INTRODUCTION

Pressure injuries (PIs) adversely affect patients’ quality of life and can result in mortality and morbidity.1 Although guidelines have been established for PI prevention, they remain a significant healthcare challenge.2–4 Pressure injuries negatively affect patients physically, socially, and psychologically. Moreover, PIs cause significant increases in costs in the healthcare system.3

According to the National Pressure Injury Advisory Panel, PI incidence ranges from 0.4% to 2.2% in acute care units and 23.9% in long-term care units.5 Various systematic reviews and meta-analyses have been carried out to determine the incidence of PI in the world. In a global systematic review and meta-analysis, Borojeny et al6 found the overall incidence of PI in inpatients to be 12%. However, the included studies were conducted primarily in European countries.6 Research investigating the incidence of PI in Turkey is limited, but reports range from 14% to 54.8% in all clinics.7–9 In a study conducted in Turkey, Kaşıkçı et al10 reported that PIs were most common in ICUs with an incidence of 35.3%.10 According to a meta-analysis conducted in Iran, PI incidence was 57%.11 Further, the incidence of PI in the ICU was 23.7% in South Korea12 and 35.7% in Saudi Arabia.13

A multidisciplinary team approach is essential for PI prevention and care, as well as identifying risk factors at an early stage.14 Nurses have an important role and responsibility in the detection and prevention of PI.8,15 Nurses and other health professionals must have sufficient knowledge to prevent PI, provide care, and make the best care decisions.14 Nursing care has a significant effect on PI prevention and healing.16,17 However, in studies and systematic reviews in which nurses’ PI knowledge was examined, nurses did not have sufficient knowledge (answering an average of 55.4% of questions incorrectly).2,18,19 Nurses must have up-to-date and evidence-based information about the PI risk factors, evaluation, staging, and care.20

Along with their level of knowledge, nurses’ attitudes toward PI are also very important.21 According to the theory of planned behavior, a person who has positive attitudes toward a behavior or practice will perform that behavior, whereas a person with negative attitudes toward the behavior will not.22 According to the theory, for a person to exhibit a behavior, the person must first have an intention toward that behavior. One of the indicators of a person’s intention is his/her attitude toward the behavior. If a person has a negative attitude toward an issue, he/she is unlikely to exhibit a positive behavior on that issue.23 Thus, nurses’ attitudes toward PI prevention will likely affect their PI practices. Those who have a positive attitude toward PI will reflect this in their care practices.1 Previous researchers have noted a direct correlation between nurses’ attitudes and practices regarding PI prevention.19,21

Research Questions

Because PIs have many negative effects on patients and healthcare organizations, and nurses play a leading role in PI prevention, it is thus important to determine nurses’ PI knowledge levels and attitudes, which play a mediating role in transferring their knowledge to practice. In the present study, the authors determined the level of knowledge and attitudes of nurses in Turkey regarding PI and evaluated the relationship between these variables. They investigated the following research questions:

What are nurses’ levels of knowledge regarding PI? What are nurses’ attitudes toward PI? Which, if any, predictors affect nurses’ levels of knowledge and attitudes? METHODS Research Population, Sample, and Research Group

This descriptive study was carried out from November 2022 to April 2023 in a training and research hospital in Turkey. The sample size was calculated with the G*Power analysis based on the sample sizes in similar studies conducted in the literature. According to the G*Power analysis (CI of 95%, error rate of 5%, and incidence of 50%), 604 nurses were included for a power of 98%. The study consisted of nurses 18 years or older, who provided care to patients with PIs, and who agreed to participate in the study.

Data Collection Tools Nurse Introduction Form

The researchers created a Nurse Introduction Form in line with the literature.1,8,24 Five colleagues, all of whom had at least a doctoral degree and had performed studies on PI, provided expert opinions on the included questions. They evaluated all items on the introduction form and assigned each a score of 1 (appropriate), 2 (revision required), or 3 (inappropriate). Researchers then revised the form in line with the opinions of the experts, the experts reviewed the form again, and the form was finalized. The final form consisted of eight questions about descriptive characteristics: age, sex, education status, unit of employment, years of employment, weekly working pattern, PI as a nursing care indicator, and knowledge of PI guidelines.

Pressure Ulcer Knowledge Assessment Tool (PUKAT) 2.0

The PUKAT was developed by Beeckman et al25 in 2010 and updated by Manderlier et al26 to the PUKAT 2.0 in 2017. The Turkish validity and reliability of the scale were established by Dallı et al27 in 2022. The scale consists of 25 multiple-choice items and six subthemes: etiology, classification and observation, risk assessment, nutrition, prevention, and specific patient groups. Some questions are supported by case studies. The intraclass correlation coefficient of the PUKAT 2.0 was 0.69. Each correct answer is scored as 1 point, with a total possible score of 25. In the present study, the Cronbach α value of the scale was .65. The researchers obtained permission to use the PUKAT 2.0 from the scale’s creators.

Attitude towards Pressure Ulcer Prevention (APuP) Instrument

The APuP scale was developed by Beeckman et al28 in 2010 and adapted into Turkish by Üstün and Çınar Yücel29 in 2013. It consists of 13 items across five subscales: personal competency to prevent PI (3 items), priority of prevention (3 items), the impact of PI (3 items), personal responsibility (2 items), and effectiveness of prevention (2 items). Items are scored on a 4-point Likert-type scale (1, strongly disagree; 2, disagree; 3, agree; 4, strongly agree). Seven items with negative statements are reverse scored (items 3, 5, 7, 8, 9, 10, and 13). Total possible scores range from 13 to 52. A mean attitude score of 75% or more is considered satisfactory. In the present study, the Cronbach α was .72.

Data Collection

Nurses completed the questionnaires in a paper-and-pencil format in an empty room in the clinic where they worked. Prior to data collection, researchers told the nurses that they would not be informed about the answers to the questionnaire forms. Nurses were allowed to ask questions only if they did not understand something in the survey forms.

Statistical Methods

The data obtained from the research were analyzed in the SPSS 21.0 program (IBM Corp). The Shapiro-Wilk test was used to determine whether the data were normally distributed. The researchers used descriptive statistics (number, percentage, mean, SD, and range), independent-sample t test, and analysis of variance for comparisons due to the normal distribution of the data. Correlation analyses were performed to compare scale scores, and regression analyses were performed to determine predictors. P < .05 was considered significant. The number of correct answers was divided by the total number of items and multiplied by 100 to calculate the percentage of correct answers.

Ethical Considerations

The study was approved by the Ethics Committee of İzmir Bakircay University Non-Interventional Clinical Research (No:780-760). The researchers also obtained permission from the hospital where the study was conducted. Nurses provided informed consent to participate in the study.

RESULTS Participant Characteristics

A total of 604 nurses (439 women, 72.7%) participated in this study. The mean age of the nurses was 35.9 ± 3.6 years. Of the nurses, 60.9% (n = 368) had a bachelor’s degree, 51.2% (n = 309) had been working in the unit for 6 to 10 years, and 41.6% (n = 251) worked in intensive care. Further, the majority of nurses stated that PIs were not an indicator of nursing care (n = 348, 57.6%) and that they did not have information about the guidelines for PI prevention (n = 420, 69.4%; Table 1).

Table 1. - DEMOGRAPHIC CHARACTERISTICS OF NURSES (N = 604) Characteristic n (%) Age, mean ± SD, y 35.9 ± 3.60 Sex Female 439 (72.7) Male 165 (27.3) Education level High school or associate’s degree 166 (27.5) Bachelor’s degree 368 (60.9) Master’s degree 70 (11.6) Work experience, y 1-5 118 (19.5) 6-10 309 (51.2) 11-15 61 (10.1) 16-20 99 (16.4) ≥21 17 (2.8) Unit type Internal medicine 218 (36.1) ICU 251 (41.6) Surgical 135 (22.4) PI is an indicator of nursing care Yes 256 (42.4) No 348 (57.6) Knowledge of PI prevention guidelines Yes 184 (30.6) No 420 (69.4)

Abbreviation: PI, pressure injury.

Nurses’ Level of Knowledge

The highest possible PUKAT 2.0 score is 25. Nurses’ mean PUKAT 2.0 score was 9.40 ± 2.47, which corresponds to 46.72% correct answers. The subthemes with the lowest percentages of correct answers were risk assessment (30.9%) and specific patient groups (34.6%). In contrast, the highest scoring subthemes were etiology (65.4%), classification and observation (53.3%), and nutrition (51.9%). An overview of knowledge scores in total and by subtheme is reported in Table 2.

Table 2. - PARTICIPANTS’ PUKAT 2.0 TOTAL SCORE AND THEME SCORES Theme No. Items Mean ± SD Correct Answers, % Theme 1: Etiology and development 6 2.25 ± 1.41 65.4 Theme 2: Classification and observation 4 2.01 ± 1.13 53.3 Theme 3: Risk assessment 2 0.61 ± 0.65 30.9 Theme 4: Nutrition 3 1.55 ± 0.73 51.9 Theme 5: Prevention 8 2.54 ± 1.09 41.8 Theme 6: Specific patient groups 2 0.69 ± 0.49 34.6 Total 25 9.40 ± 2.47 46.7

Abbreviation: PUKAT, Pressure Ulcer Knowledge Assessment Tool.

Nurses’ Attitudes toward PI

Nurses’ mean total APuP score was 32.39 ± 2.752. Among the subscale scores, the nurses scored lowest on responsibility (4.64 ± 1.09) and highest on competency (8.86 ± 1.62) (Table 3).

Table 3. - PARTICIPANTS’ APuP TOTAL SCORE AND SUBDIMENSION SCORES Attitude Subdimensions Mean ± SD Range Competence 8.86 ± 1.62 4–12 Priority 7.59 ± 1.57 3–10 Impact 6.07 ± 1.51 3–12 Responsibility 4.64 ± 1.09 2–8 Effectiveness of prevention 5.21 ± 1.48 3–8 Total scale score 32.39 ± 2.75 23–42

Abbreviation: APuP: Attitudes towards Pressure Ulcer Prevention.

Relationships among Demographic Characteristics, Knowledge, and Attitude

Total scores on the PUKAT 2.0 and APuP differed significantly by sex. Women had a higher level of knowledge than men (t = 5.084, P < .001), whereas men had a more positive attitude toward PI (t = 5.670, P < .001).

There was also a significant correlation between nurses’ education level and total PUKAT 2.0 and APuP scores. Nurses with a bachelor’s degree had higher knowledge (F = 7.392, P < .001) and attitude (F = 8.841, P < .001) scores than those in the other education groups.

Years worked also correlated with knowledge and attitude scores. The knowledge scores of nurses who had worked for 16 to 20 years (F = 8.387, P < .001) and the attitude scores of those who had worked for 11 to 15 years (F = 9.126, P < .001) were higher than those in the other work duration groups.

Finally, there was a significant correlation between unit of employment and nurses’ knowledge and attitude scores. The knowledge (F = 13.893, P < .001) and attitude (F = 12.962, P < .001) scores of nurses working in ICUs were higher than those of nurses working in other units (Table 4).

Table 4. - RELATIONSHIP OF DEMOGRAPHIC CHARACTERISTICS WITH KNOWLEDGE AND ATTITUDE PUKAT 2.0 Total Score APuP Total Score Variable Mean ± SD Test P Mean ± SD Test P Sex t = 5.084 .00 t = −5.670 .00 Female 9.70 ± 1.43 31.87 ± 3.70 Male 8.58 ± 1.39 33.76 ± 3.54 Education level F = 7.392 .001 F = 8.841 .000 High school or associate’s degree 9.27 ± 1.47 30.20 ± 3.45 Bachelor's degree 9.95 ± 1.84 33.42 ± 3.51 Master's degree 8.72 ± 2.13 32.14 ± 3.45 Work experience, y F = 8.387 .000 F = 9.126 .000 1–5 8.93 ± 1.77 33.88 ± 2.46 6–10 9.29 ± 2.71 31.76 ± 2.76 11–15 9.44 ± 2.87 35.32 ± 2.60 16–20 12.52 ± 1.06 32.07 ± 1.49 ≥21 9.71 ± 1.88 30.52 ± 2.81 Unit type F = 13.893 .000 F = 12.962 .000 Internal medicine 9.87 ± 1.35 29.73 ± 3.90 ICU 11.42 ± 2.02 34.15 ± 2.47 Surgical 7.90 ± 2.51 33.40 ± 3.01

Abbreviations: APuP, Attitudes towards Pressure Ulcer Prevention; PUKAT, Pressure Ulcer Knowledge Assessment Tool.

Correlations of Knowledge and Attitude

Correlations among variables were tested by Pearson correlation. Total PUKAT 2.0 score and total APuP score were correlated. The most significant correlated domains were risk assessment (knowledge) and responsibility in PI prevention (attitudes; ρ = 0.374; P = .013; Table 5).

Table 5. - SIGNIFICANT CORRELATIONS AMONG VARIABLES Correlated Variables Pearson Correlation P Total PUKAT 2.0 score (knowledge) and total APuP score (attitude) 0.761 .007 Etiology and development (knowledge) and responsibility in PI prevention (attitude) 0.309 .000 Risk assessment (knowledge) and effectiveness of prevention (attitude) 0.248 .000 Risk assessment (knowledge) and responsibility in PI prevention (attitude) 0.374 .013 Prevention of PI (knowledge) and competence (attitude) 0.322 .024 Prevention of PI (knowledge) and effectiveness of prevention (attitude) 0.271 .001

Abbreviations: APuP, Attitudes towards Pressure Ulcer Prevention; PI, pressure injury; PUKAT, Pressure Ulcer Knowledge Assessment Tool.

Linear regression analyses were performed among sex, education level, years worked, unit of employment, and PUKAT 2.0 score. Results indicated that demographic variables were significant predictors of PUKAT 2.0 score. Among the independent variables, the unit of employment (intensive care) explained 56% of the variance in the total knowledge score. In addition, sex (female; 51% of the variance), education level (bachelor’s degree; 36%), and years worked (16–20 years; 23%) were significant predictors of PUKAT 2.0 score (Table 6).

Table 6. - THE RESULTS OF LINEAR REGRESSION ANALYSIS ON THE EFFECT OF DEMOGRAPHIC CHARACTERISTICS ON NURSES’ KNOWLEDGE AND ATTITUDE ABOUT PI PREVENTION Knowledge Attitude Independent Variables B Coefficient β P R B Coefficient β P R Sex −1.127 .203 .00 0.413 1.895 .225 .00 0.225 Education 0.681 .123 .01 0.362 1.281 .384 .68 0.374 Work experience 0.419 .216 .00 0.236 0.339 .217 .00 0.391 Unit 1.971 .386 .001 0.562 2.421 .184 .026 0.537

Abbreviation: PI, pressure injury.

Linear regression analyses were also performed among sex, education level, years worked, unit of employment, and APuP score. Demographic variables were significant predictors of attitude scale scores. Among the independent variables, the unit of employment (intensive care) explained 53% of the total variance in attitude score. In addition, sex (male; 22%) and years worked (11–15 years; 39%) were significant predictors of the attitude scale (Table 6).

DISCUSSION Nurses’ PI Knowledge

Whereas the highest possible score on the PUKAT 2.0 is 25, the average knowledge score of the nurses in this study was 9.40. With only 46.7% correct answers, the nurses’ knowledge of PI prevention was inadequate. This finding aligns with the literature; previous studies have also reported that nurses’ knowledge of PI prevention was inadequate.20,24,30 Evidence-based PI training programs improve nurses’ knowledge, care practices, and ability to transfer theoretical knowledge into practice to improve outcomes.31,32 Kim et al32 reported that knowledge starts to decrease if continuous education is not maintained. For this reason, the authors recommend that hospitals organize regular and continuous up-to-date PI prevention training programs for nurses.

In the present study, the domains with the lowest scores on the knowledge scale were risk assessment (30.9%) and prevention (41.8%). Hu et al20 reported that only 5.1% of nurses had PI prevention knowledge. In a meta-analysis including studies conducted in Belgium, Italy, Turkey, Australia, Mexico, and China, the lowest knowledge scores were on reducing pressure (under preventive measures), and the highest score was on nutrition.33

In units, nurses have important responsibilities in the prevention of PI. In particular, risk assessment and preventive interventions for PI are among nurses’ duties.14,20 Inadequate risk assessment and knowledge of PI prevention may lead to an inability to provide effective and adequate nursing care. In the present study, nurses scored highly on the etiology subscale, indicating that they had knowledge of the etiology of PI. However, their knowledge about PI prevention was inadequate. In this case, it may be that nurses have deficiencies in transferring theoretical knowledge into practice. Providing nurses with theoretical and practical training on PI prevention may be helpful.

There are several up-to-date guidelines on the prevention, care, management, and treatment of PIs.5 One of the first clinical practice guidelines on PI prevention was published more than two decades ago by the US Agency for Health Policy and Research.34 Since then, numerous other clinical practice guidelines addressing the prevention and treatment of PIs have been published and regularly updated.35–37 In 2009, the National Pressure Injury Advisory Panel in the US and the European Pressure İnjury Advisory Panel published the first international guideline for the prevention and treatment of PIs. This guideline is regularly updated. In the United States, healthcare organizations prepare PI prevention and treatment protocols based on international guidelines.38 Systematic reviews have indicated that evidence-based prevention packages are important in reducing the number and severity of PIs.31,39 In this study, most nurses (69.4%) had no knowledge of these guidelines. It is important to provide training on these guidelines so that nurses have appropriate guidance on early detection and prevention of PI.

In the present study, nurses with a bachelor’s degree had higher knowledge scores than those with less education. Similar results were reported in the studies conducted by Hu et al20 and Jiang et al.40 These results may suggest that nurses with higher education levels are more open to learning or more careful. However, the low number of graduate nurses participating in this study impacts this result.

Work history was another important predictor of nurses’ PI prevention knowledge. In particular, nurses with more years of work experience (16-20 years) had higher levels of knowledge. Similarly, in studies conducted by Lin et al,41 Barakat-Johnson et al,42 Kim and Cho,43 and Khojastehfar et al,19 nurses with more worked years had higher knowledge levels. It may be that these nurses had greater knowledge because they were more likely to have encountered patients with PIs during their long years of working and therefore had more experience with care practices. However, some researchers found opposite results.44,45 Wei et al46 stated that many worked years increased burnout and decreased empathy in nurses. These may negatively affect nurses’ behaviors.

Another important predictor affecting nurses’ knowledge of PI prevention was the unit of employment, with nurses working in ICUs having greater knowledge. Similarly, Ünlü and Andsoy47 found that nurses working in ICUs had statistically higher mean scores on the modified PUKAT than nurses working in surgical units.47 Other researchers have also reported that nurses working in ICUs have higher levels of knowledge.2,48,49 A patient being in the ICU is a risk factor for PI. The high number of medical devices used in ICUs and patients’ prolonged hospitalizations increase PI risk. For example, it was reported that the risk of developing a PI increased by 4.2% every day a patient was connected to a ventilator in the ICU.50 These factors are reflected in the PI prevalence of 14% to 41% in ICUs.50 In a study conducted in Turkey, the incidence of PI in the ICU was 35.3%.10 It is likely that nurses working in ICUs have a high level of PI knowledge because they often encounter patients with PIs.

Nurses’ Attitudes toward PI Prevention

Nurses’ attitudes toward PI prevention were at an average level, neither high nor low. Lotfi et al45 similarly found that nurses had an average attitude, whereas Lin et al41 reported that approximately half of the nurses had a negative attitude toward PI prevention. Further, in the study by Lin et al,41 nurses scored highest in the personal responsibility domain among the attitude subscales. This result is not consistent with the present study findings. In this study, nurses scored lowest on the responsibility domain and highest on the competency domain. This finding indicates that the nurses feel competent to prevent PIs, but do not consider themselves responsible for doing so. This result contradicts the statement frequently mentioned in the literature: “Pressure injury are the responsibility of nurses.” The fact that nurses in the present study do not consider themselves responsible for preventing PI may negatively affect their behaviors in practice.

It is necessary to transfer the professional competencies of nurses into practice and confirm that they are responsible for PI prevention and care. Accordingly, hospitals should organize in-service training programs. In a descriptive cross-sectional study, Lotfi et al45 reported that a relevant training program can improve nurses’ attitudes toward the prevention of medical device-related PIs.45

The literature is mixed regarding differences in attitudes toward PI prevention by sex. In this study, male nurses had more positive attitudes than did female nurses. Etafa et al1 also reported that the attitudes of men were more positive, whereas Khojastehfar et al19 reported the opposite findings. In a systematic review, Aydin et al2 found that sex had no effect and that nurses generally had positive attitudes toward PI prevention.2

Correlation of Knowledge and Attitude

In the literature, it has been reported that nurses’ knowledge of PI affects their attitude levels.25,51 In the present study, nurses’ PI knowledge was significantly positively correlated with their attitude toward PI prevention. Thus, nurses with more knowledge were also likely to have a more positive attitude. Zhang et al51 also found a significant correlation between knowledge and attitude. In contrast, in a study with nurses and nurse assistants working in nursing homes in Belgium, Demarré et al52 found no significant correlation between knowledge level and attitude.52 Further, in a study by Beeckman et al18 in internal, surgical, and geriatric wards and ICUs in Belgium, the correlation between knowledge and attitude was weakly significant. Aydogan and Caliskan53 also found a weak, positive correlation between nurses’ attitude scores regarding PI prevention and their levels of knowledge. In a cross-sectional study, Khojastehfar et al19 found that nurses with low levels of knowledge had negative attitudes toward preventing PI.19

Therefore, increasing nurses’ knowledge of PI prevention will likely lead to more positive attitudes and improvements in care. According to the theory of planned behavior, developing a positive attitude toward the behavior to be performed will positively affect the behavior (ie, care practices for nurses). To prevent PI and enable early diagnosis and intervention, it is necessary to increase nurses’ PI knowledge.

In the present study, researchers also found a significant correlation among education level, years worked, and attitude: nurses with a bachelor’s degree and nurses working for 11 to 15 years had more positive attitudes toward PI prevention. It may be that nurses with a bachelor’s degree have greater awareness of PI, and this is reflected in their attitudes. The authors suggest that perhaps nurses with high education levels and those who have been working for many years have positive attitudes toward patient care because of increased empathy skills.

Study Limitations

This study shows results for only one country; therefore, the findings cannot be generalized for all nurses. When comparing the present findings with those reported in the literature, results differed regarding the total and subscale scores of knowledge, total and subscale scores of attitudes, comparison of knowledge and attitudes, and affecting factors. These disparities may be due to variations in sample sizes as well as differences in the scales used to determine knowledge and attitudes toward PI prevention (eg, the PUKAT scale has been updated). Measuring nurses’ knowledge and attitudes toward PI with a single scale will give more accurate and generalizable results.

CONCLUSIONS

Nurses in this study had an inadequate level of PI knowledge, and their attitudes toward PI prevention were average. Inadequate knowledge of nurses likely increases patients’ risk of PI development and causes delays in the healing process of patients with a PI. However, the attitudes of nurses toward PI prevention increase positively as their level of knowledge increases. Nurses with more positive attitudes will likely also provide more effective care.

To increase nurses’ levels of knowledge and attitudes toward PI prevention, the authors recommend that nurses in health services receive theoretical and practical training on all facets of PI prevention, assessment, and care. Further, including informative posters and brochures about PI in hospital units may help nurses keep their knowledge up-to-date and make the steps for PI care more visible. The authors also recommend that care packages and scales used by nurses for PI prevention be standardized and used in health institutions. Future research should investigate the knowledge and attitudes of nurses toward PI prevention cross-culturally, comparing the factors affecting these variables and the methods used in differ