Pressure injuries (PIs) continue to be an important problem affecting healthcare institutions and patients globally, despite developments in the field of health, continuous training, as well as the publication of evidence-based practice guidelines.1 Apart from increased hospital stays, cost of care, and mortality and morbidity rates, PIs negatively affect patient quality of life by causing pain and discomfort, as well as psychosocial problems, such as anxiety, loss of independence and social isolation.1,2,3,4,5 In a meta-analysis, it was reported that the PI prevalence in hospitalised adult patients (surgical, medical, and ICU patients combined) was 12.8%.6 It is suspected that the prevalence of PIs in ICUs is, in fact, higher, as PI prevalence in adults in ICUs has been reported to be between 16.9 and 23.8%.7
Since the occurrence of a PI can have harmful effects on patient outcomes and can negatively influence healthcare costs, prevention of PIs is seen as an essential component of the quality of healthcare organisations. The National Pressure Injury Advisory Panel (NPIAP), the European Pressure Ulcer Advisory Panel (EPUAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) have published a guide offering evidence-based recommendations on the prevention and treatment of PIs, for health professionals.8 This guide includes steps such as formalised risk assessment, skin assessment, repositioning, as well as use of support surfaces. It also proposes regular evaluation of health professionals' knowledge and attitudes regarding the prevention and management of PIs, facilitating compliance with clinical guidelines, identifying potential obstacles and ensuring quality improvement actions. It also states that the evaluation of knowledge, the determination of training needs and appropriate interventions for the institution, as well as the development of evidence-based education and training can help prevent and treat PIs.8
A multidisciplinary approach plays a crucial role in preventing PIs, and nurses, who are bedside care providers and leading actors in healthcare,8 are a driving force in inpatient care, especially when it come to the prevention of PIs.9
Nurses working in intensive care units (ICUs), where PIs are most common, provide care to those patients at risk of developing PIs and/or who have developed PIs.10 It is noted that increasing awareness of the prevention of PIs—which is also considered an essential indicator in evaluating the quality of nursing care—will improve patient care.10,11 A study by Teo et al.11 reported that the prevention and management of PIs were improved by eliminating the knowledge–practice gaps. Another study suggested that after the PI prevention training programme, the prevalence of PIs decreased in ICU patients, reflecting the nursing preventive initiatives in the clinic.12
The present study was conducted to determine the level of knowledge and practices of ICU nurses in preventing PIs, as well as the relationship between this knowledge and the prevalence of PIs. The high prevalence in ICUs reveals the importance of these factors in regard to its prevention and, for this reason, our study makes a valuable contribution to the literature.
Methods
Study design
This study used a descriptive and correlational design.
Participants and setting
The setting was a tertiary hospital in Turkey. The hospital has 10 adult ICUs with a capacity of 126 beds. Patients with multi-organ failure and who are immobile are hospitalised and closely monitored in level 3 ICUs.
As stated in Guidelines for the Provision of Intensive Care Services, patients requiring advanced respiratory support alone, or basic respiratory support together with the support of at least two organ systems are hospitalised in level 3 ICUs.13 Patients in these circumstances are at higher risk of PIs and, for this reason, the study was carried out in these specific ICUs.
The hospital has a PI prevention protocol, which was first published in 2007 and last revised in 2019. This protocol defines the prevention of PIs and what to do if they develop. PI prevention is based on the evidence-based practice guidelines by the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance.8 This includes skin assessment, and risk assessment every shift using the Norton scale,15 repositioning, support surface use, moisture management and nutrition assessment.
ICU nurses are provided with a training programme on PIs. This programme starts when they begin working in the hospital, during the adaptation process and continues with in-service training every year. Training is provided by registered nurses working in the Directorate of Nursing Services and includes guidance on PIs, stages, risk factors, PI prevention, care and treatment.
The study participants were selected from those who met the following inclusion criteria:
- Working in the level 3 ICU for at least six months
- Voluntarily agreed to participate in the study.
Nurses who did not continue to fill in the forms following initial enrolment to the study were excluded from the final analysis.
Data collection
Data was collected from September–October 2018. After the purpose of the study was explained by the researchers, the nurses who met the research criteria were provided with the questionnaire forms. The nurses answered the questions individually during working hours and the time to complete these was approximately 20 minutes. In total, four instruments were used at the data collection stage.
Nurse information form
The first instrument was made up of sociodemographic data (age, profession, time in the profession and shift in the ICU). In addition, questions on PI training, experience and familiarity with PI prevention were included in this form (Tables 1 and 2).
Table 1.
Characteristics of the nurses (n=91)
| Characteristics | Total, n (%) | PI prevention knowledge level | Test value and p-value | |
|---|---|---|---|---|
| Sufficient, n (%) | Insufficient, n (%) | |||
| Age | ||||
| 20–25 years | 29 (31.9) | 4 (30.8) | 25 (32.1) | χ2=0.528 p=0.913 |
| 26–30 years | 31 (34.1) | 5 (38.69 | 26 (33.3) | |
| 31–35 years | 20 (21.9) | 2 (15.4) | 18 (23.1) | |
| 36 years and over | 11 (12.1) | 2 (15.4) | 9 (11.5) | |
| Mean±SD | 28.72±5.58 | t= –1.186 p=0.289 | ||
| Marital status | ||||
| Married | 51 (56.0) | 6 (46.2) | 45 (57.7) | χ2=0.718 p=0.699 |
| Single | 40 (44.0) | 7 (53.8) | 33 (42.3) | |
| Working time, years | 5.12±0.52 | t=1.121 p=0.186 | ||
| Education | ||||
| Bachelor's degree | 82 (90.1) | 12 (92.3) | 70 (89.7) | χ2=0.082 p=0.774 |
| Postgraduate | 9 (9.9) | 1 (7.7) | 8 (10.3) | |
| Work shift | ||||
| Day | 11 (12.1) | 1 (7.7) | 10 (12.8) | χ2=0.276 p=0.599 |
| Night | 80 (87.9) | 12 (92.3) | 68 (87.2) | |
| Clinics (intensive care) | ||||
| Internal medicine | 23 (25.2) | 3 (23.1) | 20 (25.6) | χ2=5.444 p=0.364 |
| Anaesthesia and reanimation | 20 (22.0) | 1 (7.7) | 19 (24.4) | |
| General surgery | 19 (21.0) | 5 (38.5) | 14 (17.9) | |
| Neurosurgery | 15 (16.4) | 3 (23.1) | 12 (15.4) | |
| Respiratory | 6 (6.6) | 1 (7.7) | 5 (6.4) | |
| Cardiovascular surgery | 8 (8.8) | – | 8 (10.3) | |
| Caring for pressure injuries* | ||||
| Nurse | 91 (100) | 13 (100) | 78 (100) | χ2=2.637 p=0.451 |
| Physician | 5 (5.5) | 1 (7.6) | 4 (5.1) | |
| Other health personnel | 15 (16.5) | 4 (30.7) | 11 (14.1) | |
| Frequency of encountering patients with pressure injuries | ||||
| Sometimes | 33 (36.3) | 6 (46.2) | 27 (34.6) | χ2=1.286 p=0.732 |
| Often | 44 (48.4) | 6 (46.2) | 38 (48.7) | |
| Always | 14 (15.3) | 1 (7.6) | 13 (6.7) | |
| Training on pressure injuries | ||||
| Yes | 30 (32.9) | 3 (23.1) | 27 (34.6) | χ2=0.671 p=0.413 |
| No | 61 (67.1) | 10 (76.9) | 51 (65.4) | |
| Training (n=30) | ||||
| In-service training | 15 (50.0) | 1 (3.3) | 14 (51.9) | χ2=2.037 p=0.565 |
| Course, congress and seminar | 15 (50.0) | 2 (66.7) | 13 (48.1) | |
| Reflection the training to nursing care | ||||
| Yes | 18 (60.0) | 3 (100) | 15 (55.6) | χ2=2.222 p=0.329 |
| Partially | 11 (36.7) | – | 11 (40.7) | |
| No | 1 (3.3) | – | 1 (3.7) | |
| Adequacy of nursing practices for the prevention/treatment of pressure injuries | ||||
| Sufficient | 11 (12.1) | 1 (7.7) | 10 (12.8) | χ2=0.639 p=0.726 |
| Partially sufficient | 69 (75.8) | 11 (84.6) | 58 (74.4) | |
| Insufficient | 11 (12.1) | 1 (7.7) | 10 (12.8) | |
*
More than one option has been marked;
χ2=Chi-squared test; t=independent sample test; SD–standard deviation
Table 2.
Nurses' Pressure Injury Prevention Knowledge Assessment scores
| Assessment scores | n (%) |
|---|---|
| Sufficient | 13 (14.3) |
| Insufficient | 78 (85.7) |
| Mean score, % | 43.2±11.4 |
Mean score: correctness mean score calculated over 100 points within the sample
Pressure Injury Prevention Knowledge Assessment instrument (PUKT)
The second instrument, PUKT16 had 26 questions on the prevention of PIs (Table 3), in the version adapted and validated in Turkish.9
Table 3.
Pressure injury prevention knowledge assessment categories
| Questionnaire category | Items in category, n |
|---|---|
| Aetiology and development | 6 |
| Classification and observation | 5 |
| Risk assessment | 2 |
| Nutrition | 1 |
| Preventive measures to reduce amount of pressure/shear | 7 |
| Preventive measures to reduce duration of pressure/shear | 5 |
In total, three response choices were given for each item, with only one being the correct answer. The total number of correct answers from each theme category, and of the entire instrument indicated individual knowledge levels. The maximum score was 26 and a mean knowledge score of ≥60% was considered to be satisfactory.17 In this study, ≥16 correct answers were accepted as sufficient. Cronbach's alpha value of PUKT was reported as 0.77 in Beekman et al.,12 and 0.80 in Tulek et al.,9 which shows that PUKT has an excellent overall internal consistency.
Nurses' Pressure Injury Prevention Practices form
The third tool was the Nurses' Pressure Injury Prevention Practices Form, developed and prepared by researchers utilising the Prevention and Treatment of Pressure Ulcers Clinical Practice Guideline.8 The form consists of 22 questions, including nursing practices to prevent PIs (Table 4). Each nursing practice in the form is rated as: ‘always applied’; ‘sometimes applied’; or ‘not applied.’ Prior to its use, five nurses tested the tool for readability, intelligibility, and completion time, before starting this study.
Table 4.
Nurse practices to prevent pressure injuries (PIs)
| Nurse's PI prevention practices | Always, n (%) | Sometimes, n (%) | None, n (%) |
|---|---|---|---|
| Risk assessment practices | |||
| Using a risk scale to identify individuals at risk of developing PIs | 56 (61.5) | 28 (30.8) | 7 (7.7) |
| Comprehensive evaluation of the risk of developing PIs on admission to the clinic | 47 (51.6) | 34 (37.4) | 10 (11.0) |
| Repeating the risk assessment regularly and frequently as required according to the individual condition of the patient | 41 (45.1) | 44 (48.4) | 6 (6.6) |
| If the patient is found to be at risk of developing PIs, making a prevention plan and implementing it | 46 (50.5) | 40 (44.0) | 5 (5.5) |
| Skin evaluation | |||
| Increasing the frequency of observation in case of any deterioration in the general condition of the patient | 37 (40.7) | 45 (49.5) | 9 (9.9) |
| Regular skin monitoring for signs of redness in patients at risk for PIs | 70 (76.9) | 20 (22.0) | 1 (1.1) |
| Observing the skin for pressure damage caused by medical devices and instruments (catheters, oxygen pipes, ventilators, semi-rigid neck collars, etc.) | 51 (56.0) | 39 (42.9) | 1 (1.1) |
| Evaluating whether the patient has any discomfort or pain indicating pressure damage in any part of the body | 47 (51.6) | 39 (42.9) | 5 (5.5) |
| Performing a full skin assessment | 64 (70.3) | 27 (29.7) | – |
| Recording the skin assessment | 45 (49.5) | 41 (45.1) | 5 (5.5) |
| Skin care | |||
| Using emollient/moisturising products to reduce skin damage to dry skin | 53 (58.2) | 37 (40.7) | 1 (1.1) |
| Not rubbing or massaging the skin at risk of PIs | 38 (41.8) | 41 (45.1) | 12 (13.2) |
| Nutrition | |||
| Evaluation of nutritional status | 60 (65.9) | 31 (34.1) | – |
| Providing adequate nutrition based on the appropriate diet | 62 (68.1) | 28 (30.8) | 1 (1.1) |
| Calculation and determination of nutritional requirements | 59 (64.8) | 30 (33.0) | 2 (2.2) |
| Re-evaluating the nutritional status of individuals who are at risk, at frequent intervals | 63 (69.2) | 26 (28.6) | 2 (2.2) |
| Comparison of calculated requirements with the amount of food that the patient has consumed | 53 (58.2) | 36 (39.6) | 2 (2.2) |
| Monitoring and evaluating nutrition results | 52 (57.1) | 35 (38.5) | 4 (4.4) |
| Repositioning | |||
| Repositioning in all patients at risk of developing PIs | 56 (61.5) | 35 (38.5) | |
| Determining the frequency of repositioning by evaluating the patient's tissue tolerance, physical activity and mobility level, general medical condition, goals of treatment and skin condition | 51 (56) | 38 (41.8) | 2 (2.2) |
| Support surfaces | |||
| Choosing the appropriate support surface considering factors such as the level of movement of the patient in the bed, comfort, temperature control, and care conditions | 45 (49.5) | 42 (46.2) | 4 (4.4) |
| Using foam mattresses with higher properties for all individuals who are at risk of developing PIs | 33 (36.3) | 32 (35.2) | 26 (28.6) |
Pressure injuries prevalence form
To determine the prevalence of PIs, patient risk assessment is performed by the nurses in ICUs every day and the patient's whole body is checked for PIs. Patients with PIs identified after observation were recorded in the PI data report. At the end of the three-month period, the prevalence was calculated as ‘the number of patients with PI×100/number of patients hospitalised in the ICU’. Prevalence values are given every three months and four times a year. Prevalence of PIs and nurses' knowledge of PI prevention was assessed from October–December 2018.
Ethical considerations
Institution permission was received from the relevant hospital, and ethical approval was obtained from the university human research ethics committees (EU-KAEK-2018/82). Nurses were informed about the study by the authors, and consent was obtained from them.
Data analysis
Statistical analyses were performed using SPSS 22.0 (SPSS Inc., US). The answer to each PUKT question was dichotomised (correct/incorrect). Descriptive data were presented in frequencies (percentages) and means (±standard deviation). A normality test (Shapiro-Wilk test) was applied to define the use of parametric or non-parametric tests. To test the difference in scores between the groups, one-way analysis of variance was performed when the grouping variable was 3 and above (ICUs, age, etc.), and independent sample t-tests were performed when the grouping variable was 2 (PI prevention knowledge level, sex, work shift). The Chi-squared test was used to determine the relationship between two categorical variables. A p-value of ≤0.05 was considered statistically significant.
Results
The population of the study consisted of 111 nurses working in level 3 ICU, of which 91 (82%) completed the study. The nurses' characteristics were presented comparatively according to insufficient/sufficient level of PI prevention knowledge.
The mean age of nurses who had sufficient and insufficient PI prevention knowledge was 27.23±6.32 years and 29.12±5.17 years, respectively. All the nurses stated that they carried out PI care in the ICUs where they worked. Most of the nurses (63.7%) frequently encountered patients with PIs and provided care but did not receive additional training on PIs. Those who previously received PI training did so from in-service training and courses, as well as through attending conferences and seminars. There was no statistical difference between the knowledge of PI prevention and the characteristics of nurses (Table 1).
According to the evaluation made using the PUKT scale in Table 2, the average score of nurses' knowledge in preventing PIs was 43.2±11.4%, with 14.3% of the nurses possessing a sufficient level of knowledge for preventing PIs.
No significant difference was found between the nurses' age, educational status, service duration, frequency of encountering PIs, their PI-related training status, and PUKT qualification/scores (p>0.05). The ICUs in which the nurses worked with the highest PUKT scores were: general surgery (26.3%); neurosurgery (20%); and pulmonary intensive care (16.7%). There was no significant relationship between these ICUs and the PUKT score (p>0.05).
When the nurses' practices regarding the prevention of PIs were evaluated, 50.0–76.9% of the nurses stated that they always performed the practices for 17 of the 22 questions (Table 4). No significant relationship was found between the nurses' age, educational status, duration of service, frequency of PI care, and PI-related training and PI prevention practices (p>0.05).
The comparison of PI prevalence with the knowledge scores of the nurses in various ICU settings is provided in Table 5. There was no relationship between PI prevalence in ICUs and PI prevention knowledge scores of ICU nurses. While the three-month PI prevalence of all ICUs was 6.4%, the anaesthesia and reanimation ICU had the highest PI prevalence among the ICUs, with 11.8%.
Table 5.
Relationship between nurses' scores and pressure injury prevalence
| Clinics (intensive care) | Assessment scores | PI prevalence |
|---|---|---|
| Internal medicine | 11.5±3.15 | %8 |
| Anaesthesia | 11.1±2.53 | %11.8 |
| General surgery | 11.6±3.59 | %2.4 |
| Neurosurgery | 11.8±2.69 | %2.4 |
| Respiratory | 10.8±2.31 | %7.4 |
| Cardiovascular surgery | 9.2±1.83 | %2 |
| Pearson correlation | r=-0.002 | p=0.984 |
Discussion
Level of knowledge
The study results show that nurses' knowledge of PI prevention was poor. Beeckman et al.17 similarly evaluated nurse's knowledge in preventing PIs with the PUKT scale and found that less than a quarter of the nurses had sufficient knowledge, with an average knowledge score of 49.7%. Kim et al.18 found that the average knowledge score of nurses was 48.85%, and in their systematic meta-analysis study, Wu et al19 noted that the knowledge level of nurses and nursing students about PI prevention is insufficient. Another study reported that 91.5% of participants had inadequate knowledge of PI prevention.21 In Iran and Nigeria, similar results were found by Tirgary et al. 21 and Uba et al.,20 respectively.,
The findings of low levels of nurses' knowledge about the prevention of PIs supports other studies in the literature. In particular, the fact that nurses work in intensive care and provide care to patients who are at high risk of developing PIs, further increases the severity of the situation and the urgent need for training and knowledge development in PI prevention. Despite regular training on PIs in the hospital, the reasons for the low scores on PI prevention knowledge should be investigated. In this regard, it is important to review the training content, which is one of the important factors that should increase knowledge. Training frequency can also be enhanced to ensure its effectiveness. After the training is provided, its impact on the level of knowledge and whether it has provided sufficient information should be evaluated.
Notably, some researchers have found that the nurses' knowledge levels were reasonably high. Nuru et al.23 reported that approximately half of the nurses (54.4%) had a good level of knowledge. The study found that the knowledge level of nurses was measured with an instrument designed by the researchers for the study. In addition, nurses who scored above the mean score for the knowledge questions, were considered as having good knowledge on the prevention of PIs.
Our study found no relationship between the nurses' age, educational status, experience, the clinic where they work, training on PIs, and knowledge levels. El Enein et al.24 found that the knowledge level of nurses was low, and that their clinical and professional experience had negligible impact on PI knowledge scores. Similarly, Ilesanmi et al.25 found no significant difference in PI prevention–intervention knowledge scores between nurses with different educational backgrounds or work experience.
On the other hand, some studies have shown that knowledge scores are higher in nurses who have received PI training. Beeckman et al.17 reported a statistically significant relationship between educational status, participation in additional education and knowledge. Tirgary et al.21 noted that as age, experience and PI education increased, nurses' PI prevention knowledge scores also increased. For their part, Nuru et al.23 found that there was a significant correlation between education, work experience and PI prevention knowledge level.
Level of practices
Most of the nurses in our study stated that practices to prevent PIs are always performed in ICUs. In the skin assessment section of the form, 70% of the nurses reported that the practice of ‘regularly observing the skin for signs of redness in patients with PI risk’ was ‘always applied’. According to the results, the practice of ‘using PI prevention mattresses instead of standard sponge hospital mattresses for all individuals with the risk of developing PIs’ was the least applied (36.3%).
Also, surprisingly, there was no relationship between nurses' PI prevention knowledge scores and their practices. Based on the nurses' responses, PI prevention practices were consistently applied, even with low knowledge scores.
This situation suggests that nurses did not provide information-oriented care, and only performed mandatory PI prevention practices as part of hospital care procedures. In addition, it can be thought that there is a disconnect between what the nurse can articulate versus what is done in practice. The PI prevention knowledge level of nurses can be increased by enhancing the training methods and/or increasing the training frequency. In addition, regular observation and evaluation of the nurses' clinical practices should be performed, to confirm the translation of information into behaviour following training. Observational studies can provide a more accurate assessment to determine the actual practices of nurses to prevent PIs.
Prevalence of pressure injuries
When the PI prevalence and knowledge scores of the ICUs were compared, the lowest PI prevalence and the lowest knowledge scores were seen in the cardiovascular surgery unit. This finding is most likely due to the small patient population of the clinic, short-term hospitalisation, and the short immobilisation period of the patients due to the surgical procedure. In addition, it may be that the nurses working in this clinic are working with individuals with a lower risk of developing PIs.
It was found that there was no relationship between the nurses' PI prevention knowledge scores and PI prevalence. This result supports our understanding that nurses do not provide information-oriented care and only provide practical hospital care.
Certainly, PI prevention and prevalence are not only a result of nursing interventions but are also affected by additional factors, such as types of beds, mattresses and medical devices for instance, quality of nurse/patient care, patient adherence to treatment and patients' clinical conditions. For example, a study by Strazzieri-Pulido25 revealed that nursing workload was a new predictor for development of PIs. It was shown that the rate of PIs was found to be higher in patients who were cared for by nurses with a higher workload. In addition, a review of the literature showed that major risk factors for PI development in ICU patients included age, diabetes, hypotension, mobility, prolonged ICU admission, mechanical ventilation and vasopressor administration.27 Nurses' level of PI prevention knowledge and practice cannot solely be expected to explain the prevalence of PIs in ICUs. In addition, the occurrence of unavoidable PIs is feasible even when all preventive measures are taken in critically ill patients.27
Implications for future research
The present results indicate that more research is needed to evaluate nurses' PI prevention knowledge and practices.
Observational studies to determine the actual practices of nurses to prevent PIs will help fill some of the current gaps in the literature. In addition, the impact of different training methods on increasing the knowledge of nurses can be evaluated.
Finally, considering that the prevalence of PIs is affected by many factors, studies on the prevention of PIs should be planned in consideration of the patients' condition and nurses' working conditions.
Limitations
Several limitations should be considered with regards to this study. The findings cannot be generalised to all ICU nurses, as the study was conducted with a small sample group. In addition, as PI prevention practices were evaluated based on the results of a questionnaire by nurses, we were unable to measure whether PI prevention practices are completed, as it is based on the nurses' voluntary answers to the survey questions. Another limitation of the study was its cross-sectional design, not allowing for longitudinal comparisons. Prevalence may not be the right strategy for comparing nurses' knowledge scores of PI prevention, and incidence is a more appropriate approach to measure PI prevention. Finally, although nurses were asked to complete the forms individually and not to communicate the answers with each other, this could not be guaranteed.
Conclusion
In this study, nurses referred to applying PI prevention practices, but their PI prevention knowledge level was insufficient. It may useful to plan in-service training that supports both theoretical and practical knowledge and applications, to improve knowledge and practices and raise awareness about PI prevention in nurses. In addition, it is recommended that this training be conducted in ICUs and that post-training practices are followed-up post-training practices regularly. Observational studies should be conducted to determine the nurses' actual rather than perceived practices of the prevention of PIs.
Reflective questions
- How do intensive care unit (ICU) nurses practice pressure injury (PI) prevention?
- How can ICU nurses build and maintain an adequate level of knowledge about prevention of PI?
- How are the ICU nurses' levels of knowledge and practice for PI prevention related to each other?
- How does PI prevention knowledge and its application affect PI prevalence?