with 1–5 years (p < 0.001), those with 6–10 years scored significantly higher than those with 1–5 years (p = 0.001), and the 11 years and above cohort scored significantly higher than the 6–10 years cohort (p = 0.038). Finally, a statistically significant difference was observed based on training status; the Independent Samples t-test revealed that the mean scores of participants who received training (43.9 ± 3.4) were significantly higher than those who did not (39.9 ± 1.9) (t = 5.03, p < 0.001) (Table 4).
Table 4.
Analysis of the relationship between participants’ APuP scale score averages and demographic data
| Variables | APuP Scale Score | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Number (n) | Mean ± SD | Statistical analysis* | Post-hoc Pairwise Comparisons (p-value) |
|||||||||
| Age Groups | ||||||||||||
| 20–26 years (1) | 33 | 40.9 ± 4.3 | F = 3.29, p = 0.04b |
2 vs. 1 (p = 0.183); 3 vs. 1 (p = 0.191); 3 vs. 2 (p = 0.824) |
||||||||
| 27–33 years(2) | 42 | 43.0 ± 3.7 | ||||||||||
| 34 years and older (3) | 7 | 44.0 ± 4.4 | ||||||||||
| Education Level | ||||||||||||
| High School (1) | 15 | 42.6 ± 3.9 | F = 1.29, p = 0.28b | - | ||||||||
| Bachelor’s Degree (2) | 58 | 41.9 ± 4.2 | ||||||||||
| Master’s Degree (3) | 9 | 42.3 ± 4.1 | ||||||||||
| Work Time | ||||||||||||
| 1–5 years (1) | 37 | 40.0 ± 3.8 | F = 22.4, p < 0.001b |
3 vs. 1 (p < 0.001); 2 vs. 1 (p = 0.001); 3 vs. 2 (p = 0.038) |
||||||||
| 6–10 years (2) | 29 | 44.0 ± 2.2 | ||||||||||
| 11 years and above (3) | 16 | 45.9 ± 3.2 | ||||||||||
| Previous Pressure Injury Training | ||||||||||||
| Yes (1) | 48 | 43.9 ± 3.4 | t = 5.03, p < 0.001a | 1 vs. 2 (p < 0.001) | ||||||||
| No (2) | 34 | 39.9 ± 1.9 | ||||||||||
*a Independent Samples t-test (t-value), b One-Way ANOVA test (F-value). Pairwise comparisons were evaluated utilizing Tukey’s Honestly Significant Difference (HSD) post-hoc test
When the relationship between the participants’ cumulative PUKAT and APuP metrics was evaluated, Pearson correlation analysis demonstrated a weak but statistically significant positive linear association between the total knowledge and professional attitude mean scores (r = 0.237, p = 0.032) (Table 5).
Table 5.
Analysis of the relationship between participants’ PUKAT and APuP
| Variables | APuP Scale Score | |
|---|---|---|
| PUKAT Scale Score | Pearson r | 0.237 |
| p | 0.032 | |
| n | 82 | |
Note: Data are analyzed utilizing *Pearson Product-Moment Correlation Analysis; r: Pearson correlation coefficient; p: exact statistical significance; n: cumulative sample size
Discussion
Nurses’ knowledge of pressure injury prevention
Nurses play a key role in preventing pressure injuries. Nurses must have a high level of knowledge to provide effective care [26]. This study evaluated nurses’ knowledge and attitudes regarding pressure injury prevention in the intensive care units of a university hospital in Turkey. Our results showed that the total pressure injury knowledge score obtained from nurses was 46.8%. The themes that achieved a score of ≥ 60%, which is considered the threshold by the authors of the PUKAT scale, were “risk assessment” (70%) and “classification and observation” (62.5%). Total knowledge scores were inadequate, similar to findings reported in previous studies [16, 18, 27–31]. The relatively higher scores in the “risk assessment” and “classification and observation” domains suggest that nurses had greater theoretical knowledge in these areas compared with other PUKAT domains. In the intensive care unit where the study was conducted, all patients were routinely assessed for pressure injury risk using structured tools in accordance with institutional quality care standards. This routine use of risk assessment tools may have contributed to the higher scores in these domains. However, these findings should not be interpreted as evidence of bedside clinical competence because the study did not directly assess nurses’ clinical performance or the accuracy of real-world risk assessment and classification practices.
A comparison of nurses’ demographic characteristics and knowledge of pressure injury prevention revealed that knowledge scores increased with advanced age, higher educational attainment, and extended years of experience, with the highest proficiency observed in the cohort working 11 years and over. Furthermore, nurses who had received pressure injury prevention training had higher knowledge scores than those who had not. These findings are consistent with previous studies [16, 18, 19, 27–29, 32].
In a study conducted with nursing students and nurses on pressure injury knowledge, nurses were found to have higher knowledge levels. This suggests that nurses’ knowledge has increased over the years due to their exposure to pressure injuries. For those new to nursing, including information on pressure injury prevention in their course curricula will be crucial [29].
The study also identified subthemes with insufficient information: “etiology and development” (38%), “prevention” (33.8%), “nutrition” (56.7%), and “special patient groups” (50%). A striking finding of this study is the alarmingly low score (33.8%) obtained in the ‘Prevention’ sub-dimension of the PUKAT scale. While participants demonstrated adequate proficiency in ‘Risk assessment’ (70%) and ‘Classification and observation’ (62.5%), their specific knowledge regarding preventative interventions remained insufficient. This trend indicates a specific theoretical knowledge deficit regarding the core principles of prevention assessed by the instrument. This variation implies that the participants’ conceptual knowledge of evidence-based prevention guidelines is relatively low compared to their understanding of risk identification parameters. However, given the descriptive cross-sectional scope of this research, these metrics do not evaluate the actual execution of preventive protocols at the bedside, and no conclusions can be drawn regarding whether nurses are unable to apply knowledge or implement preventive strategies in their clinical routine. Nurses’ evidence-based knowledge regarding pressure injuries can be substantially reinforced and sustained through continuously updated clinical guidelines, systematic case reports, and targeted institutional training programs [16, 18, 19, 32], which naturally complement the knowledge gained through long-term clinical exposure.
Nurses’ attitudes toward pressure injury prevention
The study found that nurses’ attitude score toward pressure injury prevention was 42.3 ± 4, corresponding to 81.3% of the maximum possible APuP score. This finding indicates that the participating nurses reported generally favorable attitudes toward pressure injury prevention. Previous studies have similarly reported that nurses may demonstrate positive attitudes toward pressure injury prevention, although knowledge and practice-related competencies may remain insufficient [16, 29, 30].
In the present study, the highest mean percentage was observed in the Impact sub-dimension of the APuP scale (89.1%). This sub-dimension reflects nurses’ agreement with items related to the perceived seriousness, consequences, and importance of pressure injuries. Therefore, this result should be interpreted as a favorable attitude toward the perceived impact of pressure injuries rather than as evidence of objective clinical competence, depth of professional understanding, or actual preventive practice. The lowest percentage was observed in the Competence sub-dimension (72.5%), which may indicate comparatively lower perceived confidence regarding pressure injury prevention. However, because this study did not directly assess bedside clinical performance, protocol adherence, or patient outcomes, these findings should be interpreted only within the scope of the measured attitude variables. These results are consistent with previous studies examining nurses’ attitudes toward pressure injury prevention [13, 14, 17].
In this study, a statistically significant but weak positive correlation was identified between PUKAT and APuP total scores (r = 0.237, p = 0.032). This finding indicates that higher knowledge scores were modestly associated with more favorable attitude scores among the participating nurses. However, the weak magnitude of the correlation suggests that knowledge and attitude are related but distinct constructs. Therefore, this association should not be interpreted as causal. In addition, because workload, clinical environment, institutional culture, staffing characteristics, and organizational climate were not measured in this study, no conclusions can be drawn regarding the influence of these factors on nurses’ attitudes. Similar to the present findings, previous studies have reported positive associations between nurses’ knowledge and attitudes toward pressure injury prevention [16, 18, 32].
The study found that attitude scores significantly increased with longer years of professional experience, whereas age did not yield a distinct directional trend in the post-hoc analysis. In addition, nurses who reported receiving training on pressure injury prevention had higher attitude scores than those who did not receive such training. However, due to the descriptive cross-sectional design, this finding should not be interpreted as evidence that training directly caused more favorable attitudes. Rather, it indicates an observed association between training status and attitude scores in this sample. Previous studies have also emphasized the importance of education and training in improving nurses’ knowledge and attitudes toward pressure injury prevention [16, 19, 30, 33].
A previous meta-analysis reported that nurses’ overall attitude scores toward pressure injury prevention were below 75%, indicating that attitudes may be unsatisfactory in some settings [34]. Regular and evidence-based training may contribute to maintaining favorable attitudes toward pressure injury prevention; however, the translation of attitude and knowledge into clinical practice requires further observational and longitudinal research. Negative attitudes toward pressure injury prevention may constitute a barrier to the use of guidelines, participation in in-service training, and implementation of evidence-based practices [24].
Limitations
Our study features several methodological limitations that should be considered when interpreting the findings, in alignment with the STROBE guidelines. First, the research utilized a single-center design conducted exclusively within the intensive care unit of a university hospital, naturally limiting the target population size to 88 and restricting the direct generalizability of our results to other diverse hospital frameworks. Second, the cross-sectional design of this study captures a single point in time, which inherently prevents us from inferring causality between demographic predictors and the measured scale baselines. Third, data collection relied entirely on self-reported questionnaires, which introduces the potential for social desirability bias; participants may have reported idealized professional attitudes or knowledge perceptions rather than their exact operational baselines. Fourth, this study lacked direct, objective observations of clinical bedside practice or protocol compliance and did not gather patient-level pressure injury outcome data, such as longitudinal incidence or staging rates. Lastly, although a complete enumeration approach yielded a high response rate of 93.1% (n = 82), the relatively modest cohort size means that multiple statistical comparisons should be evaluated with caution regarding Type I error inflation, despite our use of strict post-hoc control metrics. Nevertheless, reaching nearly the entire accessible universe provides a highly accurate representation of this specific critical care environment.
Conclusion & recommendations
This study found that intensive care nurses had generally favorable attitudes toward pressure injury prevention; however, their evidence-based knowledge levels were insufficient, particularly in prevention-related knowledge areas. A weak but statistically significant positive correlation was identified between knowledge and attitude scores, indicating that higher knowledge scores were modestly associated with more favorable attitudes.
These findings should be interpreted within the scope of the descriptive cross-sectional design and the self-report instruments used in this study. The study did not directly evaluate bedside clinical performance, adherence to pressure injury prevention protocols, implementation of preventive interventions, or patient-level pressure injury outcomes. Therefore, no causal conclusions can be drawn. Future observational and longitudinal studies are recommended to examine how knowledge, attitudes, clinical practice, and patient outcomes are related.
Acknowledgements
We would like to thank the intensive care nurses who supported our study.
Abbreviations
- EPUAP
European Pressure Ulcer Advisory Panel
- NPIAP
National Pressure Injury Advisory Panel
- PPPIA
Pan Pacific Pressure Injury Alliance
- SD
Standard Deviation
- SPSS
Statistical Package for the Social Sciences
- PUKAT 2.0-T
Pressure Injury Knowledge Level Assessment Tool 2.0-Updated Version
- APuP
The Attitudes Towards Pressure Injury Prevention
- Tukey HSD
Tukey Honestly Significant Difference
Author contributions
RA: Conceptualization, Methodology, Supervision, Data analysis, and interpretation. Manuscript original draft preparation, Formal Analysis HŞ: Conceptualization, Supervision, Methodology, Formal Analysis - Original draft preparation, review, and editing. ÖK: Conceptualization, Methodology, Data collection, Manuscript original draft preparation. All authors have read and approved the manuscript.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Data availability
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was approved by the Kocaeli University Non-Interventional Clinical Research Ethics Committee (Date: 25.04.2024, Decision No: 2024/08.7). Institutional permission was obtained from the hospital where the study was conducted before data collection. All procedures involving human participants were conducted in accordance with the ethical standards of the institutional research committee and with the principles of the Declaration of Helsinki and relevant guidelines and regulations. Written informed consent was obtained from all participants before their inclusion in the study. Participation was voluntary, and participants were informed that they could withdraw from the study at any time without any consequences.
Consent for publication
Not applicable. No individually identifiable data are presented.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Haesler E, editor. Prevention and treatment of pressure ulcers/injuries: quick reference guide. 3rd ed. European pressure ulcer advisory panel, national pressure injury advisory panel, and pan pacific pressure injury alliance. Cambridge Media; 2019.
- 2.Bahar A, Özgürbüz NE. Validity and reliability of the Turkish version of the Pressure Injury Prevention Knowledge Questionnaire (PIPK). J Tissue Viability. 2022;31(1):30–7. 10.1016/j.jtv.2021.11.002. [DOI] [PubMed] [Google Scholar]
- 3.Kottner J, Blume-Peytavi U. Reliability and agreement of instrumental skin barrier measurements in clinical pressure ulcer prevention research. Int Wound J. 2021;18:716–27. 10.1111/iwj.13574. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.McEvoy N, Avsar P, Patton D, Curley G, Kearney CJ, Moore Z. The economic impact of pressure ulcers among patients in intensive care units: a systematic review. J Tissue Viability. 2021;30:168–77. 10.1016/j.jtv.2020.12.004. [DOI] [PubMed] [Google Scholar]
- 5.Haesler E, editor. Prevention and treatment of pressure ulcers/injuries: quick reference guide. 4th ed. National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. The International Guideline, 2026. Available from: https://internationalguideline.com
- 6.Kara H, Arıkan F. Prevention of medical device-related pressure injury. Intensive Care Nurs J. 2020;24(1):15–21. https://dergipark.org.tr/en/download/article-file/1095450. [Google Scholar]
- 7.Erbay Dallı Ö, Ceylan İ, Girgin Kelebek N. Incidence, characteristics and risk factors of medical device-related pressure injuries: an observational cohort study. Intensive Crit Care Nurs. 2022;69:103180. 10.1016/j.iccn.2021.103180. [DOI] [PubMed] [Google Scholar]
- 8.Crunden EA, Schoonhoven L, Coleman SB, Worsley PR. Reporting of pressure ulcers and medical device-related pressure ulcers in policy and practice: a narrative literature review. J Tissue Viability. 2022;31:119–29. 10.1016/j.jtv.2021.10.010. [DOI] [PubMed] [Google Scholar]
- 9.Coyer F, Cook JL, Doubrovsky A, Campbell J, Vann A, McNamara G. Exploring medical device-related pressure injuries in a single intensive care setting: a longitudinal point prevalence study. Intensive Crit Care Nurs. 2022;68:103155. 10.1016/j.iccn.2021.103155. [DOI] [PubMed] [Google Scholar]
- 10.Labeau SO, Afonso E, Benbenishty J, Blackwood B, Boulanger C, Brett SJ, et al. Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study. Intensive Care Med. 2021;47:503–20. 10.1007/s00134-020-06327-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Özpak Akkuş Ö, Gülşen Atalay B, Parlak E. Evaluation of the relationship between the nutritional status and the risk of pressure sore formation of patients hospitalized in the intensive care unit. Toros Univ J Food Nutr Gastronomy. 2022;1(1):43–54. 10.58625/jfng-1933. [DOI] [Google Scholar]
- 12.Borghardt AT, Prado TN, Bicudo SDS, Castro DS, Bringuente MEO. Úlcera por pressão em pacientes críticos: incidência e fatores associados. Rev Bras Enferm. 2016;69:460–7. 10.1590/0034-7167.2016690307i. [DOI] [PubMed] [Google Scholar]
- 13.Üstün Y. Adapting the attitude towards pressure ulcer prevention instrument into Turkish and studying its validity and reliability [master’s thesis]. İzmir, Türkiye: Ege University Institute of Health Sciences; 2013.
- 14.Aslan A, Yavuz Van Giersbergen M. Nurses’ attitudes towards pressure ulcer prevention in Turkey. J Tissue Viability. 2016;25:66–73. 10.1016/j.jtv.2015.10.001. [DOI] [PubMed] [Google Scholar]
- 15.Avsar P, Patton D, O’Connor T, Moore Z. Do we still need to assess nurses’ attitudes towards pressure ulcer prevention? A systematic review. J Wound Care. 2019;28:795–806. 10.12968/jowc.2019.28.12.795. [DOI] [PubMed] [Google Scholar]
- 16.Halász BG, Bérešová A, Tkáčová L, Magurová D, Lizáková Ľ. Nurses’ knowledge and attitudes towards prevention of pressure ulcers. Int J Environ Res Public Health. 2021;18:1–9. 10.3390/ijerph18041705. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Yıldızer F, Özer Z. Intensive care nurses’ knowledge and attitudes regarding the prevention of pressure ulcers. Türkiye Klinikleri J Nurs Sci. 2021;13:897–905. 10.5336/nurses.2021-81718. [DOI] [Google Scholar]
- 18.Khojastehfar S, Najafi Ghezeljeh T, Haghani S. Factors related to knowledge, attitude, and practice of nurses in intensive care units in the area of pressure ulcer prevention: a multicenter study. J Tissue Viability. 2020;29:76–81. 10.1016/j.jtv.2020.02.002. [DOI] [PubMed] [Google Scholar]
- 19.Alshahrani B, Middleton R, Rolls K, Sim J. Critical care nurses’ knowledge and attitudes toward pressure injury prevention: a pre- and post-intervention study. Intensive Crit Care Nurs. 2023;79:103528. 10.1016/j.iccn.2023.103528. [DOI] [PubMed] [Google Scholar]
- 20.Avşar P, Karadağ A. Turkish adaptation and validity-reliability study of the Waterlow Pressure Ulcer Risk Assessment Scale. Hacettepe Univ Fac Nurs J. 2016;3:1–15. [Google Scholar]
- 21.Aydın AK, Karadağ A, Gül Ş, Avşar P, Baykara ZG. Nurses’ knowledge and practices related to pressure injury: a cross-sectional study. J Wound Ostomy Cont Nurs. 2019;46:117–23. 10.1097/WON.0000000000000517. [DOI] [PubMed] [Google Scholar]
- 22.Fulbrook P, Lawrence P, Miles S. Australian nurses’ knowledge of pressure injury prevention and management: a cross-sectional survey. J Wound Ostomy Cont Nurs. 2019;46:106–12. 10.1097/WON.0000000000000508. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Manderlier B, Van Damme N, Vanderwee K, Verhaeghe S, Van Hecke A, Beeckman D. Development and psychometric validation of PUKAT 2.0, a knowledge assessment tool for pressure ulcer prevention. Int Wound J. 2017;14:1041–51. 10.1111/iwj.12758. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Beeckman D, Defloor T, Demarré L, Van Hecke A, Vanderwee K. Pressure ulcers: development and psychometric evaluation of the Attitude towards Pressure Ulcer Prevention instrument (APuP). Int J Nurs Stud. 2010;47:1432–41. 10.1016/j.ijnurstu.2010.04.004. [DOI] [PubMed] [Google Scholar]
- 25.Schober P, Schwarte LA. Correlation coefficients: appropriate use and interpretation. Anesth Analg. 2018;126:1763–8. 10.1213/ANE.0000000000002864. [DOI] [PubMed] [Google Scholar]
- 26.Li J, Zhu C, Liu Y, Li Z, Zhang L, Zhang M, et al. Critical care nurses’ knowledge, attitudes, and practices regarding pressure injury treatment: a nationwide cross-sectional survey. Risk Manag Healthc Policy. 2022;15:2125–34. 10.2147/RMHP.S389706. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Klaas N, Serebro RL. Intensive care nurses’ knowledge of pressure injury prevention. BMC Nurs. 2024. 10.1186/s12912-024-02533-4. 23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Hu L, Sae-Sia W, Kitrungrote L. Intensive care nurses’ knowledge, attitude, and practice of pressure injury prevention in China: a cross-sectional study. Risk Manag Healthc Policy. 2021;14:4257–67. 10.2147/RMHP.S323839. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Tian J, Liang XL, Wang HY, Zhao J, Li Z, Song Y, et al. Nurses’ and nursing students’ knowledge and attitudes to pressure injury prevention: a meta-analysis based on APuP and PUKAT. Nurse Educ Today. 2023;128. 10.1016/j.nedt.2023.105885. [DOI] [PubMed]
- 30.Özyürek P, Gürlek Kısacık Ö. Evaluation of nurses’ knowledge and attitudes towards preventing pressure injuries. Ordu Univ J Nurs Stud. 2023;6:340–53. 10.38108/ouhcd.1113243. [DOI] [Google Scholar]
- 31.Wu J, Wang B, Zhu L, Jia X. Nurses’ knowledge on pressure ulcer prevention: an updated systematic review and meta-analysis based on the pressure ulcer knowledge assessment tool. Front Public Health. 2022;10. 10.3389/fpubh.2022.964680. [DOI] [PMC free article] [PubMed]
- 32.Şahan S, Güler S. Evaluating the knowledge levels and attitudes regarding pressure injuries among nurses in Turkey. Adv Skin Wound Care. 2024;37:1–8. 10.1097/ASW.0000000000000195. [DOI] [PubMed] [Google Scholar]
- 33.Asiri MY, Baker OG, Alanazi HI, Alenezi A, Alshammari F, Alqahtani JS, et al. Nurses’ knowledge, attitudes, and practices in pressure injury prevention: a systematic review and meta-analysis. Healthcare. 2025;13. 10.3390/healthcare13111220. [DOI] [PMC free article] [PubMed]
- 34.Rostamvand M, Abdi K, Gheshlagh RG, Khaki S, Sarokhani D. Nurses’ attitude on pressure injury prevention: a systematic review and meta-analysis based on the Pressure Ulcer Prevention Instrument (APuP). J Tissue Viability. 2022;31:346–52. 10.1016/j.jtv.2021.12.004. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.