Factors Associated with Nurses’ Perceived Competence in Pressure Injury Care in a Tertiary Hospital in Yunnan, China : Advances in Skin & Wound Care

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Factors Associated with Nurses’ Perceived Competence in Pressure Injury Care in a Tertiary Hospital in Yunnan, China

Huang, Sijia RN; Saensom, Donwiwat PhD, RN

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Advances in Skin & Wound Care 35(8):p 1-9, August 2022. | DOI: 10.1097/01.ASW.0000834456.88566.4b
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To assess nurses’ perceived competence in pressure injury (PI) care and explore the association between perceived competence and nurses’ backgrounds, knowledge, attitudes, and self-efficacy in PI care.


This study used a descriptive correlational design. During January and February 2021, the authors sent an online questionnaire to 117 nurses caring for patients with or at risk of PI at a tertiary level hospital in Kunming, Yunnan Province, China, to collect information regarding demographics, knowledge, attitude, self-efficacy, and perceived competence in PI care. Univariate and multiple regressions were performed to assess the associations.


A total of 111 completed questionnaires were obtained, a response rate of 94.9%. Nurses reported inadequate knowledge and relatively low self-efficacy in PI care. However, they had positive attitudes and acceptable levels of perceived competence in PI care. According to a univariate analysis, being a wound specialist, having read PI-related articles or practice guideline within the past year, and having knowledge and self-efficacy in PI care were associated with nurses’ perceived competence.


Pressure injury-related knowledge, attitude, and self-efficacy are independently associated with nurses’ perception of their competency in PI care.


Pressure injury (PI) refers to localized skin and/or underlying tissue ischemic necrosis caused by pressure or pressure in combination with shear.1 Although PIs can develop in people of all ages and on any part of the body, they are more common among older adults with impaired mobility and anyone who experiences prolonged pressure on the skin, especially in areas of the body with bony prominences.1,2 The prevalence of PI is 11.62% worldwide, 5.14% in Asia,3 and 1.58% in China in hospital settings.4 However, the low PI prevalence in China may be due to underreporting (ie, reporting a high incidence of hospital-acquired PIs may reflect poor care quality and could result in penalty to nurses).4,5 It is difficult to draw direct comparisons with other countries and among studies because of different sample sizes, populations, and methods.2 However, PI prevalence in hospitalized patients in China is on an upward trend,4 and the prevalence of preexisting PIs that developed at home is higher than the prevalence of hospital-acquired PIs.4,6

A new Chinese health policy, the Hospital Extended Care Service (HECS), was introduced to meet patients’ medical resource needs in the community. Subsequently, hospital-based nurses can provide nursing care outside of the hospital to address the lack of quality healthcare resources in the community.7 As a result, hospital extended care for PI has become one of the most popular nursing projects. However, HECS remains in a pilot phase and needs constant improvement to efficiently meet future healthcare needs. In terms of PI care, nurses are facing new challenges: providing care outside of the hospital and, in many cases, working alone with little support, which requires competency and expertise in PI care.

Nurses’ competence in PI care includes the ability to integrate knowledge, skills, attitude, and self-efficacy into clinical practice, as well as the ability to adapt their experience and skills to patients with PIs or increased PI risk.8,9 Thus, nurse competence has a significant influence on the prevention and care of PI.10 The implementation of nursing care plans into practice is influenced by nurses’ knowledge, attitude, and self-efficacy.11 Lack of knowledge can lead to poor or inappropriate PI care.12 In addition, implementation of PI prevention measures is correlated with nurses’ attitude.13 A positive attitude helps nurses follow the guidelines in practice.11,14 Moreover, self-efficacy in PI care can fundamentally affect the performance and practice of nurses’ PI care,10 including nurses’ confidence in their ability to assess, prevent, care for, and educate patients regarding PIs in hospitals and in the community. Self-efficacy has been found to mediate knowledge and action,16 and nurses’ implementation of nursing plans is positively affected by their perceived self-efficacy.17

Many countries have developed guidelines for PI prevention and treatment. China has adopted the Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline18 as a standard for PI care. However, recent evidence indicates that many nurses lack competence in PI care. In terms of knowledge, studies have found that nurses working in hospitals answer approximately 50% of PI care questions correctly.19,20 In China, nurses typically answer between 61.1% and 67.73% of questions correctly on PI knowledge questionnaires.21,22 Although nurses consistently demonstrate positive attitudes toward PI care across various studies, their implementation of proper PI practices is low.23,24 For example, 51% of nurses reported poor PI prevention in Northwest Ethiopia.25 Despite the availability of evidence-based PI guidelines, PI care does not consistently follow guidelines and may differ among nurses. In addition, some nurses may delegate PI care to less-qualified caregivers.26 Nurses’ reported self-efficacy in PI care varies, with ratings of confidence in providing PI care ranging from 12% to 90%.27,28 Because self-efficacy is nurses’ belief that the practice will produce the desired results, low self-confidence may lead them to practice less than what is recommended by the evidence-based practice guidelines.29 It appears that many nurses provide skin care for patients with PI risk by relying primarily on their own knowledge and experience rather than regular use of assessment tools and practice guidelines.30

In China, nurses face challenges in carrying out the HECS policy for PI care in the community. A pilot study conducted in a tertiary care hospital in Yunnan found that nurses’ knowledge about PI care was insufficient, they lacked self-efficacy, and they felt unprepared to carry out the HECS PI care at patients’ homes. To ascertain the level of nurses’ readiness and competence in performing PI care at patients’ homes, it is necessary to study nurses’ perceived competence, knowledge, attitudes, and self-efficacy in PI care. This study assesses nurses’ perceived competence in PI care and explores associations between perceived competence and nurses’ backgrounds, knowledge, attitudes, and self-efficacy in PI care. Results from this study will help provide a better understanding of major nursing barriers to PI care, which can then contribute to the formulation of effective education strategies. Such results may also have consequences for further assessment, preparation, and management, leading to better patient outcomes.


Study Design, Setting, and Period

This correlational descriptive study aimed to explore associations between knowledge, attitude, and self-efficacy in PI care and nurses’ perceived competence regarding PI prevention and management in one tertiary care hospital in Yunnan Province, China. This hospital is the largest three-level general hospital in the southern district of Kunming city and the first hospital extension to provide PI nursing care for patients in their homes in Yunnan Province. This study was conducted from January to February 2021.


The study participants were 117 nurses who provided PI care and met the following inclusion criteria: (1) RNs older than 18 years; (2) working full-time as an RN at the study hospital; (3) willing to take part in this study and provide informed consent; and (4) having at least 1 year of experience in PI care.

Research Instrument

This study used an online survey that included five parts: demographic data, nurses’ knowledge, nurses’ attitudes, nurses’ self-efficacy, and nurses’ perceived competence in PI care. Demographic data included sex; age; level of education; length of service; professional category; wound specialist certification; year of last PI education; and year of last reading PI-related books, journal articles, and/or practice guidelines. The nurses’ knowledge in PI care was assessed by the Pieper-Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT).31 The 72-item knowledge questionnaire consists of three domains including knowledge about PI prevention, wounds, and wound staging. Participants were asked to choose whether the statement in each question is “true,” “false,” or “do not know” based on their knowledge. One point was given for each correct answer, and no point was awarded for incorrect answers. Items that were left blank or answered with “do not know” were considered incorrect. The score was calculated by dividing the total number of correct answers by the total number of questions to obtain the percentage of correct answers.31 Higher scores indicate a higher level of knowledge in PI care. The authors of the PZ-PUKT did not stratify different PI knowledge scores. As a result, it is possible to assess the level of PI knowledge according to the study environment and population. The content validity index (CVI) of the Chinese translated version of the PZ-PUKT was 0.83 to 1.00,32 and the internal consistency was evident with a Cronbach α of .887.

Nurses’ attitudes were assessed with the Attitude towards Pressure ulcer Prevention (APuP) questionnaire.26 This questionnaire contains 13 items that represent five domains, including attitude about personal competence to prevent PI, priority of PI prevention, impacts of PI, personal responsibility in PI prevention, and confidence in the effectiveness of prevention; total scores range from 13 to 52. A four-point Likert scale was used to assess the attitude of nurses. Each item ranged from strongly agree (4 points) to strongly disagree (1 point), and scores for negative choices ranged from strongly disagree (4 points) to strongly agree (1 point). A higher score indicates a more positive attitude toward PI prevention. The CVI of the Chinese translated version of the APuP was 0.87 to 1.0033 with a Cronbach α of .813.

Nurses’ self-efficacy was measured by the Self-efficacy in Pressure Injury Care (SEPIC) scale, which was developed by the researchers for this study. The SEPIC scale consists of 12 items, which include self-efficacy in PI assessment, PI prevention, PI education, and PI nursing care. The SEPIC scale was based on the Pressure Ulcer Management Self-efficacy Scale17 and the Pressure Injury Nursing Behavior (PINB) questionnaire.9 A five-point Likert scale was used to assess nurses’ self-efficacy, with each item ranging from completely capable (5 points) to completely incapable (1 point). A higher score indicates greater self-efficacy toward PI care. The SEPIC scale has a CVI of 1.00 and a Cronbach α of .940.

Nurses’ perceived competence was measured with the PINB questionnaire.9 The 36-item questionnaire consists of five domains, including competence in PI risk assessment, PI prevention intervention, PI risk awareness, PI wound assessment and treatment, and PI health education. A five-point Likert scale assesses the nurses’ perceived competence, with each item ranging from every time (5 points) to never (1 point). A higher score indicates greater perceived competency toward PI care. The PINB questionnaire has a CVI of 0.952 and a Cronbach α of .972.

Ethical Approval

The Ethical Review Board of the Ethics Review Committee at Khon Kaen University independently reviewed and approved the study protocol; the director of the study hospital and the head of the nursing department approved data collection. Participants were informed about the purpose and benefits of the study and asked to sign a consent form to confirm that they volunteered to participate. All data were collected anonymously and stored securely.

Data Collection Procedures

Two nurses from the wound clinic were recruited as research assistants. Before data collection began, the researchers discussed the study protocol, the rights of study participants, the data collection method, questionnaire structures, and response method with the research assistants to ensure that they clearly and accurately understood the study processes. Study participants were identified through the NP archive. All eligible participants were asked about their experience in PI care and their willingness to participate in the study by the research assistants. The research assistants then explained the purpose of the study and participants’ rights. Prospective participants were asked to carefully read and complete the informed consent form.

When the participant clearly understood the study and agreed to participate, research assistants distributed a QR code for the online survey to all participants. The survey was administered by Wenjuanxing, which is an online questionnaire collection application. Participants spent 20 to 30 minutes answering the questionnaire online. The data collection process did not record the names of participants. The questionnaire application automatically checked the questionnaire for completeness; if the questionnaire was incomplete, the participant was asked to fill in the missing information. However, if participants could not or did not wish to fully respond, they were allowed to leave an answer blank. Incomplete answers were not included in the final statistical analysis. The research assistants presented a small gift to each study participant as a token of appreciation.

Data Analysis

The researchers used the Statistical Package for the Social Sciences version 26.0 (IBM Corp, Armonk, New York) for data analysis. They used descriptive statistics to summarize characteristics of each research variable and calculated frequencies, percentages, means, and SDs.

Factors associated with nurses’ perceived competence in PI care were determined in two steps. (1) A univariate regression was used to explore associations between nurses’ demographic characteristics, knowledge, attitudes, and self-efficacy and their perceived competence related to PI care. (2) In a multivariate analysis, the researchers included those variables that were significantly associated with nurses’ perceived competence according to the univariate analysis and fitted multiple linear regression models to identify factors associated with nurses’ perceived competence. Assumptions of multiple regressions were assessed after data analysis was completed.


Demographic Characteristics of the Participants

Overall, 117 nurses participated in this study. Of the 117 responses received, 6 questionnaires were excluded because of incomplete answers, resulting in a response rate of 94.9%. The majority of the remaining 111 participants were women (95.5%). The average age of nurses was 29.47 (SD, 5.69) years. Most nurses graduated from junior college (52.3%). The average work experience was 8.2 (SD, 5.93) years, with the largest proportion being nurses who had been working for 1 to 5 years (40.5%). Most nurses held junior professional titles, which included primary nurse (36.9%) and NP (45%). Further, most nurses were not trained as wound specialists (82%) and never read PI practice guidelines (65.8%). In the previous year, 67% of the nurses had participated in PI care training (mean, 0.61 years [SD, 1.13] years), and 71% had read books or articles related to PI (mean, 0.59 [SD, 1.33]). Detailed results are displayed in Table 1.

Characteristics Mean (SD) Frequency Percentage (%)
Male 5 4.5
Female 106 95.5
Age, y (range, 20-49 y) 29.47 (5.69)
18–25 31 27.9
26–35 66 59.5
36–45 12 10.8
46–55 2 1.8
Education level
Technical secondary school 9 8.1
Junior college 58 52.3
Bachelor’s degree 43 38.7
Master’s degree 1 0.9
Length of service, y 8.20 (5.93)
1–5 45 40.5
6–10 38 34.2
11–15 14 12.6
16–20 9 8.1
>20 5 4.5
Professional category
Primary nurse 41 36.9
NP 50 45.0
Nurse-in-charge 19 17.1
Deputy director nurse 1 0.9
Wound specialist
Yes 20 18
No 91 82
Last time attending a pressure injury lecture, y 0.61 (1.13)
<1 74 66.7
1–3 26 23.4
>3 11 9.9
Last time reading an article or book about pressure injury, y 0.59 (1.33)
<1 83 74.8
1–3 18 16.2
>3 10 9.0
Experience in reading the International Pressure Ulcer Prevention and Treatment Guidelines
Yes 38 34.2
No 73 65.8
Gastroenterology and nephrology 14 12.61
Neurology 13 11.72
General medical 12 10.81
Cardiology 13 11.72
ICU 23 20.72
The first surgery ward 10 9.00
The second surgery ward 9 8.11
Spinal cord center 10 9.00
Orthopedics 7 6.31

RNs’ Knowledge, Attitude, Self-efficacy, and Perceived Competence in PI Care

Nurses possessed a moderate level of knowledge regarding PI care with an average of 71.97% answers correct. Almost all nurses (97.88%) answered PI staging questions correctly, and most nurses (69.40%) correctly answered questions about wound characteristics, staging, and prevention. However, approximately only half of the participants (55.66%) answered questions about PI prevention correctly.

In terms of attitude, nurses possessed a moderately high level of positive attitude toward PI care (79.23%; mean, 41.20 [SD, 4.91]). Nurses also reported high levels of positive attitude in prioritizing PI prevention (84.33%; mean, 10.12 [SD, 1.62]), personal responsibility in PI prevention (83.50%; mean, 6.68 [SD, 1.14]), and impact of PI (80.67%; mean, 9.68 [SD, 1.48]). However, nurses reported the lowest level of positive attitude in their personal competence to prevent PI (69.50%; mean, 8.34 [SD, 1.58]).

Nurses reported low levels of self-efficacy toward PI care (66.05%; mean, 36.33 [SD, 8.36]). They reported slightly higher levels of self-efficacy in the education (67.70%; mean, 6.77 [SD, 1.80]) and assessment (67.13%; mean, 10.07 [SD, 2.44]) aspects of PI care. Nurses reported the lowest level of self-efficacy in their PI nursing care (64.80%; mean, 12.96 [SD, 3.22]).

Finally, nurses possessed high levels of perceived competence toward PI care (83.59%; mean, 150.47 [SD, 18.74]). Nurses reported the highest level of perceived competence in PI risk assessment (86.52%; mean, 21.63 [SD, 2.45]), with similar levels of perceived competence in intervention for PI prevention (84.80%; mean, 33.92 [SD, 4.65]) and PI risk awareness (84.74%; mean, 29.66 [SD, 3.90]). Nurses reported the lowest levels of perceived competence in PI health education (80.75%; mean, 16.15 [SD, 2.69]). Detailed results are displayed in Table 2.

Item Mean SD Min Max %
Knowledge of PI care 51.82 6.41 28.00 65.00 71.97
PI prevention 15.58 2.28 9.00 20.00 55.66
Wounds 16.66 2.95 3.00 22.00 69.40
PI staging 19.58 2.71 12.00 26.00 97.88
Attitude toward PI care 41.20 4.91 32.00 52.00 79.23
Personal competence to prevent PI 8.34 1.58 4.00 12.00 69.50
Priority of PI prevention 10.12 1.62 6.00 12.00 84.33
Impact of PI 9.68 1.48 6.00 12.00 80.67
Personal responsibility in PI prevention 6.68 1.14 4.00 8.00 83.50
Confidence in the effectiveness of prevention 6.38 1.08 4.00 8.00 79.75
Self-efficacy in PI care 36.33 8.36 11.00 55.00 66.05
Assessment 10.07 2.44 3.00 15.00 67.13
Prevention 6.54 1.73 2.00 10.00 65.40
Education 6.77 1.80 2.00 10.00 67.70
Nursing care 12.96 3.22 4.00 20.00 64.80
Perceived competence in PI care 150.47 18.74 86.00 180.00 83.59
Risk assessment 21.63 2.45 16.00 25.00 86.52
Intervention for PI 33.92 4.65 16.00 40.00 84.80
Risk awareness 29.66 3.90 16.00 35.00 84.74
Wound assessment and treatment 49.11 8.67 22.00 60.00 81.85
Health education 16.15 2.69 8.00 20.00 80.75
Abbreviation: PI, pressure injury.

Factors Associated with Perceived Competence in PI Care

The univariate analysis indicated that attending PI lectures, being a wound specialist, having read an article or book about PI, having read PI practice guidelines, and reporting PI knowledge and self-efficacy were all significantly associated with nurses’ perceived competence in PI care. Detailed results are displayed in Table 3.

Item Competence
B β P R 2
Sex 4.745 0.053 .582 0.003
Age 0.610 0.185 .051 0.034
Level of education 3.930 0.103 .282 0.011
Length of service 5.198 0.137 .152 0.019
Professional category 6.747 0.139 .146 0.019
Wound specialist 12.541 0.258 .006 0.067
Last time attending a PI lecture 8.892 0.225 .018 0.050
Last time reading an article or book about PI 11.373 0.265 .005 0.070
Experience in reading PI guidelines 10.772 0.274 .004 0.075
Knowledge of PI care 1.082 0.370 .000 0.137
Attitude toward PI care 0.431 0.113 .238 0.013
Self-efficacy in PI care 1.048 0.468 .000 0.219
Abbreviation: PI, pressure injury

In a stepwise multiple regression analysis, three factors were independently associated with perceived competence in PI care, accounting for 35.7% of the variance. For each 1-point increase in PI care knowledge, perceived competence in PI care scores increased by 0.866 points. Similarly, for each 1-point increase in self-efficacy in PI care, perceived competence in PI care increased by 1.096 points. In contrast, for each 1-point increase in positive attitude toward PI care, the perceived competence in PI care score decreased by 1.04 points. Detailed results are displayed in Table 4.

Model B β P VIF R 2
(Constant) 109.587 0.357
Wound specialist 0.424 0.009 .925 1.369
Last time attending a PI lecture 0.431 0.011 .912 1.540
Last time reading an article or book about PI 6.580 0.153 .116 1.493
Experience in reading PI practice guidelines 1.248 0.032 .724 1.287
Knowledge 0.866 0.296 .003 1.470
Attitude −1.040 −0.273 .005 1.470
Self-efficacy 1.096 0.490 .000 1.581
Abbreviations: PI, pressure injury; VIF, variance inflation factor.


The results of this study indicate that nurses’ knowledge of PI care was inadequate. Overall, the participants answered 71.97% of PI care questions correctly. Participants had better knowledge of wound classification and PI descriptions than they did of PI prevention and wound care. However, these PI care knowledge scores are similar to those reported in other studies. A review of studies that applied the PZ-PUKT showed that overall scores ranged from 63% to 80% correct. Knowledge about wound staging ranged from 64% to 87.1% correct, knowledge about wound prevention ranged from 70% to 79.1% correct, and knowledge about wound management ranged from 56% to 77% correct.31,32,34 The researchers concluded that the participants’ knowledge of PI care was inadequate.

Nurses’ PI knowledge has been shown to influence the quality of care provided. As nurses’ PI knowledge improves, they are better able to provide best practices to patients, which can enhance patient satisfaction and outcomes. Nurses’ scores for the domains of staging and prevention showed a dramatic contrast. This discrepancy may be related to a lack of updates in PI knowledge. One study reported that the PI information taught in basic education courses in China was insufficient and lagging.35 The International National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory Panel Pressure Ulcer Guidelines are updated every 5 years. However, updating the content of school textbooks in remote areas may take time. In addition, in clinical practice, older nurses usually lead the care routine. Thus, if older nurses do not update their knowledge, younger nurses would also be less likely to acquire new knowledge. Younger nurses might also be reluctant to apply new PI knowledge in practice because they do not want to contradict their seniors.

In this study, nurses reported positive attitudes toward PI care. This finding is consistent with other related research in China.36,37 The overall average score of nurses’ attitudes toward PI care accounts for 79.23% of the total score in the APuP questionnaire. Scores higher than 75% reflect positive attitudes toward PI care.13 However, the average score for attitude toward PI care was lower than the Chinese average (85.02%).38 Thus, although nurses reported positive attitudes toward PI care, their scores could be further improved. In this study, all attitude subscales showed a positive trend, with the exception of attitude toward personal competence to prevent PI (69.5%). Nurses showed high personal responsibility and belief that PI care should be prioritized, but a lack of personal competence. In other words, the nurses who participated in this study did not think they are competent in providing PI care.

The results of the study indicated that nurses’ self-efficacy in PI care was at a relatively low level. The overall average score of nurses’ self-efficacy in PI care accounts for 66.05% of the total score in the SEPIC questionnaire, which may reflect that most participants in this study feel that they lack confidence in providing PI care. Because of the lack of research on nurses’ self-efficacy in PI care, it was difficult to make a cross-sectional comparison. However, studies examining nurses’ confidence in PI care similarly found that most nurses lack confidence.27,28 Because the PI healing period takes between 9 and 21 weeks,39 and patients stay in hospitals for an average of only 2 to 4 weeks in China, nurses do not gain self-efficacy from witnessing PIs heal. In addition, the same patient may receive PI care from many different nurses. Thus, it is difficult for nurses to get feedback regarding their PI care practice. In this study, 82% of nurses were not wound specialists, 66% never read PI practice guidelines, and approximately 30% had not taken a PI care course or read an article or book about PI in the past year. These factors may lead to nurses’ lack of self-efficacy in PI care as well.

Nurses’ perceived competence in PI care was at an acceptable level. The overall average score of nurses’ perceived competence in PI care accounts for 83.59% of the total score in the PINB questionnaire. The result was slightly lower than those of previous similar studies (86.1%) but greater than the 80% threshold that the PINB questionnaire developers suggest using to define competence.9 In this study, the highest score was in the risk assessment subscale. This finding may be related to hospital policies that require nurses to assess PI risk and record the result of risk assessment. The prevalence of hospital-acquired PI is an important quality index of nursing care,9 and punishment systems for hospital-acquired PIs are applied to evaluate nurses’ work.4,5 These factors likely contributed to the nurses’ provision of risk assessment to patients. The lowest competence score was in health education, indicating that nurses felt they had not received adequate PI-related health education. In this study, the researchers found that nurses had self-efficacy in health education, but they put it into practice at the lowest rate.

Three factors independently associated with perceived competence in PI care: knowledge, self-efficacy, and attitude. In terms of knowledge, for every 1-point increase in knowledge score, the nurses’ perceived competence increased by 1.08 points. This result was consistent with previous studies.27,40 Increased knowledge helps to improve nurses’ competence in PI care. However, although nurses’ perceived competence in PI care was at an acceptable level, their knowledge was inadequate. Lack of knowledge may lead to nurses engaging in inappropriate nursing practices.13 When nurses provide nursing care that is based on disinformation, this action is likely to be ineffective and perhaps even harmful. In addition, nurses’ limited awareness of PI clinical practice guidelines may be a barrier when they provide PI care according to those recommendations, which in turn could impact their competence.13,41

In terms of self-efficacy, for each 1-point increase in nurses’ self-efficacy score, their perceived competence score increased by 1.05 points. Although previous studies noted that nurses lack confidence in PI care, they did not examine the association between nurses’ self-efficacy and competence. Higher self-efficacy leads to better job performance.42 The results of this study are consistent with this view. The main sources of self-efficacy are past performance, verbal persuasion, vicarious experience, and emotional cues.43 Self-efficacy regulates human behavior through cognitive, emotional, motivational, and selection processes.15 Improving nurses’ self-efficacy can significantly improve nurses’ perceived competence in PI care. Based on Bandura’s theory,15,43 successful experiences, peer role models, encouragement, and motivation should all be considered to improve nurses’ self-efficacy.

In the univariate regression analysis, attitude and nurses’ perceived competence in PI care were not correlated. However, in the multiple regression model, attitude was one of the most important predictors of nurses’ perceived competence. This finding may indicate that nurses with a positive attitude alone may not show better competence in practice. Previous studies have shown that although nurses have a positive attitude toward PI care, they are not necessarily more competent.23,24 In this study, most nurses showed positive attitudes toward PI care. A positive attitude increases the likelihood that a person will initiate an action.44 However, barriers, such as lack of time and knowledge, are likely to affect nurses’ attitudes and thus their perceived competence.45

Compared with other countries, China has a severe shortage of nurses because of its large population base.46,47 Nurses in China are expected to take on tasks beyond their regular nursing responsibilities, such as patient account management. Thus, nurses feel they have the responsibility and obligation to provide PI care, but heavy nursing workloads may result in nurses having less time and energy to provide care.

Nurses scored their attitudes regarding their personal competence to prevent PI very low in this study, which may have resulted from some items in the APuP assessing nurses’ self-efficacy and ability rather than attitude. However, nurses reported low levels of self-efficacy in this study. This may be a reason why the attitude toward PI care variable showed a negative association with perceived competence in the multivariate regression. The attitude variable was also influenced by other covariables. Thus, the results suggest that attitude positively correlated with perceived competence in PI care.

The results of the univariate regression indicated that being a wound specialist, having attended PI lectures, having read articles or books about PI, and having read PI practice guidelines were all significantly associated with nurses’ perceived competence in PI care. These results were consistent with evidence from previous research, which reported that being a wound specialist had a significant impact on knowledge of PI care.32,48 The present study further confirms that wound specialist nurses have significantly higher perceived competence than non-wound specialists. Education related to PIs is effective in improving the knowledge, attitude, and confidence of nurses in PI care.11,27,40 Thus, regularly providing education or information regarding PIs, especially based on clinical practical guidelines, can help improve nurses’ perceived competence in PI care.

The results of this study suggest that sex, age, level of education, length of service, and professional category were not significantly associated with nurses’ perceived competence in PI care. These results were at odds with some of the evidence from previous studies. One study suggested that gender differences can have a significant impact on nursing practice.49 In this study, the male-to-female ratio was 1 to 21. Large gaps in sex ratio are difficult to compare with statistical effect. Older age, higher professional category, and longer working experience were associated with better knowledge, attitude, and competence.9,24,48,49 However, these factors were not associated with nurses’ perceived competence in this study. Perhaps this result may have been related to occupation burnout and long-time work habits: Older nurses might be less willing to acquire new knowledge and implement new clinical practices.35 Heavy workloads tended to reduce a nurse’s willingness to conduct clinical practice. This may help explain why older nurses did not show higher nursing competence despite having more practical experience. High education level was associated with higher positive intentions.49 In this study, most nurses graduated from junior college. Only 38% of nurses in the study had a bachelor’s degree, and most nurses chose continuing education to enhance their education level credentials. However, the difference in student development between degrees obtained through continuing education and those obtained through full-time study has been questioned.46,47 Even though some nurses had high-level degrees, their knowledge and abilities did not necessarily match their corresponding education level. This may be one reason why level of education was not significantly associated with nurses’ perceived competence in PI care.

Study Limitations and Strengths

This study had a very high response rate from nurses who met the inclusion criteria (94.87%), which helps minimize statistical bias. Because nurses completed the questionnaire online, they likely felt comfortable and could be honest in their answers. This is the first study to identify an association between nurses’ self-efficacy and perceived competence in China.

However, this study assessed only nurses’ perceived competence rather than their actual competence in PI care, and the data were participants’ subjective responses. This study focused only on nurses’ personal factors associated with their perceived competence in PI care and did not consider additional factors such as the context of care, facilities, or policies that may be associated with nurses’ perceived competency in PI care. In addition, because nurses’ knowledge of PI care was measured through an online questionnaire rather than an in-person examination, participants could have looked up the correct answers. Thus, nurses’ actual knowledge scores may differ from what was recorded in this study.


This study found that nurses’ knowledge of PI care was inadequate. Although they expressed positive attitudes, self-efficacy was relatively low. Nurses’ perceived competence was acceptable, but room for improvement remains. Knowledge, attitude, and self-efficacy were positively associated with perceived competence in PI care. In addition, being a wound specialist, having attended a PI lecture, having read an article or book about PI, and having read PI practice guidelines were also significantly associated with nurses’ perceived competence in PI care.

Relevance to Clinical Practice

  • (1) When considering the improvement of nurses’ competence, nurse administrators should also focus on updating and refreshing nurses’ knowledge and self-efficacy.
  • (2) Nurses’ competence in PI care can be improved through taking PI courses and reading relevant books or articles about PI and wound care training. Wound care training should be offered at least once a year, and the course designers should incorporate the latest PI practice guidelines into the course content.
  • (3) To facilitate nurses’ positive attitudes toward PI care, nurse managers may need to improve other factors, such as nurse workload, facility unavailability, and policy preferences.
  • (4) Future research should evaluate nurses’ competence in practice. Measuring nurses’ actual competence can reflect the various influences on nurses’ abilities more objectively and avoid the influence of subjective factors.
  • (5) Future research should uncover the unknown 65% variance in nurses’ competence in PI care. In this study, only 35% of the variance in nurses’ competence was explained. Thus, future studies should consider the impacts of other factors such as the care environment, policies, and facilities on nurses’ competence in PI care.


1. Agrawal K, Chauhan N. Pressure ulcers: back to the basics. Indian J Plast Surg 2012;45:244–54.
2. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. 3rd ed. Haesler E, ed. 2019.
3. Al Mutairi KB, Hendrie D. Global incidence and prevalence of pressure injuries in public hospitals: a systematic review. Wound Med 2018;22:23–31.
4. Guo Y, Liang X, Zhu W, Zhang Y, Zhu H, Zhu Z. The prevalence of pressure ulcer and hospital acquired pressure ulcer in hospitalized patients in China: a meta-analysis. Chinese Nurs Manage 2018;18:907–14.
5. Geng T, Zhao Q, Xiao M, Liu L. Investigation and analysis on prevalence of hospitalized patients with pressure ulcers. J Chongqing Med Univ 2013;38:694–6.
6. Cheng J, Li D, Song G, et al. An analysis of pressure injury of inpatients in a tertiary level hospital in Kunming. Int J Nurs 2017;36:3428–30.
7. National Health Commission of the People’s Republic of China. China greenlights “internet hospitals”. Published April 17, 2018. http://en.nhc.gov.cn/2018-04/17/c_73325.htm. Last accessed May 15, 2022.
8. Fukada M. Nursing competency: definition, structure and development. Yonago Acta Med 2018;61(1):1–7.
9. Jiang L, Li L, Lommel L. Nurses’ knowledge, attitudes, and behaviours related to pressure injury prevention: a large-scale cross-sectional survey in mainland China. J Clin Nurs 2020;29:3311–24.
10. Caruso R, Fida R, Sili A, Arrigoni C. Towards an integrated model of nursing competence: an overview of the literature reviews and concept analysis. Prof Inferm 2016;69(1):35–43.
11. Simonetti V, Comparcini D, Flacco ME, Di Giovanni P, Cicolini G. Nursing students’ knowledge and attitude on pressure ulcer prevention evidence-based guidelines: a multicenter cross-sectional study. Nurse Educ Today 2015;35:573–9.
12. Beeckman D, Vanderwee K, Demarré L, Paquay L, van Hecke A, Defloor T. Pressure ulcer prevention: development and psychometric validation of a knowledge assessment instrument. Int J Nurs Stud 2010;47:399–410.
13. Beeckman D, Defloor T, Schoonhoven L, Vanderwee K. Knowledge and attitudes of nurses on pressure ulcer prevention: a cross-sectional multicenter study in Belgian hospitals. Worldviews Evid Based Nurs 2011;8(3):166–76.
14. Park S, Cha SK, Kim C-G. The effects of the education about new pressure ulcer classification and incontinence-associated dermatitis on knowledge and self-efficacy in pressure ulcer among nurses. J Muscle Joint Health 2013;20(1):52–61.
15. Bandura A. Self-efficacy. In: The Corsini Encyclopedia of Psychology. John Wiley & Sons: Hoboken, NJ; 2010:1–3.
16. Plaza CM, Draugalis JR, Retterer J, Herrier RN. Curricular evaluation using self-efficacy measurements. Am J Pharm Educ 2002;66(1):51–4.
17. Dellafiore F, Arrigoni C, Ghizzardi G, et al. Development and validation of the pressure ulcer management self-efficacy scale for nurses. J Clin Nurs 2019;28:3177–88.
18. Kottner J, Cuddigan J, Carville K, et al. Prevention and treatment of pressure ulcers/injuries: the protocol for the second update of the international clinical practice guideline 2019. J Tissue Viability 2019;28(2):51–8.
19. Aydin AK, Karadağ A. Assessment of nursesʼ knowledge and practice in prevention and management of deep tissue injury and stage I pressure ulcer. J Wound Ostomy Continence Nurs 2010;37:487–94.
20. Chianca TCM, Rezende JFP, Borges EL, Nogueira VL, Caliri MHL. Pressure ulcer knowledge among nurses in a Brazilian university hospital. Ostomy Wound Manage 2010;56(10):58–64.
21. Deng S, Piao Y, Feng J, et al. Investigation of the status of nurses’ knowledge about pressure ulcer. J Nurs Adm 2014;14:479–81.
22. Lei L, Li Y. Investigation on nursing knowledge level of pressure ulcers in bedridden patients by community nurses. Chinese Foreign Entrepreneurs 2019;26:207.
23. Tubaishat A, Aljezawi M, Al Qadire M. Nurses’ attitudes and perceived barriers to pressure ulcer prevention in Jordan. J Wound Care 2013;22:490–7.
24. Uba MN, Alih FI, Kever RT, Lola N. Knowledge, attitude and practice of nurses toward pressure ulcer prevention in University of Maiduguri Teaching Hospital, Borno State, North-Eastern, Nigeria. Int J Nurs Midwifery 2015;7(4):54–60.
25. Nuru N, Zewdu F, Amsalu S, Mehretie Y. Knowledge and practice of nurses towards prevention of pressure ulcer and associated factors in Gondar University Hospital, Northwest Ethiopia. BMC Nurs 2015;14(1):34.
26. Beeckman D, Defloor T, Demarré L, van Hecke A, Vanderwee K. Pressure ulcers: development and psychometric evaluation of the Attitude towards Pressure ulcer Prevention instrument (APuP). Int J Nurs Stud 2010;47:1432–41.
27. Innes-Walker K, Parker CN, Finlayson KJ, et al. Improving patient outcomes by coaching primary health general practitioners and practice nurses in evidence based wound management at on-site wound clinics. Collegian 2019;26(1):62–8.
28. Walker CA, Rahman A, Gipson-Jones TL, Harris CM. Hospitalists’ needs assessment and perceived barriers in wound care management: a quality improvement project. J Wound Ostomy Continence Nurs 2019;46:98–105.
29. Caruso R, Pittella F, Zaghini F, Fida R, Sili A. Development and validation of the Nursing Profession Self-efficacy Scale. Int Nurs Rev 2016;63:455–64.
30. Samuriwo R, Dowding D. Nurses’ pressure ulcer related judgements and decisions in clinical practice: a systematic review. Int J Nurs Stud 2014;51:1667–85.
31. Pieper B, Zulkowski K. The Pieper-Zulkowski pressure ulcer knowledge test. Adv Skin Wound Care 2014;27:413–20.
32. Nie W, Tang J, Zulkowski K, Wang L, Zan T. Psychometric properties of the Chinese version of the Pieper-Zulkowski pressure ulcer knowledge test in nursing practice: a cross-sectional survey. Adv Skin Wound Care 2020;33(5):1–7.
33. Wang W, Ou Y, Zeng Y, Liu Q, Liu C, Wu X. Reliability and validity of Chinese version of attitude towards pressure ulcer prevention. J Mod Med Health 2020;36:490–3.
34. Delmore B, Ayello EA, Smart H, Sibbald RG. Assessing pressure injury knowledge using the Pieper-Zulkowski pressure ulcer knowledge test. Adv Skin Wound Care 2018;31:406–12.
35. Li J, Yang L, Fan L, Wang Y. Awareness and preventive behavior of pressure injury in perioperative patients by 226 nurses. J Nurs (China) 2017;24(18):48–52.
36. Cheng C, Liu C, Cheng Y. Survey on the knowledge and attitude of pressure injury among nurses within medical consortium. China Med Herald 2020;17(33):78–81.
37. Li L, Jiang L, Zeng Y, Chen X, Li Y, Fan X. Nursing behaviors relevant to pressure injury in the general hospitals of Changsha, China. J Cent South Univ (Med Sci) 2020;45:722–32.
38. Li J, Cao J, Jiao Z, et al. Multicenter survey on nurses’ knowledge and attitude on common complications among bedridden patients in Chinese hospitals. Chin J Nurs 2017;52:327–31.
39. Öien RF, Forssell HW. Ulcer healing time and antibiotic treatment before and after the introduction of the Registry of Ulcer Treatment: an improvement project in a national quality registry in Sweden. BMJ Open 2013;3(8):1–5.
40. Hiser B, Rochette J, Philbin S, Lowerhouse N, Terburgh C, Pietsch C. Implementing a pressure ulcer prevention program and enhancing the role of the CWOCN: impact on outcomes. Ostomy Wound Manage 2006;52(2):48–59.
41. Hutchinson AM, Johnston L. Bridging the divide: a survey of nurses’ opinions regarding barriers to, and facilitators of, research utilization in the practice setting. J Clin Nurs 2004;13:304–15.
42. Lunenburg FC. Self-efficacy in the workplace: implications for motivation and performance. Int J Manage Bus Adm 2011;14(1):1–6.
43. Bandura A. Self-efficacy: The Exercise of Control. W. H. Freeman: New York, NY; 1997.
44. Ajzen I, Fishbein M. The influence of attitudes on behavior. In: The Handbook of Attitudes. Lawrence Erlbaum Associates Publishers: Mahwah, NJ; 2005:173–221.
45. Moore Z, Price P. Nurses’ attitudes, behaviours and perceived barriers towards pressure ulcer prevention. J Clin Nurs 2004;13:942–51.
46. Hou J, Michaud C, Li Z, et al. Transformation of the education of health professionals in China: progress and challenges. Lancet 2014;384:819–27.
47. Wang CC, Whitehead L, Bayes S. Nursing education in China: meeting the global demand for quality healthcare. Int J Nurs Sci 2016;3(1):131–6.
48. Lawrence P, Fulbrook P, Miles S. A survey of Australian nurses’ knowledge of pressure injury/pressure ulcer management. J Wound Ostomy Continence Nurs 2015;42:450–60.
49. Saleh MY, Qaddumi JAMS, Anthony D. An interventional study on the effects of pressure ulcer education on Jordanian registered nurses’ knowledge and practice. Proc Soc Behav 2012;47:2196–206.

care; hospital; nurse; pressure injury; perceived competence; self-efficacy

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