This is the first study to assess ICU nurses’ PU prevention knowledge, attitude, and barriers to care in Turkey. ICU nurses were found to have low levels of PU prevention knowledge; participants scored lowest in questions related to PU etiology and development and scored highest with regard to items related to the importance of nutrition. A descriptive study conducted by Özdemir and Karadağ32 in Turkey determined the behaviors least exhibited by ICU nurses (N = 30) in preventing PUs were applying a skin barrier to damp skin, protecting the skin during patient transfer, repositioning, applying moisturizer to dry skin, and documentation. In the same study, helping the patient eat was the most frequently fulfilled practice by nurses in preventing PU. This confirms nurses are more likely to perform the practices they know about and less likely to perform those they do not know, if at all.
The study by Beeckman et al13 among nurses in internal medicine, surgical units, and ICUs in Belgium, using the same PUPKAI-T scale as the current study to measure nurse knowledge levels, reported a low level of knowledge among ICU nurses (N = 68; 12.5/26 questions; 48.2%), which is in agreement with the findings of the current study. Other cross-sectional studies21-23,40 also have reported medium or low levels of knowledge among ICU nurses in preventing PUs.
A study by Tweed and Tweed24 involving a pretest for an education program offered to ICU nurses (N = 62) in a university hospital in New Zealand, reported high PU knowledge scores (mean score of nurses: 84%), unlike other research cited herein. A descriptive cross-sectional study by Strand and Lindgren16 of ICU nurses (N = 146) conducted in a university hospital in Sweden reported a high level of knowledge among nurses regarding PU risk factors (46.8% of the nurses answered correctly). A descriptive study by Köse et al41 (N = 73) conducted in the ICUs of a university hospital in Turkey reported high levels of knowledge among the nurses in preventing PU (34.97 ± 4.43; score range 24–50). A descriptive study by Aydın and Karadağ42 (N = 162) conducted in Turkey reported insufficient knowledge levels among the ICU nurses in preventing Stage I PUs and deep tissue damage (mean correct score of nurses: 49.20%). Different countries, hospital types, level and type of education, and priorities of the nurses all could be responsible for the differences in reported knowledge levels.
Another reason for insufficient knowledge levels might be outdated and inadequate content in the basic education provided to nurses. Wilborn et al43 conducted a content analysis of the PU chapters in the textbooks most frequently used in German general and geriatric nursing education that showed only a quarter of the resources used by education programs of 92 schools were compliant with the German Expert Standard of Pressure Ulcer Prevention; the rest of the textbooks used by the nursing students had insufficient content. The same study reported some textbook authors did not refer to available scientific research on preventing PU. In Turkey, a review of the literature reported studies published by nursing researchers are not used by clinical nurses.44 The fact that the nurses scored low on the knowledge scale in this study supports previously reported findings.43,44
A statistically significant correlation was not found between the knowledge levels of nurses and the education program they graduated from or their work experiences (P >.05). A descriptive study by Iranmanesh et al40 conducted among ICU nurses (N = 126) in Iran and the study by Tweed and Tweed24 also did not find a significant correlation between nurses’ knowledge levels and work experience. After offering an educational program to 32 ICU nurses in the US about preventing and staging PUs, Miller et al25 did not find any significant correlation between work experience and knowledge levels of the nurses. However, knowledge levels are expected to increase with more work experience, especially if nurses receive postgraduate education about preventing PUs, attend scientific activities such as congresses and symposiums, and follow professional periodicals. A large majority of the nurses in the current study reported they did not attend any scientific activities and half of them said they did not receive any education about preventing PUs after graduation. In agreement with current findings, many studies have reported that the majority of nurses do not receive education about preventing PU after graduation.14,26,27
An intervention study by McCluskey and Lovarini45 demonstrated that continuous education was effective in improving knowledge levels but was insufficient in creating behavioral changes. However, attitude was reported to impact behavioral change.46
This study found ICU nurses had a positive attitude toward preventing PUs. These results are similar to other studies conducted in ICUs that determined nurses had positive attitudes in this respect.13,16,30,31,47 However, the descriptive study by Beeckman et al13 reported the attitudes of ICU nurses toward preventing PUs were below the satisfactory level (75%). A descriptive study by Aslan and van Giersbergen31 conducted in Turkey demonstrated ICU nurses had a positive attitude regarding preventing pressure injury. Results of a descriptive, multimethod study in Sweden by Sving et al48 showed licensed nurses (N = 9) did not view PU prevention as a care priority and provided fewer preventive interventions.
Individuals with extensive knowledge have been reported to be more flexible and tolerant in their attitudes and behaviors compared to others, and this flexibility increases positive behavior.46 The current study found a weak but significant positive correlation between nurses’ attitude scores and knowledge levels regarding PU prevention (P <.05). Similar to the current study, Beeckman et al13 determined a weak significant correlation between the knowledge levels and attitudes of nurses (N = 553). In their cross-sectional multicenter study in Belgium (N = 145), Demarre et al28 did not find a significant correlation between knowledge levels and attitudes of nurses and assistant nurses.
The most frequently experienced barriers in preventing PUs by the nurses in the current study were low nurse staffing levels, insufficient pressure-redistribution materials and equipment, and insufficient numbers of assistive personnel. In the descriptive study by Mirshekari et al29 in Iran (N = 88 nurses), the most cited barrier to carrying out PU prevention was inadequate knowledge about PUs (64.8%). In the study by Strand and Lindgren,16 the most important barrier in preventing PUs was insufficient time (57.8%).
More than half of the nurses in the current study reported a lack of knowledge as a barrier to preventing PUs. At the same time, a large majority of the nurses expressed a willingness to obtain PU prevention education. These findings suggest nurses are aware of their lack of knowledge. However, the information provided in courses should reflect on practice, be up to date, and be reinforced. Otherwise, education cannot be expected to significantly impact knowledge levels.
A review of the literature49 has shown preventing PUs requires total team effort. If all members of the team do not contribute fully, the efforts of other members might be insufficient. Staff shortages in all areas can cause extreme stress and overload. It is very difficult to perform the necessary duties to prevent PUs, such as changing the patient’s position, without the required assistive personnel. Having an insufficient number of nurses results in more patients per nurse, which affects nurses both physically and mentally. As a result, the health care offered to patients may not be high quality. Cross-sectional studies14,50 have shown if a lack of nurses and assistive personnel remains unresolved for a long period of time, preventing PUs is not a high priority.