Pressure Ulcer Knowledge Among Nurses in a Brazilian University Hospital
To facilitate the implementation of evidence-based skin and pressure ulcer (PU) care practices and related staff education programs in a university hospital in Brazil, a cross-sectional study was conducted to evaluate nurses’ knowledge about PU prevention, wound assessment, and staging. Of the 141 baccalaureate nurses (BSN) employed by the hospital at the time of the study, 106 consented to participate. Using a Portuguese version of Pieper’s Pressure Ulcer Knowledge Test (PUKT), participants were asked to indicate whether 33 statements about PU prevention and eight about PU assessment and staging were true or false. For the 33 prevention statements, the average number answered correctly was 26.07 (SD 4.93) and for the eight assessment statements the average was 4.59 (SD 1.62). Nurses working on inpatient clinical nursing units had significantly better scores (P = 0.000). Years of nursing experience had a weak and negative correlation with correct PUKT scores (r = -0.21, P = 0.033) as did years of experience working in the university hospital (r = -.179, P <.071). Incorrect responses were most common for statements related to patient positioning, massage, PU assessment, and staging definitions. The results of this study confirm that nurses have an overall understanding of PU prevention and assessment principles but important knowledge deficits exist. Focused continuing education efforts are needed to facilitate the implementation of evidence-based care.
Potential Conflicts of Interest: none disclosed. This study had financial support of CAPES (PQI) and CNPq (Dr. Caliri’s research fellowship) and FAPEMIG (Honor Student Support).
Nurses have a duty to monitor patient skin in order to plan, implement, and evaluate interventions that maintain skin integrity. Work quality has been found to be related to the knowledge they have in this field.1
The quality of care provided to patients regarding wound management and protection of skin integrity is an important concern. The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) proposes that pressure ulcers (PUs) should be a healthcare quality indicator.2 The incidence of pressure ulcers in critical care units is considered an institutional quality of care outcome indicator by National Organization for Accreditation of Healthcare Institutions in Brazil.3
Several tools facilitate the systematic evaluation of a patient’s risk of developing a PU. The Norton and Braden scales were first mentioned in the Agency for Health Care Policy and Research (AHCPR) guideline4 as validated tools for evaluating PU risk. Later, the European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Ulcer Advisory Panel (NPUAP)5 agreed that the Norton and Braden scales are validated risk assessment tools that may be used in combination with a comprehensive skin assessment and clinical judgment to create a structured approach to identify individuals at risk for developing PU. When individuals are identified as being at risk for developing PUs, this information should be used to create and implement a PU prevention plan according to EPUAP/NPUAP prevention guidelines.
Pieper and Mott6 developed the Pressure Ulcer Knowledge Test (PUKT) to evaluate nurses’ knowledge about risk and prevention, PU staging, and wound description. The PUKT consists of 47 items and is scored by tabulating the number of correct responses. Items left unanswered or answered Don’t know are considered incorrect. The tool was tested for reliability and coefficient alpha values were .85 for the total score, .80 for the prevention subscore, .49 for staging subscore, and .59 for the wound subscore.7
In a survey conducted with a convenience sample of 228 registered nurses, Pieper and Mott6 found the mean number of correctly answered items was 33.7 (SD 4.5); of the 47 items, only 17 were answered correctly by 90% or more nurses. Higher knowledge scores were associated with how recently a nurse attended a lecture or read an article about PU. In another survey involving 75 critical care nurses, Pieper and Mattern7 found the percentages of correctly answered items on the same test ranged from 15% to 83%. The study revealed a knowledge deficit about PU among this group of nurses.
In Brazil, Caliri et al8 evaluated the knowledge and experiences of undergraduate nursing students regarding PU assessment and prevention using the test developed by Pieper and Mott6 adapted to Portuguese culture. The findings (mean score 67.7%) showed a knowledge deficit. Test scores were higher among nurses who participated in extracurricular activities or used the Internet to seek information about PU.
Rangel and Caliri9 also examined knowledge and nursing practice regarding PU prevention and treatment among a small number of nurse professionals from a hospital in the state of Sao Paulo. Using the Pieper test adapted to Portuguese, the study revealed that 36% of the respondents obtained accuracy rates between 51% and 69.9% and that 60% answered more than 70% of the items correctly. As the first step in introducing evidence-based skin care practices and implementing a staff education program in a university hospital in Brazil, a study was conducted to evaluate the knowledge about PU prevention and wound evaluation among nurses with a Bachelors degree (BSN). The purpose of this study was to examine Brazilian nurses’ knowledge of PU prevention, assessment, and staging. The following research questions were examined:
1. What do Brazilian nurses know about pressure ulcer prevention, assessment, and staging?
2. Is there a difference between knowledge scores among nurses related to work setting, years of experience in nursing, or years of working in this hospital?
The cross-sectional study was approved by the Institutional Review Board of the University Hospital and informed consent was obtained in writing from nurses who agreed to participate in the study.
Participants and setting. A convenience sample of 106 BSNs from every unit of a University Hospital in Belo Horizonte, Minas Gerais, Brazil participated in the study. The hospital is public (free) and part of the Brazilian Public Health System. It serves as a referral center for acute care within the municipal and state health system. With 467 beds and 1,600 admissions per month, the hospital offers universal access to internal medicine, surgery, and intensive care and provides diagnoses and therapy in various specialties. At the time of the study, the hospital employed 141 RNs with BSN degrees; all nurses were invited to participate, including BSNs in hospital settings without high-risk patients because these professionals may rotate to units with PU patients and provide direct or oversee patient care of these patients.
Instruments. The PUKT used in the survey was adapted to Portuguese and consists of two parts. The first covers information on demographics and educational background including nurse age, years of nursing experience, time in profession, type of academic education, and workplace. The second part is a questionnaire. In its original version, this part featured 47 questions with content based on AHCPR (now the Agency for Healthcare Research and Quality [AHRQ]) guidelines.4,6 After translation/adaption to Portuguese, the Brazilian version has 41 items with changes made by Pieper and Caliri10 to better represent nursing practice in Brazilian health institutions — 12 questions from the original version were deleted, seven were added, and minor word changes were made. nbsp;Expert face and content validity of the translated PUKT was obtained.11 Five of the seven deleted questions were related to wound description and six related to PU risk assessment and prevention practices. Of the seven added items, four were related to interventions to minimize pressure, two to risk assessment, and one to patient/caregiver education. One item related to vascular boots was deleted because this product is not used in Brazil. The item about heel protectors was modified to reflect the practice in some Brazilian hospitals of placing water-filled gloves under the heels. The item that stated, “The incidence of pressure ulcers is so high that the US government has appointed a panel to study risk, prevention, and treatment,” was deleted because it is does not pertain to Brazil.
In addition, items related to a low-humidity environment and materials that should be used to absorb moisture that are not common in Brazil were replaced by statements about required practice in the country; specifically, “Dependent patients should be repositioned or transferred by two individuals” and “Turning or lift sheets should be used to turn or to transfer patients.” Also included were items about procedures that may be misinterpreted by nurses12 such as, “Continuous prevention measures do not need to be used even when an individual has a pressure ulcer already.” On the 41-item revised test, eight questions are related to PU assessment and staging and 33 to risk assessment and prevention. All items of this test are still valid today considering the evidence presented on new guidelines for PU prevention.5
The PUKT responses are: true (T), false (F), or “Do not know” (NK). All items answered incorrectly, left unmarked, or answered NK were considered incorrect. The coefficient alpha value for the total score of all nurses was .83.
Procedures. Data were collected by the researchers and five previously trained assistants over 30 consecutive days. Nurses were invited to participate and after the study procedure was explained, they received a copy of the paper-and-pencil instrument. The participants completed the instrument in the presence of the researcher/researcher assistant in a room close to the nursing station and returned it to the research assistant who waited at the unit. Nurses took the time necessary; no time constrictions were applied.
Data analysis. The number of correct responses for each of the 41 items on the PUKT were counted and used to calculate the scores for PU prevention items, PU assessment and staging, and total score. Percentage of correct responses for each item of the PUKT was calculated, considering the number of nurses who answered that specific item (see Table 2 and Table 3). Descriptive statistics were used for all demographic variables and a t-test was used to examine group differences. A Pearson correlation test was used to examine the relationship between years of nursing experience and working in this hospital and PUKT scores. All data were analyzed using SPSS 17.0 statistical software (Chicago, IL) and a variable was found to be statistically significant if P <.05.
Participants. Of the 141 potential participants, 35 were not involved in the study because they were on vacation or did not agree to participate. The participating nurses’ ages ranged from 25 to 58 years, (M = 46.3, SD 18.5). Thirty-seven (37, 34.9%) reported more than 15 years experience in direct patient care, 33 (31.1%) reported working >5 years, and 59 (55.7%) provided direct patient care in adult and children’s medical surgical units or in ICUs. More than half of study participants (62, 58.5%) had completed a graduate specialty course in a clinical area but none had completed a wound care education program. Eight nurses (7.5%) had a master’s degree (see Table 1).
Knowledge of PU prevention. The first research question examined nurses’ knowledge about pressure ulcers. Nurses correctly answered between 61% and 75% of PUKT items (M = 26.07, SD = 4.93, range 25–31). The mean correct score for the 33 PU prevention items was 21.5 (SD 3.97). Only 14 items (42.4%) were answered correctly by 90% or more of the nurses (see Table 2).
Five items(15.15%) were answered correctly by 76.41% to 89.62% of participants and 13 items (39.39%) were answered correctly by <64.15%. Items with the lowest proportion of correct answers (<50%) were related to interventions recommended to minimize pressure, friction, and shear such as the use of pressure-reducing bed surfaces, positioning the patient at a 30˚ angle in a sidelying position, and frequency of repositioning individuals in bed or in a chair. Incorrect statements about PU prevention practices such as the use of donut/ring cushions/water gloves for prevention were frequently marked as correct instead of false. For these items, the proportion of correctly answered items ranged from 33.96% for “Stage II pressure ulcers are a full-thickness skin loss to 99% for “A blister on the heel is nothing to worry about” (see Table 3).
The arithmetical mean of correct answers related to the eight items on PU assessment and staging was 4.59 (SD1.62). The item stating that a blister on the heel is nothing to worry about was correctly identified as false by 93.4% of the nurses (see Table 3). Four items related to PU stage description and definitions were answered correctly by >56.60% of participants.
Nurses’ work setting and experience. The second research question examined the relationship between nurses’ work setting, experience, and total PUKT scores. The 59 BSN nurses who worked on direct care in adult and children’s medical-surgical units or in ICUs had higher correct scores on the PUKT (M = 27.52, SD 2.86) than the 47 BSN nurses who worked on Ambulatory or Special Units for outpatients, the maternity unit, or indirect care (ie, actions taken away from but on behalf of the patient, including patient care environment management and interdisciplinary collaborations to support the effectiveness of direct care interventions13) (M = 24.28, SD 6.28; t-test for Equality of Means P <.002). In other words, the 47 BSN nurses who worked on Ambulatory or Special Units for outpatients, or on the maternity unit, or who mainly perform treatments away from their patients but on their behalf or are involved in management of the patient care environment had fewer correct answers on the PUKT test.
Years of nursing experience had a weak and negative correlation with correct PUKT scores (r = -0.21, P = 0.033), as did years of experience working in the university hospital (r = -.179, P <.071).
Evaluating BSN knowledge of PUs using the PUKT was the first step in a program to introduce evidence-based skin care practices and implement staff education programs in a university hospital in Brazil.
Overall scores. Nurses correctly answered 61% to 75% of the 41 PUKT items (M = 26.07). For the 33 PU prevention items and the eight items related to pressure ulcer assessment and staging, the means for correctly answered questions were 21.5 and 4.59, respectively. The results of this study suggest that staff education programs about PU prevention, assessment, and staging are needed.
Scores by nursing unit and experience. Nurses working on direct care units such as adult and children’s medical-surgical units or ICUs had higher scores on the knowledge test than BSN nurses working on Ambulatory, Special Outpatient, and Maternity units and than nurses providing indirect care. Nurses with more years of nursing experience in general and more years working in this university hospital had lower scores on the PUKT than nurses with fewer years experience. Probably, more recent graduates have better knowledge because the curriculum has improved; on the other hand, this result also may imply that the institution and older nurses are not updating their knowledge/competency in this area. In Brazil, nurses earn their licenses but are not required to pursue continuing education for license renewal as in the US and Canada. The only requirement is payment of a yearly fee.
These results confirm that in order to provide evidence-based care, education strategies should include all nursing staff. Results of a comparative study conducted to evaluate the effect of educative interventions on nursing staff knowledge about PU prevention involving 50 nursing team members conducted by Fernandes et al11 in an intensive care center in Brazil showed that educational interventions affected the knowledge of nursing team professionals and some aspects of clinical practice regarding prevention of PU. All participants had contact with the educative strategies such as reading booklets and viewing posters; however, only 30% of the nurses participated in classes and group discussions. Thirty-two professionals completed the testing instrument in the pre-intervention stage (seven RNs and 25 nurse technicians or nurse auxiliaries). In post-intervention testing, none of the RNs completed the instrument compared to 36 nurse technicians and nurse auxiliaries, whose correct answers to questions on PU prevention improved from 76% to 84.3% and on PU staging from 64% to 72.2%. Using the original test designed by Pieper and Mott in a research study16 of 460 registered nurses in the US, 78% of participants performed well; nurses with wound care certification scored higher (89%, SD 4) than those without wound care certification (76.5%, SD 8), and some items were answered incorrectly by both nursing groups. Programs and strategies to help nurses improve their PU knowledge base and implement evidence-based care have been developed.14
In Brazil, all RNs have a baccalaureate degree and primarily function as administrators and supervisors of other nursing personnel (nurse technicians and auxiliaries). Nursing practice is regulated by a federal nursing council and monitored by a state nursing council. Nurses provide direct care of seriously ill patients and plan, organize, coordinate, and evaluate patient care. Based on patient assessments and patient goals of care, BSN nurses prescribe plans of nursing care and delegate implementation of the plan to nursing assistants.10 As in the US, nurses are expected to have the knowledge to assess patients, develop plans of care, and educate staff about providing care, documentation, and outcome evaluation.5 PU prevention needs to be discussed within the context of the nursing process15 and recommendations from clinical guidelines incorporated in each step of the nursing process and educational and management programs to help disseminate and evaluate evidence-based nursing practices.
Comparing scores from previous studies. Similarities between results of this and a 2003 study involving Brazilian nursing students8 were observed. In the 2003 study, one question examined the impact of extracurricular learning (reading, such as texts for courses, dissertations/thesis, bandaging manuals, and medical and surgical texts) and Internet use on student PU knowledge. Sixty-three students (75.9%) participated in PU-related extracurricular activities and 65 (78.3%) read articles, texts, or books during their undergraduate studies; 21 (25.3%) utilized the website on PU prevention and treatment and of these students, 17 used it two to five times. Students who participated (M = 31.71, SD 4.37) in extracurricular activities had significantly higher PUKT scores than those who did not (M = 29.4, SD 3.05, Mann-Whitney nonparametric z = -3.83, P <0.001). The higher number of correct answers on the PUKT used in the current study was associated with the use of the website (M = 33, SD 4,74) as opposed to not using the Internet (M = 30.9, SD = 3.69; Mann-Whitney non parametric z = -2.29; P = .02) (M = 33, SD = 4.1). In contrast, students who had read textbook or journal articles about PU did not have significantly higher PUKT scores compared to those who had not consulted these sources.
International studies. Similar results also were found in studies16,17 done in other parts of the world, implying that this might be a global issue that deserves a further investigation. In the Netherlands, the use of massage to prevent PU has been studied extensively. Results of a cross-sectional study17 conducted to identify changes in nurse knowledge, beliefs, and practice related to massage after publication of national guidelines showed that nurses were still using massage as a preventative for PU. A survey18 conducted in Spain to assess nurses’ knowledge of existing guidelines for PU prevention and treatment (N = 738, 58% RN and 42% LPN) targeted a randomized sample of RNs and LPNs working in hospitals, primary healthcare centers, and elder care centers. The study showed that prevention interventions per recommendations of the Spanish Pressure Ulcer and Chronic Wounds Advisory Panel are more familiar and more frequently implemented than treatment interventions. Specifically, inappropriate interventions still considered correct by many of the professionals included the use of donut-type devices, avoiding massage, and providing topical application of alcohol. In the Spanish study, education also was found to affect the level of knowledge — RNs provided more correct responses than LPNs and RNs who reported having received PU education also fared better than those without PU instruction.
PU assessment and staging. Nurses’ knowledge about skin and PU assessment is also important and systems of classifying PUs by stages or phases facilitate quantification of the level of tissue destruction.5
In this study, the percentage of correct answers regarding definitions of PU stages was low: 56.6% for Stage I, 58.7% for Stage II, 76.42% for Stage III, and 76.42% for Stage IV. PU classification by stage should be performed by considering the visible layers of tissue damage seen from the skin surface to the bone or other support structures such as tendons or muscles. Such assessment may be difficult for professionals who do not recognize the anatomical layers of normal tissues or other clinical aspects of the wound that might complicate assessment. However, the questions regarding awareness that the presence of a blister on the heel is a reason for concern was answered correctly by 93.39% (99) of nurses. This is important because deep tissue injury (DTI) over the heel may look like a bruise or a blood blister.5
The issue of inter-rater reliability for all classification systems has been discussed in the literature and there may be greater agreement in reporting severe (deeper) PU stages or grades than with regard to superficial stages, indicating a particular need for educating professionals for this competency.19
The results of the current study confirm that some interventions to prevent PU such as massage, positioning, and repositioning may not be well understood by nurses. In addition, some clinical practice guideline recommendations presented in nursing classes or conferences may not be considered as reliable as a reputable physician’s prescription for care, even though some physicians may prescribe treatment that could cause damage to patient skin, such as using ring cushions or continuous bed rest for ICU patients). Pillows used under calves may decrease heel interface pressure20 but the use of water-filled gloves is contraindicated for PU prevention in Brazil. Even though pillows and gloves increase pressure on the area and can be easily dislocated when the patient moves (even minimally), they are commonly used in hospitals.
The results of this and other studies suggest that educational programs should emphasize PU assessment and staging and patient positioning interventions to prevent the development of these ulcers and facilitate healing.
This study has limitations. The sample size was small and nurse participants were all employed at one university hospital in Brazil. Although PUKT reliability in this study was .83, the low percentage of correct answers suggests that further testing with nurses in Brazil is needed. Finally, this study evaluated nurse knowledge only. Future studies should examine how existing PU knowledge translates into clinical practice.
A study was conducted to evaluate PU prevention and assessment knowledge of nurses working in a Brazilian university hospital. The study identified certain knowledge deficiencies; the total median score of correct responses for all 41 questions was 26.07. Results are similar to results of other studies conducted in Brazil and other countries. More studies to evaluate the effect of educative interventions on nursing staff knowledge regarding PU assessment, prevention, and treatment would be appropriate. Programs using the Internet and other distance education strategies need to be developed to improve the level of knowledge and practice in other healthcare settings. The results of this study also suggest that continuing education programs may be more important for experienced nurses than for more recent graduates of nursing programs. Acquiring basic knowledge regarding PU prevention and care and remaining up-to-date with recent developments and evidence-based practice recommendations are challenging for nurses who provide direct patient care as well as those directing that care.
To help nurses meet the challenges of preventing these ulcers, it is essential to provide continuous training and education and explore methods to transfer new knowledge about this issue to nursing practice to facilitate the provision of evidence-based care.
Dr. Chianca and Dr. Borges are faculty members, Basic Nursing Department; Ms. Rezende was an undergraduate BSN honor student at the time of the study; and Ms. Nogueira is a Specialist Nurse at Dermatology Outpatient Clinic, Federal University of Minas Gerais (UFMG) College of Nursing, Minas Gerais, Brazil. Dr Caliri is on the faculty at Ribeirão Preto College of Nursing, University of Sao Paulo, Brazil. Please address correspondence to: Tânia Couto Machado Chianca, PhD, RN, Basic Nursing Department, Federal University of Minas Gerais (UFMG) College of Nursing, Av. Alfredo Balena, 190. CEP 30130-1000, Belo Horizonte, Minas Gerais, Brazil; email: firstname.lastname@example.org.