- Email: [email protected]
Pressure ulcers: Development and psychometric evaluation of the Attitude towards Pressure ulcer Prevention instrument (APuP)
International Journal of Nursing Studies 47 (2010) 1432–1441
Contents lists available at ScienceDirect
International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
Pressure ulcers: Development and psychometric evaluation of the Attitude towards Pressure ulcer Prevention instrument (APuP) D. Beeckman a,b,*, T. Defloor a, L. Demarre´ a, A. Van Hecke a, K. Vanderwee a a b
Nursing Science, Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium Department of Bachelor in Nursing, University College Arteveldehogeschool Ghent, Ghent, Belgium
A R T I C L E I N F O
A B S T R A C T
Article history: Received 16 March 2010 Received in revised form 16 April 2010 Accepted 16 April 2010
Background: Pressure ulcers continue to be a significant problem in hospitals, nursing homes and community care settings. Pressure ulcer incidence is widely accepted as an indicator for the quality of care. Negative attitudes towards pressure ulcer prevention may result in suboptimal preventive care. A reliable and valid instrument to assess attitudes towards pressure ulcer prevention is lacking. Aims and objectives: Development and psychometric evaluation of the Attitude towards Pressure ulcer Prevention instrument (APuP). Design: Prospective psychometric instrument validation study. Methods: A literature review was performed to design the instrument. Content validity was evaluated by nine European pressure ulcer experts and five experts in psychometric instrument validation in a double Delphi procedure. A convenience sample of 258 nurses and 291 nursing students from Belgium and The Netherlands participated in order to evaluate construct validity and stability reliability of the instrument. The data were collected between February and May 2008. Results: A factor analysis indicated the construct of a 13 item instrument in a five factor solution: (1) attitude towards personal competency to prevent pressure ulcers (three items); (2) attitude towards the priority of pressure ulcer prevention (three items); (3) attitude towards the impact of pressure ulcers (three items); (4) attitude towards personal responsibility in pressure ulcer prevention (two items); and (5) attitude towards confidence in the effectiveness of prevention (two items). This five factor solution accounted for 61.4% of the variance in responses related to attitudes towards pressure ulcer prevention. All items demonstrated factor loadings over 0.60. The instrument produced similar results during stability testing [ICC = 0.88 (95% CI = 0.84–0.91, P < 0.001)]. For the total instrument, the internal consistency (Cronbachs a) was 0.79. Conclusion: The APuP is a psychometrically sound instrument that can be used to effectively assess attitudes towards pressure ulcer prevention in patient care, education, and research. In further research, the association between attitude, knowledge and clinical performance should be explored. ß 2010 Elsevier Ltd. All rights reserved.
Keywords: Nursing Pressure ulcers Prevention Psychometric Validity Reliability Attitude Instrument
What is already known about the topic?
* Corresponding author at: Nursing Science, Ghent University, U.Z. Block A 2nd floor, De Pintelaan 185, B-9000 Ghent, Belgium. Tel.: +32 9 332 36 19; fax: +32 9 332 50 02. E-mail address: [email protected] (D. Beeckman). 0020-7489/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2010.04.004
Pressure ulcer prevalence has not declined in recent years despite the availability of internationally accepted evidence-based prevention guidelines. A negative attitude towards pressure ulcer prevention is expected to be a barrier to using pressure ulcer prevention guidelines.
D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441
Psychometric aspects of instruments to assess attitudes towards pressure ulcer prevention are not evaluated. What this paper adds The Attitude towards Pressure ulcer Prevention instrument (APuP) can be considered as a brief, conceptually sound, rigorously developed instrument with evidence supporting its psychometric properties. The APuP can be used in education, research and clinical practice to assess attitudes towards pressure ulcer prevention. Further research should focus on the predictive validity of the instrument and on the exploration of the relation between attitude, knowledge, and clinical performance. 1. Introduction A pressure ulcer is a localised injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated (European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel, 2009). The ulcers are most often observed in geriatric patients and patients dealing with physical disabilities caused by inactivity, immobility and deprived health status (Schoonhoven et al., 2007; Vanderwee et al., 2007a) Pressure ulcers are recognised as an international patient safety problem and are associated with quality of care (Gunningberg and Stotts, 2008; Baharestani et al., 2009). The lesions are considered as adverse outcomes with a significant impact on patients, their family, caregivers and healthcare organisations (Lardenoye et al., 2009; Gorecki et al., 2009). Recent studies indicate that pain, infectious complications, prolonged and expensive hospitalisations, persistent open ulcers, increased risk of death and reduced health-related quality of life are associated with the development of pressure ulcers (Hopkins et al., 2006; Essex et al., 2009). Appropriate prevention should be considered early in all patients at risk and whenever early signs of pressure ulcer development are observed (nonblanchable erythema) (Schoonhoven et al., 2007; Vanderwee et al., 2007b, 2009). Prevention should focus on the reduction of the amount and/or duration of pressure and shear (European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel, 2009). Despite the availability and accessibility of internationally accepted evidence-based prevention guidelines, pressure ulcer prevalence has not declined in recent years (Gunningberg, 2006; Schoonhoven et al., 2007, Vanderwee et al., 2007a; Hurd and Posnett, 2009; Shahin et al., 2009). The rationale for this is unclear. The identification of factors contributing to compliance and non-compliance for pressure ulcer prevention guidelines is expected to be important to be able to implement new insights effectively (van Gaal et al., 2010). A negative attitude towards pressure ulcer prevention may be one of those factors (Grol and Wensing, 2004). Nevertheless, attitudes are
1433
frequently overlooked when planning guideline dissemination and implementation (Moulding et al., 1999). An attitude can be defined as a relatively enduring organisation of interrelated beliefs (Rockeach, 1966) and may indicate what can be expected from others (Petty and Cacioppo, 1996). An individual who believes that performing a given behaviour will lead to mostly positive outcomes, will probably hold a more favourable attitude towards performing the behaviour and vice versa (Ajzen and Madden, 1986). An accurate assessment method for attitudes may be useful in predicting clinical performance. 2. Literature overview This literature overview focuses on research describing the development and psychometric validation of instruments and methods to assess attitudes towards pressure ulcer prevention. The databases PubMed, The Cochrane Library Central Register of Controlled Trials (CENTRAL) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for research published in English, Dutch, French and German. The keywords ‘attitude’; ‘attitude to health’; ‘pressure ulcer’; ‘instrument’; ‘scale’; ‘psychometric properties’; and ‘psychometric validation’ were combined to conduct the search. The literature search was completed in January 2010 and revealed five publications in English and one publication in German. Kimura and Pacala (1997) developed an instrument to study the attitudes of family physicians towards the Agency Health Care Policy and Research (AHCPR) guideline on pressure ulcer prevention. The questionnaire consisted of four items to be rated on a four-point Likert scale: (1) adequacy of the training to manage pressure ulcers, (2) perceived effectiveness in treating pressure ulcers, (3) importance of pressure ulcers in primary care practice, and (4) the role of family physicians in pressure ulcer management. No information on psychometric validation of the instrument was reported. Moore and Price (2004) conducted a literature review to develop an instrument to assess the attitudes of staff nurses towards pressure ulcer prevention. The instrument included 11 items to be rated on a five-point Likert scale. The instrument was pilottested in a small sample of 16 nurses from teaching hospitals to assess internal consistency. No further validation was performed. Krause et al. (2004) developed a semi-standardised questionnaire to assess the attitudes of nurses and physicians towards pressure ulcers. No information about the design and validation of the instrument was described. Ka¨llman and Suserud (2009) developed a Swedish version of the instrument developed by Moore and Price (2004) to assess the attitudes of registered nurses and nursing assistants towards pressure ulcer prevention in Sweden. The layout and content of the questionnaire were reviewed by three pressure experts. The questionnaire was pilot-tested in a small sample of four registered nurses and four nursing assistants. The final instrument consisted of 11 items to be rated on a five-point Likert scale. In two studies, qualitative methods were used to describe the views and beliefs about pressure ulcer
1434
D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441
prevention of nurses and nursing aides in nursing homes (Buss et al., 2004; Goldsworthy, 2008). This literature overview reveals that various researchers studied attitudes towards the prevention of pressure ulcers. The limited evaluation of the psychometric aspects of the instruments is a major problem to be able to evaluate and compare these findings. Both quantitative (questionnaires) and qualitative research designs have been used. Construct validity and stability of the instruments were never evaluated. Internal consistency was evaluated in only one study. The development and psychometric evaluation of an instrument to assess attitudes regarding pressure ulcer prevention is necessary. 3. Aims and objectives The aim of this study was to develop and to evaluate the psychometric characteristics of the Attitude towards Pressure ulcer Prevention instrument (APuP). 4. Methods 4.1. Design A two-phase prospective psychometric instrument validation study was conducted. Phase 1 included the design of the instrument and phase 2 included the psychometric evaluation. 4.1.1. Phase 1: Design of the instrument A literature review was performed in order to define eight attitude subscales: 1. Attitude towards the impact of pressure ulcers on patients. 2. Attitude towards the financial impact of pressure ulcers on society. 3. Attitude towards the support by management. 4. Attitude towards the priority of pressure ulcer prevention. 5. Attitude towards personal responsibility in pressure ulcer prevention. 6. Attitude towards the importance of a sound knowledge base. 7. Attitude towards confidence in personal skills. 8. Attitude towards confidence in the effectiveness of prevention. A range of items was formulated to be covered by the subscales. All items were derived from literature, clinical experience and deductive reasoning by the developers. As recommended by Clark and Watson (2005), the number of items was chosen so as to sample systematically all content that potentially could be relevant to the target construct. Because the subsequent psychometric analyses could potentially identify weak, unrelated items, the item pool was selected broader than initially was derived from the literature review. This allowed to drop out some items from the emerging instrument. Half of the items was worded negatively and half was worded positively. All items were developed to be rated on a four-point Likert rating scale (1 = strongly
disagree, 2 = disagree, 3 = agree, 4 = strongly agree). The relevance of each item was evaluated in a double Delphi procedure by two expert panels (McKenna, 1994; Thomas et al., 1992; Polit and Beck, 2007). The first panel consisted of nine trustees of the European Pressure Ulcer Advisory Panel (EPUAP) who each had an extensive experience in pressure ulcer care and research (PhD level). The second panel consisted of five experts (geriatrician, dermatologist, nursing researcher, psychologist, sociologist). The experts independently reviewed each item for appropriateness and relevance in assessing attitudes towards pressure ulcer prevention. A five-point Likert scale was used to indicate the relevance of the items under study (from 1 = irrelevant to 5 = highly relevant). The content validity index (CVI) was computed using the proportion of experts wh agreed about item relevance. The CVI was between 0.87 and 1.00, indicating adequate content validity (Polit and Beck, 2007). Twelve items were re-worded to improve item relevance. After this item modification, the instrument was pilot-tested in a sample of five nurses and five nursing students. The aim was (1) to evaluate the clarity of the items and report any ambiguous items and items difficult to interpret, (2) to receive feedback about the format/layout of the instrument, and (3) to get insight into the time needed to complete the instrument. In general the participants did not have any problems with the wording, length and format of the instrument. An overview of the instrument design process is provided in Fig. 1. 4.1.2. Phase 2: Psychometric evaluation of the instrument The psychometric evaluation included the evaluation of the construct validity (factor analysis, discriminating power and internal consistency) and stability reliability testing of the instrument. 4.2. Sample The initial 32-item APuP instrument was administered to a convenience sample of qualified nurses (n = 258) and nursing students (n = 291) in Belgium and The Netherlands. The sample size determination was based on Polit and Beck (2007) who states that 10 respondents per item is mostly recommended as a minimum to support the factor analysis. In Belgium, 210 qualified nurses from two general hospitals (n = 172) and one psychiatric hospital (n = 38) were included. In this group of qualified nurses, 67 of them attended a Master of Sciences in Nursing (MScN) educational programme. Besides, nursing students from two schools with an undergraduate nursing education (n = 77) and two nursing colleges (n = 214) were included. All nursing students were at the second semester of their particular year of basic nursing education. In the Netherlands, 48 pressure ulcer nurses were asked to participate because of their specific specialty in the prevention and treatment of pressure ulcers. To allow the evaluation of the discriminating power of the APuP instrument, eight subgroups were pre-defined based on a theoretically expected difference in attitudes towards pressure ulcer prevention. An overview of these pre-defined groups is provided in Table 1.
D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441
1435
Fig. 1. Phase 1: Design of the instrument.
4.3. Ethical approval Ethical approval was provided by the ethics review committee of Ghent University Hospital (B/67020072806). The questionnaire included a cover letter addressing the purpose of the study. Anonymity and confidentiality were assured. All data were treated as confidential at all times. The return of a completed instrument was considered as the consent to participate. 4.4. Procedure The study was performed in Belgium and The Netherlands between February and May 2008. To be able to study
the stability of the instrument over a time period, data were collected at two different points in time (a 1-week interval). The 1-week period between the test and the retest was used to reduce confounding factors during the intervening time interval as much as possible (Polit and Beck, 2007). These confounding factors included: (1) the possibility that the attitudes changed over time (independently of the measure’s stability), and (2) the possibility that the respondents were influenced by their memory of initial responses. The participants were not informed in advance of the test–retest procedure. The same conditions were ensured at both data collecting time points. The time to complete the instrument was 10 min. 4.5. Data analysis
Table 1 Pre-defined groups based on the theoretically expected attitude levels. Pre-defined groups
1 2 3 4 5 6 7 8
Theoretically expected more positive attitude
Theoretically expected more negative attitude
Pressure ulcer nursesa Pressure ulcer nurses Infection control nursesc Third year nursing students Third year nursing students Second year nursing students General nurses Bachelor degree
vs. vs. vs. vs. vs. vs. vs. vs.
Bedside nursesb First year nursing students MScN studentsd First year nursing students Second year nursing students First year nursing students Mental health nurses Undergraduate degree
a Pressure ulcer nurse, qualified nurse in The Netherlands, specialised in the prevention and treatment of pressure ulcers. b Bedside nurse, qualified nurse working on a hospital ward c Infection control nurse, qualified nurse in Belgium with the specific task to identify and control infections that occur in the community or in a hospital setting d MScN, qualified bachelor nurse studying to obtain a Master of Sciences in Nursing.
Construct validity and stability reliability of the instrument were assessed. Construct validity was assessed by (1) factor analysis using principal component analysis, (2) discriminating power (known-groups technique), and (3) internal consistency analysis. In the factor analysis, the varimax rotation with Kaiser normalisation was used. The numbers of factors were determined by eigenvalues (1). The Kaiser–Meyer–Olkin (KMO) Measure of Sampling Adequacy over 0.50, Bartlett’s test of sphericity, scree plot, factor loadings of over 0.40, and explainable percentages of variance (minimum of 5% reported variance per factor) were evaluated. Item reduction and attitude subscale modification were performed based on this factor analysis. Analysis on discriminating power, internal consistency, and stability reliability were executed on the modified model. Sum scores were calculated to obtain the total attitude score. Scores on the negatively worded items were reversed to obtain a total score. The independent sample
1436
D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441
Fig. 2. Phase 2: Psychometric evaluation of the instrument.
t-test was used to signify differences between the attitude scores of the pre-defined groups (discriminating power). The internal consistency was studied by calculating interitem correlations Cronbachs a (Polit and Beck, 2007). The criteria for Cronbachs a as described by Streiner and Norman (2003) were used for the interpretation of the results: 0.70 < Cronbachs a < 0.90. To assess the reliability of the instrument, the intraclass correlation coefficient was calculated for each theme and for the overall instrument. Reliability coefficients 0.70 were considered as satisfactory (Polit and Beck, 2007). All statistical analyses were performed using SPSS1 15.0 (SPSS1 Inc., Chicago, IL, USA). An a level of 0.05 was applied for all statistical tests. An overview of the psychometric evaluation of the instrument is provided in Fig. 2. 5. Results 5.1. Basic characteristics of the participants A total of 258 nurses and 291 nursing students participated. About 70% of the nurses were between the age of 25 and 50. More than half of the nurses (54.2%) stated to have more than 10 years experience in nursing care. Approximately 65% of the nurses worked in a hospital and 17.1% worked in mental healthcare. Almost 75% of the nursing students were bachelor students and 79.4% of
them were specialising in general nursing. Half of the students were first year nursing students. An overview of the demographic data is provided in Table 2. 5.2. Psychometric evaluation of the instrument 5.2.1. Construct validity 5.2.1.1. Factor analysis. Several exploratory analyses were conducted on the 32-item instrument. The model chosen included five factors, covering 13 items, and had the most meaningful content. The KMO for this model indicated sampling adequacy (KMO = 0.72). Bartlett’s test of sphericity was statistically significant (x2 = 1062.6, df = 78, P < 0.001). Following factors were defined: Factor 1: Attitude towards personal competency to prevent pressure ulcers. Factor 2: Attitude towards the priority of pressure ulcer prevention. Factor 3: Attitude towards the impact of pressure ulcers. Factor 4: Attitude towards responsibility in pressure ulcer prevention. Factor 5: Attitude towards confidence in the effectiveness of prevention. The five factors accounted for 61.4% of the variance in responses related to attitudes towards pressure ulcer
D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441 Table 2 Demographic data. Nurses (n = 258) % (n)
Student nurses (n = 291) % (n)
Gender Male Female
20.5% (53) 79.5% (205)
14.8% (43) 85.2% (248)
Education Undergraduate degree Bachelor degree (BA) MScN degree (MScN)
28.3% (73) 65.5% (169) 6.2% (16)
26.5% (77) 73.5% (214) N/Aa
Age category <25 years 25–34 years 35–50 years >50 years
18.2% 31.4% 37.6% 12.8%
85.2% (248) 8.2% (24) 5.8% (17) 0.7% (2)
Work experience No experience <5 years 5–10 years 10–20 years >20 years
7.4% (19) 20.9% (54) 17.4% (45) 24.0% (62) 30.2% (78)
N/Aa N/Aa N/Aa N/Aa N/Aa
Year of education 1st year 2nd year 3rd year
N/Aa N/Aa N/Aa
46.6% (138) 19.9% (58) 32.6% (95)
Specialisation General nursing Geriatrics Pediatrics Mental health Community nursing
73.6% (190) 3.5% (9) 1.9% (5) 17.8% (46) 3.1% (8)
79.4% (231) 7.2% (21) 1.7% (5) 7.6% (22) 4.1% (12)
a
(47) (81) (97) (33)
Not applicable.
prevention. Factor 1 consisted of 2 positively and 1 negatively worded items, explaining 14.6% of the variance. Factor 2 included 1 positively and 2 negatively worded items, explaining 14.0% of the variance. Factor 3 included 1 positively and 2 negatively worded items, explaining 11.5% of the variance. Factor 4 included 1 positively and 1 negatively worded items, explaining 10.8% of the variance. Factor 5 included 1 positively and 1 negatively worded items, explaining 10.5% of the variance. All items demonstrated strong factor loadings (>0.60; See Table 3).
1437
5.2.1.2. Discriminating power. Group scores of participants having a theoretically expected more positive attitude were found to be statistically significantly higher than those of participants with theoretically expected more negative attitudes. Expert nurses proved to have more positive attitudes than non-expert nurses (resp. 30.6/52 vs. 27.4/52, t = 4.61, df = 139, P < 0.001) (See Table 4). There was no difference between the group scores of second year nursing students (26.3/52, SD = 3.1) and first year nursing students (26.4/52, SD = 3.0) (t = 0.3, df = 194, P = 0.74) (See Table 4). In general, nurses proved to have more positive attitudes towards pressure ulcers than nursing students (resp. 28.0/52 vs. 26.9/52, t = 3.55, df = 547, P < 0.001) for the total APuP instrument. Nurses proved to have more positive attitudes for ‘competence’ (5.6/12 vs. 4.9/12, t = 5.50, df = 547, P < 0.001) and ‘impact’ (7.9/12 vs. 6.3/12, t = 2.41, df = 547, P = 0.016) than nursing students. No significant differences were found between nurses and nursing students in the other subscales. 5.2.1.3. Internal consistency. Cronbachs a was 0.79 for the total APuP instrument, 0.81 for ‘competence’, 0.75 for ‘priority’, 0.79 for ‘impact’, 0.82 for ‘responsibility’, and 0.76 for ‘effectiveness of prevention’. 5.2.2. Stability reliability (intraclass correlation) The overall intraclass correlation coefficient was 0.88 (95% CI = 0.84–0.91, P < 0.001). The intraclass correlation coefficient for the subscales ranged between 0.77 (95% CI = 0.70–0.83, P < 0.001) and 0.85 (95% CI = 0.80–0.89, P < 0.001). The final version of the APuP is presented in Table 5. 6. Discussion An accurate assessment of attitudes towards pressure ulcer prevention is an important step in identifying interventions to improve pressure ulcer prevention. As evidenced by the literature overview, none of the actual instruments exhibits fully satisfactory psychometric characteristics. The results from the psychometric evaluation of the APuP indicated that the instrument and the subscales
Table 3 Factor analysis using principal component analysis. Item Factor loadings 1. I feel confident in my ability to prevent pressure ulcers. 2. I am well trained to prevent pressure ulcers. 3. Pressure ulcer prevention is too difficult. Others are better than I am. 4. Too much attention goes to the prevention of pressure ulcers. 5. Pressure ulcer prevention is not that important. 6. Pressure ulcer prevention should be a priority. 7. A pressure ulcer almost never causes discomfort for a patient. 8. The impact of pressure ulcers on a patient should not be exaggerated. 9. The financial impact of pressure ulcers on society should not be exaggerated. 10. I personally feel not responsible if a pressure ulcer develops in my patient. 11. I personally have an important task in pressure ulcer prevention. 12. Pressure ulcers are preventable in high risk patients. 13. Pressure ulcers are never preventable.
Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Competence Priority Impact Responsibility Effectiveness 0.83 0.75 0.75 0.09 0.01 0.21 0.02 0.01 0.06 0.09 0.18 0.03 0.11
0.07 0.15 0.00 0.75 0.72 0.63 0.15 0.23 0.16 0.05 0.29 0.05 0.03
0.05 0.02 0.11 0.01 0.33 0.02 0.69 0.65 0.64 0.03 0.11 0.01 0.04
0.06 0.04 0.09 0.00 0.01 0.29 0.17 0.02 0.01 0.86 0.69 0.08 0.06
0.01 0.03 0.13 0.21 0.03 0.20 0.08 0.19 0.01 0.08 0.11 0.78 0.74
1438
D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441
Table 4 Known-groups technique. Group
N
Mean score (max = 52) (SD)
Significance
Group A Theoretically expected more positive attitude
Group B Theoretically expected more negative attitude
to
dfoo
Pooo
48 93
30.6 (3.8)
27.4 (3.9)
4.6
139
<0.001
48 138
30.6 (3.8)
26.4 (3.0)
7.7
184
<0.001
5 67
31.0 (4.1)
26.8 (4.1)
2.2
70
95 138
27.8 (3.4)
26.4 (3.0)
3.3
231
0.001
95 58
27.8 (3.4)
26.3 (3.1)
2.8
151
0.005
Second year nursing students (A) vs. first year nursing students (B)
58 138
26.3 (3.1)
26.4 (3.0)
0.3
194
0.74
General nurses (A) vs. mental health nurses (B)
172 46
28.6 (4.0)
25.9 (3.9)
4.1
216
<0.001
Bachelor degree (A) vs. undergraduate degree (B)
383 150
28.3 (3.6)
26.9 (3.5)
4.1
531
<0.001
Pressure ulcer nursesa (A) vs. bedside nursesb (B) Pressure ulcer nursesa (A) vs. first year nursing students (B) Infection control nursesc (A) vs. MScN studentsd (B) Third year nursing students (A) vs. first year nursing students (B) Third year nursing students (A) vs. second year nursing students (B)
0.03
o
Value independent sample t-test. Degrees of freedom. ooo P-value. a Pressure ulcer nurse, qualified nurse in The Netherlands, specialised in the prevention and treatment of pressure ulcers. b Bedside nurse, qualified nurse working on a hospital ward. c Infection control nurse, qualified nurse in Belgium with the specific task to identify and control infections that occur in the community or in a hospital setting. d MScN, qualified bachelor nurse studying to obtain a Master of Sciences in Nursing. oo
Table 5 Final version of the Attitude towards Pressure ulcer Prevention instrument (APuP) (maximum score = 52). Strongly agree
Agree
Disagree
Strongly disagree
o o o
o o o
o o o
o o o
o o o
o o o
o o o
o o o
o o o
o o o
o o o
o o o
o o
o o
o o
o o
o o
o o
o o
o o
F1. Personal competency to prevent pressure ulcers (three items) (maximum score = 12) F1.1. (+)a I feel confident in my ability to prevent pressure ulcers. F1.2. (+)a I am well trained to prevent pressure ulcers. F1.3. ( )b Pressure ulcer prevention is too difficult. Others are better than I am. F2. Priority of pressure ulcer prevention (three items) (maximum score = 12) F2.1. ( )b Too much attention goes to the prevention of pressure ulcers. F2.2. ( )b Pressure ulcer prevention is not that important. F2.3. (+)a Pressure ulcer prevention should be a priority. F3. Impact of pressure ulcers (three items) (maximum score = 12) F3.1. ( )b A pressure ulcer almost never causes discomfort for a patient. F3.2. ( )b The financial impact of pressure ulcers on a patient should not be exaggerated. F3.3. (+)a The financial impact of pressure ulcers on society is high. F4. Responsibility in pressure ulcer prevention (two items) (maximum score = 8) F4.1. ( )b I am not responsible if a pressure ulcer develops in my patients. F4.2. (+)a I have an important task in pressure ulcer prevention. F5. Confidence in the effectiveness of prevention (two items) (maximum score = 8) F5.1. (+)a Pressure ulcers are preventable in high risk patients. F5.2. ( )b Pressure ulcers are almost never preventable. a b
Positively worded item. Negatively worded item.
are reliable and construct valid to be used to assess attitudes towards pressure ulcer prevention. The subscales and the items in the initial version of the instrument were developed based on important issues
within pressure ulcer preventive care. All subscales together represented what in this study was postulated as attitudes towards pressure ulcer preventive care. Content validity was achieved through literature review
D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441
and consultation with experienced pressure ulcer and psychometric validation experts. The content validity index fully achieved Lynn’s (1986) criterion for content validity. Additionally, based on the pilot study in five experts and five non-experts, the instrument was found to have an established content validity. Construct validity of the APuP was assessed in a factor analysis by using a principal component analysis. A principal component analysis was used because it is considered to be a well-suited approach to combine a large number of items into a few principal factors. In a factor analysis, principal component analysis is an easily understood and commonly used extraction technique. The Bartlett test of sphericity indicated that the correlations did not happen by chance and there was justification for the factor analysis. There was also an adequate sample for the factor analysis based on calculated KMO. After testing the instrument in a factor analysis, the number of subscales and items was reduced and the proportions of items within the subscales were changed. While modifying the instrument, attention was paid to the meaningfulness of the content of the total instrument and the subscales, as this also has an effect on instrument reliability. The five underlying factors showed a logical connection to the theoretical framework used during the design of the instrument. The range of items as defined in during the creation of the instrument allowed to test a diversity of models and to remove items if they were found to be weak and/or unrelated after factor analysis. All kinds of models, with different compositions/numbers of items, were tested. The composition of these models was primarily based on a meaningful content and theoretical sense. In the final model chosen, all included items (n = 13) possessed factor loadings over 0.6 and the five factors accounted for 61.4% of the variance in responses related to attitudes towards pressure ulcer prevention. The final model made good theoretical sense and contained fewer similar items than in the initial version. The ‘‘competence’’ subscale reflects the attitude towards the perceived own ability to provide adequate pressure ulcer preventive care. A competence is defined as the ability to perform a specific task, action or function successfully and is closely related to knowledge. In a recent study by Athlin et al. (2009), competences among healthcare personnel was described as an important factor to prevent pressure ulcers. The second subscale, ‘‘priority’’, deals with the importance given to pressure ulcer prevention in daily care. The importance to assess the priority of pressure ulcer prevention in care is supported in research by Gunningberg et al. (2001) and Moore and Price (2004). These authors stated that a majority of the nurses consider pressure ulcer prevention as being of low priority in their daily work. Also in a study by Buss et al. (2004), pressure ulcer prevention was found not to be a great issue in the daily work of nurses. If low priority is given to the prevention of pressure ulcers, it will be unlikely to expect good preventive care. The ‘‘impact’’ subscale reflects the perceived consequences of pressure ulcers on patients (discomfort and financial impact) and on society (financial impact).
1439
Evidence concerning the important impact of pressure ulcers on patients and society is provided by multiple researchers (Hopkins et al., 2006; Essex et al., 2009; Lardenoye et al., 2009; Gorecki et al., 2009). If pressure ulcers are considered as being of low impact, it will be unlikely to expect good preventive care. In the initial version of the instrument, the impact of pressure ulcers on patients and the impact on society were defined in two separate subscales. The factor analyses provided evidence that one subscale was able to explain this attitude. The ‘responsibility’ subscale is defined as the perception about who is responsible for pressure ulcer prevention. The nurse responsibility was stressed as an important factor in pressure ulcer preventive care by Athlin et al. (2009). The researchers claim that, although pressure ulcer care is often seen as a task of licensed practical nurses, the registered nurses should have the superior responsibility due to their higher level of education. This responsibility should concern prevention, risk assessment and the supervision of licensed practical nurses. Confidence in the effectiveness of prevention was defined as the final subscale. The attitude that pressure ulcer prevention is not effective might probably have an impact on the application of prevention. Buss et al. (2004) state that the use of preventive interventions in daily practice depends very much on the nurses’ conviction about the effectiveness of the intervention. This statement was supported in research by Halfens and Eggink, 1995. The more pressure ulcer prevention is valued, the greater the likelihood of preventative practices being carried out (Maylor and Torrance, 1999). The evidence to support construct validity, using the known-groups technique, was strong. The known-groups method is a typical method to support construct validity and is provided when the instrument is able to discriminate between a group of individuals expected to have a particular trait and a group who do not have the trait. According to Polit and Beck (2007), this technique gives a good indication of what construct an instrument actually measures. In this study, data collection procedure was rigorously set up in different types of clinical and educational settings. Eight groups having a different expertise in pressure ulcer care were pre-defined and group scores were compared. The discriminant validity of the APuP was strongly supported by statistically significant mean differences among pressure ulcer experts and non-experts, suggesting its potential usefulness to track changes in attitudes across different clinical and educational settings in intervention outcome studies.Cronbachs a coefficients were calculated to assess the internal consistency of the instrument and its subscales. The study demonstrated acceptable to excellent internal consistency for both the total instrument and its subscales, with Cronbachs a ranging from 0.75 to 0.82. The intraclass correlation of the APuP reached the established recommendations, indicating that the scale can provide a reliable assessment for both group and individual measurements, comparisons, or both. The strength of the APuP to yield consistent responses on different rating moments, effectively demonstrates the ease of use and clinical usefulness of the instrument.
1440
D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441
In contrast to the actual instruments, the APuP is able to offer a more comprehensive picture of the attitude towards pressure ulcer prevention. The instrument has several potential applications. This study attempted to construct a short instrument for use in clinical practice, education and research. Along with the ease of administration and scoring, the APuP can be included in any rapid survey for assessing attitudes towards pressure ulcer prevention and for evaluating efficacy of intervention programmes. The evaluation of interventions to improve attitudes is possible using this instrument in pretest–posttest setting or in randomised-controlled trials. The instrument can help to develop strategies for improving quality of pressure ulcer prevention by identifying priorities based on lowscoring subscales. Alternatively, this instrument can be used for individuals to determine an objective measure of personal attitude. Further research should include testing the instrument in different healthcare settings with varying characteristics in order to study predictive validity of the instrument and to explore the possible link between attitude, knowledge, and clinical performance. 6.1. Limitations A first limitation reflects on the use of a convenience sample. Besides, data on non-response were not collected. It is possible that potential participants who declined participation may be different from the study participants. This might limit the generalisability of the findings. Secondly, the fact that no more than three items were included in each subscale should be a point of special interest. Ideally more items should be added, especially to the subscales on ‘personal responsibility’, and ‘confidence in the effectiveness of prevention’. On the other hand, the development of a short instrument facilitates the ease of administration and contributes to the application in practice. 7. Conclusion The results of this study indicate that the Attitude towards Pressure ulcer Prevention instrument (APuP), as well as each subscale, can be considered a brief, conceptually sound, rigorously developed instrument with evidence supporting the psychometric properties. Conflicts of interest: None declared. Funding: None. Ethical approval: Ghent University Hospital (B/67020072806). References Ajzen, I., Madden, T., 1986. Prediction of goal-directed behaviour: attitudes, intentions and perceived behavioural control. Journal of Experimental Social Psychology 22 (3), 453–474. Athlin, E., Idvall, E., Jernfa¨lt, M., Johansson, I., 2009. Factors of importance to the development of pressure ulcers in the care trajectory: perceptions of hospital and community care nurses. Journal of Clinical Nursing, doi:10.1111/j.1365-2702.2009.02886.x. Baharestani, M., Black, J., Carville, K., Clark, M., Cuddigan, J., Dealey, C., Defloor, T., Harding, K., Lahmann, N., Lubbers, M., Lyder, C., Ohura, T., Orsted, H., Reger, S., Romanelli, M., Sanada, H., 2009. Dilemmas in
measuring and using pressure ulcer prevalence and incidence: an international consensus. International Journal of Wound Care 6 (2), 97–104. Buss, I., Halfens, R., Abu-Saad, H., Kok, G., 2004. Pressure ulcer prevention in nursing homes: views and beliefs of enrolled nurses and other health care workers. Journal of Clinical Nursing 13 (6), 668–676. Clark, L., Watson, D., 2005. Constructing validity: basic issues in objective scale development. Psychological Assessment 7 (3), 309–319. European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel, 2009. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. National Pressure Ulcer Advisory Panel, Washington, DC. Essex, H., Clark, M., Sims, J., Warriner, A., Cullum, N., 2009. Health-related quality of life in hospital in patients with pressure ulceration: assessment using generic health-related quality of life measures. Wound Repair and Regeneration 17 (6), 797–805. Goldsworthy, R., 2008. Home health aides’ beliefs regarding pressure ulcer preventive care. Home Healthcare Nurse 26 (2), 113–120. Gorecki, C., Brown, J., Nelson, E., Briggs, M., Schoonhoven, L., Dealey, C., Defloor, T., Nixon, J., European Quality of Life Pressure Ulcer Project Group, 2009. Impact of pressure ulcers on quality of life in older patients: a systematic review. Journal of the American Geriatrics Society 57 (7), 1175–1183. Grol, R., Wensing, M., 2004. What drives change? Barriers to and incentives for achieving evidence-based practice. The Medical Journal of Australia 180 (6 suppl.), 57–60. Gunningberg, L., Lindholm, C., Carlsson, M., Sjo¨de´n, P., 2001. Risk prevention and treatment of pressure ulcers–nursing staff knowledge and documentation. Scandinavian Journal of Caring Sciences 15 (3), 257–263. Gunningberg, L., 2006. EPUAP pressure ulcer prevalence survey in Sweden: a two-year follow-up of quality indicators. Journal of Wound, Ostomy, and Continence Nursing 33 (3), 258–266. Gunningberg, L., Stotts, N., 2008. Tracking quality over time: what do pressure ulcer data show? International Journal for Quality in Health Care 20 (4), 246–253. Halfens, R., Eggink, M., 1995. Knowledge, beliefs and use of nursing methods in preventing pressure sores in Dutch hospitals. International Journal of Nursing Studies 32 (1), 16–26. Hopkins, A., Dealey, C., Bale, S., Defloor, T., Worboys, F., 2006. Patient stories of living with a pressure ulcer. Journal of Advanced Nursing 56 (4), 345–353. Hurd, T., Posnett, J., 2009. Point prevalence of wounds in a sample of acute hospitals in Canada. International Wound Journal 6 (4), 287–293. Ka¨llman, U., Suserud, B., 2009. Knowledge, attitudes and practice among nursing staff concerning pressure ulcer prevention and treatment—a survey in a Swedish healthcare setting. Scandinavian Journal of Caring Sciences 23 (2), 334–341. Kimura, S., Pacala, J., 1997. Pressure ulcers in adults: family physicians’ knowledge, attitudes, practice preferences, and awareness of AHCPR guidelines. The Journal of Family Practice 44 (4), 361–368. Krause, T., Anders, J., Von Renteln-Kruse, W., 2004. [Pressure sores: knowledge of risk factors and awareness of problems with quality of care as reflected by questionnaire answers by nursing staff and physicians]. Zeitschrift fu¨r Gerontologie und Geriatrie 37 (2), 86–91. Lardenoye, J., Thie´faine, J., Breslau, P., 2009. Assessment of incidence, cause, and consequences of pressure ulcers to evaluate quality of provided care. Dermatologic Surgery 35 (11), 1797–1803. Lynn, M., 1986. Determination and quantification of content validity. Nursing Research 35 (6), 382–385. Maylor, M., Torrance, C., 1999. Pressure ulcer survey part 3: locus of control. Journal of Wound Care 8 (3), 101–105. McKenna, H., 1994. The Delphi technique: a worthwhile research for nursing? Journal of Advanced Nursing 19 (6), 1221–1225. Moore, Z., Price, P., 2004. Nurses’ attitudes, behaviours and perceived barriers towards pressure ulcer prevention. Journal of Clinical Nursing 13 (8), 942–951. Moulding, N., Silagy, C., Weller, D., 1999. A framework for effective management of change in clinical practice: dissemination and implementation of clinical practice guidelines. Quality in Health Care 8 (3), 177–183. Petty, R., Cacioppo, J., 1996. Introduction to attitude and persuasion. In: Attitudes and Persuasion: Classic and Contemporary Approaches, Westview Press, Oulder, CO, USA, pp. 3–37. Polit, D., Beck, C., 2007. Nursing Research: Generating and Assessing Evidence for Nursing Practice. Lippincott Williams & Wilkins, Philadelphia. Rockeach, M., 1966. Attitude change and behavioral change. Public Opinion Quarterly 30, 529–550. Schoonhoven, L., Bousema, M., Buskens, E., prePURSE-Study Group, 2007. The prevalence and incidence of pressure ulcers in hospitalised
D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441 patients in the Netherlands: a prospective inception cohort study. International Journal of Nursing Studies 44 (6), 927–935. Shahin, E., Dassen, T., Halfens, R., 2009. Incidence, prevention and treatment of pressure ulcers in intensive care patients: a longitudinal study. International Journal of Nursing Studies 46 (4), 413–421. Streiner, L., Norman, R., 2003. Health Measurement Scales. A Practical Guide to Their Development and Use. Oxford University Press, New York. Thomas, S., Hathaway, D., Arheart, K., 1992. Technical notes: face validity. Western Journal of Nursing Research 14 (1), 109–112. Vanderwee, K., Clark, M., Dealey, C., Gunningberg, L., Defloor, T., 2007a. Pressure ulcer prevalence in Europe: a pilot study. Journal of Evaluation in Clinical Practice 13 (2), 227–235.
1441
Vanderwee, K., Grypdonck, M., Defloor, T., 2007b. Non-blanchable erythema as an indicator for the need for pressure ulcer prevention: a randomised-controlled trial. Journal of Clinical Nursing 16 (2), 325– 335. Vanderwee, K., Grypdonck, M., De Bacquer, D., Defloor, T., 2009. The identification of older nursing home residents vulnerable for deterioration of grade 1 pressure ulcers. Journal of Clinical Nursing 18 (21), 3050–3058. van Gaal, B., Schoonhoven, L., Vloet, L., Mintjes, J., Borm, G., Koopmans, R., van Achterberg, T., 2010. The effect of the SAFE or SORRY? programme on patient safety knowledge of nurses in hospitals and nursing homes: a cluster randomised trial. International Journal of Nursing Studies, doi:10.1016/j.ijnurstu.2010.02.001.
Contents lists available at ScienceDirect
International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
Pressure ulcers: Development and psychometric evaluation of the Attitude towards Pressure ulcer Prevention instrument (APuP) D. Beeckman a,b,*, T. Defloor a, L. Demarre´ a, A. Van Hecke a, K. Vanderwee a a b
Nursing Science, Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium Department of Bachelor in Nursing, University College Arteveldehogeschool Ghent, Ghent, Belgium
A R T I C L E I N F O
A B S T R A C T
Article history: Received 16 March 2010 Received in revised form 16 April 2010 Accepted 16 April 2010
Background: Pressure ulcers continue to be a significant problem in hospitals, nursing homes and community care settings. Pressure ulcer incidence is widely accepted as an indicator for the quality of care. Negative attitudes towards pressure ulcer prevention may result in suboptimal preventive care. A reliable and valid instrument to assess attitudes towards pressure ulcer prevention is lacking. Aims and objectives: Development and psychometric evaluation of the Attitude towards Pressure ulcer Prevention instrument (APuP). Design: Prospective psychometric instrument validation study. Methods: A literature review was performed to design the instrument. Content validity was evaluated by nine European pressure ulcer experts and five experts in psychometric instrument validation in a double Delphi procedure. A convenience sample of 258 nurses and 291 nursing students from Belgium and The Netherlands participated in order to evaluate construct validity and stability reliability of the instrument. The data were collected between February and May 2008. Results: A factor analysis indicated the construct of a 13 item instrument in a five factor solution: (1) attitude towards personal competency to prevent pressure ulcers (three items); (2) attitude towards the priority of pressure ulcer prevention (three items); (3) attitude towards the impact of pressure ulcers (three items); (4) attitude towards personal responsibility in pressure ulcer prevention (two items); and (5) attitude towards confidence in the effectiveness of prevention (two items). This five factor solution accounted for 61.4% of the variance in responses related to attitudes towards pressure ulcer prevention. All items demonstrated factor loadings over 0.60. The instrument produced similar results during stability testing [ICC = 0.88 (95% CI = 0.84–0.91, P < 0.001)]. For the total instrument, the internal consistency (Cronbachs a) was 0.79. Conclusion: The APuP is a psychometrically sound instrument that can be used to effectively assess attitudes towards pressure ulcer prevention in patient care, education, and research. In further research, the association between attitude, knowledge and clinical performance should be explored. ß 2010 Elsevier Ltd. All rights reserved.
Keywords: Nursing Pressure ulcers Prevention Psychometric Validity Reliability Attitude Instrument
What is already known about the topic?
* Corresponding author at: Nursing Science, Ghent University, U.Z. Block A 2nd floor, De Pintelaan 185, B-9000 Ghent, Belgium. Tel.: +32 9 332 36 19; fax: +32 9 332 50 02. E-mail address: [email protected] (D. Beeckman). 0020-7489/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2010.04.004
Pressure ulcer prevalence has not declined in recent years despite the availability of internationally accepted evidence-based prevention guidelines. A negative attitude towards pressure ulcer prevention is expected to be a barrier to using pressure ulcer prevention guidelines.
D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441
Psychometric aspects of instruments to assess attitudes towards pressure ulcer prevention are not evaluated. What this paper adds The Attitude towards Pressure ulcer Prevention instrument (APuP) can be considered as a brief, conceptually sound, rigorously developed instrument with evidence supporting its psychometric properties. The APuP can be used in education, research and clinical practice to assess attitudes towards pressure ulcer prevention. Further research should focus on the predictive validity of the instrument and on the exploration of the relation between attitude, knowledge, and clinical performance. 1. Introduction A pressure ulcer is a localised injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated (European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel, 2009). The ulcers are most often observed in geriatric patients and patients dealing with physical disabilities caused by inactivity, immobility and deprived health status (Schoonhoven et al., 2007; Vanderwee et al., 2007a) Pressure ulcers are recognised as an international patient safety problem and are associated with quality of care (Gunningberg and Stotts, 2008; Baharestani et al., 2009). The lesions are considered as adverse outcomes with a significant impact on patients, their family, caregivers and healthcare organisations (Lardenoye et al., 2009; Gorecki et al., 2009). Recent studies indicate that pain, infectious complications, prolonged and expensive hospitalisations, persistent open ulcers, increased risk of death and reduced health-related quality of life are associated with the development of pressure ulcers (Hopkins et al., 2006; Essex et al., 2009). Appropriate prevention should be considered early in all patients at risk and whenever early signs of pressure ulcer development are observed (nonblanchable erythema) (Schoonhoven et al., 2007; Vanderwee et al., 2007b, 2009). Prevention should focus on the reduction of the amount and/or duration of pressure and shear (European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel, 2009). Despite the availability and accessibility of internationally accepted evidence-based prevention guidelines, pressure ulcer prevalence has not declined in recent years (Gunningberg, 2006; Schoonhoven et al., 2007, Vanderwee et al., 2007a; Hurd and Posnett, 2009; Shahin et al., 2009). The rationale for this is unclear. The identification of factors contributing to compliance and non-compliance for pressure ulcer prevention guidelines is expected to be important to be able to implement new insights effectively (van Gaal et al., 2010). A negative attitude towards pressure ulcer prevention may be one of those factors (Grol and Wensing, 2004). Nevertheless, attitudes are
1433
frequently overlooked when planning guideline dissemination and implementation (Moulding et al., 1999). An attitude can be defined as a relatively enduring organisation of interrelated beliefs (Rockeach, 1966) and may indicate what can be expected from others (Petty and Cacioppo, 1996). An individual who believes that performing a given behaviour will lead to mostly positive outcomes, will probably hold a more favourable attitude towards performing the behaviour and vice versa (Ajzen and Madden, 1986). An accurate assessment method for attitudes may be useful in predicting clinical performance. 2. Literature overview This literature overview focuses on research describing the development and psychometric validation of instruments and methods to assess attitudes towards pressure ulcer prevention. The databases PubMed, The Cochrane Library Central Register of Controlled Trials (CENTRAL) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for research published in English, Dutch, French and German. The keywords ‘attitude’; ‘attitude to health’; ‘pressure ulcer’; ‘instrument’; ‘scale’; ‘psychometric properties’; and ‘psychometric validation’ were combined to conduct the search. The literature search was completed in January 2010 and revealed five publications in English and one publication in German. Kimura and Pacala (1997) developed an instrument to study the attitudes of family physicians towards the Agency Health Care Policy and Research (AHCPR) guideline on pressure ulcer prevention. The questionnaire consisted of four items to be rated on a four-point Likert scale: (1) adequacy of the training to manage pressure ulcers, (2) perceived effectiveness in treating pressure ulcers, (3) importance of pressure ulcers in primary care practice, and (4) the role of family physicians in pressure ulcer management. No information on psychometric validation of the instrument was reported. Moore and Price (2004) conducted a literature review to develop an instrument to assess the attitudes of staff nurses towards pressure ulcer prevention. The instrument included 11 items to be rated on a five-point Likert scale. The instrument was pilottested in a small sample of 16 nurses from teaching hospitals to assess internal consistency. No further validation was performed. Krause et al. (2004) developed a semi-standardised questionnaire to assess the attitudes of nurses and physicians towards pressure ulcers. No information about the design and validation of the instrument was described. Ka¨llman and Suserud (2009) developed a Swedish version of the instrument developed by Moore and Price (2004) to assess the attitudes of registered nurses and nursing assistants towards pressure ulcer prevention in Sweden. The layout and content of the questionnaire were reviewed by three pressure experts. The questionnaire was pilot-tested in a small sample of four registered nurses and four nursing assistants. The final instrument consisted of 11 items to be rated on a five-point Likert scale. In two studies, qualitative methods were used to describe the views and beliefs about pressure ulcer
1434
D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441
prevention of nurses and nursing aides in nursing homes (Buss et al., 2004; Goldsworthy, 2008). This literature overview reveals that various researchers studied attitudes towards the prevention of pressure ulcers. The limited evaluation of the psychometric aspects of the instruments is a major problem to be able to evaluate and compare these findings. Both quantitative (questionnaires) and qualitative research designs have been used. Construct validity and stability of the instruments were never evaluated. Internal consistency was evaluated in only one study. The development and psychometric evaluation of an instrument to assess attitudes regarding pressure ulcer prevention is necessary. 3. Aims and objectives The aim of this study was to develop and to evaluate the psychometric characteristics of the Attitude towards Pressure ulcer Prevention instrument (APuP). 4. Methods 4.1. Design A two-phase prospective psychometric instrument validation study was conducted. Phase 1 included the design of the instrument and phase 2 included the psychometric evaluation. 4.1.1. Phase 1: Design of the instrument A literature review was performed in order to define eight attitude subscales: 1. Attitude towards the impact of pressure ulcers on patients. 2. Attitude towards the financial impact of pressure ulcers on society. 3. Attitude towards the support by management. 4. Attitude towards the priority of pressure ulcer prevention. 5. Attitude towards personal responsibility in pressure ulcer prevention. 6. Attitude towards the importance of a sound knowledge base. 7. Attitude towards confidence in personal skills. 8. Attitude towards confidence in the effectiveness of prevention. A range of items was formulated to be covered by the subscales. All items were derived from literature, clinical experience and deductive reasoning by the developers. As recommended by Clark and Watson (2005), the number of items was chosen so as to sample systematically all content that potentially could be relevant to the target construct. Because the subsequent psychometric analyses could potentially identify weak, unrelated items, the item pool was selected broader than initially was derived from the literature review. This allowed to drop out some items from the emerging instrument. Half of the items was worded negatively and half was worded positively. All items were developed to be rated on a four-point Likert rating scale (1 = strongly
disagree, 2 = disagree, 3 = agree, 4 = strongly agree). The relevance of each item was evaluated in a double Delphi procedure by two expert panels (McKenna, 1994; Thomas et al., 1992; Polit and Beck, 2007). The first panel consisted of nine trustees of the European Pressure Ulcer Advisory Panel (EPUAP) who each had an extensive experience in pressure ulcer care and research (PhD level). The second panel consisted of five experts (geriatrician, dermatologist, nursing researcher, psychologist, sociologist). The experts independently reviewed each item for appropriateness and relevance in assessing attitudes towards pressure ulcer prevention. A five-point Likert scale was used to indicate the relevance of the items under study (from 1 = irrelevant to 5 = highly relevant). The content validity index (CVI) was computed using the proportion of experts wh agreed about item relevance. The CVI was between 0.87 and 1.00, indicating adequate content validity (Polit and Beck, 2007). Twelve items were re-worded to improve item relevance. After this item modification, the instrument was pilot-tested in a sample of five nurses and five nursing students. The aim was (1) to evaluate the clarity of the items and report any ambiguous items and items difficult to interpret, (2) to receive feedback about the format/layout of the instrument, and (3) to get insight into the time needed to complete the instrument. In general the participants did not have any problems with the wording, length and format of the instrument. An overview of the instrument design process is provided in Fig. 1. 4.1.2. Phase 2: Psychometric evaluation of the instrument The psychometric evaluation included the evaluation of the construct validity (factor analysis, discriminating power and internal consistency) and stability reliability testing of the instrument. 4.2. Sample The initial 32-item APuP instrument was administered to a convenience sample of qualified nurses (n = 258) and nursing students (n = 291) in Belgium and The Netherlands. The sample size determination was based on Polit and Beck (2007) who states that 10 respondents per item is mostly recommended as a minimum to support the factor analysis. In Belgium, 210 qualified nurses from two general hospitals (n = 172) and one psychiatric hospital (n = 38) were included. In this group of qualified nurses, 67 of them attended a Master of Sciences in Nursing (MScN) educational programme. Besides, nursing students from two schools with an undergraduate nursing education (n = 77) and two nursing colleges (n = 214) were included. All nursing students were at the second semester of their particular year of basic nursing education. In the Netherlands, 48 pressure ulcer nurses were asked to participate because of their specific specialty in the prevention and treatment of pressure ulcers. To allow the evaluation of the discriminating power of the APuP instrument, eight subgroups were pre-defined based on a theoretically expected difference in attitudes towards pressure ulcer prevention. An overview of these pre-defined groups is provided in Table 1.
D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441
1435
Fig. 1. Phase 1: Design of the instrument.
4.3. Ethical approval Ethical approval was provided by the ethics review committee of Ghent University Hospital (B/67020072806). The questionnaire included a cover letter addressing the purpose of the study. Anonymity and confidentiality were assured. All data were treated as confidential at all times. The return of a completed instrument was considered as the consent to participate. 4.4. Procedure The study was performed in Belgium and The Netherlands between February and May 2008. To be able to study
the stability of the instrument over a time period, data were collected at two different points in time (a 1-week interval). The 1-week period between the test and the retest was used to reduce confounding factors during the intervening time interval as much as possible (Polit and Beck, 2007). These confounding factors included: (1) the possibility that the attitudes changed over time (independently of the measure’s stability), and (2) the possibility that the respondents were influenced by their memory of initial responses. The participants were not informed in advance of the test–retest procedure. The same conditions were ensured at both data collecting time points. The time to complete the instrument was 10 min. 4.5. Data analysis
Table 1 Pre-defined groups based on the theoretically expected attitude levels. Pre-defined groups
1 2 3 4 5 6 7 8
Theoretically expected more positive attitude
Theoretically expected more negative attitude
Pressure ulcer nursesa Pressure ulcer nurses Infection control nursesc Third year nursing students Third year nursing students Second year nursing students General nurses Bachelor degree
vs. vs. vs. vs. vs. vs. vs. vs.
Bedside nursesb First year nursing students MScN studentsd First year nursing students Second year nursing students First year nursing students Mental health nurses Undergraduate degree
a Pressure ulcer nurse, qualified nurse in The Netherlands, specialised in the prevention and treatment of pressure ulcers. b Bedside nurse, qualified nurse working on a hospital ward c Infection control nurse, qualified nurse in Belgium with the specific task to identify and control infections that occur in the community or in a hospital setting d MScN, qualified bachelor nurse studying to obtain a Master of Sciences in Nursing.
Construct validity and stability reliability of the instrument were assessed. Construct validity was assessed by (1) factor analysis using principal component analysis, (2) discriminating power (known-groups technique), and (3) internal consistency analysis. In the factor analysis, the varimax rotation with Kaiser normalisation was used. The numbers of factors were determined by eigenvalues (1). The Kaiser–Meyer–Olkin (KMO) Measure of Sampling Adequacy over 0.50, Bartlett’s test of sphericity, scree plot, factor loadings of over 0.40, and explainable percentages of variance (minimum of 5% reported variance per factor) were evaluated. Item reduction and attitude subscale modification were performed based on this factor analysis. Analysis on discriminating power, internal consistency, and stability reliability were executed on the modified model. Sum scores were calculated to obtain the total attitude score. Scores on the negatively worded items were reversed to obtain a total score. The independent sample
1436
D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441
Fig. 2. Phase 2: Psychometric evaluation of the instrument.
t-test was used to signify differences between the attitude scores of the pre-defined groups (discriminating power). The internal consistency was studied by calculating interitem correlations Cronbachs a (Polit and Beck, 2007). The criteria for Cronbachs a as described by Streiner and Norman (2003) were used for the interpretation of the results: 0.70 < Cronbachs a < 0.90. To assess the reliability of the instrument, the intraclass correlation coefficient was calculated for each theme and for the overall instrument. Reliability coefficients 0.70 were considered as satisfactory (Polit and Beck, 2007). All statistical analyses were performed using SPSS1 15.0 (SPSS1 Inc., Chicago, IL, USA). An a level of 0.05 was applied for all statistical tests. An overview of the psychometric evaluation of the instrument is provided in Fig. 2. 5. Results 5.1. Basic characteristics of the participants A total of 258 nurses and 291 nursing students participated. About 70% of the nurses were between the age of 25 and 50. More than half of the nurses (54.2%) stated to have more than 10 years experience in nursing care. Approximately 65% of the nurses worked in a hospital and 17.1% worked in mental healthcare. Almost 75% of the nursing students were bachelor students and 79.4% of
them were specialising in general nursing. Half of the students were first year nursing students. An overview of the demographic data is provided in Table 2. 5.2. Psychometric evaluation of the instrument 5.2.1. Construct validity 5.2.1.1. Factor analysis. Several exploratory analyses were conducted on the 32-item instrument. The model chosen included five factors, covering 13 items, and had the most meaningful content. The KMO for this model indicated sampling adequacy (KMO = 0.72). Bartlett’s test of sphericity was statistically significant (x2 = 1062.6, df = 78, P < 0.001). Following factors were defined: Factor 1: Attitude towards personal competency to prevent pressure ulcers. Factor 2: Attitude towards the priority of pressure ulcer prevention. Factor 3: Attitude towards the impact of pressure ulcers. Factor 4: Attitude towards responsibility in pressure ulcer prevention. Factor 5: Attitude towards confidence in the effectiveness of prevention. The five factors accounted for 61.4% of the variance in responses related to attitudes towards pressure ulcer
D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441 Table 2 Demographic data. Nurses (n = 258) % (n)
Student nurses (n = 291) % (n)
Gender Male Female
20.5% (53) 79.5% (205)
14.8% (43) 85.2% (248)
Education Undergraduate degree Bachelor degree (BA) MScN degree (MScN)
28.3% (73) 65.5% (169) 6.2% (16)
26.5% (77) 73.5% (214) N/Aa
Age category <25 years 25–34 years 35–50 years >50 years
18.2% 31.4% 37.6% 12.8%
85.2% (248) 8.2% (24) 5.8% (17) 0.7% (2)
Work experience No experience <5 years 5–10 years 10–20 years >20 years
7.4% (19) 20.9% (54) 17.4% (45) 24.0% (62) 30.2% (78)
N/Aa N/Aa N/Aa N/Aa N/Aa
Year of education 1st year 2nd year 3rd year
N/Aa N/Aa N/Aa
46.6% (138) 19.9% (58) 32.6% (95)
Specialisation General nursing Geriatrics Pediatrics Mental health Community nursing
73.6% (190) 3.5% (9) 1.9% (5) 17.8% (46) 3.1% (8)
79.4% (231) 7.2% (21) 1.7% (5) 7.6% (22) 4.1% (12)
a
(47) (81) (97) (33)
Not applicable.
prevention. Factor 1 consisted of 2 positively and 1 negatively worded items, explaining 14.6% of the variance. Factor 2 included 1 positively and 2 negatively worded items, explaining 14.0% of the variance. Factor 3 included 1 positively and 2 negatively worded items, explaining 11.5% of the variance. Factor 4 included 1 positively and 1 negatively worded items, explaining 10.8% of the variance. Factor 5 included 1 positively and 1 negatively worded items, explaining 10.5% of the variance. All items demonstrated strong factor loadings (>0.60; See Table 3).
1437
5.2.1.2. Discriminating power. Group scores of participants having a theoretically expected more positive attitude were found to be statistically significantly higher than those of participants with theoretically expected more negative attitudes. Expert nurses proved to have more positive attitudes than non-expert nurses (resp. 30.6/52 vs. 27.4/52, t = 4.61, df = 139, P < 0.001) (See Table 4). There was no difference between the group scores of second year nursing students (26.3/52, SD = 3.1) and first year nursing students (26.4/52, SD = 3.0) (t = 0.3, df = 194, P = 0.74) (See Table 4). In general, nurses proved to have more positive attitudes towards pressure ulcers than nursing students (resp. 28.0/52 vs. 26.9/52, t = 3.55, df = 547, P < 0.001) for the total APuP instrument. Nurses proved to have more positive attitudes for ‘competence’ (5.6/12 vs. 4.9/12, t = 5.50, df = 547, P < 0.001) and ‘impact’ (7.9/12 vs. 6.3/12, t = 2.41, df = 547, P = 0.016) than nursing students. No significant differences were found between nurses and nursing students in the other subscales. 5.2.1.3. Internal consistency. Cronbachs a was 0.79 for the total APuP instrument, 0.81 for ‘competence’, 0.75 for ‘priority’, 0.79 for ‘impact’, 0.82 for ‘responsibility’, and 0.76 for ‘effectiveness of prevention’. 5.2.2. Stability reliability (intraclass correlation) The overall intraclass correlation coefficient was 0.88 (95% CI = 0.84–0.91, P < 0.001). The intraclass correlation coefficient for the subscales ranged between 0.77 (95% CI = 0.70–0.83, P < 0.001) and 0.85 (95% CI = 0.80–0.89, P < 0.001). The final version of the APuP is presented in Table 5. 6. Discussion An accurate assessment of attitudes towards pressure ulcer prevention is an important step in identifying interventions to improve pressure ulcer prevention. As evidenced by the literature overview, none of the actual instruments exhibits fully satisfactory psychometric characteristics. The results from the psychometric evaluation of the APuP indicated that the instrument and the subscales
Table 3 Factor analysis using principal component analysis. Item Factor loadings 1. I feel confident in my ability to prevent pressure ulcers. 2. I am well trained to prevent pressure ulcers. 3. Pressure ulcer prevention is too difficult. Others are better than I am. 4. Too much attention goes to the prevention of pressure ulcers. 5. Pressure ulcer prevention is not that important. 6. Pressure ulcer prevention should be a priority. 7. A pressure ulcer almost never causes discomfort for a patient. 8. The impact of pressure ulcers on a patient should not be exaggerated. 9. The financial impact of pressure ulcers on society should not be exaggerated. 10. I personally feel not responsible if a pressure ulcer develops in my patient. 11. I personally have an important task in pressure ulcer prevention. 12. Pressure ulcers are preventable in high risk patients. 13. Pressure ulcers are never preventable.
Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Competence Priority Impact Responsibility Effectiveness 0.83 0.75 0.75 0.09 0.01 0.21 0.02 0.01 0.06 0.09 0.18 0.03 0.11
0.07 0.15 0.00 0.75 0.72 0.63 0.15 0.23 0.16 0.05 0.29 0.05 0.03
0.05 0.02 0.11 0.01 0.33 0.02 0.69 0.65 0.64 0.03 0.11 0.01 0.04
0.06 0.04 0.09 0.00 0.01 0.29 0.17 0.02 0.01 0.86 0.69 0.08 0.06
0.01 0.03 0.13 0.21 0.03 0.20 0.08 0.19 0.01 0.08 0.11 0.78 0.74
1438
D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441
Table 4 Known-groups technique. Group
N
Mean score (max = 52) (SD)
Significance
Group A Theoretically expected more positive attitude
Group B Theoretically expected more negative attitude
to
dfoo
Pooo
48 93
30.6 (3.8)
27.4 (3.9)
4.6
139
<0.001
48 138
30.6 (3.8)
26.4 (3.0)
7.7
184
<0.001
5 67
31.0 (4.1)
26.8 (4.1)
2.2
70
95 138
27.8 (3.4)
26.4 (3.0)
3.3
231
0.001
95 58
27.8 (3.4)
26.3 (3.1)
2.8
151
0.005
Second year nursing students (A) vs. first year nursing students (B)
58 138
26.3 (3.1)
26.4 (3.0)
0.3
194
0.74
General nurses (A) vs. mental health nurses (B)
172 46
28.6 (4.0)
25.9 (3.9)
4.1
216
<0.001
Bachelor degree (A) vs. undergraduate degree (B)
383 150
28.3 (3.6)
26.9 (3.5)
4.1
531
<0.001
Pressure ulcer nursesa (A) vs. bedside nursesb (B) Pressure ulcer nursesa (A) vs. first year nursing students (B) Infection control nursesc (A) vs. MScN studentsd (B) Third year nursing students (A) vs. first year nursing students (B) Third year nursing students (A) vs. second year nursing students (B)
0.03
o
Value independent sample t-test. Degrees of freedom. ooo P-value. a Pressure ulcer nurse, qualified nurse in The Netherlands, specialised in the prevention and treatment of pressure ulcers. b Bedside nurse, qualified nurse working on a hospital ward. c Infection control nurse, qualified nurse in Belgium with the specific task to identify and control infections that occur in the community or in a hospital setting. d MScN, qualified bachelor nurse studying to obtain a Master of Sciences in Nursing. oo
Table 5 Final version of the Attitude towards Pressure ulcer Prevention instrument (APuP) (maximum score = 52). Strongly agree
Agree
Disagree
Strongly disagree
o o o
o o o
o o o
o o o
o o o
o o o
o o o
o o o
o o o
o o o
o o o
o o o
o o
o o
o o
o o
o o
o o
o o
o o
F1. Personal competency to prevent pressure ulcers (three items) (maximum score = 12) F1.1. (+)a I feel confident in my ability to prevent pressure ulcers. F1.2. (+)a I am well trained to prevent pressure ulcers. F1.3. ( )b Pressure ulcer prevention is too difficult. Others are better than I am. F2. Priority of pressure ulcer prevention (three items) (maximum score = 12) F2.1. ( )b Too much attention goes to the prevention of pressure ulcers. F2.2. ( )b Pressure ulcer prevention is not that important. F2.3. (+)a Pressure ulcer prevention should be a priority. F3. Impact of pressure ulcers (three items) (maximum score = 12) F3.1. ( )b A pressure ulcer almost never causes discomfort for a patient. F3.2. ( )b The financial impact of pressure ulcers on a patient should not be exaggerated. F3.3. (+)a The financial impact of pressure ulcers on society is high. F4. Responsibility in pressure ulcer prevention (two items) (maximum score = 8) F4.1. ( )b I am not responsible if a pressure ulcer develops in my patients. F4.2. (+)a I have an important task in pressure ulcer prevention. F5. Confidence in the effectiveness of prevention (two items) (maximum score = 8) F5.1. (+)a Pressure ulcers are preventable in high risk patients. F5.2. ( )b Pressure ulcers are almost never preventable. a b
Positively worded item. Negatively worded item.
are reliable and construct valid to be used to assess attitudes towards pressure ulcer prevention. The subscales and the items in the initial version of the instrument were developed based on important issues
within pressure ulcer preventive care. All subscales together represented what in this study was postulated as attitudes towards pressure ulcer preventive care. Content validity was achieved through literature review
D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441
and consultation with experienced pressure ulcer and psychometric validation experts. The content validity index fully achieved Lynn’s (1986) criterion for content validity. Additionally, based on the pilot study in five experts and five non-experts, the instrument was found to have an established content validity. Construct validity of the APuP was assessed in a factor analysis by using a principal component analysis. A principal component analysis was used because it is considered to be a well-suited approach to combine a large number of items into a few principal factors. In a factor analysis, principal component analysis is an easily understood and commonly used extraction technique. The Bartlett test of sphericity indicated that the correlations did not happen by chance and there was justification for the factor analysis. There was also an adequate sample for the factor analysis based on calculated KMO. After testing the instrument in a factor analysis, the number of subscales and items was reduced and the proportions of items within the subscales were changed. While modifying the instrument, attention was paid to the meaningfulness of the content of the total instrument and the subscales, as this also has an effect on instrument reliability. The five underlying factors showed a logical connection to the theoretical framework used during the design of the instrument. The range of items as defined in during the creation of the instrument allowed to test a diversity of models and to remove items if they were found to be weak and/or unrelated after factor analysis. All kinds of models, with different compositions/numbers of items, were tested. The composition of these models was primarily based on a meaningful content and theoretical sense. In the final model chosen, all included items (n = 13) possessed factor loadings over 0.6 and the five factors accounted for 61.4% of the variance in responses related to attitudes towards pressure ulcer prevention. The final model made good theoretical sense and contained fewer similar items than in the initial version. The ‘‘competence’’ subscale reflects the attitude towards the perceived own ability to provide adequate pressure ulcer preventive care. A competence is defined as the ability to perform a specific task, action or function successfully and is closely related to knowledge. In a recent study by Athlin et al. (2009), competences among healthcare personnel was described as an important factor to prevent pressure ulcers. The second subscale, ‘‘priority’’, deals with the importance given to pressure ulcer prevention in daily care. The importance to assess the priority of pressure ulcer prevention in care is supported in research by Gunningberg et al. (2001) and Moore and Price (2004). These authors stated that a majority of the nurses consider pressure ulcer prevention as being of low priority in their daily work. Also in a study by Buss et al. (2004), pressure ulcer prevention was found not to be a great issue in the daily work of nurses. If low priority is given to the prevention of pressure ulcers, it will be unlikely to expect good preventive care. The ‘‘impact’’ subscale reflects the perceived consequences of pressure ulcers on patients (discomfort and financial impact) and on society (financial impact).
1439
Evidence concerning the important impact of pressure ulcers on patients and society is provided by multiple researchers (Hopkins et al., 2006; Essex et al., 2009; Lardenoye et al., 2009; Gorecki et al., 2009). If pressure ulcers are considered as being of low impact, it will be unlikely to expect good preventive care. In the initial version of the instrument, the impact of pressure ulcers on patients and the impact on society were defined in two separate subscales. The factor analyses provided evidence that one subscale was able to explain this attitude. The ‘responsibility’ subscale is defined as the perception about who is responsible for pressure ulcer prevention. The nurse responsibility was stressed as an important factor in pressure ulcer preventive care by Athlin et al. (2009). The researchers claim that, although pressure ulcer care is often seen as a task of licensed practical nurses, the registered nurses should have the superior responsibility due to their higher level of education. This responsibility should concern prevention, risk assessment and the supervision of licensed practical nurses. Confidence in the effectiveness of prevention was defined as the final subscale. The attitude that pressure ulcer prevention is not effective might probably have an impact on the application of prevention. Buss et al. (2004) state that the use of preventive interventions in daily practice depends very much on the nurses’ conviction about the effectiveness of the intervention. This statement was supported in research by Halfens and Eggink, 1995. The more pressure ulcer prevention is valued, the greater the likelihood of preventative practices being carried out (Maylor and Torrance, 1999). The evidence to support construct validity, using the known-groups technique, was strong. The known-groups method is a typical method to support construct validity and is provided when the instrument is able to discriminate between a group of individuals expected to have a particular trait and a group who do not have the trait. According to Polit and Beck (2007), this technique gives a good indication of what construct an instrument actually measures. In this study, data collection procedure was rigorously set up in different types of clinical and educational settings. Eight groups having a different expertise in pressure ulcer care were pre-defined and group scores were compared. The discriminant validity of the APuP was strongly supported by statistically significant mean differences among pressure ulcer experts and non-experts, suggesting its potential usefulness to track changes in attitudes across different clinical and educational settings in intervention outcome studies.Cronbachs a coefficients were calculated to assess the internal consistency of the instrument and its subscales. The study demonstrated acceptable to excellent internal consistency for both the total instrument and its subscales, with Cronbachs a ranging from 0.75 to 0.82. The intraclass correlation of the APuP reached the established recommendations, indicating that the scale can provide a reliable assessment for both group and individual measurements, comparisons, or both. The strength of the APuP to yield consistent responses on different rating moments, effectively demonstrates the ease of use and clinical usefulness of the instrument.
1440
D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441
In contrast to the actual instruments, the APuP is able to offer a more comprehensive picture of the attitude towards pressure ulcer prevention. The instrument has several potential applications. This study attempted to construct a short instrument for use in clinical practice, education and research. Along with the ease of administration and scoring, the APuP can be included in any rapid survey for assessing attitudes towards pressure ulcer prevention and for evaluating efficacy of intervention programmes. The evaluation of interventions to improve attitudes is possible using this instrument in pretest–posttest setting or in randomised-controlled trials. The instrument can help to develop strategies for improving quality of pressure ulcer prevention by identifying priorities based on lowscoring subscales. Alternatively, this instrument can be used for individuals to determine an objective measure of personal attitude. Further research should include testing the instrument in different healthcare settings with varying characteristics in order to study predictive validity of the instrument and to explore the possible link between attitude, knowledge, and clinical performance. 6.1. Limitations A first limitation reflects on the use of a convenience sample. Besides, data on non-response were not collected. It is possible that potential participants who declined participation may be different from the study participants. This might limit the generalisability of the findings. Secondly, the fact that no more than three items were included in each subscale should be a point of special interest. Ideally more items should be added, especially to the subscales on ‘personal responsibility’, and ‘confidence in the effectiveness of prevention’. On the other hand, the development of a short instrument facilitates the ease of administration and contributes to the application in practice. 7. Conclusion The results of this study indicate that the Attitude towards Pressure ulcer Prevention instrument (APuP), as well as each subscale, can be considered a brief, conceptually sound, rigorously developed instrument with evidence supporting the psychometric properties. Conflicts of interest: None declared. Funding: None. Ethical approval: Ghent University Hospital (B/67020072806). References Ajzen, I., Madden, T., 1986. Prediction of goal-directed behaviour: attitudes, intentions and perceived behavioural control. Journal of Experimental Social Psychology 22 (3), 453–474. Athlin, E., Idvall, E., Jernfa¨lt, M., Johansson, I., 2009. Factors of importance to the development of pressure ulcers in the care trajectory: perceptions of hospital and community care nurses. Journal of Clinical Nursing, doi:10.1111/j.1365-2702.2009.02886.x. Baharestani, M., Black, J., Carville, K., Clark, M., Cuddigan, J., Dealey, C., Defloor, T., Harding, K., Lahmann, N., Lubbers, M., Lyder, C., Ohura, T., Orsted, H., Reger, S., Romanelli, M., Sanada, H., 2009. Dilemmas in
measuring and using pressure ulcer prevalence and incidence: an international consensus. International Journal of Wound Care 6 (2), 97–104. Buss, I., Halfens, R., Abu-Saad, H., Kok, G., 2004. Pressure ulcer prevention in nursing homes: views and beliefs of enrolled nurses and other health care workers. Journal of Clinical Nursing 13 (6), 668–676. Clark, L., Watson, D., 2005. Constructing validity: basic issues in objective scale development. Psychological Assessment 7 (3), 309–319. European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel, 2009. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. National Pressure Ulcer Advisory Panel, Washington, DC. Essex, H., Clark, M., Sims, J., Warriner, A., Cullum, N., 2009. Health-related quality of life in hospital in patients with pressure ulceration: assessment using generic health-related quality of life measures. Wound Repair and Regeneration 17 (6), 797–805. Goldsworthy, R., 2008. Home health aides’ beliefs regarding pressure ulcer preventive care. Home Healthcare Nurse 26 (2), 113–120. Gorecki, C., Brown, J., Nelson, E., Briggs, M., Schoonhoven, L., Dealey, C., Defloor, T., Nixon, J., European Quality of Life Pressure Ulcer Project Group, 2009. Impact of pressure ulcers on quality of life in older patients: a systematic review. Journal of the American Geriatrics Society 57 (7), 1175–1183. Grol, R., Wensing, M., 2004. What drives change? Barriers to and incentives for achieving evidence-based practice. The Medical Journal of Australia 180 (6 suppl.), 57–60. Gunningberg, L., Lindholm, C., Carlsson, M., Sjo¨de´n, P., 2001. Risk prevention and treatment of pressure ulcers–nursing staff knowledge and documentation. Scandinavian Journal of Caring Sciences 15 (3), 257–263. Gunningberg, L., 2006. EPUAP pressure ulcer prevalence survey in Sweden: a two-year follow-up of quality indicators. Journal of Wound, Ostomy, and Continence Nursing 33 (3), 258–266. Gunningberg, L., Stotts, N., 2008. Tracking quality over time: what do pressure ulcer data show? International Journal for Quality in Health Care 20 (4), 246–253. Halfens, R., Eggink, M., 1995. Knowledge, beliefs and use of nursing methods in preventing pressure sores in Dutch hospitals. International Journal of Nursing Studies 32 (1), 16–26. Hopkins, A., Dealey, C., Bale, S., Defloor, T., Worboys, F., 2006. Patient stories of living with a pressure ulcer. Journal of Advanced Nursing 56 (4), 345–353. Hurd, T., Posnett, J., 2009. Point prevalence of wounds in a sample of acute hospitals in Canada. International Wound Journal 6 (4), 287–293. Ka¨llman, U., Suserud, B., 2009. Knowledge, attitudes and practice among nursing staff concerning pressure ulcer prevention and treatment—a survey in a Swedish healthcare setting. Scandinavian Journal of Caring Sciences 23 (2), 334–341. Kimura, S., Pacala, J., 1997. Pressure ulcers in adults: family physicians’ knowledge, attitudes, practice preferences, and awareness of AHCPR guidelines. The Journal of Family Practice 44 (4), 361–368. Krause, T., Anders, J., Von Renteln-Kruse, W., 2004. [Pressure sores: knowledge of risk factors and awareness of problems with quality of care as reflected by questionnaire answers by nursing staff and physicians]. Zeitschrift fu¨r Gerontologie und Geriatrie 37 (2), 86–91. Lardenoye, J., Thie´faine, J., Breslau, P., 2009. Assessment of incidence, cause, and consequences of pressure ulcers to evaluate quality of provided care. Dermatologic Surgery 35 (11), 1797–1803. Lynn, M., 1986. Determination and quantification of content validity. Nursing Research 35 (6), 382–385. Maylor, M., Torrance, C., 1999. Pressure ulcer survey part 3: locus of control. Journal of Wound Care 8 (3), 101–105. McKenna, H., 1994. The Delphi technique: a worthwhile research for nursing? Journal of Advanced Nursing 19 (6), 1221–1225. Moore, Z., Price, P., 2004. Nurses’ attitudes, behaviours and perceived barriers towards pressure ulcer prevention. Journal of Clinical Nursing 13 (8), 942–951. Moulding, N., Silagy, C., Weller, D., 1999. A framework for effective management of change in clinical practice: dissemination and implementation of clinical practice guidelines. Quality in Health Care 8 (3), 177–183. Petty, R., Cacioppo, J., 1996. Introduction to attitude and persuasion. In: Attitudes and Persuasion: Classic and Contemporary Approaches, Westview Press, Oulder, CO, USA, pp. 3–37. Polit, D., Beck, C., 2007. Nursing Research: Generating and Assessing Evidence for Nursing Practice. Lippincott Williams & Wilkins, Philadelphia. Rockeach, M., 1966. Attitude change and behavioral change. Public Opinion Quarterly 30, 529–550. Schoonhoven, L., Bousema, M., Buskens, E., prePURSE-Study Group, 2007. The prevalence and incidence of pressure ulcers in hospitalised
D. Beeckman et al. / International Journal of Nursing Studies 47 (2010) 1432–1441 patients in the Netherlands: a prospective inception cohort study. International Journal of Nursing Studies 44 (6), 927–935. Shahin, E., Dassen, T., Halfens, R., 2009. Incidence, prevention and treatment of pressure ulcers in intensive care patients: a longitudinal study. International Journal of Nursing Studies 46 (4), 413–421. Streiner, L., Norman, R., 2003. Health Measurement Scales. A Practical Guide to Their Development and Use. Oxford University Press, New York. Thomas, S., Hathaway, D., Arheart, K., 1992. Technical notes: face validity. Western Journal of Nursing Research 14 (1), 109–112. Vanderwee, K., Clark, M., Dealey, C., Gunningberg, L., Defloor, T., 2007a. Pressure ulcer prevalence in Europe: a pilot study. Journal of Evaluation in Clinical Practice 13 (2), 227–235.
1441
Vanderwee, K., Grypdonck, M., Defloor, T., 2007b. Non-blanchable erythema as an indicator for the need for pressure ulcer prevention: a randomised-controlled trial. Journal of Clinical Nursing 16 (2), 325– 335. Vanderwee, K., Grypdonck, M., De Bacquer, D., Defloor, T., 2009. The identification of older nursing home residents vulnerable for deterioration of grade 1 pressure ulcers. Journal of Clinical Nursing 18 (21), 3050–3058. van Gaal, B., Schoonhoven, L., Vloet, L., Mintjes, J., Borm, G., Koopmans, R., van Achterberg, T., 2010. The effect of the SAFE or SORRY? programme on patient safety knowledge of nurses in hospitals and nursing homes: a cluster randomised trial. International Journal of Nursing Studies, doi:10.1016/j.ijnurstu.2010.02.001.