Critical care nurses' knowledge about pressure ulcer in southeast of Iran

Abstract

Pressure ulcer prevention needs nurses' awareness of sore classification/onset, its item characteristics, and its prevention. Using Pieper's Pressure Ulcer Knowledge Test, 126 critical care nurses' knowledge about pressure ulcer was examined. The questionnaire was divided into three categories including: (1) sore classification/onset; (2) wound characteristics, and (3) preventive measure. The level of nurse's knowledge was insufficient. The highest rate of correct answers belonged to section 2 – prevention of pressure ulcer. Programs aimed at raising nurses' knowledge accompanied by interventions intended to decrease incidence of pressure ulcer are important parts in educational programs. Continuing education may need to be added to the pressure ulcer care to improve the quality of care at intensive care units.

INTRODUCTION

Pressure ulcer or sores, also referred to as decubitus ulcers (1) is a localised tissue necrosis that develops when soft tissue is compressed between a prominent bone and the external surface for a long time (2). Common pressure ulcer points include the occiput, scapula, sacrum, buttocks, ischium, heels, and toes (1, 3). In Iran, Reihani and Haghiri (4) reported that the incidence of pressure ulcer was 22·7% among cranial and spinal injured patients. They found that the most common sites were intergluteal cleft (33·3%) and sacral regions (28·9%). Pressure ulcer prevention and management are of major importance in today's health care environment. With regard to injuries to skin integrity, pressure ulcer (in hospitalised patients) represents an important problem because of the high ratios found and the emotional and financial costs they entail. Pressure ulcer entails high costs for the patient, family, hospital, health institution, and society as a whole (5, 6). However, despite the increasing expenditure on pressure ulcer prevention, neither the incidence nor prevalence of pressure ulcers is reducing (5) and pressure ulcer remains a common problem across all health care settings (7).

One of the main aspects of nursing care is maintaining skin integrity and nurses are requested to check the skin for any sign of the occurrence of pressure ulcers (2). Prevention of pressure ulcers is seen to be a key quality indicator of nursing care and pressure ulcers are widely supported as a nursing sensitive outcome (8) with directed efforts to reduce its incidence by means of prevention programs (9). Pressure ulcer prevention requires better understanding of the professionals about the aspects involving its development, as well as attitudes towards ethical care with the adoption of recommended practices, including the search of suitable resources (9). Good care is based on the profound knowledge. Profound knowledge of pressure ulcers is important to enable good prevention (10) and lack of knowledge might lead to misconceptions about pressure ulcer prevention (11).

Studies of knowledge of nurses in relation to the pressure ulcers reported differently. Fernandes et al. (11) who surveyed impact of educational program on Brazilian nurses, reported that they have moderate knowledge about pressure ulcer. Hulsenboom et al. (12) in 2002, who assessed knowledge of pressure ulcer prevention between nurses in Dutch, reported that their knowledge was moderate when compared to the knowledge level of Dutch nurses in 1991. Aydin's et al. (13) assessed knowledge of critical care nurses in Turkey about pressure ulcer stage one and reported that nurses have low level of knowledge about pressure ulcer prevention. In contrast with Aydin et al. (13), in New Zealand Tweed et al. (13) who examined effects of an educational program on the level of critical care nurses' awareness about pressure showed that the intensive care unit (ICU) nursing staff had a high level of knowledge of pressure ulcers before any educational intervention. Snaerska et al. (14) accessed knowledge of nursing students about pressure ulcer prevention in Poland. They reported that nursing students have low level of knowledge about pressure ulcer and they need to implement comprehensive action towards increasing pressure ulcers prevention knowledge.

Patients in ICU are at higher risk for development of pressure ulcers because of severity of illness, the presence of multiple diseases, and complications of bed rest or other positioning restrictions (15). Therefore, pressure ulcer prevention needs critical care nurses' awareness of sore classification/onset, its item characteristics, and its prevention. In the Iranian context, no study was found to examine critical care nurses' knowledge about pressure ulcer prevention. Educating nurses in regard of pressure ulcer needs a primary assessment of nurses' information. This study was thus designed to fulfil this goal.

METHODS

Design and sample

There was an approval from the heads of Kerman and Zahedan Hospital prior to the collection of data. The study used a descriptive design and was conducted in five hospitals. All qualified registered nurses working within the ICU were invited to participate in the study.

The instrument

Data were collected between November and October 2010, using an instrument with items related to demographic data and a knowledge test called Pieper's Pressure Ulcer Knowledge Test (PUKT) (16). This test is based on the recommendations proposed in international guidelines and comprises 41 true (T)‐or‐false (F) assertions. The questionnaire was divided into three categories including: (1) sore classification/onset (items 1, 6, 9, 20, 33, and 38); (2) wound characteristics (items 31 and 32), and (3) preventive measure (the rest). The correct response was given the value 1 and the incorrect or blank ones were given a value of 0. The total score on the knowledge test was the sum of all correct answers. In the original study, participants were expected to give 90% or more of correct answers for knowledge to be considered adequate (16). For translation of questionnaire from English into Farsi, the standard forward–backward procedure was applied. Translation of the items and the response categories was independently performed by five professional translators and then temporary versions were provided. Later they were back translated into English and after a careful cultural adaptation, the final versions were provided. Translated questionnaire went through pilot testing. Suggestions by nurses were combined into the final questionnaire versions. A factor analysis (rotated component matrix) on the PUKT was done to examine the context validity of the questionnaire. The concession of the items was similar to the original items and three components were identified. The validity of scale has been assessed through a content validity discussion. The validity of questioner has been assessed through a content validity discussion. Scholars of statistics and nursing care have reviewed the content of the questioner. To reassess the reliability of translated questioner alpha coefficients of internal consistency and 3 weeks test–retest coefficients (n = 50) of stability were computed. The alpha coefficient for questionnaire was 0·88. The 3 weeks test–retest coefficient of stability for questionnaire was 0·73. So totally, translated scale presented an acceptable reliability. Participants answered individually during work hours and returned the test to the researcher immediately in an unidentified envelope. To guarantee the participant privacy, there was no information collection that could show their identities. Descriptive statistics were used for demographic variables and Pearson correlation test was used to examine the relationship between years of nursing experience and PUKT scores. Chi‐square exact tests were used to associate qualitative variables. All data were analysed using SPSS 18·0 statistical software and a variable was found to be statistically significant if P < 0·05.

RESULTS

Of the 126 nurses who participated in this study, 88·1% was women and 11·9% was men. The mean age of participants was 30·23 (SD = 5·97) and mean years of their experiences was 6·07 (SD = 5·29).

The test results in the pressure onset part are shown in Table 1. The nurses answered correctly to 54·36% of all questions. The highest rate of correct answer belonged to question number 9 with 90·5% (Pressure ulcers in stage IV show total skin loss with intense destruction and tissue necrosis or muscles, bones or supporting structures damage) and the lower rate belonged to question number 33 with 12·7% (A blister in the calcaneus should be a reason for concern). Four items related to pressure ulcer stage description and definitions were answered correctly by 55·75% of participants. The results show that category of pressure ulcer evaluation with 83·35% correct answer have the highest rate of correct answer compared with other categories. In this category, question number 31 with 73% (Pressure ulcers are sterile wounds) has lower rate of correct answer and question 32 (A pressure ulcer scar may be damaged faster than the whole skin) had the higher rate of correct answer (Table 2). The mean correct score for the 33 pressure ulcer prevention items was 73·41%. Only 15 items with 45·45% were answered correctly by 90% or more of the nurses. Items with the lowest percentage of correct answers (<50%) were related to question numbers 5, 11, 13, 14, 17, and 28. In this section the lower rate belonged to question number 17 with 2·4% (A person who cannot move should be repositioned while sitting in bed every 2 hours) and the higher rate belonged to question number 24 with 100% (Mobilisation and transference of totally dependent patients should be performed by two or more people). Only question that all nurses answered correctly was question number 24. Participants correctly answered 67·52% to all 41 items in tree section. According to Pearson correlation test no significant correlation was found between nurses knowledge about pressure ulcer and their years of professional experiences (P > 0·05).

Table 1.

Rates of correct answers of nurses, in the test questions regarding pressure ulcer onset

Question number	Number of correct answers	Percentage of correct answers
9. Pressure ulcers in stage IV show total skin loss whit intense destruction and tissue necrosis or muscles, bones or supporting structures damage (T)	114	90·5
1. Stage I of pressure ulcer is defined as an erythema that those not whiten (T)	109	86·5
38. The pressure ulcers in stage II may be extremely painful because of the exposure of the nervous ends (T)	92	73
6. A pressure ulcer in stage III is a partial skin loss involving epidermis (F)	50	39·7
20. Pressure ulcers in stage II show skin loss in the total thickness (F)	30	23·8
33. A blister in the calcaneus should be a reason for concern (F)	16	12·7

Table 2.

Rates of correct answers of nurses, in the test questions regarding pressure ulcer evaluation

Question number	Number of correct answers	Percentage of correct answers
32. A pressure ulcer scar may be damaged faster than the whole skin (T)	118	93·7
31. Pressure ulcers are sterile wounds (F)	92	73

DISCUSSION

The purpose of this study was to determine Iranian critical care nurses' knowledge about pressure ulcer. According to the findings, level of nurse's knowledge was insufficient. Using the same questionnaire Miyazaki et al. (6) and Chianca et al. (17) assessed Brazilian nurses' knowledge about pressure ulcer in different wards. Their findings were approximately similar to the findings of the present study. Rate of Iranian and Brazilian nurses' correct answer to questions related to pressure ulcer onset part was almost the same. In the category of pressure ulcer prevention, Iranian nurses in this study were more knowledgeable about pressure ulcer compared with their colleagues in Brazil (73·41 versus 63·63). Total score determined by Chienda et al. (17) ranged between 61% and 75%. This is also similar to the findings of present study (67·52% correct answer). Snarska et al. (14) assessed pressure ulcers prevention knowledge among 50 female part‐time nursing students in Poland and reported an urgent necessity to implement comprehensive intervention towards increasing pressure ulcers prevention knowledge among part‐time nursing students. In Turkey, Aydin et al. (13) surveyed intensive care nurses knowledge about pressure ulcer and reported that nurses have lack in sufficient knowledge regarding prevention and management. The results of this study are consistent with the findings of the following study, although Aydin et al. (13) examined nurses' knowledge about stage one of pressure ulcer. In a recent study carried out in New Zealand, Tweed et al. (18) created a knowledge test on pressure ulcer prevention, based on international guidelines. Using a modified Delphi technique and electronic communication, they reached a consensus on the questions' contents and on 76% of correct answers as a minimum competency level for nurses to pass the test. The test was used to assess the impact of an educative program on 62 critical care nurses regarding pressure ulcer in New Zealand. Measurements took place before, 2, and 20 weeks after the course. The nurses answered 84% of questions correctly before the course, 89% on the first assessment 2 weeks after, and 85% on the second assessment after 20 weeks. Level of nurse's knowledge reported by Tweed et al. (18) was acceptable. Their finding is in contrast with findings in present study. This difference can be related to difference in sample size of two studies (126 versus 62) or different types of instruments used in two studies. Questionnaire used by Tweed et al. (18) consisted of 11 questions which is not enough to examine nurses' knowledge in this regard. In another study by Fernandes et al. (11), they surveyed effect of the educative interventions on nursing staff knowledge about pressure ulcer prevention in Intensive Care Centres, using some questionnaire, and identified 86·4% of correct answers by nurses in the pre‐intervention phase, but no professional participated in the post‐intervention assessment. This difference in results between present study and Fernandes et al. (11) can be related to the difference in sample size of two studies, because only seven nurses participated in Fernnandes et al. (11) study.

Although questionnaire used in this study measured nurses' knowledge about pressure ulcer in three sections, number of questions belonged to section 2 (prevention of pressure ulcer) was much more than those in two other sections (33 versus 6 and 2). Nurses' rate of correct answers in this category was significantly more than mean correct answers to all questions in three categories (73·4 versus 67·52%). As, nurses have an important role in prevention of pressure ulcers and that percentage of participant nurses' correct answers' was almost high, it can be considered as a positive point in their evaluation (Table 3).

Table 3.

Rates of correct answers of nurses, in the test questions regarding pressure ulcer prevention

Question number	Number of correct answers	Percentage of correct answers
24. Mobilisation and transference of totally dependent patients should be performed by two or more people (T)	126	100
39. For people with incontinence, the cleaning of the skin should start the moment it occurs and in the routine intervals (T)	123	97·6
27. Patients and relatives should be oriented about the causes and risk factors of development of pressure ulcer (T)	122	96·8
40. Educational programs may reduce the pressure ulcer incidence (T)	122	96·8
12. A timetable for decubitus change should be written for each patient (T)	121	96
23. Mobile sheets or bedding should be used to transfer or move patients (T)	121	96
29. Every person evaluated as at risk of developing pressure ulcer should be placed on a pressure reducing mattress (water mattress) (T)	121	96
26. Every patient admitted in the Intensive Therapy Unit should be subjected to a risk evaluation of developing pressure ulcer (T)	120	95·2
37. Friction may occur when the person is moved in bed (T)	119	94·4
30. The skin exposed to humidity is more easily damaged (T)	118	93·7
10. A diet intake suitable to the patient protein–calorie needs should be maintained during the disease (T)	117	92·9
25. Rehabilitation measures should be instituted if the general status of the patient permits (T)	117	92·9
21.The skin should remain clean and dry (T)	116	92·1
19. The people who remain in the chair should use a cushion for the chair protection (T)	114	90·5
22. Prevention measures are not required to prevent new lesions when the patient already has pressure ulcer (F)	114	90·5
7. Everybody, at admission, should be evaluated regarding the risk of developing pressure ulcer (T)	113	89·7
2. Risks of developing pressure ulcer: mobility; incontinence; suitable nutrition and alteration in the consciousness level (T)	112	88·9
35. All the administered care to prevent and treat pressure ulcers should not be documented (F)	108	85·7
18. The people who can learn should be oriented to change their weight every 15 minutes while sitting in the chair (T)	102	81
34. A measure to reduce the calcaneus pressure is to elevate them (T)	100	79·4
15. Laterally, the person should be in a 30 degree angle with the bed (T)	95	75·5
3. All the individuals at pressure ulcer risk should have a systematic skin inspection at least once a week (F)	93	73·8
41. Hospitalised patients need to be evaluated regarding the risk of pressure ulcer only once (F)	90	71·4
16. The bed should be raised and maintained in a low level of elevation(not higher than a 30 degree angle) in compliance with the clinical conditions and medical recommendation (T)	87	69
36. Shear is the power that occurs when the skin adheres to a surface and the body slides in the opposite direction (T)	81	64·3
4. Hot water and soap may dry the skin and increase the risk of pressure ulcer (T)	80	63·5
8. Starch, creams, transparent dressings and hydrocolloid dressing do not protect against the friction effects (T)	74	58·7
28. The osseous prominences may be in touch (F)	47	27·3
5. It is important to massage the osseous prominences if they are reddish (F)	32	25·4
11. Bedridden people should be repositioned every 3 hours (F)	26	20·6
13. Protector such as water gloves soothe the calcaneus pressure (F)	19	15·1
14. Donut‐shaped or ring‐shaped cushions help with the pressure ulcer prevention (F)	12	9·5
17. A person who cannot move should be repositioned while sitting in bed every 2 hours (F)	3	2·4

Based on the results, no relationship was found between nurses' years of experiences and their level of knowledge regarding pressure ulcer. Similarly, Teweed et al. (18) reported no association between years of experience and nurses knowledge about pressure ulcers. In contrast, Chienda et al. (17) reported negative correlation between years of nursing experience and their knowledge considering pressure ulcer.

LIMITATION

The respondents were predominantly female, which limits the generalisability of the results for male nurses. As this study was based on a convenient sample and the participation was voluntary, there might have been a selection bias that affected the possibility to generalise the results to all nurses. As about 300 nurses are working in the ICU units in southeast of Iran, the results could be generalised to all of them. Furthermore, use of the self‐reported questionnaires may have led to an overestimation of some of the findings because of the variance that is common in different methods.

CONCLUSION

This study provides Iranian nurses with some insights about their level of knowledge about pressure ulcer. The study showed that nurses had insufficient knowledge about pressure ulcer. Programs aimed at raising nurses' knowledge, accompanied by interventions intended to decrease incidence of pressure ulcer are important parts in educational programs. Continuing education may need to be added to the pressure ulcer care to improve the quality of care at ICUs. The results cannot indicate how nurses' knowledge applied in their clinical practice. This creates a need to further understand how nurses' knowledge reflected in their clinical performance. Future research is recommended to study nurses' knowledge in different areas, such as the emergency department, operating room, and any other department where the patient is at high risk of pressure ulcers development.