A Descriptive, Cross-sectional Survey of Turkish Nurses’ Knowledge of Pressure Ulcer Risk, Prevention, and Staging
Abstract
Nurses’ knowledge of pressure ulcer (PU) prevention and management is an important first step in the provision of optimal care. To evaluate PU prevention/risk, staging, and wound description knowledge, a descriptive, cross-sectional survey was conducted among nurses working in an acute care Turkish hospital.
The survey instrument was a modified and translated version of the Pieper Pressure Ulcer Knowledge Test (PUKT), and its validity and reliability were established. Nurses completed a Personal Characteristics Form, including sociodemographic information and exposure to educational presentations and information about and experience with PUs, followed by the 49-item modified PUKT which includes 33 prevention/risk items, 9 staging items, and 7 wound description items. All items are true/false questions with an I don’t know option (scoring: minimum 0, maximum 49). Correct answers received 1 point and incorrect/unknown answers received 0 points. The paper-pencil questionnaires were distributed by 2 researchers to all nurses in the participating hospital and completed by those willing to be included. Responses were analyzed using descriptive statistics. Pearson’s correlation test was used to examine the relationship between quantitative variables, and mean scores were compared using the Mann-Whitney U and Kruskal-Wallis tests. Among the 308 participating nurses (mean age 29.5 ± 8.1 [range 19–56] years) most were women (257, 83.4%) with 7.3 ± 7.8 (range 1–36) years of experience. The mean knowledge score for the entire sample was 29.7 ± 6.7 (range 8–42). The overall percentage of correct answers was 60.6% to 61.8% for PU prevention/risk assessment, 60% for wound description, and 56.6% for PU staging. Knowledge scores were significantly (P <.05) higher for participants who attended at least 1 lecture/conference/course on PUs in the last year, read articles/books about PUs, cared for patients with PUs, or believed their patients were at risk for PU development. Most participants (180, 58.4%) scored 60% or more correct; 8 (2.6%) correctly answered 80% or more of the items. The lowest number of correct answers was for the item, “Bunny boots and gel pads relieve pressure on the heels” (22, 7.1%). The results of this study suggest education and experience caring for patients who are at risk for or have a PU affect nurses’ knowledge. This study, and additional research examining nurse knowledge, will help the development of much-needed education programs.
A pressure ulcer (PU) or pressure injury (the term currently recommended by the National Pressure Ulcer Advisory Panel1) is considered substantially preventable.2,3 However, a systematic review by Sullivan and Schoelles4 indicated the incidence of PUs increased 80% between 1995 and 2008, commensurate with an increase in the number of persons who are obese, have diabetes mellitus, and are elderly, and PUs remain an important problem for health care systems.5,6 PUs involve ischemic tissue loss over bony prominences due to excessive exposure to pressure,7 and friction and shear are important predictors of PU development.4 In a cross-sectional study8 using data from 14 different hospitals and community care sites in Norway (N = 146), the sacrum and heels were the most common sites.
In a consensus study9 conducted in 2014, immobility, existing and previous PUs, general skin status, perfusion, skin moisture, dual incontinence, diabetes, sensory perception, nutrition, and albumin were shown to increase the risk of PUs. PUs lead to increased mortality and morbidity, pain, lengthened hospital stays, and increased medical costs; thus, they negatively affect quality of life.2,6,10,11
In the United States, an estimated 2.5 million patients per year develop PUs.4 In long-term care units, the annual treatment cost of PUs is $355 million.5 In a systematic review in Canada, Woodbury and Houghton12 found the overall prevalence of PUs is high (26%). In Turkey, the prevalence is 5.4% to 17.5%.13 Inan and Öztunç11 found a PU prevalence of 10.4% among 404 patients in medical, surgical, and critical care units. In a cross-sectional, analytical study in Brazil among 140 hospitalized patients in 22 intensive care units, Gomes et al14 identified the following risk factors for PUs: hospitalization time >15 days, sensory perception (completely limited), moisture (constant and very moist), activity (bedfast), mobility (completely immobile), nutrition (inadequate), and friction and shear. PUs are considered a serious public health problem regardless of the scientific and technological advancements in medicine.15
Results of a descriptive study (N = 110) by Acaroglu and Sendir16 showed nurses are primarily responsible for the prevention and management of PUs. The core principle in PU prevention is to detect patients at risk and take the appropriate precautions.11 Assessment of skin and PU risk should guide nurses in risk reduction and precautionary actions, requiring that nurses have knowledge regarding PU prevention, risk assessment, diagnosis, and management.10 According to a systematic review,17 PU risk assessment and skin inspection should be performed at the first encounter with the patient and repeated at regular intervals and appropriate interventions such as support surfaces, regularly repositioning, optimizing nutritional status, and moisturizing/protecting the sacral skin instituted.4,17
Education programs have been shown to aid in the prevention of PUs and increase the quality of care.9,11 In order to achieve quality in care, nursing professionals need to have the scientific knowledge and ability to implement quality care while collaborating with colleagues on the interdisciplinary team to effectively serve patients with PUs.18,19 A descriptive, correlational study in Canada by Claudia et al2 reported nurse knowledge of PU level of risk, prevention, and staging is insufficient. Similar results were found in other descriptive studies.15,20,21 A national descriptive study in Turkey by Aydin and Karadağ22 determined nurses’ knowledge of prevention and management of deep tissue injury and Stage I PUs was inadequate.
The purpose of this study was to evaluate Turkish nurses’ knowledge of PUs regarding prevention/risk, staging, and wound description among hospitalized patients.
Methods
Study design and setting. The study was a descriptive cross-sectional survey design conducted in a 612-bed research and training hospital located in the European side of Istanbul during May and June 2015. After obtaining permission from the Hospital Research Ethics Committee, all nurses working at the study hospital received verbal information regarding the study objective. All nurses caring for patients and willing to participate were eligible.
Instruments. Paper-pencil questionnaires were distributed to all nurses in the participating hospital by 2 researchers and completed by those willing to participate. Researchers went to different clinics at different times in the hospital, and questionnaires were distributed to the nurses. The participants completed the test during working hours; the collected questionaires were stored in a steel, locked cabinet. Participants were assured their information would not be shared with other parties. Nurses who agreed to participate after receiving the information on the study objective were included in the sample.
Demographic questionnaire. A Personal Characteristics form included questions regarding age, gender, years of experience, exposure to educational presentations and books regarding PUs, and questions on whether their patients had or were at risk for PUs. The questions were multiple choice with the exception of items on age and years of experience.
Modified Pieper Pressure Ulcer Knowledge Test (PUKT). The PUKT was developed by Pieper and Mott23 in 1995. The original instrument is a 47-item test designed to measure knowledge of PU prevention/risk, staging, and wound description. The test includes true/false questions. Correct answers receive 1 point, and incorrect/unknown responses receive 0 points. The PUKT was used in numerous studies worldwide to evaluate the effectiveness of nursing clinical education programs.2,18,20,21,24
This study utilized the 49-item (33 prevention/risk assessment items, 9 PU staging items, and 7 wound description items) modified version used by Lawrence et al10 (1 question was removed and 3 new questions were added to the test), who reported that scores >70% corresponded to a satisfactory knowledge level and scores >80% and 90% indicated knowledge levels were good and very good, respectively.
The modified instrument was translated into Turkish by 2 people with English language proficiency and translated back to English to compare the original translation for this study. Minor changes were made to address spelling and meaning, and the number of items that corresponded to true/false answers, which previously were equal in number, were changed to 25 true and 24 false. In the current study, a third response category (I don’t know) was added to the test. Missing responses were accepted as “I don’t know” and received 0 points.
For content validity, the test was reviewed by 6 nursing professors who were experts in the field. The content validity index (CVI) was 0.918 for the entire test. Thus, the language equivalency and cultural adaptation of the modified version PUKT were determined and the test was found to be linguistically appropriate and valid.
Test-retest of the modified instrument to evaluate the reliability of the modified PUKT’s constancy over time involved 30 nurses. The level of consistency between test-retest mean scores was not statistically significantly different (t = 1.988, P = .056).The correlation coefficient was 0.926, and the relationship between the 2 test scores was determined to be highly significant (P = .000). The internal consistency reliability Cronbach’s alpha of the test was 0.814 for all items.
Kuder-Richardson and Kappa statistics tested validity, internal, and test-retest reliability with statistical significance set at P <.05. The Kuder-Richardson 20 value, which was calculated for testing internal reliability, was found to be 0.735. The Kappa value was determined to be 0.646; thus, the test had good interrater reliability. The mean cut-off score for proficient knowledge was 60%.
Statistical collection and analysis. Data were analyzed using the Statistical Package for Social Sciences software program version 21.0 (SPSS, Chicago, IL). Descriptive statistics were used to analyze all PUKT items, and mean scores for the total modified PUKT scores were calculated. The number of correct answers was divided by the total number of items and multiplied by 100 to calculate the percent of correct answers. Pearson’s correlation test was used to correlate quantitative variables, and the Mann-Whitney U and Kruskal-Wallis tests were used to compare the mean score of independent groups. P value was set at α = .05.
Results
The total number of eligible nurses was 420; of these, 312 volunteered to participate in the study, a response rate of 74.3%. Four (4) questionnaires were excluded due to missing data. The final sample size was 308. The mean age among the study participants was 29.5 ± 8.1 (range 19–56) years. Most were women (257, 83.4%), with 7.3 ± 7.8 (range 1–36) years of experience; 7 (2.3%) had participated in a 1-week training program on wounds and PUs. One hundred, forty-eight (148, 48%) of the participants attended a lecture/conference/course on PUs within the past year, 229 (74.4%) read articles/books on the subject, 174 (56.5%) cared for patients who developed PUs, and 230 (74.7%) reported their patients were at risk for PUs (see Table 1). 
The participants’ mean knowledge score for the sample was 29.7 ± 6.7 (range 8–42). For total score, 180 (58.4%) scored 60% or more on PU knowledge; 128 (41.6%) obtained 60% or below. Knowledge of PU prevention/risk assessment was strongest with a score of 20.4 out of 33 (range 4–29, 61.8%), followed by 4.2 out of 7 (range 0–7, 60%) for wound description and 5.1 out of 9 (range 0–9, 56.6%) for PU staging. Eight (8) nurses (2.6%) correctly answered 80% or more of the items.
A weak negative correlation was noted between age and total score (r = -0.197; P = .001). No correlation between years of experience and total score of the nurses was noted (r = -.051; P = .371).
The total score was statistically higher among nurses who read articles/books about PUs (P = .002), cared for patients with PUs (P = .005), and took patient risk for PUs into consideration (P = .000). Knowledge scores were generally higher among participants who had attended at lecture/conference/course on PUs within the past year (148, 48.1%). Using the Kruskal-Wallis test, a statistically significant difference in average scores was noted between persons who attended a course/conference on PU during the year preceding the test compared to participants who attended 4 years earlier (P = 0.001) or who never attended (P = .013)
Analysis of knowledge items indicated that 287 nurses (93.2%) correctly answered, “Some risk factors for development of PUs include immobility, incontinence, impaired nutrition, and altered level of consciousness.” Two hundred, seventy-three (273, 88.6%) correctly answered the question, “All care given to prevent or treat PUs must be documented.” Two hundred, sixty-eight (268, 87%) correctly answered the item, “It is necessary to assess the patient’s risk for PUs and to establish a rotation schedule which will be noted on the bedside.” The lowest number of correct answers were to “Bunny boots and gel pads relieve pressure on the heels” (22, 7.1%), “A Stage 3 PU is a partial-thickness skin loss involving the epidermis and/or dermis” (38, 12.3%), and “Persons who can be taught should shift their weight every 60 minutes while sitting in a chair” (38, 12.3%) (see Table 2).
Discussion
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.
Limitations
The study sample only included nurses working in 1 acute care hospital. In addition, participants volunteered for the study, which may have biased the results in favor of nurses interested in the topic of PUs. Also, the nurses verbally expressed the concern that the questions were difficult. As a result, the findings of the current study cannot be generalized to the population of nurses in Turkey.
Conclusion
The prevention of PUs is a marker of quality of care, and nurses play a vital and major role. The results of this study that employed a modified version of the PUKT to assess nurses’ knowledge indicate significant knowledge gaps regarding PU prevention/risk, staging, and wound description. Education programs should be planned to provide nurses the knowledge necessary; knowledge and practice should be monitored and updated continuously. The findings of the current study demonstrated that education programs for nurses can increase knowledge and should be expanded to include PU staging, diagnosis, and treatment. Exploratory, descriptive, and quantitative studies are needed for determining the optimal content of nursing education programs. n
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Potential Conflicts of Interest: none disclosed
Dr. Gul is an associate professor, University of Health Science, Faculty of Health Science, Istanbul, Turkey. Dr. Andsoy is an assistant professor, Karabük University, Faculty of Health Science, Karabük, Turkey. Ms. Ozkaya is a staff nurse, General Surgery Unit; and Ms. Zeydan is a staff nurse, Intensive and Critical Care Unit, Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey. Please address correspondence to: Asiye Gul, PhD, Mekteb-i Tıbbiye-i Şahane, Selimiye Mah. Tıbbiye Cad. No:38, 34668 Üsküdar, Istanbul, Turkey; email: asiye.gul@sbu.edu.tr or asiyegul2003@yahoo.com.