Pressure ulcers (PUs) are a common concern in most healthcare settings. Several studies have been conducted around the globe to estimate the size of this medical condition. In the United States, the prevalence in acute care settings ranges from 12% to 19.7% (Jenkins & O’Neal, 2010), while across five European countries, the prevalence was 18.1% (Vanderwee, Clark, Dealey, Gunningberg, & Defloor, 2007). In the United Kingdom, a point prevalence study in general wards, which considered a range of wounds (surgical wounds, leg and foot ulcers, diabetics, cancer, and PU), reported a PU prevalence aggregate rate of 17% in hospitals, community, and nursing homes (Srinivasaiah, Dugdall, Barrett, & Drew, 2007). In Jordan, where this study took place, the rate was 12% (Tubaishat, Anthony, & Saleh, 2011). However, it would be impossible to compare these studies unless a unified methodology is used, and in these studies, different classification schemes, settings, populations, and procedures may have been used (Baharestani et al., 2009). Moreover, the risk profiles might be different as well. In the study conducted by Tubaishat et al., for example, the participants were from a younger and less frail population, making the risk for developing PU lower.
In addition to the pain, scarring, and interference with the activity of daily living that it causes sufferers, PUs are a costly medical condition. Bennett, Dealey, and Posnett (2004) indicated that the annual cost of treating PUs in the health and social care system in the United Kingdom was between £1.4 and £2.1 billion ($2.18 and $3.26 billion). In addition, it can add 7 days to a hospital admission (Anthony, Reynolds, & Russell, 2004). Thus, prevention of the occurrence of this problem is a necessity and deserves greater attention (Severens, Habraken, Duivenvoorden, & Frederiks, 2002). To prevent these ulcers, nurses have to possess knowledge of the risk factors that predispose patients to PU. Moreover, they have to be aware of strategies that can be used to prevent ulcers (Panagiotopoulou & Kerr, 2002). Knowledge is a prerequisite to high-quality care. Lack of knowledge might result in misconceptions about PU care (Beeckman et al., 2010).
Although nurses generally have a positive attitude toward PU prevention (Moore & Price, 2004), several studies have shown a gap between theory and practice (Bours, Halfens, Abu-Saad, & Grol, 2002; Maylor & Torrance, 1999; Rodgers, 2000). Hence, knowledge alone is not enough; nurses need to apply the knowledge they have (Clark, Bours, & Defloor, 2002).
Risk Factors for PUs
There is a paucity of research discussing nurses’ knowledge of PU risk factors. Comparisons between studies are complicated because of the range of methodologies employed. Maylor and Torrance (1999) explored trained and untrained nurses’ (n = 625) knowledge of risk factors using a cross-sectional survey. The trained nurses were registered nurses, whereas the untrained nurses were nurse assistants. The participants, who were working in a National Health Service trust in Wales, were asked to indicate their level of agreement with a number of risk factors. The results showed adequate level of agreement between respondents’ opinions and that of the expert.
In another study by Beitz, Fey, and O’Brien (1999), the opposite was reported. Here, 86 qualified and unqualified nurses (i.e., registered nurses and nurse assistants) from a community setting in the United States showed that their knowledge was limited in regard to certain risk factors, namely, friction and age. Participants did not agree that these were risk factors for PU development. However, the use of convenience sample of nurses, and some of them were unqualified, may limit the generalizability of this study.
Beitz et al.’s (1999) results were supported by Parker, Morgan, Clayton, Gerrish, and Nolan (1998). The latter conducted a survey of 275 nurses in a general hospital in England. The findings revealed that nurses’ knowledge of risk factors was limited. Nutritional status, body weight, incontinence, neurological factors, and age were all poorly reported as risk factors for PU development. In relation to extrinsic factors, the proportion who considered pressure, shear, and friction as risk factors was small (17%, 8%, and 8%, respectively).
Strategies for PU Prevention
Again, there is a shortage of studies exploring nurses’ knowledge and practice of preventive strategies. Halfens and Eggink (1995) carried out a cross-sectional study to investigate nurses’ knowledge and use of PU preventive interventions. About 373 nurses returned a questionnaire, which contained a list of 27 preventive measures developed from the Dutch Consensus report on prevention. The results revealed that the nurses had a good knowledge of preventive strategies but that they did not transform their knowledge into practice. For example, 89% of nurses were aware that they should prevent maceration, but only 59% always ensured that maceration was prevented during their practice. There was poor knowledge about measures that must not be used, and these measures were used in practice, with a high percentage of nurses reporting that topical creams, massage, and donuts were used regularly. The donut is a ring-shaped cushion used under the head, sacrum, or any other body part that was introduced in 1980s, but its effectiveness as a preventive measure has since been discredited.
After new guidelines were launched in the Netherlands, Hulsenboom, Bours, and Halfens (2007) conducted a cross-sectional study to investigate nurses’ knowledge of these guidelines. The results revealed that the Dutch nurses’ knowledge about the usefulness of different preventive intervention measures was moderate. Furthermore, knowledge about nonuseful intervention was disappointingly still widespread.
Pancorbo-Hidalgo, Garcia-Fernandez, Lopez-Medina, and Lopez-Ortega (2007) conducted a survey to examine Spanish nurses’ level of knowledge and application of available PU prevention and management guidelines. Seven hundred forty registered and associate nurses working in hospitals, elderly care, and health centers participated. The results indicated that the rate of application of the guidelines (68.1%) was evidently lower than the level of knowledge (79.1%). The authors suggest that a possible explanation is that nurses face obstacles that inhibit complete application of this knowledge into practice. These could be lack of specific education on PU care, understaffed nursing teams, large number of patients, and lack of time and equipments.
Saliba et al. (2003) explored the application of PU prevention recommendations in 35 nursing homes in the United States. Disappointingly, the recommendations were followed only 41% of the time, with high variation existing between participating homes.
A cross-sectional study was conducted in 14 Belgian hospitals to assess the adequacy of PU prevention in these hospitals and the knowledge of 553 working nurses regarding PU prevention. The results revealed that the knowledge of nurses in Belgian hospitals about the prevention of PU is inadequate (Beeckman, Defloor, Schoonhoven, & Vanderwee, 2011).
To summarize, it is clear that there is a paucity of evidence regarding nurses’ knowledge of PU risk factors and prevention measures. This study was conducted in Jordan to determine how Jordan PU nursing knowledge is compared with other countries.
The aims of this study were to (1) explore nurses “knowledge of risk factors” and “preventive strategies” and (2) explore reported preventive practice in clinical settings.
This is a descriptive, cross-sectional multicenter study.
Three hospitals in Jordan took part in the study: one university hospital and two public hospitals in the north of Jordan.
All registered and associate nurses working in these hospitals were invited to participate in the study. The nurses were required to be directly connected with patient care. Hence, head nurses, supervisors, nursing directors, and those who no longer worked as bedside nurses were excluded.
The tool used in this study to collect data was adapted from the literature (Halfens & Eggink, 1995; Maylor & Torrance, 1999; Panagiotopoulou & Kerr, 2002). Some of the items in the earlier tools were omitted as they were not applicable in Jordan, and for the purpose of the current study, some demographic questions were appended.
It is acknowledged that a valid and reliable tool is important in assessing PU knowledge (Beeckman et al., 2010). Therefore, the face and content validity of the translated instrument used in the current study were obtained by experts, including nursing educators holding PhD degrees and experienced nurse researchers (n = 5). This panel assessed the order and wording of questions and the design of the questionnaire. The content validity index was excellent for all the subsections of the questionnaire (content validity index = 0.76–0.94). In addition, the tool was piloted by being distributed to a random sample of 30 nurses from one of the research sites, who were excluded from the final analysis. The internal consistency reliability (Cronbach’s alpha) of the subsections of the instrument was between 0.87 and 0.92. Thus, the adapted tool used in this study showed acceptable properties of reliability and validity and can be used effectively to assess PU knowledge and practice. However, the tool contained some outdated practices for PU prevention, and these were sought to explore if the Jordanian nurses still use these intervention. Nurses from different countries still use these to some extent.
In fact, there was a prospective psychometric instrument validation study conducted to test an instrument developed from the literature that assess knowledge of PU prevention (Beeckman et al., 2010). This instrument, which consists of 26 items, showed acceptable psychometric proprieties. However, it focuses on essential knowledge concerning the PU prevention; some items like risk factors were not within this tool, whereas the one used in the current research contains a risk factor knowledge assessment.
The questionnaire was divided into four parts as detailed below:
* Demographic data: nurses’ age, gender, qualifications, clinical experience, and area of specialty.
* Risk factor knowledge: Twenty-five statements were derived from the literature (Maylor & Torrance, 1999; Panagiotopoulou & Kerr, 2002). Participants were asked to indicate their acceptance of these statements on a 3-point scale (yes, no, don’t know). However, not all the mentioned statements present risk factors; some of them were included to elicit participants’ knowledge about PU risk factors. For instance, the statements “low albumin” and “high albumin” were presented for contrasting purposes and to extract participants’ accurate knowledge.
* Prevention knowledge: This section was composed of 20 preventive interventions, originating from Halfens and Eggink (1995), used for patients at high risk of PU. Seven of these methods were said by the authors to be useful for all patients at risk of PU development, six were judged as useful in certain high-risk cases only, and seven methods were considered not useful at all. Participants were requested to rate the methods, based on their knowledge, as “always useful,” “sometimes useful,” “never useful,” or “don’t know.” The nurses’ knowledge was compared with expert opinion about these interventions, which were derived from the literature.
* Prevention practice: The same 20 methods were offered again to the subjects, who were, this time, asked to specify if they used the interventions in practice for all patients at risk for PU (always), only in some high-risk cases (sometimes), or not at all (never).
Data Collection Procedures
A contact person in each ward or unit in every research site was identified. This was usually the head nurse of the ward. These individuals played a major role in receiving, distributing, and delivering the questionnaires, and they were all given comprehensive details about the objectives and procedures of the study. The questionnaires and information sheets were handed to the contact person in each research site, to be circulated to the nurses.
Participants who agreed to take part in the study were instructed to complete and hand back the questionnaire to the contact person in each department within 1 week. The researchers then collected them from each contact person.
The study was approved by the research and ethics committee of Al al-Bayt University and by the institutional review board of each participating hospital. Each questionnaire contained detailed information about the objectives and procedure of the study. Participation was completely voluntary, and anonymity was ensured as no personal identification data were required. Returning of the questionnaire was taken as proof of consent.
Data were coded and entered into the statistical software package SPSS 17 (SPSS, Inc., Chicago, IL). Descriptive and inferential statistics were executed. The percentage of agreement between the nurses’ opinion and expert opinion in the areas of knowledge of PU preventive methods, practice of PU preventive methods, and knowledge of risk factors was calculated. The chi-square test was used to test whether there was a difference between the qualifications of the participants and some of the preventive strategies. The level of significance (p) was set at ≤.05. The relationship between knowledge and practice of PU preventive methods was investigated using Pearson product–moment correlation coefficient (r).
The questionnaires were sent to 386 nurses working in the three hospitals. Two hundred sixty-three questionnaires were returned by the nurses to the appointed contact people. A number of questionnaires were returned either blank or incomplete (n = 59). Thus, the total number of questionnaires analyzed was 204, giving a response rate of 52.9%.
The characteristics of the sample are presented in Table 1. As shown, 57.4% (n = 117) were women. The nurses were, on the whole, very young; the mean age was 29.36 (SD = 5.36) years. Most of the participants were registered nurses (87.7%, n = 179), holding either a bachelor degree or a master’s degree. The mean number of years of experience was 6.6 (SD = 4.82) years, and the nurses worked in various different specialties, as indicated in Table 1.
Knowledge of Risk Factors
The nurses’ knowledge of risk factors is given in Table 2. The answers judged as “correct” in terms of expert opinion were highlighted in bold for easy identification. In general, there was agreement between the sample’s response and expert opinion regarding the risk factors of PU development. As shown in Table 2, the level of agreement (“yes” responses) with expert opinion was particularly high for some risk factors, such as immobility (90.9%), body weight (above average, 88.4%), high pressure over a long period (86.3%), and friction (85.9%). Level of agreement with expert opinion was limited in the following areas: low albumin level (40.4%), high pressure over a short period (40.8%), body weight (below average, 44.1%), and low hemoglobin level (45.7%).
Knowledge of Preventive Strategies
The results for knowledge and practice of PU preventive strategies are presented in Table 3, with the correct answers given in bold for quick identification. The level of agreement with expert opinion regarding the measures judged as “always useful” was generally high.
In relation to the strategies deemed useful only in certain cases, the nurses had poor knowledge. For example, “air mattress” was wrongly judged by the bulk of participants to be “always useful” (81.6%) although, according to the international guidelines for PU prevention, it should be used only in some high-risk cases (Halfens & Eggink, 1995). Finally, poor knowledge was reported of the methods that should not be used at all. For instance, only 12.2% of the participating nurses declared correctly that “massage” was “never useful,” whereas half of them (50.0%) incorrectly considered that it is “always useful.”
To evaluate the nurses’ level of knowledge regarding preventive interventions, a knowledge score was created. A score of 1 was given for each correct response, and 0 was given for each incorrect response. The correct answer as indicated by the expert opinion was given in bold in Table 3. Because there were 20 items in total, the achievable knowledge scores varied from 0 (lowest) to 20 (highest).
As pointed out in Table 3, again, the level of agreement with the guidelines regarding the methods that are useful for all patients at risk for PU was generally high. However, 22.7% of the participants did not attempt to reposition every patient at risk.
Nurses were unable to distinguish between the measures that should be applied in all cases and those only useful in some cases. For example, more than half of the sample (61%) provided air mattresses for all patients, despite the fact that they should only be used in certain individual cases. In relation to the methods that should never be used, merely a quarter (24.9%) of participants stated that they “never used massage,” a method that is considered to be a poor practice in PU prevention.
A practice score was also calculated to measure the nurses’ degree of appropriate practice. Correct answers are given in bold in Table 3. Similarly, a score of 1 was given for practice that was in compliance with the PU prevention guidelines, and 0 was given for practice that was not concurrent with recommended practice. The summated scores would therefore range from 0 (lowest) to 20 (highest).
Table 3 illustrates as well the relationship between knowledge and practice for each preventive method. In general, no strong correlation was noticed, with most of them indicating a medium correlation between knowledge and practice, which is clear from the results in Table 3 (r < .5). According to Cohen (1988), coefficients ranging from 0.50 to 1.0 show a strong correlation. Of the seven methods that are considered useful in all cases (i.e., these are the methods that are useful and are advised for general application in patients at risk, like repositioning patient at regular intervals), 5.7 of them were known, whereas 4.5 methods were actually applied in practice.
In regard to methods that are useful only in some cases (i.e., these are the methods that are expected to be useful in individual cases but are not advised for general application in patient at risk, like involving family and friends in prevention) and the methods that are never useful (i.e., these are the methods that are not useful at all, like applying a massage), the situation is reversed. Of the six methods that are useful in some cases, 1.4 methods were known, and 2.4 were applied. Of the seven methods judged as not useful, 1.6 were known, and 2.4 were applied. Nurses apply these methods despite that they have no adequate knowledge of these methods.
The qualifications of the participating nurses were also investigated to discover any effect that these may have on the knowledge and practice of PU prevention. Surprisingly, no statistically significant difference exists between the registered and associate nurses in terms of their knowledge of PU prevention, except in relation to using warm compressors. Chi-square testing revealed that a significantly greater proportion of registered nurses knew that these compressors should not used (χ2 = 3.86, df = 1, p = .049). However, there is a significant difference between the two groups of nurses’ practice. Also, a significantly greater proportion of associate nurses were not aware that massage should not be used (χ2 = 4.75, df = 1, p = .029).
The purpose of this cross-sectional study was to explore Jordanian nurses’ knowledge and practice in relation to PU knowledge and practice. According to the results, the level of agreement with expert opinion was high for most of the risk factors. The findings were supported by a previous research, which has indicated that nurses’ knowledge of risk factors is good (Maylor & Torrance, 1999). The areas of strongest agreement were the risk factors immobility, body weight (above average), high pressure over a long period, and friction (Maylor & Torrance, 1999). On the contrary, others have reported nurses’ poor knowledge of PU risk factors in their studies (Beitz et al., 1999; Parker et al., 1998). Regarding prevention, the nurses’ overall knowledge was inadequate, as the level of agreement with expert opinion was only 42.9%. In a similar study, the level of agreement was reported to be 50% (Panagiotopoulou & Kerr, 2002). However, there was greater agreement about the preventive measures that should be used in all cases that are at risk for PU development and less agreement about the measures that are useful in individual cases or methods that are never useful. In fact, these findings are consistent with other similar works (Halfens & Eggink, 1995; Hulsenboom et al., 2007; Panagiotopoulou & Kerr, 2002).
Although the current study showed that the level of knowledge of PU prevention was low, the literature on knowledge regarding PU prevention is often contradictory. Some studies have shown nurses to have a high level of knowledge about PU prevention (Ayello & Lyder, 2008; Tweed & Tweed, 2008), some showed their knowledge to be moderate (Gunningberg, 2004; Panagiotopoulou & Kerr, 2002; Sinclair et al., 2004), and others reported insufficient knowledge (Beeckman et al., 2011; Enein & Zaghloul, 2011; Iranmanesh, Rafiei, & Foroogh Ameri, 2011; Miyazaki, Caliri, & Santos, 2010). A comparison between these studies would be difficult because of the lack of clarity of content, differences in scoring, and differences in the setting of the assessment tools used (Enein & Zaghloul, 2011).
There is evidence that supports the findings of this study. Snarska, Jarocka, Sierzantowicz, Lagoda, and Jurkowska (2005) evaluated prevention knowledge among 50 female part-time nursing students in Poland. Their findings revealed that the students’ knowledge was inadequate and that some actions were needed to enhance their knowledge. In Turkey, Aydin and Karadag (2010) assessed intensive care nurses’ knowledge concerning PU and found that they lacked knowledge of PU prevention and management.
One of the most remarkable findings of this study was that nurses are less knowledgeable about some of the outdated methods that are no longer recommended to be used, such as massage. However, this is not the case only in Jordan but has also been reported in Greece and Holland that they still use such old measures (Halfens & Eggink, 1995; Hulsenboom et al., 2007; Panagiotopoulou & Kerr, 2002).
Regarding the practice of PU prevention methods, the average level of agreement with what can be labeled “good preventive practice” based on expert opinion as reported in the literature was 45%, which is much lower than the rate of 54.5% reported by a similar study (Panagiotopoulou & Kerr, 2002). The relatively low scores for Jordanian nurses’ knowledge and practice of PU prevention could be related to the fact that Jordanian nurses are typically young and with limited experience. This is connected to the demographic characteristics of Jordan in general, where around one third (31.3%) of the population are under 15 years old, 64.5% are aged between 15 and 64 years, and merely 4.2% are aged 65 years and above (U.S. Department of State, 2007). In this study, more than half of the sample (n = 116, 64.4%) were young nurses, aged under 29 years, and around half of them had less than 4 years of experience (n = 87, 45.3%).
The correlation between knowledge and practice was moderate. Nurses had knowledge about preventive methods that should be used in all cases, but they did not translate this knowledge into practice. The same findings have been reported by other researchers (Halfens & Eggink, 1995; Hulsenboom et al., 2007; Panagiotopoulou & Kerr, 2002). This could be related to a lack of equipment in the Jordanian settings or even to a lack of education to practice these preventive measures. Moreover, it could be that nurses face obstacles during the application of preventive measures. A recent study conducted in Jordan found that lack of staff, time, and patient condition are the major barriers for PU prevention (Tubaishat, Aljezawi, & Al Qadire, 2013). Moore and Price (2004) reported shortages of time, staff, training, resources, and guidelines as the most commonly cited obstacles.
Surprisingly, nurses applied the methods that should only be used in some cases and those that are not useful at all without having adequate knowledge of them. The justification for such a scenario is that, in Jordan, there are no formal PU prevention guidelines and protocols available to follow. Diffusion of such guidelines is a prerequisite to enhance the quality of PU prevention (Hulsenboom et al., 2007). Jordanian nurses tend to focus on what they think it is in the “safe area,” even if it is not based on nursing evidence. For example, they may use massage without adequate knowledge of its unsuitability. However, the same problem also exists in many developed countries. In the current study, the percentage of participants who apply massage frequently or occasionally is 75.2%; in the Netherlands, it is 88% (Halfens & Eggink, 1995); in Greece, it is 87.3% (Panagiotopoulou & Kerr, 2002); and in Spain, it is 77% (Pancorbo-Hidalgo et al., 2007) although massage is documented to be a poor practice in preventing PUs (Duimel-Peeters, Hulsenboom, Berger, Snoeckx, & Halfens, 2006). It is thought that nurses’ beliefs are based on tradition (Halfens & Eggink, 1995), which is not a solid basis for knowledge. Until a few years ago, Jordanian nurses and many others around the world would have almost certainly learned during their study about the benefits of massage as a preventive method for PU.
The effect of qualifications on PU prevention has been explored in many studies. Tweed and Tweed (2008), Smith and Waugh (2009), and Iranmanesh et al. (2011) all reported similar results to those of the current study, with nurses’ qualifications having no effect on the area of interest. Conversely, Pancorbo-Hidalgo et al. (2007) argued that a nurse with a bachelor degree would have a superior level of knowledge and practice to an associate nurse. The positive effect of qualifications has also been reported in several other works (Maylor & Torrance, 1999; Miyazaki et al., 2010; Panagiotopoulou & Kerr, 2002).
The main limitation of this study is its use of the self-report questionnaire. The fact that a nonrandom convenience sample has been used could affect the generalizability of the findings. The nonresponders could affect any obtainable conclusion, because we are unaware of their knowledge and practice. However, the response rate for this study was reasonable (52.9%). Another possible limitation is that the study’s findings are based on perceived practice rather than observed practice, which could introduce subjectivity. This work focused on the existing knowledge of the nurses, but it was impossible to tell whether the nurses had consulted textbooks, internet resources, or other nurses when completing the questionnaire.
Despite the limitations, this study plays a major role in providing baseline data about Jordanian nurses’ knowledge and practice regarding PU care. Knowledge about PU risk factors is generally adequate, but the level of knowledge and practice of appropriate PU prevention methods needs to be improved. The practice of some ineffective methods is questionable. The application of organized educational programs designed to improve nurses’ knowledge in the area of PU is necessary. This, in turn, could lower the high prevalence rates of PU in different clinical settings including Jordan.
Because the level of knowledge about PU preventive methods is not up to the required level, educational programs offered to the nurses in their hospitals using the continuous education departments are essential. Moreover, the adaptation of PU materials in the nursing program curriculum is paramount in terms of increasing nursing students’ level of knowledge, and this could be reflected in their future career. Furthermore, repeating this study at the national level is recommended to obtain represented data from the Jordanian nursing community.
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