- Email: [email protected]
Attitudes of surgical nurses towards pressure ulcer prevention
Accepted Manuscript Attitudes of surgical nurses towards pressure injury prevention Seher Ünver, Ümmü Yıldız Fındık, Zeynep Kızılcık Özkan, Çağla Sürücü PII:
S0965-206X(17)30004-9
DOI:
10.1016/j.jtv.2017.09.001
Reference:
JTV 251
To appear in:
Journal of Tissue Viability
Received Date: 20 January 2017 Revised Date:
11 July 2017
Accepted Date: 1 September 2017
Please cite this article as: Ünver S, Yıldız Fındık Üü, Kızılcık Özkan Z, Sürücü Çğ, Attitudes of surgical nurses towards pressure injury prevention, Journal of Tissue Viability (2017), doi: 10.1016/ j.jtv.2017.09.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT ATTITUDES OF SURGICAL NURSES TOWARDS PRESSURE INJURY PREVENTION * Seher Ünver1, Ümmü Yıldız Fındık2, Zeynep Kızılcık Özkan3, Çağla Sürücü4
Seher ÜNVER, Assistant Professor (BSN, MSc, Ph.D), Trakya University, Faculty of Health
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Sciences, Department of Surgical Nursing, Edirne, Turkey, [email protected] +90 505 500 72 17
Ümmü YILDIZ FINDIK, Associated Professor (BSN, MSc, Ph.D), Trakya University,
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Faculty of Health Sciences, Department of Surgical Nursing, Edirne, Turkey [email protected] +90 535 424 61 97
of
Health
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Zeynep KIZILCIK ÖZKAN, Research Assistant (BSN, MSc), Trakya University, Faculty Sciences,
Department
of
Surgical
Nursing,
Edirne,
Turkey
[email protected] +90 505 601 01 01
Çağla SÜRÜCÜ, Student of Bachelor degree (third class), Trakya University, Faculty of
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Health Sciences, Department of Nursing, Edirne, Turkey [email protected] +90 543 932 30 86 Corresponding author: Seher ÜNVER
Edirne/Turkey
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Trakya University, Faculty of Health Science, Department of Surgical Nursing,
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Phone Number: +90-505 500 72 17 Conflict of interest: None
E-mail: [email protected] Financial and other support: None
Acknowledgments: Special thanks to the nurses participated this study and saved their time.
* This study was presented as an oral presentation (virtually) at the 20th International Nursing Research Conference, Coruna-Spain between 15-18 November, 2016
ACCEPTED MANUSCRIPT ATTITUDES OF SURGICAL NURSES TOWARDS PRESSURE INJURY PREVENTION ABSTRACT Study aim: Nurses play the key role in prevention of pressure injuries, and negative attitudes
attitudes towards pressure injury prevention.
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of them may affect preventive care strategies. This research aimed to identify surgical nurses’
Materials and methods: A descriptive and cross-sectional study design was used to collect data between March 31-May 16, 2016 on 101 voluntary nurses (66.01% of all nurses)
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working in surgical units of a university hospital in Turkey. “Attitude towards Pressure Ulcer Prevention Instrument” and “Nurse Information Form” were used to investigate nurses’
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attitude toward preventing pressure injury. Descriptive statistics, Mann-Whitney U test, independent samples t-test, Pearson’s chi-squared, and correlation tests were used to analyse the data.
Results: The mean age of nurses’ was 32.0±6.3 years and, the average duration of clinical experience was 72.3±61 months. A total of 54.5% were working in surgical wards and, 40.6% gained additional education about pressure injury care. The mean total attitude score was
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found to be 80.5% (41.8±4.8). Gaining additional education significantly effected the total attitude score of nurses (p<0.05).
Conclusion: The total scale score showed that surgical nurses had a positive attitude towards
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pressure injury prevention and gaining additional education about pressure injury care has a positive effect on nurses’ attitude. It is recommended that effective in-service education
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programs be developed at hospitals or that nurses be required to attend courses to help them to improve their pressure injury care. Keywords: attitude; nurse; pressure injury; surgical
ACCEPTED MANUSCRIPT 1. Introduction The National Pressure Ulcer Advisory Panel (NPUAP), a professional organization dedicated to the prevention and management of pressure injuries, defines pressure injury as ‘localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device’. Formerly, ‘pressure ulcer’ was the term used for this
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type of injury, but NPUAP announced a change in the terminology from ‘pressure ulcer’ to ‘pressure injury’ on April 13, 2016 [1].
Pressure injuries are recognized as a common problem in healthcare that contribute not
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only to increased health care costs, but also to high morbidity and mortality rates, prolonged hospitalization and emotional problems in patients [2-4]. Studies showed that the prevalence of pressure injuries in hospitals ranged from 7.2% to 20.56% [5-7]. In another study that
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researched pressure injury-related pain, of the 176 patients, 75.6% reported pain [8]. Additional research which focused on surgical patients reported that there was a 54.8% incidence of pressure injuries in surgical patients [9]. In Schultz et al.’s study [10], the incidence in surgical patients was 12%-66%, and the incidence of pressure injury development during surgery was reported as 21.2% [11]. According to an analysis done in Turkey, Koç et al. [12] calculated the cost of pressure injury treatments and stated that the
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total cost ranged from $340.077 to $2.452.686 over a one year span. There are many extrinsic (shear, friction, pressure, etc.) and intrinsic factors (anaemia, oedema, immobilization, etc.) that play a role in the development of surgery-related pressure
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injuries. Some of the factors that occur during surgery are related to the duration of continued pressure, low core temperature, length of surgery, anaesthesia and circulatory changes related
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to the surgical procedure itself [4,13,14]. Prevention of pressure injuries is necessary to reduce their incidence, and guidelines
are available to help clinicians make appropriate decisions about pressure injury prevention [14,15]. A multidisciplinary approach is needed for successful pressure injury prevention, and nurses play the key role in it and have a great responsibility in the approach [16]. It is reported that with evidence-based nursing care the incidence of pressure injury can be reduced by up to 50% [17]. Thus, nurses should be aware of the risk factors associated with pressure injury development when examining at-risk patients, follow the guidelines and apply them to their clinical interventions through pressure injury prevention and treatment [14,18]. In the literature, many studies have been conducted to evaluate nurses’ knowledge and prevention
ACCEPTED MANUSCRIPT methods [19,20], and results showed their improved knowledge was not consistently linked with improved care [21-23]. In their study, Beeckman et al. [24] explored the correlation between knowledge, attitudes and the application of prevention, but found no independent correlation between knowledge and adequate prevention; however, there was a significant correlation between the application of adequate prevention and the attitudes of the nurses.
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Thus, not only knowledge, but also the nurses’ attitudes are important in pressure injury prevention.
Attitude is defined as ‘a summary evaluation of an object of thought’ [25] and includes feelings, thoughts or beliefs that lead to specific action so that attitude may influence the
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decisions or guide the behaviour of an individual [26]. Determining nurses’ attitudes towards pressure injury prevention may identify their behaviours and beliefs about pressure injury
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care. Moreover, negative attitudes towards pressure injury prevention may affect preventive care strategies [27]. It is widely accepted that clinical nurses are responsible for providing safe and evidenced-based care [28], and Grimshaw et al. [29] highlighted that negative attitudes are the principal barriers to evidence-based practice. However, there are very few studies which examine the attitudes of nurses in relation to the prevention of pressure injuries and which draw attention to this issue by publishing their results. Thus, the objective of the study
2. Material and methods
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was to identify surgical nurses’ attitudes towards pressure injury prevention.
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2.1. Study design and sample
This descriptive, cross-sectional study was carried out at a university hospital in Eastern Thrace, Turkey. The research population consisted of a total of 153 nurses working in
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surgical units, nine surgical wards, three intensive care units and the operating room. The sample consisted of 101 nurses (66.01%) who volunteered to participate in this study and who were actively working in the units. No participants were pregnant or ill during the study’s data collection.
2.2. Data collection Data were collected from March 31 to May 16, 2016 using two instruments: the ‘Nurse Information Form’ and the ‘Attitude Towards Pressure Ulcer Prevention Instrument’. Nurses were informed about the study and were given approximately 15 minutes to complete the individual data collection forms.
ACCEPTED MANUSCRIPT 2.2.1. Nurse Information Form This form consisted of nine questions used to collect data on the characteristics of the nurses (six items). The questions gathered data regarding gender, education level, specific work unit, age, previous education about pressure injury care and duration of clinical
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experience. 2.2.2. Attitude towards Pressure ulcer Prevention (APuP) instrument
This instrument was developed by Beeckman et al. [30] at Ghent University, Belgium. The validity and reliability of the instrument for the Turkish population was conducted by
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Üstün [31] at Ege University, Turkey, and it was found adequate to use with Cronbach’s alpha of 0.714. This instrument is a four-point Likert-type scale rated as follows: (1) strongly
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disagree, (2) disagree, (3) agree and (4) strongly agree. It consists of 13 items collected for five factors: attitude towards personal competency to prevent pressure ulcers (items 1-3), attitude towards the priority of pressure ulcer prevention (items 4-6), attitude towards the impact of pressure ulcers (items 7-9), attitude towards personal responsibility in pressure ulcer prevention (items 10-11) and attitude towards confidence in the effectiveness of prevention (items 12-13). Items 3, 5, 7-10 and 13 contain negative expressions and are reversely
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calculated in the scoring. The minimum score is 13 and the maximum score is 52. The higher scale scores show more positive attitudes [30,31]. Cronbach’s alpha was found to be 0.799 for this study.
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2.3. Data analysis
Descriptive statistics (mean, standard deviation, frequency, and numbers with
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percentages), the Mann-Whitney U test, independent samples t-test, Pearson’s chi-squared and correlation tests were used to analyse the data. The one way analysis of variance (ANOVA) test was used for the normally distributed data of the three groups. Non-parametric tests were used for the not normally distributed data, and p < 0.05 was considered significant. The IBM SPSS Statistics ver. 21.0 (IBM, Armonk, NY, USA) software package was used for coding and analysing the data. 2.4. Ethical consideration Permission to use the Turkish version of the instrument in this study was obtained via mail. The study was approved by the Ethics Committee of the Trakya University Medical
ACCEPTED MANUSCRIPT Faculty (TÜTF-BAEK 2016/168-decision number 05/24), and permission to conduct the study was obtained from the directorate of the hospital. The participating nurses were thoroughly informed about this study, and their informed verbal consent was obtained to have their data published. To ensure confidentiality, they were instructed not to write their names on the forms.
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3. Results
The majority of the participants were female 91.1% (n = 92), 75.2% (n = 76) had bachelor’s degrees and 24.8% (n = 25) had a high school degree. A total of 54.5% (n = 55)
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were working in surgical wards, 29.7% (n = 30) were working in intensive care units and 15.8% (n = 16) were working in operating rooms. The mean age was 32.0 ± 6.3 years, and the
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average duration of clinical experience was 72.3 ± 61 months.
The mean total attitude score was found to be 80.5% (41.8 ± 4.8). According to the scale factors, the mean score of ‘impact of pressure ulcers’ was the highest (85.7%), and the mean score of ‘confidence in the effectiveness of prevention’ was relatively lower than other scores (53.7%) (Figure 1).
The attitude score of nurses who had previous education about pressure injury
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prevention was significantly higher than those who did not (p = 0.017; p < 0.05). The statistical analysis of the nurses’ characteristics revealed that there was no significant difference between the mean attitude score of nurses and their gender, education level and
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work units. No statistically significant correlation was found between the attitude scores and age or clinical experience duration (Table 1).
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4. Discussion
Nurses in the present study had a positive attitude towards pressure injury prevention,
and the mean attitude score was 80.5% (41.8 ± 4.8). In keeping with previous studies [19,32,33], nurses exhibited a positive attitude towards pressure injury prevention. In Ireland, Moore et al. [34] also researched nurses’ attitudes; they reported a positive attitude of nurses towards pressure injury prevention. Beeckman et al. [24] stated that only half of the nurses showed attitude scores of ≥ 75% concerning pressure injury prevention in Belgian hospitals. Similarly, another study assessed nurses’ attitudes towards pressure injury prevention in Turkey, and the mean total score was 84.1% [35]. This result showed that surgical unit nurses
ACCEPTED MANUSCRIPT have positive attitudes, and this may reflect that their benefits are also positive about pressure injury prevention. Based on the results, gaining additional education about pressure injury care has a positive effect on nurses’ attitude scores about pressure injury prevention. In Tubaishat et al.’s study [36], a statistically significant difference was found between getting more education and
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the attitude score. Beeckman et al. [24] reported that the mean attitude score of nurses was not correlated with pressure injury education, but knowledge scores were significantly increased. McCluskey and Lovarini [37] found that the impact of the targeted education intervention on behaviour was limited, but that the knowledge of individuals could be improved. A study
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conducted on intensive care unit nurses working at a Turkish state hospital also reported that 45% of the nurses who had received education about pressure injury did not use this new
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information at patient follow-up [38]. This may be related to the different teaching methods used and the content of that education. The fact that gaining additional education influences the attitude of nurses but not their knowledge requires some further investigation. Future studies may research the effectiveness of educational interventions on both the attitudes and knowledge levels of nurses.
According to the scale factors, the mean score of ‘attitude towards the impact of
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pressure ulcers’ was highest, while the mean score of ‘confidence in the effectiveness of prevention’ was relatively lower than the other factors. In a study conducted by Aslan et al. [35], nurses disagreed (81.2%) with the statement that pressure injuries do not have negative
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impacts on patients, and ‘attitude towards personal competency to prevent pressure ulcers’ had the lowest mean score. Demarre et al. [32] examined the attitudes of nurses about pressure injury prevention, and the lowest attitude scores among nurses were found in
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‘attitude towards impact of pressure ulcer’. This was in contrast to the present study findings. It appears that nurses in the present study do not have confidence in pressure injury prevention, although they have a highly positive attitude about the impact of pressure injuries. In this study, the statistical analysis of the nurses’ characteristics revealed no
significant difference between mean attitude scores and their education level. In Kallman and Suserud’s study [39], they assessed the attitudes of nursing staff towards pressure injury prevention in Sweden and did not find any statistically significant difference between the attitude scores of registered nurses and nursing assistants. Similarly, Demarre et al. [32] reported that nurses had a more positive attitude towards pressure injury prevention than
ACCEPTED MANUSCRIPT nursing assistants, but there was not any difference in the attitude score of the two groups. As formal educational is essential in the nursing profession, limited training and formal educational background concerning wound care may affect the attitude level of nurses. Additional in-service education and training courses about specific topics, such as wound care, pressure injuries, etc., may need to be added as continuing education options.
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In terms of attitude scores found with the instrument, a statistically significant difference was not determined among the work units of the nurses, but nurses working in intensive care units had a higher attitude score than the others. Similarly, according to a study conducted in Belgian hospitals, a statistically significant difference was not found between
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nurses’ attitudes on pressure injury prevention and the wards they worked in, but intensive care nurses had a slightly higher attitude score (70.8%) than surgical ward nurses (70.2%)
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[24]. In another study, Iranmanesh et al. [40] assessed the knowledge of nurses regarding pressure injuries in Iran, and they reported that critical care nurses had a higher level of knowledge than orthopaedic nurses. Chianda et al. [41] examined Brazilian nurses’ knowledge about pressure injuries in different wards and determined that nurses working in clinical nursing units had significantly better scores. As patients in long-term care and in intensive care are at risk of developing pressure injuries [14], and as expressed in a study by
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Beeckman et al. [24] that intensive care units showed the highest prevalence of pressure injury, this may contribute to the high attitude scores of nurses working in intensive care units. The results showed that the effect of individual characteristics of the nurses on attitudes
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to prevent pressure injuries was controversial.
The study had some limitations that should be considered. First, data of this study are limited to the surgical departments of one Turkish university hospital. Thus, results cannot be
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generalized to all nurses. Second, the use of a self-reported questionnaire may allow nurses to give socially and institutionally desirable answers during the attitude assessment. 5. Conclusions
As a result of this study, the total scale score shows that surgical nurses had a positive attitude towards pressure injury prevention and that gaining additional education about pressure injury care has a positive effect on nurses’ attitudes. It is recommended that effective in-service education programs be developed at hospitals or that nurses be required to attend courses to help them to improve their pressure injury care.
ACCEPTED MANUSCRIPT Conflict of interest None Funding This research did not receive any specific grant from funding agencies in the public,
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commercial, or not-for-profit sectors. References
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ACCEPTED MANUSCRIPT [22] Athlin E, Idvall E, Jernfalt M, Johansson I. Factors of importance to the development of pressure ulcers in the care trajectory: Perceptions of hospital and community care nurses. J Clin Nurs 2009;19(15-16):2252-58. http://dx.doi.org/10. 1111 /j.1365-2702.2009.02886.X. [23] Moore Z. Bridging the theory-practice gap in pressure ulcer prevention. Br J Nurs 2010;19(15):15-8. http://dx.doi.org/10.12968/bjon.2010.19.Sup5.77703.
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Sudbury: Ed. Borkowski N. Jones and Bartlett Publishers; 2005, p. 44.
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ACCEPTED MANUSCRIPT Eastern, Nigeria. Int J Nurs Midwifer 2015;7(4):54-60. http://dx.doi.org/10.5897/IJNM2014. 0155 [34] Moore Z, Price P. Nurses attitudes, behaviors and perceived barriers towards pressure ulcer prevention. J Clin Nurs 2004;13(8):942-51. http://dx.doi.org/10.1111/j.1365-2702.2004. 00972.x
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Scand J Caring Sci 2009;23(2):334-41. http://dx.doi.org/10.1111/ j.1471-6712.2008.00627.x. [40] Iranmanesh S, Tafti AA, Rafiei H, Dehghan M, Razban F. Orthopaedic nurses' knowledge about pressure ulcers in Iran: a cross-sectional study. J Wound Care 2013;22(3):138-40. http://dx.doi.org/10.12968/jowc.2013.22.3.138
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ACCEPTED MANUSCRIPT Figure 1: Total and factor scores received from the Attitude toward Pressure Ulcer Prevention Instrument.
75.4%
Personal competency to prevent pressure ulcers
83.4%
Impact of pressure ulcers
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Priority of pressure ulcer prevention
85.7%
50.8%
Confidence in the effectiveness of prevention
53.7%
Total score
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Personal responsibility in pressure ulcer prevention
80.5%
0
10
30
40
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Mean %
20
50
60
70
80
90 100
Table 1: Attitude scores of nurses according to nurses’ characteristics and taking additional education about pressure injury n (%)
Score (%)
P value-Test
92 (91.1) 9 (8.9)
80.4 81.8
P: 0.667 t: -.431
25 (24.8) 76 (75.2)
77.5 81.5
P: 0.060 t: -1.90
55 (54.5) 30 (29.7) 16 (15.8)
80.5 81.9 78.0
P: 0.386 F: 0.960
41 (40.6) 60 (59.4)
83.2 78.7
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Variables Gender Female Male Education level High school degree Bachelor’s degree Work units Surgical ward Intensive care unit Operating room Previous education Yes No Age
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P: 0.017 t: 2.428 P: 0.378 32.0±6.3 years rp: -0.089 P: 0.101 Clinical experience 72.3±61 months rs: -0.164 t: Independent t-test, F: ANOVA test; rp:Pearson correlation, rs: Spearman correlation
ACCEPTED MANUSCRIPT HIGHLIGHTS 1- Surgical nurses have a positive attitude toward pressure injury prevention. 2- Taking an additional education has a positive effect on attitude.
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3- Effective in-service education may help nurses to conduce pressure injury care.
S0965-206X(17)30004-9
DOI:
10.1016/j.jtv.2017.09.001
Reference:
JTV 251
To appear in:
Journal of Tissue Viability
Received Date: 20 January 2017 Revised Date:
11 July 2017
Accepted Date: 1 September 2017
Please cite this article as: Ünver S, Yıldız Fındık Üü, Kızılcık Özkan Z, Sürücü Çğ, Attitudes of surgical nurses towards pressure injury prevention, Journal of Tissue Viability (2017), doi: 10.1016/ j.jtv.2017.09.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT ATTITUDES OF SURGICAL NURSES TOWARDS PRESSURE INJURY PREVENTION * Seher Ünver1, Ümmü Yıldız Fındık2, Zeynep Kızılcık Özkan3, Çağla Sürücü4
Seher ÜNVER, Assistant Professor (BSN, MSc, Ph.D), Trakya University, Faculty of Health
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Sciences, Department of Surgical Nursing, Edirne, Turkey, [email protected] +90 505 500 72 17
Ümmü YILDIZ FINDIK, Associated Professor (BSN, MSc, Ph.D), Trakya University,
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Faculty of Health Sciences, Department of Surgical Nursing, Edirne, Turkey [email protected] +90 535 424 61 97
of
Health
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Zeynep KIZILCIK ÖZKAN, Research Assistant (BSN, MSc), Trakya University, Faculty Sciences,
Department
of
Surgical
Nursing,
Edirne,
Turkey
[email protected] +90 505 601 01 01
Çağla SÜRÜCÜ, Student of Bachelor degree (third class), Trakya University, Faculty of
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Health Sciences, Department of Nursing, Edirne, Turkey [email protected] +90 543 932 30 86 Corresponding author: Seher ÜNVER
Edirne/Turkey
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Trakya University, Faculty of Health Science, Department of Surgical Nursing,
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Phone Number: +90-505 500 72 17 Conflict of interest: None
E-mail: [email protected] Financial and other support: None
Acknowledgments: Special thanks to the nurses participated this study and saved their time.
* This study was presented as an oral presentation (virtually) at the 20th International Nursing Research Conference, Coruna-Spain between 15-18 November, 2016
ACCEPTED MANUSCRIPT ATTITUDES OF SURGICAL NURSES TOWARDS PRESSURE INJURY PREVENTION ABSTRACT Study aim: Nurses play the key role in prevention of pressure injuries, and negative attitudes
attitudes towards pressure injury prevention.
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of them may affect preventive care strategies. This research aimed to identify surgical nurses’
Materials and methods: A descriptive and cross-sectional study design was used to collect data between March 31-May 16, 2016 on 101 voluntary nurses (66.01% of all nurses)
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working in surgical units of a university hospital in Turkey. “Attitude towards Pressure Ulcer Prevention Instrument” and “Nurse Information Form” were used to investigate nurses’
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attitude toward preventing pressure injury. Descriptive statistics, Mann-Whitney U test, independent samples t-test, Pearson’s chi-squared, and correlation tests were used to analyse the data.
Results: The mean age of nurses’ was 32.0±6.3 years and, the average duration of clinical experience was 72.3±61 months. A total of 54.5% were working in surgical wards and, 40.6% gained additional education about pressure injury care. The mean total attitude score was
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found to be 80.5% (41.8±4.8). Gaining additional education significantly effected the total attitude score of nurses (p<0.05).
Conclusion: The total scale score showed that surgical nurses had a positive attitude towards
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pressure injury prevention and gaining additional education about pressure injury care has a positive effect on nurses’ attitude. It is recommended that effective in-service education
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programs be developed at hospitals or that nurses be required to attend courses to help them to improve their pressure injury care. Keywords: attitude; nurse; pressure injury; surgical
ACCEPTED MANUSCRIPT 1. Introduction The National Pressure Ulcer Advisory Panel (NPUAP), a professional organization dedicated to the prevention and management of pressure injuries, defines pressure injury as ‘localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device’. Formerly, ‘pressure ulcer’ was the term used for this
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type of injury, but NPUAP announced a change in the terminology from ‘pressure ulcer’ to ‘pressure injury’ on April 13, 2016 [1].
Pressure injuries are recognized as a common problem in healthcare that contribute not
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only to increased health care costs, but also to high morbidity and mortality rates, prolonged hospitalization and emotional problems in patients [2-4]. Studies showed that the prevalence of pressure injuries in hospitals ranged from 7.2% to 20.56% [5-7]. In another study that
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researched pressure injury-related pain, of the 176 patients, 75.6% reported pain [8]. Additional research which focused on surgical patients reported that there was a 54.8% incidence of pressure injuries in surgical patients [9]. In Schultz et al.’s study [10], the incidence in surgical patients was 12%-66%, and the incidence of pressure injury development during surgery was reported as 21.2% [11]. According to an analysis done in Turkey, Koç et al. [12] calculated the cost of pressure injury treatments and stated that the
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total cost ranged from $340.077 to $2.452.686 over a one year span. There are many extrinsic (shear, friction, pressure, etc.) and intrinsic factors (anaemia, oedema, immobilization, etc.) that play a role in the development of surgery-related pressure
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injuries. Some of the factors that occur during surgery are related to the duration of continued pressure, low core temperature, length of surgery, anaesthesia and circulatory changes related
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to the surgical procedure itself [4,13,14]. Prevention of pressure injuries is necessary to reduce their incidence, and guidelines
are available to help clinicians make appropriate decisions about pressure injury prevention [14,15]. A multidisciplinary approach is needed for successful pressure injury prevention, and nurses play the key role in it and have a great responsibility in the approach [16]. It is reported that with evidence-based nursing care the incidence of pressure injury can be reduced by up to 50% [17]. Thus, nurses should be aware of the risk factors associated with pressure injury development when examining at-risk patients, follow the guidelines and apply them to their clinical interventions through pressure injury prevention and treatment [14,18]. In the literature, many studies have been conducted to evaluate nurses’ knowledge and prevention
ACCEPTED MANUSCRIPT methods [19,20], and results showed their improved knowledge was not consistently linked with improved care [21-23]. In their study, Beeckman et al. [24] explored the correlation between knowledge, attitudes and the application of prevention, but found no independent correlation between knowledge and adequate prevention; however, there was a significant correlation between the application of adequate prevention and the attitudes of the nurses.
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Thus, not only knowledge, but also the nurses’ attitudes are important in pressure injury prevention.
Attitude is defined as ‘a summary evaluation of an object of thought’ [25] and includes feelings, thoughts or beliefs that lead to specific action so that attitude may influence the
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decisions or guide the behaviour of an individual [26]. Determining nurses’ attitudes towards pressure injury prevention may identify their behaviours and beliefs about pressure injury
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care. Moreover, negative attitudes towards pressure injury prevention may affect preventive care strategies [27]. It is widely accepted that clinical nurses are responsible for providing safe and evidenced-based care [28], and Grimshaw et al. [29] highlighted that negative attitudes are the principal barriers to evidence-based practice. However, there are very few studies which examine the attitudes of nurses in relation to the prevention of pressure injuries and which draw attention to this issue by publishing their results. Thus, the objective of the study
2. Material and methods
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was to identify surgical nurses’ attitudes towards pressure injury prevention.
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2.1. Study design and sample
This descriptive, cross-sectional study was carried out at a university hospital in Eastern Thrace, Turkey. The research population consisted of a total of 153 nurses working in
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surgical units, nine surgical wards, three intensive care units and the operating room. The sample consisted of 101 nurses (66.01%) who volunteered to participate in this study and who were actively working in the units. No participants were pregnant or ill during the study’s data collection.
2.2. Data collection Data were collected from March 31 to May 16, 2016 using two instruments: the ‘Nurse Information Form’ and the ‘Attitude Towards Pressure Ulcer Prevention Instrument’. Nurses were informed about the study and were given approximately 15 minutes to complete the individual data collection forms.
ACCEPTED MANUSCRIPT 2.2.1. Nurse Information Form This form consisted of nine questions used to collect data on the characteristics of the nurses (six items). The questions gathered data regarding gender, education level, specific work unit, age, previous education about pressure injury care and duration of clinical
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experience. 2.2.2. Attitude towards Pressure ulcer Prevention (APuP) instrument
This instrument was developed by Beeckman et al. [30] at Ghent University, Belgium. The validity and reliability of the instrument for the Turkish population was conducted by
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Üstün [31] at Ege University, Turkey, and it was found adequate to use with Cronbach’s alpha of 0.714. This instrument is a four-point Likert-type scale rated as follows: (1) strongly
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disagree, (2) disagree, (3) agree and (4) strongly agree. It consists of 13 items collected for five factors: attitude towards personal competency to prevent pressure ulcers (items 1-3), attitude towards the priority of pressure ulcer prevention (items 4-6), attitude towards the impact of pressure ulcers (items 7-9), attitude towards personal responsibility in pressure ulcer prevention (items 10-11) and attitude towards confidence in the effectiveness of prevention (items 12-13). Items 3, 5, 7-10 and 13 contain negative expressions and are reversely
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calculated in the scoring. The minimum score is 13 and the maximum score is 52. The higher scale scores show more positive attitudes [30,31]. Cronbach’s alpha was found to be 0.799 for this study.
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2.3. Data analysis
Descriptive statistics (mean, standard deviation, frequency, and numbers with
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percentages), the Mann-Whitney U test, independent samples t-test, Pearson’s chi-squared and correlation tests were used to analyse the data. The one way analysis of variance (ANOVA) test was used for the normally distributed data of the three groups. Non-parametric tests were used for the not normally distributed data, and p < 0.05 was considered significant. The IBM SPSS Statistics ver. 21.0 (IBM, Armonk, NY, USA) software package was used for coding and analysing the data. 2.4. Ethical consideration Permission to use the Turkish version of the instrument in this study was obtained via mail. The study was approved by the Ethics Committee of the Trakya University Medical
ACCEPTED MANUSCRIPT Faculty (TÜTF-BAEK 2016/168-decision number 05/24), and permission to conduct the study was obtained from the directorate of the hospital. The participating nurses were thoroughly informed about this study, and their informed verbal consent was obtained to have their data published. To ensure confidentiality, they were instructed not to write their names on the forms.
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3. Results
The majority of the participants were female 91.1% (n = 92), 75.2% (n = 76) had bachelor’s degrees and 24.8% (n = 25) had a high school degree. A total of 54.5% (n = 55)
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were working in surgical wards, 29.7% (n = 30) were working in intensive care units and 15.8% (n = 16) were working in operating rooms. The mean age was 32.0 ± 6.3 years, and the
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average duration of clinical experience was 72.3 ± 61 months.
The mean total attitude score was found to be 80.5% (41.8 ± 4.8). According to the scale factors, the mean score of ‘impact of pressure ulcers’ was the highest (85.7%), and the mean score of ‘confidence in the effectiveness of prevention’ was relatively lower than other scores (53.7%) (Figure 1).
The attitude score of nurses who had previous education about pressure injury
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prevention was significantly higher than those who did not (p = 0.017; p < 0.05). The statistical analysis of the nurses’ characteristics revealed that there was no significant difference between the mean attitude score of nurses and their gender, education level and
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work units. No statistically significant correlation was found between the attitude scores and age or clinical experience duration (Table 1).
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4. Discussion
Nurses in the present study had a positive attitude towards pressure injury prevention,
and the mean attitude score was 80.5% (41.8 ± 4.8). In keeping with previous studies [19,32,33], nurses exhibited a positive attitude towards pressure injury prevention. In Ireland, Moore et al. [34] also researched nurses’ attitudes; they reported a positive attitude of nurses towards pressure injury prevention. Beeckman et al. [24] stated that only half of the nurses showed attitude scores of ≥ 75% concerning pressure injury prevention in Belgian hospitals. Similarly, another study assessed nurses’ attitudes towards pressure injury prevention in Turkey, and the mean total score was 84.1% [35]. This result showed that surgical unit nurses
ACCEPTED MANUSCRIPT have positive attitudes, and this may reflect that their benefits are also positive about pressure injury prevention. Based on the results, gaining additional education about pressure injury care has a positive effect on nurses’ attitude scores about pressure injury prevention. In Tubaishat et al.’s study [36], a statistically significant difference was found between getting more education and
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the attitude score. Beeckman et al. [24] reported that the mean attitude score of nurses was not correlated with pressure injury education, but knowledge scores were significantly increased. McCluskey and Lovarini [37] found that the impact of the targeted education intervention on behaviour was limited, but that the knowledge of individuals could be improved. A study
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conducted on intensive care unit nurses working at a Turkish state hospital also reported that 45% of the nurses who had received education about pressure injury did not use this new
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information at patient follow-up [38]. This may be related to the different teaching methods used and the content of that education. The fact that gaining additional education influences the attitude of nurses but not their knowledge requires some further investigation. Future studies may research the effectiveness of educational interventions on both the attitudes and knowledge levels of nurses.
According to the scale factors, the mean score of ‘attitude towards the impact of
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pressure ulcers’ was highest, while the mean score of ‘confidence in the effectiveness of prevention’ was relatively lower than the other factors. In a study conducted by Aslan et al. [35], nurses disagreed (81.2%) with the statement that pressure injuries do not have negative
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impacts on patients, and ‘attitude towards personal competency to prevent pressure ulcers’ had the lowest mean score. Demarre et al. [32] examined the attitudes of nurses about pressure injury prevention, and the lowest attitude scores among nurses were found in
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‘attitude towards impact of pressure ulcer’. This was in contrast to the present study findings. It appears that nurses in the present study do not have confidence in pressure injury prevention, although they have a highly positive attitude about the impact of pressure injuries. In this study, the statistical analysis of the nurses’ characteristics revealed no
significant difference between mean attitude scores and their education level. In Kallman and Suserud’s study [39], they assessed the attitudes of nursing staff towards pressure injury prevention in Sweden and did not find any statistically significant difference between the attitude scores of registered nurses and nursing assistants. Similarly, Demarre et al. [32] reported that nurses had a more positive attitude towards pressure injury prevention than
ACCEPTED MANUSCRIPT nursing assistants, but there was not any difference in the attitude score of the two groups. As formal educational is essential in the nursing profession, limited training and formal educational background concerning wound care may affect the attitude level of nurses. Additional in-service education and training courses about specific topics, such as wound care, pressure injuries, etc., may need to be added as continuing education options.
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In terms of attitude scores found with the instrument, a statistically significant difference was not determined among the work units of the nurses, but nurses working in intensive care units had a higher attitude score than the others. Similarly, according to a study conducted in Belgian hospitals, a statistically significant difference was not found between
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nurses’ attitudes on pressure injury prevention and the wards they worked in, but intensive care nurses had a slightly higher attitude score (70.8%) than surgical ward nurses (70.2%)
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[24]. In another study, Iranmanesh et al. [40] assessed the knowledge of nurses regarding pressure injuries in Iran, and they reported that critical care nurses had a higher level of knowledge than orthopaedic nurses. Chianda et al. [41] examined Brazilian nurses’ knowledge about pressure injuries in different wards and determined that nurses working in clinical nursing units had significantly better scores. As patients in long-term care and in intensive care are at risk of developing pressure injuries [14], and as expressed in a study by
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Beeckman et al. [24] that intensive care units showed the highest prevalence of pressure injury, this may contribute to the high attitude scores of nurses working in intensive care units. The results showed that the effect of individual characteristics of the nurses on attitudes
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to prevent pressure injuries was controversial.
The study had some limitations that should be considered. First, data of this study are limited to the surgical departments of one Turkish university hospital. Thus, results cannot be
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generalized to all nurses. Second, the use of a self-reported questionnaire may allow nurses to give socially and institutionally desirable answers during the attitude assessment. 5. Conclusions
As a result of this study, the total scale score shows that surgical nurses had a positive attitude towards pressure injury prevention and that gaining additional education about pressure injury care has a positive effect on nurses’ attitudes. It is recommended that effective in-service education programs be developed at hospitals or that nurses be required to attend courses to help them to improve their pressure injury care.
ACCEPTED MANUSCRIPT Conflict of interest None Funding This research did not receive any specific grant from funding agencies in the public,
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commercial, or not-for-profit sectors. References
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Scand J Caring Sci 2009;23(2):334-41. http://dx.doi.org/10.1111/ j.1471-6712.2008.00627.x. [40] Iranmanesh S, Tafti AA, Rafiei H, Dehghan M, Razban F. Orthopaedic nurses' knowledge about pressure ulcers in Iran: a cross-sectional study. J Wound Care 2013;22(3):138-40. http://dx.doi.org/10.12968/jowc.2013.22.3.138
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ACCEPTED MANUSCRIPT Figure 1: Total and factor scores received from the Attitude toward Pressure Ulcer Prevention Instrument.
75.4%
Personal competency to prevent pressure ulcers
83.4%
Impact of pressure ulcers
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Priority of pressure ulcer prevention
85.7%
50.8%
Confidence in the effectiveness of prevention
53.7%
Total score
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Personal responsibility in pressure ulcer prevention
80.5%
0
10
30
40
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Mean %
20
50
60
70
80
90 100
Table 1: Attitude scores of nurses according to nurses’ characteristics and taking additional education about pressure injury n (%)
Score (%)
P value-Test
92 (91.1) 9 (8.9)
80.4 81.8
P: 0.667 t: -.431
25 (24.8) 76 (75.2)
77.5 81.5
P: 0.060 t: -1.90
55 (54.5) 30 (29.7) 16 (15.8)
80.5 81.9 78.0
P: 0.386 F: 0.960
41 (40.6) 60 (59.4)
83.2 78.7
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Variables Gender Female Male Education level High school degree Bachelor’s degree Work units Surgical ward Intensive care unit Operating room Previous education Yes No Age
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P: 0.017 t: 2.428 P: 0.378 32.0±6.3 years rp: -0.089 P: 0.101 Clinical experience 72.3±61 months rs: -0.164 t: Independent t-test, F: ANOVA test; rp:Pearson correlation, rs: Spearman correlation
ACCEPTED MANUSCRIPT HIGHLIGHTS 1- Surgical nurses have a positive attitude toward pressure injury prevention. 2- Taking an additional education has a positive effect on attitude.
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3- Effective in-service education may help nurses to conduce pressure injury care.