This study utilized a modified version the Pieper PUKT, adapted into Turkish. Once the reliability, content, and construct validity of the new Turkish version were established, the test was administered to nurses in a Turkish hospital. Test results showed gaps in nurses’ knowledge of PUs prevention/risk, staging, and wound description; only 8 participants (2.6%) scored above 80% and none of the items was answered correctly by all participants.
In a descriptive study in 1995 (N = 228) by Pieper and Mott using the PUKT,23 participants achieved a mean score of 76%. In an Australian study by Lawrence et al10 (N = 827) using the PUKT, participants achieved an overall mean score of 79% with mean scores of 77.1% for PU prevention, 80.8% for staging, and 85.1% for wound description (the highest score); 15 participants (1.8%) scored 90% and above. In a 2012 descriptive study by Ilesanmi et al21 (N = 111), the range of PUKT scores was categorized as follows: 80% for high knowledge; 59% to 79% for moderate knowledge, and <59% for low knowledge. The authors reported that evidence-based interventions for PU prevention were inadequate because 70.3% participants scored 59%.21 Based on the results of their 2010 study, Claudia et al2 concluded nurses’ knowledge of PUs is largely insufficient. In a descriptive study22 conducted in 2010 among 237 neurology, orthopedics, physiotherapy, rehabilitation, and intensive care nurses in 3 hospitals in Turkey, the authors concluded nurses had inadequate knowledge of Stage I PUs and deep tissue damage, similar to the results of the current study.
In the current study, nurses had better but not sufficient knowledge levels regarding PU prevention/risk assessment than PU staging. Ilesanmi et al21 reported 95.5% of nurses correctly defined the risk factors for PUs. The Braden Pressure Ulcer Assessment Scale was administered to all hospitalized patients in this study, so nurses’ sensitivity and knowledge related to the subject may be higher. Nevertheless, the results did not reach desirable levels.
Years of experience and total mean knowledge score were not significantly correlated. However, a weak negative correlation was noted between age and the mean knowledge score: as participant age increased, the total score decreased. Similarly, in a 2016 cross-sectional study (N = 105) using the PUKT in Saudi Arabia, Kaddourah et al25 found younger participants had significantly higher mean knowledge scores than the older group. This finding may seem contradictory; however, it might be explained by the fact that the younger participants had more up-to-date knowledge from recent education and more efficient use of the internet and computers. In this study, participants who had recently attended a lecture/conference/course on PUs had higher knowledge scores than those who did not. According to a prospective, quasi-experimental study by Gonçalves et al,24 participation in lectures provides opportunities both for the process of learning knowledge and for developing teaching skills. Participants who read material on PUs, had patients with PUs, and reported risk for PUs in their patients had higher mean scores. In the study by Aydin and Karadag,22 the mean knowledge score for deep tissue damage and Stage I PUs obtained by nurses who had clinical experience with PUs patients was higher than the mean scores of persons who did not have clinical experience caring for patients with PUs. A cross-sectional study (N = 426 nurses) by Aslan and Yavuz van Giersbergen13 using the Attitude Towards Pressure Ulcer Prevention Instrument found a statistically significant difference according to whether the nurses had read the European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel Pressure Ulcer Treatment Quick Reference Guide. Similarly, Zulkowski et al26 reported knowledge scores showed a significant difference between nurses who read relevant books and articles versus those who did not (100% versus 63%). The current authors believe that if nurses seek information about the PUs, their knowledge may increase.
In this study, the top 3 items correctly answered by the majority of participants involved prevention/risk assessment. Almost all nurses (93.2%) reported that lack of mobility, incontinence, malnutrition, and alterations in consciousness were risk factors for PUs. The next item most commonly answered correctly was “All care given to prevent or treat pressure ulcers must be documented.” Nurses need to record all care provided for the patient; nurses should know about risk factors and be diligent about keeping records.
Although most participants believed heel protectors and gel pillows reduce pressure on the heels, Zulkowski et al26 reported that vascular boots and heel protectors do not adequately prevent PUs. In another study,21 all participants believed it is important to massage bony prominence and that ring pillows are used for preventing PUs. Lawrence et al10 reported that 93% of nurses were unaware massage and 81% were unaware ring pillows are no longer recommended for PU prevention. These findings indicate the knowledge of many nurses is out-of-date and needs refreshing.
In the current study, approximately 75% of the participants correctly answered the item, “The incidence of PUs is so high that the government has appointed a panel to study risk, prevention, and treatment.” Although such practices are unavailable in Turkey, this item was not deleted from the test because the authors wanted nurses’ opinions on this subject (ie, leaving it in would not make a significant difference in terms of nurses’ knowledge/scores of PUs). Slightly more than half of the participants reported they did not know the answer to the item, “Reactive hyperemia disappears within 45 minutes.” However, reactive hyperemia is a first external sign of ischemia due to pressure and generally resolves within half to three quarters of the duration of pressure.27 In the study by Lawrence et al,10 the proportion of persons with the correct response was 52%. In education programs, staging of PUs, in particular, should be taught. Education and training should address material in the questions that are consistently answered incorrectly.