Operating room nurses' self‐reported knowledge and attitude on perioperative pressure injury

Abstract

Surgical patients are at risk of developing a perioperative pressure injury (ORPI) during surgery. Accurate assessment and prompt implementation of prevention strategies or treatment of ORPI are dependent on knowledge and skills of operating room (OR) nurses. The study examined the knowledge and attitude of OR nurses in identifying at‐risk patients. A cross‐sectional, prospective, descriptive study was adopted. OR nurses were invited to complete the survey using the attitude towards pressure ulcer prevention instrument (Cronbach α of 0.79) and pressure ulcer knowledge assessment tool (Cronbach α of 0.77). Approximately, 28% of OR nurses took part in the survey. Most of them were females (99%) with a mean age of 38.4 ± 12.9 years old. Of these, 73% of the nurses described not having adequate experience in preventing ORPI, and 88% of them were uncertain about the treatment strategies. The mean overall knowledge score was 47.8 ± 9.1% for this cohort. The study demonstrated that approximately 8.9% of OR nurses passed with a score ≥ 60% for knowledge. The mean overall attitude score was 74.6 ± 6.1% for this cohort. About 35.6% of these nurses gave positive scores of greater than 75% for attitudes. The knowledge scores have no relationship with the working experience, role responsibility, academic qualification, ethnicity, nationality, and gender except for age 35 years older or equal and younger. Still, both the knowledge and attitude scores obtained have a strong relationship with the nurses' experiences with PI prevention. Personal competency to prevent PI has a strong correlation with risk identifying and preventing PI. There are strong associations between being responsible for PI development and the knowledge on risk identification and prevention of PI. The attitude regarding the prioritisation of PI prevention is also strongly correlated to the nurses' knowledge in preventing PI. Positive attitudes of OR nurses have no relationship with the overall knowledge scores. The prevention of ORPI is not on the list of priorities among OR nurses. The knowledge of preventive measures and risk identification of PI was limited among local OR nurses. Incorporating a standard screening and assessment tool within the current assessment list will support and promote ORPI risk assessment and continuous assessment. Contextualised education on ORPI prevention and management should be considered part of the training for OR nurses.

1. INTRODUCTION

Pressure injury (PI) has been a worldwide concern to health care providers, particularly among patients who are not deemed at risk of developing a PI before surgery but were at risk for a PI during or after undergoing surgery. Several extrinsic factors, such as the pressure sustained during operation, the effects of anaesthesia, and surgical trauma imposed; the presence of risk assessment and inequality of risk; and the availability of prevention strategies, and patient factors, such as individual tolerance capacity and existing comorbidity, predispose them to develop PI when undergoing an operation.1 An operating room‐related PI (ORPI) is any PI that develops within 48 to 72 hours intra‐, inter‐, or postoperatively, and the anatomical position is associated with the position of the surgery.1, 2 Such PIs commonly present as non‐blanchable erythema, purple discolouration, or blistering and are classified as Stage 1, Stage 2, or deep tissue pressure injury.1, 3

The prevention of PI is essential as the treatment cost of PI is high. In order to appropriately assess, prevent, or treat patients for PI, knowledge and skills are required. The authors, Gordon and Watts,4 purported that the delivery of holistic, quality nursing care happens when the nursing practice is being informed using the best available evidence. With the knowledge gain, nurses can then apply the principles of care prevention, knowledge in PI risk assessment, prevention, and management. Literature reported varied opinions on nurses' knowledge and attitudes influencing the practice of PI prevention.5, 6, 7, 8 Some studies reported strong, direct correlations between knowledge and attitudes in PI prevention,5, 8 while others contradicted the relationship.6, 7 Beeckman et al.7 explained that knowledge alone is not capable of influencing an individual's likelihood of carrying out PI prevention strategies. A review identified some nurses relying on solely their knowledge and personal experiences to judge whether their patients need PI prevention.9 Studies have confirmed that nurses' attitudes affect their compliance with PI preventive strategies, and nurses' knowledge altered their perceptions of the need and importance of PI prevention.5, 6, 10 Other factors such as time constraints and human resources may also affect the attitudes of nurses in providing PI‐related preventive care and prioritisation of skin care.10

In an effort to drive safety and quality nursing care, all healthcare institutions encourage nurses to routinely assess patients' skin pre‐, intra‐, and post‐operation for the presence of pressure injury. Any hospital‐acquired PI is considered an adverse event and will be reported through the incidence reporting information system (IRIS). An ORPI is an adverse event of direct harm from an untoward incident, therapeutic misadventure, or iatrogenic injury.11 In the writers' hospital, a Stage 4 ORPI was discovered 10 days post‐operation. A root cause analysis was conducted and showed that one probable reason attributed to the delay in recognising ORPI was the lack of knowledge in PI staging or nurses' attitude in PI risk prevention. However, to the best of our knowledge, the nurses' attitudes and knowledge of PI prevention have not been elucidated both in the local setting and in other Asian countries. Understanding the nurses' attitude and knowledge may be important in influencing their behaviours in complying with PI preventive measures, which directly cause the varied PI preventive practices in OR.

2. CONCEPTUAL FRAMEWORK

A Knowledge, Skill, and Attitude framework (KAS) was adopted using the concepts posited by Bloom et al.12 and Cutcliffe and Sloan13 that competency of a nurse to deliver care is dependent on the acquired cognitive or affective knowledge that affects the attitude in translating skills. Knowledge is defined as having the know‐how and using all or some this knowledge on ORPI prevention and management when providing the standard of care.14 The knowledge of nurses includes empirical knowing of PI (factual, quantitative information), ethical knowing (moral values), personal knowing (personal knowledge), and aesthetic knowing (nurse's perception of the patient and needs) that facilitated nurses in providing better care.14 An attitude is defined as “an evaluation of an object of thought”15 as it foretells the behaviour of an individual when she or he makes a deliberate, reflective skin assessment.16 A nurse's attitude is thought to control the individual's intention and volition to action in providing PI prevention and management.17 The nurse's likelihood of putting into action her or his intention correlates positively with her or his attitude.18

3. INSTRUMENTS

The instrument used for the study consisted of a covering note and two sections: socio‐demographic section and the validated instruments from attitude towards pressure ulcer prevention instrument (APuP) and pressure ulcer knowledge assessment tool (PuKAT). A covering note was included as an introductory page to the subjects. This page informed the study purpose, outlined voluntary participation, and instructed on the steps to answer the questions as well as the return of the survey. The KAS framework guided these tools. The survey time was approximately 20 minutes.

3.1. Socio‐demography

The socio‐demographic section measured nine items that were considered key characteristics of the study population (OR nurses) that might influence their knowledge and attitude. They comprised the following: age, gender, citizenship, ethnicity, job designation, the number of years of service, the number of years of working experience as a nurse, the highest academic qualification attained, and personal experience in wound care management.

3.2. Pressure ulcer knowledge assessment tool

The PuKAT is a 26‐item instrument that uses multiple choices to measure six concepts of knowledge on the PI. These concepts covered the topics of aetiology and development, classification and observation, risk assessment, nutrition, preventive measures to reduce the amount of pressure/shear, and the preventive measures to reduce the duration of pressure/shear.19 The subjects chose their answers from four options, inclusive of an answer for “I do not know the answer.” This instrument achieved an overall Cronbach's α of 0.77, and the items' Cronbach's α ranged between 0.40 and 0.87.19 The lowest internal consistency was found for the concept of “risk assessment” (Cronbach's α = 0.40). The instrument is stable with an overall intraclass correlation coefficient (ICC) of 0.88 (95% CI 0.79, 0.93, P < .001).19 The PuKAT has been utilised in multiple study sites.6, 7, 20

3.3. Attitude towards pressure ulcer prevention instrument

The APuP is a 13‐item instrument that examines the attitudes of OR nurses in PI prevention, education, and research.21 The 13 items were scored on a 4‐point Likert scale (1 = strongly disagree to 4 = strongly agree). The tool measured five concepts of attitude towards1 personal competency to prevent pressure injuries2; the priority of pressure injury prevention3; the impact of pressure injuries4; personal responsibility in pressure injury prevention; and5 confidence in the effectiveness of prevention.21 This instrument had good reliability with an overall Cronbach's α of 0.79 and validity with an overall ICC of 0.88 (95% CI 0.84, 0.91, P < .001).21 This instrument has been used in other sites.6, 7, 20

4. METHODS

4.1. Study design, population, and sampling

A cross‐sectional, descriptive study was adopted with convenience sampling. The study site is a tertiary, acute hospital of 1500 beds with 24 major and 3 minor operating rooms. All OR nurses (enrolled and registered nurses) were invited to participate in the study. By natural selection, nurses who were on leave (sick, maternity, paternity, or study leave) during the study period were excluded.

4.2. Sample size determination

The sample size was calculated referencing Dilie and Mengistu.8 The margin of error was set as 5% based on the common formula for a single proportion with a 95% CI—p ± 1.96 $\frac{\sqrt{p\left(1-p\right)}}{n}$, where p was the prior estimate of the proportion of operating room nurses, and n was the sample size needed for this study, where p = 0.83 was the estimate proportion available, and Z score is a standard normal distribution value at 95% confidence level. A possible non‐response rate of approximately 20%22 was considered. The sample size of 264 OR nurses was finalised as predicted and was sufficiently large to provide useful and meaningful information.

4.3. Ethical considerations

This study was reviewed and approved by the local institutional review National Healthcare Group Domain Specific Review Board (DSRB Number: 2016/01288). Information on the study (purpose and procedure, privacy and confidentiality, benefits, and voluntary participation) was made available via the patient information sheet along with the survey to all eligible participants. Self‐participation and submission of the survey indicated implied consent.

4.4. Procedure

The study was conducted over 2 months from the end of December 2015 to the end of February 2016. Local nursing officers were engaged and shared the purpose and nature of the study. Posters on the survey were publicised at the local tea room and lecture rooms. The sequential tagged questionnaire surveys (including a sealable envelope) were left at a designated place for OR nurses to participate voluntarily. Interested nurses self‐administered the surveys in their own time. Upon completion, nurses were required to drop the sealed questionnaire into the sealed box kept at their nursing counters with restricted access. The completed surveys were collected by the research team daily at the end of the day.

4.5. Statistical analysis

The data from the questionnaire were entered in an Excel spreadsheet, validated by an independent person and imported to the Social Sciences (SPSS) IBM Version 23.23 A score of 1 was allotted to all correct answers, and the total scores were summed for PuKAT. A passing score of above 60% was used as a cut‐off measure of adequacy of knowledge.7 The APuP items were coded as 1 for “Strongly disagree” to 4 for “Strongly agree,” with the scores reversed for negative items. A higher mean attitude score of ≥75% implied satisfactory positive attitudes.7 Descriptive data were analysed for the study sample characteristics (eg, frequency, percentages, mean, and standard deviations). The domain scores for PuKAT and APuP were calculated based on the answers given divided by the number of questions stipulated within the domain in percentage. Inferential statistics such as χ², multivariate, and ANOVA, with a significance level of .05, were used to examine the relationships between subjects' knowledge and attitude scores.

5. RESULTS

The total participation rate was 28%. The demographic profiles of the subjects were tabulated in Table 1. The mean age of the subjects was 38.5 ± 12.9 years old, and they were mainly female nurses. About 68% of the participants were staff nurses who directly cared for these surgical patients. The ethnic groups were representative of the local nursing population. Nearly, 66.7% of the OR nurses possessed a degree or advanced certification in OR care. About 71% of them had worked in OR for 5 years or more. Most of them (76.7%) were residents of Singapore. Only one‐third of the participants reported having confidence in preventing and treating PIs. There was no significant relationship between the knowledge scores or their attitude scores with age, gender, nationality, ethnicity, role responsibilities, academic qualifications, the years of working experiences, and personal reporting of experiences in the treatment of PI. However, self‐reported experiences for the prevention of PI was significantly correlated to their knowledge and attitude scores with χ² 5.4 (P = .03) and χ² 4.5 (P = .02), respectively.

Table 1.

Subjects' demographic profiles

Characteristics	n	%	PuKAT <60%	PuKAT ≥60%	P	APuP <75%	APuP ≥75%	P
Age (missing = 1)
<35 years old	48	53.9	41	7	.05*	29	19	.77
≥35 years old	41	46.1	40	1		26	15
Gender
Female	89	98.9	81	8	.75	56	33	.197
Male	1	1.1	1	0		0	1
Nationality
Singaporean	50	55.6	47	3	.44	32	18	.06
Permanent resident	19	21.1	16	3		15	4
Other nationality	21	23.3	19	2		9	12
Ethnicity
Chinese	55	61.1	47	8	.13	37	18	.27
Malay	11	12.2	11	0		8	3
Indian	7	7.8	7	0		3	4
Other ethnic groups	17	18.9	17	0		8	9
Role responsibilities
Enrolled nurses	15	16.7	15	0	.12	8	7	.36
Staff nurses	61	67.8	53	8		41	20
Nursing officers	14	15.6	14	0		7	7
Academic qualifications
Diploma certification	30	33.3	28	2	.73	20	10	.72
Degree certification	6	6.7	5	1		3	3
Master's degree and above certification	54	60.0	49	5		33	21
Years of working experiences
<1 year	7	7.8	3	2	.09	2	3	.23
1–5 years	19	21.1	14	3		11	6
5‐10 years	23	25.6	21	1		13	9
10‐15 years	15	16.7	15	1		12	4
15‐20 years	13	14.4	9	0		8	1
>20 years	13	14.4	20	1		10	11
Experience with pressure injury prevention
Score ≤5	54	60.0	52	2	.03*	39	15	.02*
Score >5	36	40.0	30	6		17	19
Experience with pressure injury treatment
Score ≤ 5	65	72.2	60	5	.52	43	22	.21
Score > 5	25	27.8	22	3		13	12

Note: Asterisk * and bold indicated significance set at .05.

These nurses scored a mean knowledge score of 47.8 ± 9.1% (Table 2) despite 45.6% of them having more than 10 years of working experience in the OR. Approximately, 8.9% of them scored 60% and above in the knowledge item using the PuKAT tool. The highest overall knowledge score obtained was 73.1%, and the lowest overall knowledge score obtained was 30.8%. Notably, nurses reported an overall low knowledge domain mean score below 60%, with an exception for the knowledge domain of nutrition (83.3 ± 37.5%). The highest gap in the knowledge scores was risk assessment and preventing PI, where 85.6% and 92.2% of the nurses scored below 60%, respectively. Multivariate analysis demonstrated no significant relationship between the domains of knowledge and the overall attitude scores, except for the knowledge on preventive measures (P < .05).

Table 2.

Summation scores for Pressure ulcer Knowledge Assessment (PuKAT)

Descriptions	n	%	Domain mean score ± SD (%)	APuP P‐ value
Summation scores
Scores <60%	82	91.1	47.8 ± 9.1	.44
Scores ≥60%	8	8.9
Aetiology and development
Scores <60%	54	60.0	53.3 ± 18.7	.11
Scores ≥60%	36	40.0
Classification and observation
Scores <60%	52	57.8	47.6 ± 18.4	.56
Scores ≥60%	38	42.2
Risk assessment
Scores <60%	77	85.6	40.6 ± 33.4	.06
Scores ≥60%	13	14.4
Nutrition
Scores <60%	15	16.7	83.3 ± 37.5	.12
Scores ≥60%	75	83.3
Preventive measures
Scores <60%	83	92.2	43.2 ± 13.8	.03*
Scores ≥60%	7	7.8

Note: Asterisk * and bold indicated significance set at .05.

The three most difficult questions for the OR nurses to answer were item Q1 “A lack of oxygen causes pressure ulcers,” item Q11 “The heels of patients who lie on a pressure redistributing surface should be observed minimum a day,” and item Q19 “For a patient at risk of developing a pressure ulcer, a visco‐elastic foam mattress has to be combined with repositioning every 4 hours.” Only 12.2%, 13.3%, and 16.7% of them could provide the correct answers, respectively. The easiest questions were item Q14 “Which statement is correct? Optimizing nutrition can improve the patients' general physical condition which may contribute to a reduction of the risk of pressure ulcers” and item Q23 “Fewer patients will develop a pressure ulcer if patients are mobilized,” with 83.3% and 81.1% selecting the correct answer, respectively. The χ² test did not show any significant correlation between positive attitude scores ≥75% and the correct answers given in PuKAT, except for item Q13 “Which statement is correct? A patient with a history of pressure ulcers runs a higher risk of developing new pressure ulcers” with P = .01 (Table 3).

Table 3.

Detailed summary of the answers given for Pressure ulcer Knowledge Assessment (PuKAT)

Descriptions	Correct answer (n/%)	APuP P‐value
Aetiology and development
Q1 Which statement is correct? A lack of oxygen causes pressure ulcers	11 (12.2%)	.44
Q2 Extremely thin patients are more at risk of developing a pressure ulcer than obese patients. Correct. The contact area involved is small and thus the amount of pressure is higher	60 (66.7%)	.09
Q3 What happens when a patient, sitting in bed in a semi‐upright position (60°), slides down? Shearing increases when the skin sticks to the surface	45 (50.0%)	.20
Q4 Which statement is correct? Shear is the force which occurs when the body slides and the skin sticks to the surface	48 (53.3%)	.18
Q5 Which statement is correct? Recent weight loss which has brought a patient below his or her ideal weight, increases the risk of pressure ulcers	54 (60.0%)	.13
Q6 There is NO relationship between pressure ulcer risk and: Hypertension.	70 (77.8%)	.77
Classification and observation
Q7 Which statement is correct? A pressure ulcer extending down to the fascia is a grade 3 pressure ulcer	25 (27.8%)	.49
Q8 Which statement is correct? When necrosis occurs, it is a grade 3 or a grade 4 pressure ulcer	51 (56.7%)	.91
Q9 Which statement is correct? Friction or shear may occur when moving a patient in bed	59 (65.6%)	.90
Q10 In a sitting position, pressure ulcers are most likely to develop on: Pelvic area, elbow and heel.	67 (74.4%)	.88
Q11 Which statement is correct? The heels of patients who lie on a pressure redistributing surface should be observed minimum a day	12 (13.3%)	.74
Risk assessment
Q12 Which statement is correct? A risk assessment scale may not accurately predict the risk of developing a pressure ulcer and should be combined with clinical judgement	39 (43.3%)	.91
Q13 Which statement is correct? A patient with a history of pressure ulcers runs a higher risk of developing new pressure ulcers.	34 (37.8%)	.01*
Nutrition
Q14 Which statement is correct? Optimizing nutrition can improve the patients' general physical condition which may contribute to a reduction of the risk of pressure ulcers	75 (83.3%)	.12
Preventive measures
Q15 The sitting position with the lowest contact pressure between the body and the seat is: A backwards sitting position, with both legs resting on a footrest	27 (30.0%)	.13
Q16 Which repositioning scheme reduces pressure ulcer risk the most? Supine position – side 30° lateral position – side 30° lateral position—supine position—30° lateral position—supine position	30 (33.3%)	.88
Q17 Which statement is correct? Patients who are able to change position while sitting should be taught to shift their weight minimum every 60 minutes while sitting in a chair	51 (56.7%)	.58
Q18 If a patient is sliding down in a chair, the magnitude of pressure at the seat can be reduced the most by: A thick air cushion	19 (21.1%)	.09
Q19 For a patient at risk of developing a pressure ulcer, a visco‐elastic foam mattress has to be combined with repositioning every 4 hours	15 (16.7%)	.44
Q20 A disadvantage of a water mattress is: Spontaneous small body movements are reduced	58 (64.4%)	.97
Q21 When a patient is lying on a pressure reducing foam mattress, elevation of the heels is important	34 (37.8%)	.61
Q22 Repositioning is an accurate preventive method because the duration of pressure and shear will be reduced	24 (26.7%)	.60
Q23 Fewer patients will develop a pressure ulcer if patients are mobilised	73 (81.1%)	.82
Q24 Which statement is correct? Patient's at risk lying on a non pressure reducing foam mattress should be repositioned every 2 hours	48 (53.3%)	.71
Q25 When a patient is lying on an alternating pressure air mattress, the prevention of heel pressure ulcers includes: A cushion under the lower legs elevating the heels	39 (43.3%)	.24
Q26 If a bedridden patient cannot be repositioned, the most appropriate pressure ulcer prevention is: An alternating pressure air mattress	49 (54.4%)	.83

Note: Asterisk * and bold indicated significance set at .05.

Nurses had an overall mean attitude score of 74.6 ± 6.1% for PI prevention and management (Table 4). Approximately, 51.1% of the nurses had an average APuP item score of equal or more than 3.0 ± 0.2, with the lowest mean scores for personal competency (67.9 ± 8.5%) and confidence in effectiveness (74.6 ± 12.2%) in preventing PI. Notably, nurses reported lower attitudes towards being well trained to prevent pressure ulcers, forced attention on preventing PI, and the financial impact of PI on a patient. There is no significant difference between the five domains in PuKAT and APuP.

Table 4.

Summation Scores for Attitude towards Pressure ulcer Prevention (APuP)

Descriptions	n	%	Mean score ± SD (%)	PuKAT P‐value
Summation scores (average score per item = 3.0 ± 0.3)
Scores ≤75%	58	64.4	74.6 ± 6.1	.91
Scores >75%	32	35.6
Personal competency to prevent PI
Scores ≤75%	85	94.4	67.9 ± 8.5	.48
Scores >75%	5	5.6
Priority of PI prevention
Scores ≤75%	57	63.3	77.1 ± 9.1	.96
Scores >75%	33	36.7
Impact of PI
Scores ≤75%	65	72.2	75.2 ± 10.1	.53
Scores >75%	25	27.8
Responsibility in PI prevention
Scores ≤75%	55	61.1	80.1 ± 11.5	.93
Scores >75%	35	38.9
Confidence in the effectiveness of prevention
Scores ≤75%	71	78.9	74.6 ± 12.2	.13
Scores >75%	19	21.1

Notably, six items for APuP had mean item scores of less than 3, which were: item Q1 “I feel confident in my ability to prevent pressure ulcers,” item Q2 “I am well trained to prevent pressure ulcers,” item Q3 “PI prevention is too difficult. Others are better than I am,” item Q4 “Too much attention goes to the prevention of PI,” item Q8 “The financial impact of PI on a patient should not be exaggerated,” and item Q12 “PIs are preventable in high risk patients” (Table 5).

Table 5.

Correlation between the Attitude towards Pressure ulcer Prevention (APuP) and the knowledge domains

Descriptions of the APuP tool	Item score (χ ± SD)	Understand the aetiology of PI	Classify PI	Risk identify PI	Nutrition needs	Prevent PI
Personal competency to prevent PI		.15	.62	.05*	.22	.01*
Q1 I feel confident in my ability to prevent pressure ulcers	2. 8 ± 0.4	.69	.63	.21	.63	.07
Q2 I am well trained to prevent pressure ulcers	2.6 ± 0.5	.66	.26	.23	.79	.15
Q3 PI prevention is too difficult. Others are better than I am	2.8 ± 0.5	.68	.80	.10	.86	.80
Priority of PI prevention		.31	.43	.51	.99	.50
Q4 Too much attention goes to the prevention of PI	2.6 ± 0.6	.50	.98	.93	.80	.56
Q5 PI prevention is not that important	3.3 ± 0.7	.18	.86	.90	.34	.01*
Q6 PI prevention should be a priority	3.3 ± 0.5	.16	.32	.59	.30	.93
Impact of PI		.97	.97	.62	.52	.06
Q7 A PI almost never causes discomfort for a patient	3.3 ± 0.8	.77	.95	.16	.73	.06
Q8 The financial impact of PI on a patient should not be exaggerated	2.7 ± 0.7	.45	.82	.33	.88	.11
Q9 The financial impact of PI on society is high	3.1 ± 0.6	.90	.72	.90	.74	.39
Responsibility in PI prevention		.74	.47	.23	.59	.25
Q10 I am not responsible if a PI develops in my patients	3.2 ± 0.6	.82	.76	.04*	.74	.05*
Q11 I have an important task in PI prevention	3.2 ± 0.6	.81	.13	.49	.65	.50
Confidence in the effectiveness of prevention		.25	.90	.24	.22	.44
Q12 PIs are preventable in high risk patients.	2.9 ± 0.6	.41	.48	.79	.23	.41
Q13 PIs are almost never preventable	3.1 ± 0.6	.30	.88	.88	.71	.49

Note: Asterisk * with bold indicated statistically significant.

Abbreviations: PI, pressure injury; χ, mean.

The correlational analyses did not show any significant relationship between overall attitude score ≥75% and overall knowledge score ≥60% obtained, except for the personal competency to prevent PI with the knowledge of risk identification (F = 4.1, P = .05) and preventing PI (F = 6.8, P = .01) (Table 5). The attitude item Q5 “PI prevention is not that important” has a significant relationship with the knowledge of preventing PI (F = 7.4, P = .01). The attitude item Q10 “I am not responsible if a PI develops in my patients” has a significant correlation with the knowledge score in risk identification (F = 4.2, P = .04) and preventive measures (F = 4.0, P = .05).

6. DISCUSSION

Our examination of the knowledge of the OR nurses working at the study site demonstrated a lack of knowledge among them, as has been echoed by other studies with higher participation rates in the literature.6, 7, 24 The overall mean knowledge score was similar to the inpatient nurses working in Belgian hospitals7 but lower than Sweden's hospital nurses24 and Korea's long‐term care nurses25 and are higher than those in Belgian nursing homes.6 Less than one‐tenth of them scored ≥60% for knowledge, which was 2.6 times lower than the nurses in Belgian hospitals.7 The OR nurses had acceptable overall attitude scores towards PI prevention and management.7, 25 However, only two‐fifth of the OR nurses reported having positive attitudes in preventing and managing ORPI, which was lower compared to Beeckman et al.7 Nurses displayed favourable positive attitudes with PI prevention and management but remained weak in their knowledge of PI.5, 6, 25 Still, positive attitudes do not necessarily translate to higher knowledge or application through skills in the delivery of care. This study did not establish any association between the nurses' total attitudes and knowledge scores as purported by Simonetti et al.20 and Beeckman et al.7 Nevertheless, OR nurses' attitudes have some influence on their acquisition and application of knowledge. Being empowered, setting PI as a priority, and being accountable and responsible in PI prevention significantly influence the desire of nurses to acquire more knowledge on risk identification and prevention of ORPI.

Notably, risk identifying and preventing PIs have been challenging in the OR without a specific risk identification tool for ORPI. Although the Braden score was used for risk screening for all admitted patients, it remained less relevant for identifying PI risk among patients going for surgery because of its low sensitivity and predictive validity.26, 27 At the time of the study, no specific tool for risk assessment of OR patients had yet been developed.

Gordon and Watts,4 opined that improvement in the knowledge of nurses necessitates a principal in care practice that translates through nursing skills. As the existing awareness of ORPI is limited, perhaps the utilisation of root cause analysis (RCA) for any ORPI developed would demonstrate possible contributing factors from the local population. Indeed, knowledge precedes clinical practice. Black28 and Scott and Bennett29 posited that the use of RCA would benefit the organisation in identifying possible human factors and system gaps in ORPI development. Without adequate knowledge of assessment, prevention, and treatment, OR nurses will continue to face challenges in providing optimal preventive strategies and management of ORPI.

This study has a few limitations. First, the results cannot be generalised beyond the study population for two reasons: the response rates were low, and nurses who volunteered might be more enthusiastic and optimistic about ORPI prevention and management. In addition, variances may be present in how the OR nurses perceived and prioritised ORPIs while caring for patients undergoing surgery. The low response rate could be because of their de‐prioritisation of the prevention and management of ORPIs, in comparison with their other competing nursing roles that more noticeably influence the patients' life and death in the OR. Second, like all other self‐reported studies, the results obtained are subjected to response bias. Of note, the subjects who participated in this study may have a more vested interest in ORPIs. They may also provide answers that were socially acceptable, particularly the survey on attitudes. However, the response to the knowledge survey may be less affected by response bias as the questions posed were based on personal knowledge. Third, the causal effect in the relationship cannot be ascertained in such a descriptive study. In addition, this is the first time, to our knowledge, that the PuKAT and APuP instruments were administered to OR nurses; hence, comparability is limited. Finally, the low knowledge scores may indicate that the items used in PuKAT did not adequately measure the nurses' knowledge for ORPIs.

7. CONCLUSIONS

This prevalence and incidence study examined the local hospital‐acquired ORPIs and heightened the system issues surrounding ORPI. The OR nurses have yet to recognise PIs as an adverse event demanding priority in prevention and management while caring for surgical patients. There is a lack of awareness of ORPI as an adverse event. Although the attitudes of the local OR nurses may be acceptable, their knowledge of PI prevention and management remained inadequate. The consideration of personal capability to prevent and care for PI will affect the acquisition of knowledge in PI prevention and management. Focused unit‐based training on ORPI prevention and management should be adopted as routine education for OR nurses. As a Braden scale may be inadequate to meet the screening needs of ORPI, there is a need to develop or incorporate a risk screening and assessment with a management (prevention and treatment) tool into the current assessment tool for ORPI risk and continued reassessment. Perhaps in hospitals with ORPI, a mandatory RCA may help unravel unknown contributing factors to the development of ORPI.

CONFLICT OF INTEREST

There is no conflict of interest in this study for all the authors.

AUTHOR CONTRIBUTIONS

B.K.P.C. contributed towards the conception and design, data collection, analysis and interpretation, and finalising the manuscript. T.D., G.B.C, and P.L.Y. provided direct supervision on data collection and contributed towards the interpretation of the data. All authors proofread and approved the final manuscript for important intellectual content and have met at least one of the criteria stipulated by the ICMJE (http://www.icmje.org/recommendations/).

Khong BPC, Goh BC, Phang LY, David T. Operating room nurses' self‐reported knowledge and attitude on perioperative pressure injury. Int Wound J. 2020;17:455–465. 10.1111/iwj.13295