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Pressure Injury Prevention: Knowledge and Attitudes of Iranian Intensive Care Nurses

Tirgari, Batool PhD; Mirshekari, Leili MSN; Forouzi, Mansooreh Azzizadeh MSN

Author Information
Advances in Skin & Wound Care: April 2018 - Volume 31 - Issue 4 - p 1-8
doi: 10.1097/01.ASW.0000530848.50085.ef
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Pressure injury is the third most expensive condition after cancer and cardiovascular disease.1 This localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device,2 can engage skin, muscle, connective tissue, cartilage, and bone.1 More than 50 US and European studies published between 1988 and 2008 have reported on pressure injury prevalence rates, with estimates ranging from 3.5% to 83.6%.3 It is estimated that 4% to 10% of hospitalized patients in the United Kingdom develop a pressure injury during their hospital stay and that there are 22,000 to 23,000 patients in UK hospitals with a pressure injury at any given time.3

Pressure injuries are a significant clinical complication for patients and a financial and quality issue for healthcare facilities.4 In addition to the high cost of care associated with this condition, the development of pressure injuries can interfere with functional recovery, may be complicated by pain and infection, and can increase hospital lengths of stay.5 The majority of pressure injuries become chronic; healing can take up to 12 weeks.6 In Iran, pressure injuries increase patient hospitalization by at least 4 days and increase the risk of hospital-acquired infections by 25%.7

The main patients at risk are those in palliative care, critical care, and pediatric and operating room settings; individuals who are overweight or obese; individuals with spinal cord injury; and older adults.8 Critically ill patients who are hemodynamically compromised because of hypotension, shock, or dehydration are at risk of deep tissue injury.9 Other risk factors include urinary or fecal incontinence and high-dose vasopressor therapy. Underweight status, low albumin levels, hip fracture, advanced age, and terminal illness have also been found to increase pressure injury risk in critically ill patients.10

The technology and equipment used in intensive care units (ICUs) also increase the risk of pressure injury. For example, the risk of developing a pressure injury increases by 4.2% each day a patient is connected to a ventilator.7 These factors are reflected in the pressure injury prevalence of 14% to 41% and an incidence of up to 56% in ICUs in Iran.7

In conclusion, patients, families, healthcare providers, and the community are dramatically affected by the physical, financial, and social consequences of pressure injuries.3 Healthcare teams also spend a lot of time navigating the physical, psychological, and financial challenges of pressure injury treatment.3,11,12 Among care providers, nurses are usually responsible for the direct and continuous care, prevention, and treatment of pressure injuries.13 Despite the multidisciplinary aspects of pressure injuries, nurses are the direct care providers most responsible for the prevention of pressure injuries,14 and with each pressure injury, a nurse’s workload increases by 50%.15

Pressure injury is the fourth most preventable medical error.16 The high incidence of pressure injuries and their costly treatment compared with the low cost of prevention increase the need for careful planning and awareness.17 Preventing pressure injury is a priority for nursing care18 and considered a key indicator of quality care.17 Various studies19 have shown that, despite all this, pressure injury prevention strategies often are not emphasized in healthcare organizations.3 In addition, despite recent advancements in the care of pressure injuries, nurse knowledge and practice in this field are not up to date, and negative attitudes toward prevention efforts can reduce their impact.

Review of Literature

Search terms included pressure ulcer, knowledge, attitude, and intensive care. Study authors reviewed more than 60 articles, but only 40 were selected for inclusion.

Mwebaza et al20 examined nurses’ knowledge, practices, and barriers in care of patients with pressure injuries in a Ugandan teaching hospital. A composite self-administered questionnaire and an observation checklist were utilized. They showed that the nurses had limited knowledge about the critical parameters of pressure injuries.20 In another study, Qaddumi and Khawaldeh21 assessed pressure injury prevention knowledge among Jordanian nurses using the Pressure Ulcer Knowledge Tool (PUKT) developed and validated by Beeckman et al.1 They reported that the majority of nurses (73%) had inadequate knowledge about pressure injury prevention.21

Aydin and Karadag18 studied a sample of 243 nurses working in ICUs in Turkey. A questionnaire was developed in consultation with wound care experts to measure nurses’ knowledge and practice for preventing deep tissue injury and Stage I pressure ulcers. They also found that knowledge about pressure injuries was inadequate.18

In a cross-sectional study, orthopedic nurses’ knowledge about pressure injuries was examined in 2 teaching hospitals in Iran by Iranmanesh et al.22 They used the Pieper-Zulkowski Pressure Ulcer Knowledge test. The results of this study suggested that orthopedic nurses in Iran were not sufficiently knowledgeable about pressure injuries.22 In a different study, Iranmanesh et al23 assessed knowledge about pressure injuries among 126 critical care nurses working in southeast Iran. Results showed that the level of knowledge was insufficient to provide optimal care.23

Nurse knowledge plays an important role in the prediction, prevention, and treatment of pressure injuries, as well as the incidence and prevalence in hospitalized patients.24 Therefore, intensive care nurses’ knowledge should be evaluated on a regular basis and maintained at a high level.23 Although most nurses know the common risk factors, many nurses do not have sufficient knowledge about contributing factors, and this lack of knowledge negatively affects their performance.1 Further, positive attitudes toward prevention are an important component for successful interventions to prevent pressure injury.25 Therefore, this study aimed to examine the relationship between knowledge and attitudes toward prevention of pressure injuries among nurses working in ICUs of hospitals affiliated with Zahedan Medical Sciences University.



This was a cross-sectional, descriptive analysis study that aimed to examine the knowledge and attitudes of intensive care nurses toward the prevention of pressure injury.


Using a census method, all of the 107 nurses working in ICUs of hospitals affiliated with Zahedan University of Medical Sciences were asked to participate in this study. The response rate was 100%, but 18 questionnaires were not fully completed and were not included in the analysis.


Data collection was done using an author-created questionnaire in English consisting of 3 parts that asked for nurses’ background information and their knowledge about pressure injuries and examined their attitudes toward pressure injury prevention.

Part 1, the demographic questionnaire, asked about variables such as age, gender, level of education, years of clinical experience, years of clinical experience in ICU setting, and previous exposure to pressure injury education.

To assess participant knowledge about pressure injuries, study authors selected the PUKT, developed and validated by Beeckman et al.1 Limited evaluation of the psychometric aspects of other evaluation instruments is a major problem; an extensive literature review was performed to develop the PUKT, making it a superior choice. Face and content validity were positively evaluated in a double Delphi procedure by an expert panel of 9 trustees of the European Pressure Injury Advisory Panel, each of whom has extensive experience in pressure injury care and research. Further, this instrument has acceptable reliability and validity.1

The PUKT includes 26 multiple-choice questions in 6 categories: etiology and development (6 questions), classification and observation (5 questions), risk assessment (2 questions), nutrition (1 questions), preventive measures to reduce the amount of pressure (7 questions), and preventive measures to reduce the duration of pressure (5 questions). Each question has 4 answer options, and the fourth option is “I do not know the answer,” which is included to prevent respondents from guessing the answer. Each correct answer is scored 1 point, and incorrect answers are scored 0, resulting in a final score between 0 and 26; higher scores indicate more knowledge.

The PUKT was validated for difficulty, discriminating index, and quality of the response alternatives. The internal consistency reliability (Cronbach α) was .77, and the 1-week test-retest interclass correlation coefficient (stability) was 0.88. Content validity index was 0.78 to 1.00. The item difficulty index of the questions ranged from 0.27 to 0.87, whereas values for item discrimination ranged from 0.29 to 0.65.1

The authors chose the Attitude towards Pressure ulcer Prevention (APuP) instrument developed by Beeckman et al26 to assess nurse attitudes toward pressure injury prevention. This questionnaire contains 13 questions: attitude toward personal capacity to prevent pressure injury (3 items), attitude toward priority prevention of pressure injury (3 items), attitude toward the impact of pressure injury (3 items), attitude toward the responsibility for the prevention of pressure injury (2 items), and attitude toward the effectiveness of prevention (2 items). Answers and scores are measured using a Likert-type scale from strongly agree (4) to strongly disagree (1). Seven of the items (items 3, 4, 5, 7, 8, 10, and 13) are negatively phrased and therefore reverse scored. A final score is a number between 13 and 52.

The APuP produced similar reliability results to the PUKT during stability testing (interclass correlation coefficient, 0.88; 95% confidence interval, 0.84–0.91; and P < .001). For the total instrument, the internal consistency (Cronbach α) was .79.26

Validity and Reliability

Because the questionnaire was written in English and had not been used in Iranian national studies to that point, the translation of the questionnaire was done using forward-backward translation. The questionnaire was translated into Farsi by a person fluent in English, and then a person who was fluent in both English and Farsi translated it back into English. The questionnaire was then given to 10 related experts, and their comments were applied. For reliability, these tools were given to 18 nurses working in ICUs in Zahedan, and after the completion, internal consistency with Cronbach α measurements of .86 and .78 was calculated for the knowledge and attitude questionnaires, respectively.

Data Analysis

The data from the questionnaire were analyzed using SPSS version 19 (IBM, Armonk, New York). A Kolmogorov–Smirnov test indicated that the variables were normally distributed. Descriptive statistics were used to draw summary measures of central tendency and frequencies for demographic items. A Pearson correlation was used to determine the correlation between knowledge and attitudes. A t test was used to compare the nurse knowledge and attitude scores between 2 demographic variables (gender and previous exposure to pressure injury education), and analysis of variance was used to compare 3 or more variables (age, years of clinical experience in the ICU setting, level of education, employment status, and/or years of clinical experience). Differences were considered statistically significant at a level of P < .05.

Ethical Considerations

Before the collection of data, this study was approved by the Ethics Committee of the Kerman University of Medical Sciences (K/92/382). All study participants were provided with an informed consent form as approved by the committee. The researchers explained voluntary participation, guarantee of anonymity, and freedom to withdraw from the study.


Demographic Information

The findings showed that 61.8% of the participants were between 20 and 30 years old, and their mean age was 30.18 ± 5.59 years. Of the participants, 73.03% were female, and 87.65% had a bachelor’s degree in nursing. In terms of experience, 79.78% had 1 to 6 years of work experience in the ICU, and 60.67% had not received any training about the prevention of pressure injuries (Table 1).

Table 1.
Table 1.:

Knowledge about Pressure Injury Prevention

Knowledge-related findings showed that the mean score of knowledge about pressure injury prevention was 0.44 ± 0.12. Among the different categories of knowledge about pressure injury prevention, the nutrition category had the highest mean item score (0.71 ± 0.45), and 2 categories, etiology and development (0.42 ± 0.24) and classification and observation (0.42 ± 0.21), had the lowest mean item score (Table 2). Table 3 shows the percentage of correct answers on the PUKT. The rate of correct answers ranged from 76.1% to 20.7%. The most correct answers belonged to the item “In a sitting position, pressure ulcers are most likely to develop on…” (76.1% answered correctly). The fewest correct answers belonged to the item “For a patient at risk of developing a pressure injury, a viscoelastic foam mattress…” (20.7% answered correctly; Table 3).

Table 2.
Table 2.:
Table 3.
Table 3.:

Attitude toward Pressure Injury Prevention

The mean score on the APuP was 2.69 ± 0.47, reflecting a moderate attitude. Of the different categories of attitudes toward pressure injury prevention, the category of “the impact of pressure ulcers” had the highest mean score (2.95 ± 0.56), and the category of “confidence in the effectiveness of prevention” had the lowest mean score (2.56 ± 0.46; Table 4).

Table 4.
Table 4.:

Relationship between Attitude toward and Knowledge about Pressure Injury Prevention

There was a statistically significant relationship between the total scores of the PUKT and the APuP (r = 0.30, P < .001). Of the various aspects of knowledge about pressure injury prevention, classification and observation (P = .012 and r = 0.28) and preventive measures to reduce the duration of pressure (r = 0.24, P = .035) were significantly associated with nurse attitude (Table 5).

Table 5.
Table 5.:

Relationships among Demographics, Knowledge, and Attitude

Comparing PUKT results by gender, education level, and work experience did not reveal any statistically significant differences (P >.05), but the mean scores by age, employment status, work experience in the ICU, and previous training did (P < .05; Table 6).

Table 6.
Table 6.:

Mean APuP scores, when broken down by age, sex, education level, employment status, work experience, work experience in the ICU, and training about pressure injuries, did not show a statistically significant difference (P > .05).


This study revealed that Iranian ICU nurse knowledge about pressure injury prevention is inadequate. This result is consistent with previous studies that suggested nurses had inadequate knowledge about pressure injury prevention.18,23,27,28 In Iran, Iranmanesh et al23 showed that the level of ICU nurses’ knowledge was inadequate. In Turkey, Aydin and Karadag18 had similar results. In Nigeria, Uba et al27 reported that all registered nurses working in surgical, medical, orthopedic, gynecology, obstetrics wards, and ICUs had poor knowledge of pressure injury prevention. Ilesanmi et al29 also claimed that Nigerian nurses working in medical, surgical, neurologic, and orthopedic units had inadequate knowledge in this area. Adejumo28 assessed nurse perception of pressure injury prevention for selected patients at the University College Hospital, Ibadan, Nigeria. He suggested that nurses working in the neuroscience and surgical units had inadequate knowledge in this area.28

Ayello and Baranoski30 reported the results of a survey on wound care practices in the United States. A total of 647 nurses participated in a follow-up to the 2005 survey conducted by the authors. These survey results demonstrate the need for more education about wound care for both nursing students and clinical nurses.30

In this study, a majority of the nurses who participated (61.8%) were between 20 and 30 years old, making them relative novices to the nursing profession. According to Uba et al,27 the overall low level of knowledge may be related to their formal educational background and training experience. The limited formal educational background and training of nurses in this study (87.65% had only bachelor degrees) likely correlate to nurses’ low level of knowledge about pressure injury prevention because the contents of this degree curriculum in Iran are not specifically focused on up-to-date information about pressure injury prevention. Nursing students learn about the development and care of pressure injuries, but less about how to prevent them.

Further, the majority of nurses (60.67%) had no postuniversity pressure injury education. According to Uba et al,27 the lack of opportunity to be trained and up-to-date on pressure injuries might prevent the nurses from remembering, understanding, and applying suitable knowledge regarding pressure injury prevention. Pieper and Zulkowski31 stated that having accurate, ongoing, and up-to-date knowledge regarding pressure injury risk, prevention, staging, and treatment is the most effective way to prevent them.

Cooper32 states that evidence-based care protocols for the prevention of pressure injuries are a suitable solution to any educational gap. Ayello et al33 also concluded that successful nursing education needs to incorporate evidence-based practice: scientific evidence, expert knowledge, and patient preference. Therefore, organizing in-service training courses could help address this knowledge deficit.

Based on the results of the APuP, ICU nurses’ attitudes toward the pressure injury prevention was moderate. Strand and Lindgren34 reported that the critical-care nurses they surveyed did not have favorable attitudes. However, in contrast, Uba et al27 and Simonetti et al35 found nurses had positive attitudes about their ability to prevent pressure injury. This discrepancy could be due to many factors such as healthcare policy, facility policies, and also how much autonomy nurses have to use equipment and undertake interventions to prevent pressure injury within their role. Further, having proper facilities and equipment can also promote a positive outlook.27,35 Most importantly, adequate knowledge and training can affect nurses’ attitudes.26,36

There was a significant association between knowledge and attitude. The more knowledge nurses had, the more favorable their attitudes toward pressure injury prevention. Previous studies have shown a similar relationship between knowledge and attitudes of nurses.12,16,35,37 Notably, Beeckman et al26 reported a significant relationship between knowledge and attitudes of nurses.


This small sample of participants, which is not representative of all intensive care nurses, could prevent the generalization of findings. Further, there is a risk of self-report bias in this study that could have led to an overestimation of some of the findings from variance. Another limitation was the limited time during the morning shift that participants had to complete the questionnaires. In order to mitigate this limitation, the second author asked participants to complete the questionnaire whenever they preferred, but a time restriction was still present.


This study describes the knowledge and attitudes of ICU nurses around pressure injury prevention in hospitals of southeast of Iran. The result of this study is valuable to Iranian healthcare and can form a baseline for nurses and other healthcare professionals. Understanding nurse attitudes toward care is beneficial in planning and implementation of better care to prevent costly and disabling pressure injuries. It also contributes to the development of formal pressure injury education. Therefore, nurses should update their knowledge regarding pressure injury and its prevention strategies to cultivate a positive attitude about their ability to mitigate this condition. Nurse leaders should disseminate guidelines to improve the quality of pressure injury prevention. Nursing managers should make efforts to improve the knowledge and attitudes of their direct reports based on the best scientific evidence. Improved hospital policies and guidelines are also needed. Finally, a training program on pressure injury prevention should be provided to nurse instructors to develop the knowledge they need to transmit to nursing students.


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attitude; critical care nurse; intensive care unit; knowledge; pressure injury; prevention

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