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Knowledge, attitudes and barriers towards prevention of pressure ulcers in intensive care units: A descriptive cross-sectional study
Intensive and Critical Care Nursing (2010) 26, 335—342
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ORIGINAL ARTICLE
Knowledge, attitudes and barriers towards prevention of pressure ulcers in intensive care units: A descriptive cross-sectional study Tillan Strand a,∗, Margareta Lindgren b a
Department of NeuroSurgery, Linköping University Hospital, SE-581 85 Linköping, Sweden Division of Nursing Science, Department of Medicine and Health, Faculty of Health Science, Linköping University, SE-581 83 Linköping, Sweden
b
Accepted 23 August 2010
KEYWORDS Pressure ulcers; Knowledge; Attitudes; ICU; Theory of Planned Behaviour
Summary Pressure ulcer incidence varies between 1 and 56% in intensive care and prevention is an important quest for nursing staff. Critically ill patients that develop pressure ulcers suffer from increased morbidity and mortality and also requires prolonged intensive care. Aim: The aim of this study was to investigate registered nurses’ and enrolled nurses’ (1) attitudes, (2) knowledge and (3) perceived barriers and opportunities towards pressure ulcer prevention, in an ICU setting. These are important aspects in the Theory of Planned Behaviour, a conceptual framework when trying to predict, understand and change specific behaviours. Method: The study is descriptive. Questionnaires were distributed to registered nurses and enrolled nurses in four ICUs in a Swedish hospital. Results: The mean score regarding attitude was 34 ± 4. Correct categorisation of pressure ulcers was made by 46.8% of nursing staff with enrolled nurses having significantly less correct categorisation (p = 0.019). Pressure relief (97.3%) and nutritional support (36.1%) were the most frequently reported preventive measures. Reported barriers were lack of time (57.8%) and severely ill patients (28.9%); opportunities were knowledge (38%) and access to pressure relieving equipment (35.5%). Conclusion: This study highlights areas where measures can be made to facilitate pressure ulcer prevention in intensive care units, such as raising knowledge and making pressure ulcer prevention a part of daily care. © 2010 Elsevier Ltd. All rights reserved.
Introduction
∗
Corresponding author. Tel.: +46 13 137578. E-mail address: [email protected] (T. Strand).
Pressure ulcers (PU) are common in health care (Landi et al., 2007; Lindgren et al., 2004). Treating patients with PU is connected with substantial cost. The total cost for pressure ulcers in the United Kingdom are estimated as 1.4—2.1 bil-
0964-3397/$ — see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.iccn.2010.08.006
336 lion pounds annually. Most of these are related to prolonged hospital stay and nursing time (Bennett et al., 2004). Studies show that PU extends the hospital stay by a median of 4.31 days (Graves et al., 2005). Critically ill patients are at high risk of developing PU (Elliott et al., 2008) and patients that develop PU remain significantly longer in the intensive care unit (ICU) and have significantly increased mortality (Compton et al., 2008). Nursing staff play an important part in the prevention of PU (Tweed and Tweed, 2008). A pressure ulcer is an area of localised damage to the skin and underlying tissue caused by ischaemia (European Pressure Ulcer Advisory Panel, EPUAP & National Pressure Ulcer Advisory Panel, NPUAP, 2009). Pressure ulcers develop as a result of extrinsic and intrinsic factors. Main extrinsic factors are decreased tissue perfusion due to pressure, shear or friction (Defloor et al., 2005; Elliott et al., 2008; Theaker, 2003). Intrinsic factors are related to the patient and these factors may exacerbate effects of extrinsic factors (Theaker, 2003; Thorfinn, 2006). Infectious disease such as sepsis is an important intrinsic risk factor in the ICU (Bours et al., 2001) as well as anaemia (Theaker et al., 2000), low serum albumin levels, immobilisation (Lindgren et al., 2004) and poor nutritional status (Keller et al., 2002; Lindgren et al., 2005). Vasoactive drugs are also a risk factor as they lead to decreased tissue perfusion which may lead to tissue necrosis (Elliott et al., 2008; Nijs et al., 2009; Theaker et al., 2000). Mechanical ventilation and/or oedema may also lead to decreased tissue perfusion (Pender and Frazier, 2005). Pressure ulcers are categorised from 1 to 4 (EPUAP & National Pressure Ulcer Advisory Panel, NPUAP, 2009) with category 1 being non-blanchable erythema of intact skin, category 2 partial thickness skin loss involving epidermis, dermis or both, category 3 full thickness skin loss involving damage to or necrosis of subcutaneous tissue and category 4 extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures.Prevalence of PU in the ICU varies with numbers ranging from 13.6 to 82.0% (Bours et al., 2001; Elliott et al., 2008; Keller et al., 2002; Pender and Frazier, 2005; Sterzi et al., 2003). Incidence in the ICU varies between 1 and 56% (Fife et al., 2001; Keller et al., 2002; Schuurman et al., 2009; Shahin et al., 2009; Sterzi et al., 2003; Theaker et al., 2000).Prevention of PU is important in the ICU due to high incidence and severe effects (Nijs et al., 2009) although prevention is often complicated by patient status (Keller et al., 2002). Important preventive measures are frequent repositioning (Keller et al., 2002) as well as nutritional support (Stratton et al., 2005; Lindgren, 2003; Lindgren et al., 2004). Patients admitted to the ICU should receive high-quality care including skin inspections at least once a day, pressure relief and prevention of malnutrition (Bours et al., 2001).
Theory of Planned Behaviour The Theory of Planned Behaviour (TpB) is considered to be a useful conceptual framework and methodology when trying to predict, understand and maybe change specific behaviours (Ajzen and Fishbein, 2005). In brief TpB (Fig. 1) makes a central assumption that actual behaviour is directly affected by intentions. Intention is derived from attitudes,
T. Strand, M. Lindgren
Figure 1 Theory of Planned Behaviour. Reproduced with the permission of Professor Icek Ajzen, Division of Social Psychology, University of Massachusetts. Italic letters highlight aspects of pressure ulcer prevention discussed in this study.
subjective norms and perceived behavioural control and these are results of behavioural, normative and control beliefs (Ajzen and Fishbein, 2005). These beliefs are in turn affected by background factors such as education, knowledge and experience (Ajzen, 2005). Education, knowledge and individual skills are important factors that lead to favourable intentions by affecting both behavioural beliefs and control beliefs (Ajzen and Gilbert Cote, 2008). Ajzen (2005, p. 3) defines attitudes as ‘‘. . .a disposition to respond favourably or unfavourably to an object, person, institution, or event’’. Preventing PU is an important part of intensive care nursing (Elliott et al., 2008) and there is a lack of studies aimed to provide a picture of ICU nursing staff’s knowledge about PU aetiology and prevention and attitudes towards PU prevention. The TpB can be used as a framework for understanding how these aspects affect PU prevention.
Aim The aim of this study is to investigate registered nurses’ and enrolled nurses’ (1) attitudes, (2) knowledge and (3) perceived barriers and opportunities towards pressure ulcer prevention, all in an ICU setting.
Method Setting This cross-sectional study is descriptive. Data was collected from four ICUs in a Swedish University Hospital using a questionnaire. The four ICUs were Thoracic Surgical ICU, Burn ICU, Neurosurgical ICU and General ICU. In the Thoracic Surgical ICU patients with severe pulmonary or cardiovascular morbidity are cared for and the unit has 8 beds. The Burn ICU cares for patients suffering from severe burn trauma and has 7 beds. The Neurosurgical ICU has 8 beds and care for patients after severe neurological trauma. The General ICU cares for a wide variety of severely ill patients and the unit has 8 beds.
Pressure ulcers in intensive care units
Participants Inclusion criteria were all nursing staff working part- or full time in any of the four ICUs. The nursing staff consisted of registered nurses (RN) and enrolled nurses (EN). Registered nurses have the medical and overall responsibility for patient care whereas the EN performs patient care along with an RN. At the time of the study 139 RN and 176 EN met the inclusion criteria.
337 by answer and presented in frequency tables. For example the answer providing food and drink was categorised under nutritional support. Data was also presented and described using mean and standard deviation. The comparison between independent groups, RN and EN, was made using 2 sample t-test when data was parametric and when non-parametric the chi-square test and the Mann—Whitney U-test were used. Level of significance was set at p ≤ 0.05.
Data collection
Ethical considerations
A questionnaire was used since that approach allows for a large number of respondents to be reached and also minimises the influence of the researcher on respondents’ answers, thereby allowing for a more adequate description. The questionnaire used was based on questions tested for use in a Swedish setting by Källman and Suserud (2009), which in turn were based on questions developed and validated by Moore and Price (2004) and Lewin et al. (2003). Before using the questionnaire in this study some alterations were made mainly in the wording of questions to fit an intensive care environment, hence the questionnaire was tested in a small pilot-study of 4 RN and 4 EN working in another hospital. The pilot-study revealed a high non-completion rate in open-ended questions regarding knowledge. These questions were replaced by named risk factors to which respondents should agree or disagree. For determining the attitude towards pressure ulcer prevention the summation of a five point Likert type scale, with statements ranging from strongly agree to strongly disagree, was used. Strongly agree rendered a score of five in positive statements and one in negative statements. The maximum sum was 55 and the minimum was 11. Measurement of knowledge was achieved through multiple-choice questions. The respondents were also asked to identify the EPUAP categorisation of pressure ulcers from a written description. Openended questions were used to identify perceived opportunities and barriers in pressure ulcer prevention. Each questionnaire had a letter of introduction attached in which the purpose and relevance of the study was presented as well as instructions on how to fill in and return the questionnaire. During weeks 9 and 10 in the spring of 2009, 315 questionnaires were distributed to nursing staff consisting of registered nurses (RN) and enrolled nurses (EN). Before distribution permission was obtained from the clinical managers and ward managers were informed after permission was given. The first author presented the study to nursing staff on each of the wards. During the data collection a collection box was installed for completed questionnaires or respondents could return the questionnaire using the internal postal system at the hospital. The first author regularly visited the wards during the data collection period. The respondents were informed about the start of data collection by e-mail and a reminder was also distributed by e-mail on the Monday of the second week.
Participation was completely voluntary and all questionnaires were handled confidentially and answered anonymously. Furthermore the analysis and presentation of the results were made in such a way that individuals could not be identified. The letter of introduction attached to the questionnaire clearly stated this and respondents could make an informed choice to participate. This study was performed in accordance with the Declaration of Helsinki and was also directed towards employees. Therefore the policy of the relevant institution required no further ethical permission.
Data analysis The data collected was coded and analysed using SPSS 16.0 (2007). Answers to open-ended questions were categorised
Results Background facts A total of 315 questionnaires were distributed and 146 (46%) completed forms were returned. Out of these 30 (20.5%) were from the Thoracic Surgical ICU, 37 (25.3%) from the Burn ICU, 39 (26.7%) from the Neurosurgical ICU and 40 (27.4%) from the General ICU. Out of completed forms 52.1% were answered by RN and 47.9% by EN. Overall RN had a higher response rate with 54.7% (76 of 139) versus EN 39.8% (70 of 176). Over half of the respondents worked full time (56.2%) and there were significantly fewer male respondents than female (p = 0.02). Mean age of RN was 38.8 (±7.4) and EN 43.5 (±9.7) which was a significant difference between groups (p = 0.001). Overall time following education to RN or EN was more than 15 years in 49.3% of respondents. Out of the 76 RN, 61 were educated in critical or anaesthesia care.
Attitude The lowest summation of score on the Likert type scale in this material was 25 and the highest 44 (mean 34 ± 4) and there was no significant difference in the overall score between RN and EN (p = 0.257). Answers to each statement are presented in Table 1. There were however significant differences in this section between nursing staff who had education in critical or anaesthesia care and those who did not. These significant differences are found in the statements that all patients are at risk of developing pressure ulcers (p = 0.014) with nursing staff who had further education more in agreement, and I am less interested in pressure prevention than other aspects of nursing (p = 0.009) with nursing staff who had education in critical or anaesthesia care more in disagreement.
338 Table 1
T. Strand, M. Lindgren Attitudes of registered nurses, RN and enrolled nurses, EN, towards pressure ulcer prevention.
All patients are at potential risk of developing pressure ulcers (n = 146) Pressure ulcer prevention is time consuming for me to carry out (n = 146) In my opinion patients tend not to get as many pressure ulcers nowadays (n = 145) I do not need to concern myself with pressure ulcer prevention in my practice (n = 146) Pressure ulcer treatment is a greater priority than pressure ulcer prevention (n = 145) Continuous nursing assessment of patients will give an accurate account of their pressure ulcer risk (n = 146) Most pressure ulcers can be avoided (n = 146) I am less interested in pressure ulcer prevention than other aspects of nursing (n = 146) My clinical judgment is better than any pressure ulcer risk assessment tool available to me (n = 145) In comparison with other areas of nursing care, pressure ulcer prevention is a low priority for me (n = 145) Pressure ulcer risk assessment should be regularly carried out on all patients during their stay in hospital (n = 146)
Strongly agree (%)
Agree (%)
Neither agree nor disagree (%)
Disagree (%)
Strongly disagree (%)
93 (63.7)
42 (28.8)
6 (4.1)
4 (2.7)
1 (0.7)
1 (0.7)
54 (37.0)
40 (27.4)
34 (23.3)
17 (11.6)
25 (17.2)
57 (39.3)
28 (19.3)
26 (17.9)
9 (6.2)
—
1 (0.7)
5 (3.4)
18 (12.3)
122 (83.6)
2 (1.4)
10 (6.9)
26 (17.9)
40 (27.6)
67 (46.2)
73 (50.0)
46 (31.5)
24 (16.4)
2 (1.4)
1 (0.7)
58 (39.7)
76 (52.1)
9 (6.2)
3 (2.1)
—
6 (4.1)
24 (16.4)
43 (29.5)
26 (17.8)
47 (32.2)
14 (9.7)
40 (27.6)
74 (51.0)
12 (8.3)
5 (3.4)
1 (0.7)
19 (13.1)
32 (22.1)
41 (28.3)
52 (35.9)
87 (59.6)
43 (29.5)
15 (10.3)
1 (0.7)
—
Knowledge When knowledge of risk factors was divided between RN and EN there were some significant differences (Table 2). Several respondents did not answer the questions regarding shearing forces (RN 9 and EN 19), low blood albumin levels (RN 4 and EN 18) and high albumin levels (RN 7 and EN 17). Overall, there were some missing values in all presented factors. Open-ended questions asking respondents to identify preventive measures yielded a number of reoccurring answers presented in Table 3. The alternative other consists of measures such as airing the wound and stabilising blood pressure. Two respondents did not answer this section. The international categorisation from 1 to 4 was correctly made by 46.8% of respondents. Seven respondents chose not to answer (Table 4). Significantly fewer EN could correctly identify the international categorisation (p = 0.019) as well as category 1 (p = 0.015).
Perceived barriers and opportunities Respondents were asked to list perceived opportunities as well as barriers for carrying out pressure ulcer prevention (Table 5). The most common barriers were lack of
time (57.8%) and priorities and severely ill patients (28.9%). Knowledge (38%) and access to pressure relieving equipment (35.5%) were the most commonly named factors for facilitating prevention. When asked if routines for risk assessment existed, 7.5% answered yes, 67.8% answered no and 22.6% did not know for sure.
Discussion According to TpB human action is influenced by three factors (Ajzen and Gilbert Cote, 2008). The first is the attitude towards the behaviour that originates from beliefs that a certain behaviour leads to a certain outcome such as PU prevention leading to a decline in PU formation. A majority of respondents felt that PU prevention was an important part of care, a priority in daily care and that most pressure ulcers could be avoided. This was also found by Källman and Suserud (2009). The significant differences in attitude between nursing staff with education in critical care or anaesthesia is well in line with research that show that patients in the ICU are at high risk (Elliott et al., 2008) as well as PU prevention being an important part of care in the ICU (Nijs et al., 2009). This may be an indication that a favourable attitude towards PU prevention does exist in these ICUs.
Pressure ulcers in intensive care units
339
Table 2 Registered nurses, RN and enrolled nurses, EN, degree of agreement and disagreement with the importance of named risk factors for development of pressure ulcers. Total frequency for all respondents is not presented, but showed in falling order with the most frequently reported risk factor first and so on. RN
High pressure over a bony prominence, for a long duration (n = 145) Immobility (n = 142) Underweight (n = 144) Unstable circulation (n = 145) Concurrent diseases (n = 144) Friction (n = 143) Poor nutritional status (n = 144) Poor sensory perception (n = 135) Oedema (n = 143) Shearing forces (n = 118) Medications such as inotropica and/or sedatives (n = 142) Mechanical ventilation (n = 140) Anaemia (n = 140) Dry skin (n = 140) Unstable ventilation (n = 139) Low blood albumin levels (n = 124) Analgesics (n = 133) High blood albumin levels (n = 129)
EN
p-Value
Agree (%)
Disagree (%)
Agree (%)
Disagree (%)
74 (97.4)
1 (1.3)
70 (100)
0 (0.0)
NS
75 (98.7) 74 (97.4) 74 (97.4) 73 (96.1) 74 (97.4) 75 (98.7) 70 (92.1) 74 (97.4) 66 (86.8) 65 (85.5)
1 (1.3) 1 (1.3) 2 (2.6) 2 (2.6) 2 (2.6) 1 (1.3) 4 (5.3) 1 (1.3) 1 (1.3) 9 (11.8)
65 (92.9) 68 (97.1) 67 (95.7) 68 (97.1) 64 (91.4) 60 (85.7) 54 (77.1) 66 (94.3) 47 (67.1) 60 (85.7)
1 (1.4) 1 (1.4) 2 (2.9) 1 (1.4) 3 (4.3) 8 (11.4) 7 (10.0) 2 (2.9) 4 (5.7) 8 (11.4)
NS NS NS NS NS 0.012 0.029 NS 0.016 NS
56 (73.7) 69 (90.8) 57 (75.0) 60 (78.9) 63 (82.9) 43 (56.6) 17 (22.4)
18 (23.7) 5 (6.6) 17 (22.4) 15 (19.7) 9 (11.8) 31 (40.8) 52 (68.4)
45 (64.3) 48 (68.6) 53 (75.7) 49 (70.0) 35 (50.0) 36 (51.4) 30 (32.9)
21 (30.0) 18 (25.7) 13 (18.6) 15 (21.4) 17 (24.3) 23 (32.9) 30 (42.9)
NS 0.003 NS NS <0.001 0.020 0.005
NS = non-significant.
Table 3 Preventive measures defined by all respondents (n = 144) and registered nurses, RN (n = 76) and enrolled nurses, EN (n = 68), divided.
Pressure relief Nutritional support Mobilisation Skin moisturising Skin inspection Massage Incontinence prophylaxis Risk assessment Other
Total (%)
RN (%)
EN (%)
p-Value
142 (97.3) 52 (36.1) 25 (17.1) 23 (15.8) 18 (12.3) 16 (11.0) 5 (3.4) 4 (2.8) 86 (59.7)
74 (97.4) 28 (36.8) 19 (25.0) 5 (6.6) 6 (7.9) 6 (7.9) 4 (5.3) 3 (3.9) 53 (69.7)
68 (100.0) 13 (19.1) 6 (8.8) 18 (26.5) 12 (17.6) 10 (14.7) 1 (1.5) 1 (1.5) 33 (48.5)
NS 0.019 0.011 0.001 NS NS NS NS 0.010
Multiple answers possible. NS = non-significant.
Table 4 Correct international categorisation of pressure ulcers for all respondent (n = 139) and registered nurses, RN (n = 73) and enrolled nurses, EN (n = 66), divided.
Correct categorisation Correct category 1 Correct category 2 Correct category 3 Correct category 4 NS = non-significant.
Total (%)
RN (%)
EN (%)
p-Value
65 (46.8) 75 (54.0) 78 (56.1) 109 (78.4) 120 (86.3)
41 (56.2) 48 (65.8) 48 (65.8) 61 (83.6) 62 (85)
24 (36.4) 27 (40.9) 30 (45.5) 48 (72.7) 58 (87.9)
0.019 0.015 NS NS NS
340
T. Strand, M. Lindgren
Table 5
Possibilities and barriers towards pressure ulcer prevention as perceived by nursing staff.
Barriers (n = 128a )
n (%)
Possibilities (n = 121a )
n (%)
Lack of time Priorities/severely ill patient Shortage of staff Lack of knowledge Lack of pressure relieving materials and equipment
74 (57.8) 37 (28.9) 35 (27.3) 23 (18.0) 23 (18.0)
30 (24.8) 5 (4.1) 29 (23.9) 46 (38) 43 (35.5)
Not participating in patient care Uninterested staff Patient not cooperating
7 (5.5) 6 (4.7) 5 (3.9)
Time Patient status Adequate number of staff Knowledge Access to pressure relieving materials and equipment Participating in patient care Interested staff Patient cooperation Skin inspection Routines Adequate report Risk assessment
18 (14.9) 5 (4.1) 3 (2.5) 17 (14.0) 7 (5.8) 7 (5.8) 5 (4.1)
Stressful working situation Nothing hinders No documentation Lack of continuity Do not know
9 (7.0) 7 (5.5) 3 (2.3) 2 (1.6) 2 (1.6)
Do not know
3 (2.5)
a
Multiple answers possible.
The second factor is the subjective norm which is based on the influence leaders or coworkers have on the performance of a certain behaviour such as PU prevention (Ajzen and Gilbert Cote, 2008). If there is a social pressure to perform PU prevention it is more likely that it will be performed. Since the majority of respondents reported lack of routines for risk assessment this may in turn be evidence of a weak social pressure to perform PU prevention. Perceived behavioural control is the third factor and it derives from the presence of barriers or opportunities to perform a certain behaviour (Ajzen and Gilbert Cote, 2008). Knowledge as well as aiding devices, patient status and coworkers are examples of barriers as well as opportunities. The knowledge among nursing staff in this study seemed to be good, a finding consistent with other studies (Halfens and Eggink, 1995; Maylor and Torrance, 1999a; Panagiotopoulou and Kerr, 2002; Tweed and Tweed, 2008). There were however some important significant differences among RN and EN. These findings may be associated with a difference in educational level, a trend seen in earlier studies (Maylor and Torrance, 1999a). In most cases enrolled nurses work much closer to the patient (Socialstyrelsen, 2006) which may generate negative effects like PU not being discovered since EN had significantly more difficulties identifying PU categories. Category 1 and 2 are the most common categories in the ICU with category 1 being an alarm for development of more severe PU (Schuurman et al., 2009). Studies also suggest that category 1 pressure ulcers deteriorate rapidly in the ICU (Bours et al., 2001). Respondent beliefs on what facilitates and hinders PU prevention was related to number of staff, knowledge and access to aiding devices. Lack of time and staff have earlier been reported as common barriers (Källman and Suserud, 2009; Moore and Price, 2004). Severity of patient illness was also seen as a barrier. Positioning of the patient in a 30◦ lateral position may be enough to prevent PU formation (de Laat et al., 2007) and patient status must not be routinely used as a reason for not taking preven-
tive measures.These three factors lead to the formation of intention to perform a certain behaviour (Ajzen and Gilbert Cote, 2008). In this study the aspect of attitude towards the behaviour and perceived behavioural control does indicate that PU prevention is a priority. Maylor and Torrance (1999b) conclude that greater knowledge leads to lower prevalence. However one must not forget that respondents give somewhat paradoxical answers such as PU prevention being an important part of daily care but also describe lack of time, priorities and severely ill patients as barriers. Maylor (2000) identified a feeling that PU prevention is not as important as other aspects of care and this may certainly be the case in the ICU where severe morbidity is often the reason for admission, but nevertheless respondents who have further education in critical care or anaesthesia do not report PU prevention being of lower priority than other aspects of care. In addition the subjective norm seems to be somewhat low and this may well lead to PU prevention not being performed. Earlier studies show that a low feeling of internal control actually leads to lower PU prevalence (Maylor and Torrance, 1999b). This would further stress the importance of care leaders seeing PU prevention as an important part of daily care in the ICU. This also leads to one of the study limitations namely that it did not explore who respondents identified as being responsible for preventing PU or if coworkers or managers saw PU prevention as an important part of daily care. Therefore the subjective norm of the TpB is not fully explored in this study and may be an important topic for future studies. This study did not explore the actual measures carried out, which could have further strengthened the result. The actual behaviour of PU prevention in the ICU may be of interest for further research projects. It would also be of interest to provide a clearer picture of the effects on patient haemodynamics in relation to pressure relief.
Pressure ulcers in intensive care units A study limitation is the response rate of 46% that may be due to the fact that the questionnaire was extensive as well as respondents lacking knowledge. The low response rate may also be due to a lack of interest in this area of care which can have negative effects on the PU prevalence in the ICU as well as the results of this study. If less than half of RN and EN see PU as an important part of care this may have severe implications for patient care and outcome. Respondents may also be the ones that feel they do have sufficient knowledge but since they lack knowledge in some areas this may lead to a false sense of security and preventive measures not being conducted in a correct manner. The data collected was equally distributed between wards as well as RN and EN. When analysing the material it was evident that respondents completed the questionnaire in a similar manner and, for the most part, all questions were answered. With this in mind as well as the fact that 146 questionnaires were collected and due to the even distribution of answers the result is still relevant.
Conclusion The result of this study describes the situation in four ICUs in a Swedish hospital. PU prevention seem to be viewed as an important part of care in these ICUs but on the other hand lack of time and severe morbidity is seen as barriers towards performing PU prevention. The overall knowledge among respondents seems to be acceptable which is in line with earlier studies. When applying the TpB one may assume that PU prevention is conducted in these ICUs. Nevertheless this study also highlights areas where knowledge needs to be improved such as identifying PU categories and respondents reporting important barriers such as lack of time and staff. Raising knowledge among nursing staff as well as making PU prevention a priority in daily care and providing satisfying ability, is an important organisational challenge in these ICUs.
Conflict of interest No personal or financial relations exist between the authors and organisations or respondents involved that may lead to bias.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j. iccn.2010.08.006.
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342 Nijs N, Toppets A, Defloor T, Bernaerts K, Milisen K, Van Den Berghe G. Incidence and risk factors for pressure ulcers in the intensive care unit. Journal of Clinical Nursing 2009;18(9):1258—66. Panagiotopoulou K, Kerr SM. Pressure area care: an exploration of Greek nurses’ knowledge and practice. Journal of Advanced Nursing 2002;40(3):285—96. Pender LR, Frazier SK. The relationship between dermal pressure ulcers, oxygenation and perfusion in mechanically ventilated patients. Intensive and Critical Care Nursing 2005;21(1):29—38. Schuurman J-P, Schoohoven L, Keller BPJA, van Ramshorst B. Do pressure ulcers influence length of hospital stay in surgical cardiothoracic patients? A prospective evaluation. Journal of Clinical Nursing 2009;18(17):2456—63. Shahin ESM, Dassen T, Halfens JG. Incidence, prevention and treatment of pressure ulcers in intensive care patients: a longitudinal study. International Journal of Nursing Studies 2009;46(4):413—21. Socialstyrelsen. Vård- och omsorgsassistenters kvalifikationer — grundläggande nivå (Nursing assistants qualifications— –basic level) [electronic]; 2006. Available: (accessed May 5th 2009). SPSS for Windows. Release 16.0.1. Chicago: SPSS Inc; 2007.
T. Strand, M. Lindgren Sterzi S, Selvaggi G, Romanelli A, Valente P, Bertolini C. Evaluation of prevalence and incidence of pressure ulcers and their relationship with mattresses used in a general hospital intensive care unit. European Journal of Plastic Surgery 2003;25(7-8): 401—4. Stratton RJ, Ek A-C, Engfer M, Moore Z, Rigby P, Wolfe R, et al. Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis. Ageing Research Reviews 2005;4(3):422—50. Theaker C. Pressure sore prevention in the critically ill: what you don’t know, what you should know and why it’s important. Intensive and Critical Care Nursing 2003;19(3):163—8. Theaker C, Mannan M, Ives N, Soni N. Risk factors for pressure sores in the critically ill. Anaesthesia 2000;55(3):221—4. Thorfinn, J. Studies on sitting pressure and buttocks microcirculation—–aiming at developing an alarm in the prevention of pressure ulcers in patients with spinal cord injury. Sweden: Faculty of Health Sciences, Linköping University, Dissertation 950; 2006. Tweed C, Tweed M. Intensive care nurses’ knowledge of pressure ulcers: development of an assessment tool and effect of an educational program. American Journal of Critical Care 2008;17(4):338—46.
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ORIGINAL ARTICLE
Knowledge, attitudes and barriers towards prevention of pressure ulcers in intensive care units: A descriptive cross-sectional study Tillan Strand a,∗, Margareta Lindgren b a
Department of NeuroSurgery, Linköping University Hospital, SE-581 85 Linköping, Sweden Division of Nursing Science, Department of Medicine and Health, Faculty of Health Science, Linköping University, SE-581 83 Linköping, Sweden
b
Accepted 23 August 2010
KEYWORDS Pressure ulcers; Knowledge; Attitudes; ICU; Theory of Planned Behaviour
Summary Pressure ulcer incidence varies between 1 and 56% in intensive care and prevention is an important quest for nursing staff. Critically ill patients that develop pressure ulcers suffer from increased morbidity and mortality and also requires prolonged intensive care. Aim: The aim of this study was to investigate registered nurses’ and enrolled nurses’ (1) attitudes, (2) knowledge and (3) perceived barriers and opportunities towards pressure ulcer prevention, in an ICU setting. These are important aspects in the Theory of Planned Behaviour, a conceptual framework when trying to predict, understand and change specific behaviours. Method: The study is descriptive. Questionnaires were distributed to registered nurses and enrolled nurses in four ICUs in a Swedish hospital. Results: The mean score regarding attitude was 34 ± 4. Correct categorisation of pressure ulcers was made by 46.8% of nursing staff with enrolled nurses having significantly less correct categorisation (p = 0.019). Pressure relief (97.3%) and nutritional support (36.1%) were the most frequently reported preventive measures. Reported barriers were lack of time (57.8%) and severely ill patients (28.9%); opportunities were knowledge (38%) and access to pressure relieving equipment (35.5%). Conclusion: This study highlights areas where measures can be made to facilitate pressure ulcer prevention in intensive care units, such as raising knowledge and making pressure ulcer prevention a part of daily care. © 2010 Elsevier Ltd. All rights reserved.
Introduction
∗
Corresponding author. Tel.: +46 13 137578. E-mail address: [email protected] (T. Strand).
Pressure ulcers (PU) are common in health care (Landi et al., 2007; Lindgren et al., 2004). Treating patients with PU is connected with substantial cost. The total cost for pressure ulcers in the United Kingdom are estimated as 1.4—2.1 bil-
0964-3397/$ — see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.iccn.2010.08.006
336 lion pounds annually. Most of these are related to prolonged hospital stay and nursing time (Bennett et al., 2004). Studies show that PU extends the hospital stay by a median of 4.31 days (Graves et al., 2005). Critically ill patients are at high risk of developing PU (Elliott et al., 2008) and patients that develop PU remain significantly longer in the intensive care unit (ICU) and have significantly increased mortality (Compton et al., 2008). Nursing staff play an important part in the prevention of PU (Tweed and Tweed, 2008). A pressure ulcer is an area of localised damage to the skin and underlying tissue caused by ischaemia (European Pressure Ulcer Advisory Panel, EPUAP & National Pressure Ulcer Advisory Panel, NPUAP, 2009). Pressure ulcers develop as a result of extrinsic and intrinsic factors. Main extrinsic factors are decreased tissue perfusion due to pressure, shear or friction (Defloor et al., 2005; Elliott et al., 2008; Theaker, 2003). Intrinsic factors are related to the patient and these factors may exacerbate effects of extrinsic factors (Theaker, 2003; Thorfinn, 2006). Infectious disease such as sepsis is an important intrinsic risk factor in the ICU (Bours et al., 2001) as well as anaemia (Theaker et al., 2000), low serum albumin levels, immobilisation (Lindgren et al., 2004) and poor nutritional status (Keller et al., 2002; Lindgren et al., 2005). Vasoactive drugs are also a risk factor as they lead to decreased tissue perfusion which may lead to tissue necrosis (Elliott et al., 2008; Nijs et al., 2009; Theaker et al., 2000). Mechanical ventilation and/or oedema may also lead to decreased tissue perfusion (Pender and Frazier, 2005). Pressure ulcers are categorised from 1 to 4 (EPUAP & National Pressure Ulcer Advisory Panel, NPUAP, 2009) with category 1 being non-blanchable erythema of intact skin, category 2 partial thickness skin loss involving epidermis, dermis or both, category 3 full thickness skin loss involving damage to or necrosis of subcutaneous tissue and category 4 extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures.Prevalence of PU in the ICU varies with numbers ranging from 13.6 to 82.0% (Bours et al., 2001; Elliott et al., 2008; Keller et al., 2002; Pender and Frazier, 2005; Sterzi et al., 2003). Incidence in the ICU varies between 1 and 56% (Fife et al., 2001; Keller et al., 2002; Schuurman et al., 2009; Shahin et al., 2009; Sterzi et al., 2003; Theaker et al., 2000).Prevention of PU is important in the ICU due to high incidence and severe effects (Nijs et al., 2009) although prevention is often complicated by patient status (Keller et al., 2002). Important preventive measures are frequent repositioning (Keller et al., 2002) as well as nutritional support (Stratton et al., 2005; Lindgren, 2003; Lindgren et al., 2004). Patients admitted to the ICU should receive high-quality care including skin inspections at least once a day, pressure relief and prevention of malnutrition (Bours et al., 2001).
Theory of Planned Behaviour The Theory of Planned Behaviour (TpB) is considered to be a useful conceptual framework and methodology when trying to predict, understand and maybe change specific behaviours (Ajzen and Fishbein, 2005). In brief TpB (Fig. 1) makes a central assumption that actual behaviour is directly affected by intentions. Intention is derived from attitudes,
T. Strand, M. Lindgren
Figure 1 Theory of Planned Behaviour. Reproduced with the permission of Professor Icek Ajzen, Division of Social Psychology, University of Massachusetts. Italic letters highlight aspects of pressure ulcer prevention discussed in this study.
subjective norms and perceived behavioural control and these are results of behavioural, normative and control beliefs (Ajzen and Fishbein, 2005). These beliefs are in turn affected by background factors such as education, knowledge and experience (Ajzen, 2005). Education, knowledge and individual skills are important factors that lead to favourable intentions by affecting both behavioural beliefs and control beliefs (Ajzen and Gilbert Cote, 2008). Ajzen (2005, p. 3) defines attitudes as ‘‘. . .a disposition to respond favourably or unfavourably to an object, person, institution, or event’’. Preventing PU is an important part of intensive care nursing (Elliott et al., 2008) and there is a lack of studies aimed to provide a picture of ICU nursing staff’s knowledge about PU aetiology and prevention and attitudes towards PU prevention. The TpB can be used as a framework for understanding how these aspects affect PU prevention.
Aim The aim of this study is to investigate registered nurses’ and enrolled nurses’ (1) attitudes, (2) knowledge and (3) perceived barriers and opportunities towards pressure ulcer prevention, all in an ICU setting.
Method Setting This cross-sectional study is descriptive. Data was collected from four ICUs in a Swedish University Hospital using a questionnaire. The four ICUs were Thoracic Surgical ICU, Burn ICU, Neurosurgical ICU and General ICU. In the Thoracic Surgical ICU patients with severe pulmonary or cardiovascular morbidity are cared for and the unit has 8 beds. The Burn ICU cares for patients suffering from severe burn trauma and has 7 beds. The Neurosurgical ICU has 8 beds and care for patients after severe neurological trauma. The General ICU cares for a wide variety of severely ill patients and the unit has 8 beds.
Pressure ulcers in intensive care units
Participants Inclusion criteria were all nursing staff working part- or full time in any of the four ICUs. The nursing staff consisted of registered nurses (RN) and enrolled nurses (EN). Registered nurses have the medical and overall responsibility for patient care whereas the EN performs patient care along with an RN. At the time of the study 139 RN and 176 EN met the inclusion criteria.
337 by answer and presented in frequency tables. For example the answer providing food and drink was categorised under nutritional support. Data was also presented and described using mean and standard deviation. The comparison between independent groups, RN and EN, was made using 2 sample t-test when data was parametric and when non-parametric the chi-square test and the Mann—Whitney U-test were used. Level of significance was set at p ≤ 0.05.
Data collection
Ethical considerations
A questionnaire was used since that approach allows for a large number of respondents to be reached and also minimises the influence of the researcher on respondents’ answers, thereby allowing for a more adequate description. The questionnaire used was based on questions tested for use in a Swedish setting by Källman and Suserud (2009), which in turn were based on questions developed and validated by Moore and Price (2004) and Lewin et al. (2003). Before using the questionnaire in this study some alterations were made mainly in the wording of questions to fit an intensive care environment, hence the questionnaire was tested in a small pilot-study of 4 RN and 4 EN working in another hospital. The pilot-study revealed a high non-completion rate in open-ended questions regarding knowledge. These questions were replaced by named risk factors to which respondents should agree or disagree. For determining the attitude towards pressure ulcer prevention the summation of a five point Likert type scale, with statements ranging from strongly agree to strongly disagree, was used. Strongly agree rendered a score of five in positive statements and one in negative statements. The maximum sum was 55 and the minimum was 11. Measurement of knowledge was achieved through multiple-choice questions. The respondents were also asked to identify the EPUAP categorisation of pressure ulcers from a written description. Openended questions were used to identify perceived opportunities and barriers in pressure ulcer prevention. Each questionnaire had a letter of introduction attached in which the purpose and relevance of the study was presented as well as instructions on how to fill in and return the questionnaire. During weeks 9 and 10 in the spring of 2009, 315 questionnaires were distributed to nursing staff consisting of registered nurses (RN) and enrolled nurses (EN). Before distribution permission was obtained from the clinical managers and ward managers were informed after permission was given. The first author presented the study to nursing staff on each of the wards. During the data collection a collection box was installed for completed questionnaires or respondents could return the questionnaire using the internal postal system at the hospital. The first author regularly visited the wards during the data collection period. The respondents were informed about the start of data collection by e-mail and a reminder was also distributed by e-mail on the Monday of the second week.
Participation was completely voluntary and all questionnaires were handled confidentially and answered anonymously. Furthermore the analysis and presentation of the results were made in such a way that individuals could not be identified. The letter of introduction attached to the questionnaire clearly stated this and respondents could make an informed choice to participate. This study was performed in accordance with the Declaration of Helsinki and was also directed towards employees. Therefore the policy of the relevant institution required no further ethical permission.
Data analysis The data collected was coded and analysed using SPSS 16.0 (2007). Answers to open-ended questions were categorised
Results Background facts A total of 315 questionnaires were distributed and 146 (46%) completed forms were returned. Out of these 30 (20.5%) were from the Thoracic Surgical ICU, 37 (25.3%) from the Burn ICU, 39 (26.7%) from the Neurosurgical ICU and 40 (27.4%) from the General ICU. Out of completed forms 52.1% were answered by RN and 47.9% by EN. Overall RN had a higher response rate with 54.7% (76 of 139) versus EN 39.8% (70 of 176). Over half of the respondents worked full time (56.2%) and there were significantly fewer male respondents than female (p = 0.02). Mean age of RN was 38.8 (±7.4) and EN 43.5 (±9.7) which was a significant difference between groups (p = 0.001). Overall time following education to RN or EN was more than 15 years in 49.3% of respondents. Out of the 76 RN, 61 were educated in critical or anaesthesia care.
Attitude The lowest summation of score on the Likert type scale in this material was 25 and the highest 44 (mean 34 ± 4) and there was no significant difference in the overall score between RN and EN (p = 0.257). Answers to each statement are presented in Table 1. There were however significant differences in this section between nursing staff who had education in critical or anaesthesia care and those who did not. These significant differences are found in the statements that all patients are at risk of developing pressure ulcers (p = 0.014) with nursing staff who had further education more in agreement, and I am less interested in pressure prevention than other aspects of nursing (p = 0.009) with nursing staff who had education in critical or anaesthesia care more in disagreement.
338 Table 1
T. Strand, M. Lindgren Attitudes of registered nurses, RN and enrolled nurses, EN, towards pressure ulcer prevention.
All patients are at potential risk of developing pressure ulcers (n = 146) Pressure ulcer prevention is time consuming for me to carry out (n = 146) In my opinion patients tend not to get as many pressure ulcers nowadays (n = 145) I do not need to concern myself with pressure ulcer prevention in my practice (n = 146) Pressure ulcer treatment is a greater priority than pressure ulcer prevention (n = 145) Continuous nursing assessment of patients will give an accurate account of their pressure ulcer risk (n = 146) Most pressure ulcers can be avoided (n = 146) I am less interested in pressure ulcer prevention than other aspects of nursing (n = 146) My clinical judgment is better than any pressure ulcer risk assessment tool available to me (n = 145) In comparison with other areas of nursing care, pressure ulcer prevention is a low priority for me (n = 145) Pressure ulcer risk assessment should be regularly carried out on all patients during their stay in hospital (n = 146)
Strongly agree (%)
Agree (%)
Neither agree nor disagree (%)
Disagree (%)
Strongly disagree (%)
93 (63.7)
42 (28.8)
6 (4.1)
4 (2.7)
1 (0.7)
1 (0.7)
54 (37.0)
40 (27.4)
34 (23.3)
17 (11.6)
25 (17.2)
57 (39.3)
28 (19.3)
26 (17.9)
9 (6.2)
—
1 (0.7)
5 (3.4)
18 (12.3)
122 (83.6)
2 (1.4)
10 (6.9)
26 (17.9)
40 (27.6)
67 (46.2)
73 (50.0)
46 (31.5)
24 (16.4)
2 (1.4)
1 (0.7)
58 (39.7)
76 (52.1)
9 (6.2)
3 (2.1)
—
6 (4.1)
24 (16.4)
43 (29.5)
26 (17.8)
47 (32.2)
14 (9.7)
40 (27.6)
74 (51.0)
12 (8.3)
5 (3.4)
1 (0.7)
19 (13.1)
32 (22.1)
41 (28.3)
52 (35.9)
87 (59.6)
43 (29.5)
15 (10.3)
1 (0.7)
—
Knowledge When knowledge of risk factors was divided between RN and EN there were some significant differences (Table 2). Several respondents did not answer the questions regarding shearing forces (RN 9 and EN 19), low blood albumin levels (RN 4 and EN 18) and high albumin levels (RN 7 and EN 17). Overall, there were some missing values in all presented factors. Open-ended questions asking respondents to identify preventive measures yielded a number of reoccurring answers presented in Table 3. The alternative other consists of measures such as airing the wound and stabilising blood pressure. Two respondents did not answer this section. The international categorisation from 1 to 4 was correctly made by 46.8% of respondents. Seven respondents chose not to answer (Table 4). Significantly fewer EN could correctly identify the international categorisation (p = 0.019) as well as category 1 (p = 0.015).
Perceived barriers and opportunities Respondents were asked to list perceived opportunities as well as barriers for carrying out pressure ulcer prevention (Table 5). The most common barriers were lack of
time (57.8%) and priorities and severely ill patients (28.9%). Knowledge (38%) and access to pressure relieving equipment (35.5%) were the most commonly named factors for facilitating prevention. When asked if routines for risk assessment existed, 7.5% answered yes, 67.8% answered no and 22.6% did not know for sure.
Discussion According to TpB human action is influenced by three factors (Ajzen and Gilbert Cote, 2008). The first is the attitude towards the behaviour that originates from beliefs that a certain behaviour leads to a certain outcome such as PU prevention leading to a decline in PU formation. A majority of respondents felt that PU prevention was an important part of care, a priority in daily care and that most pressure ulcers could be avoided. This was also found by Källman and Suserud (2009). The significant differences in attitude between nursing staff with education in critical care or anaesthesia is well in line with research that show that patients in the ICU are at high risk (Elliott et al., 2008) as well as PU prevention being an important part of care in the ICU (Nijs et al., 2009). This may be an indication that a favourable attitude towards PU prevention does exist in these ICUs.
Pressure ulcers in intensive care units
339
Table 2 Registered nurses, RN and enrolled nurses, EN, degree of agreement and disagreement with the importance of named risk factors for development of pressure ulcers. Total frequency for all respondents is not presented, but showed in falling order with the most frequently reported risk factor first and so on. RN
High pressure over a bony prominence, for a long duration (n = 145) Immobility (n = 142) Underweight (n = 144) Unstable circulation (n = 145) Concurrent diseases (n = 144) Friction (n = 143) Poor nutritional status (n = 144) Poor sensory perception (n = 135) Oedema (n = 143) Shearing forces (n = 118) Medications such as inotropica and/or sedatives (n = 142) Mechanical ventilation (n = 140) Anaemia (n = 140) Dry skin (n = 140) Unstable ventilation (n = 139) Low blood albumin levels (n = 124) Analgesics (n = 133) High blood albumin levels (n = 129)
EN
p-Value
Agree (%)
Disagree (%)
Agree (%)
Disagree (%)
74 (97.4)
1 (1.3)
70 (100)
0 (0.0)
NS
75 (98.7) 74 (97.4) 74 (97.4) 73 (96.1) 74 (97.4) 75 (98.7) 70 (92.1) 74 (97.4) 66 (86.8) 65 (85.5)
1 (1.3) 1 (1.3) 2 (2.6) 2 (2.6) 2 (2.6) 1 (1.3) 4 (5.3) 1 (1.3) 1 (1.3) 9 (11.8)
65 (92.9) 68 (97.1) 67 (95.7) 68 (97.1) 64 (91.4) 60 (85.7) 54 (77.1) 66 (94.3) 47 (67.1) 60 (85.7)
1 (1.4) 1 (1.4) 2 (2.9) 1 (1.4) 3 (4.3) 8 (11.4) 7 (10.0) 2 (2.9) 4 (5.7) 8 (11.4)
NS NS NS NS NS 0.012 0.029 NS 0.016 NS
56 (73.7) 69 (90.8) 57 (75.0) 60 (78.9) 63 (82.9) 43 (56.6) 17 (22.4)
18 (23.7) 5 (6.6) 17 (22.4) 15 (19.7) 9 (11.8) 31 (40.8) 52 (68.4)
45 (64.3) 48 (68.6) 53 (75.7) 49 (70.0) 35 (50.0) 36 (51.4) 30 (32.9)
21 (30.0) 18 (25.7) 13 (18.6) 15 (21.4) 17 (24.3) 23 (32.9) 30 (42.9)
NS 0.003 NS NS <0.001 0.020 0.005
NS = non-significant.
Table 3 Preventive measures defined by all respondents (n = 144) and registered nurses, RN (n = 76) and enrolled nurses, EN (n = 68), divided.
Pressure relief Nutritional support Mobilisation Skin moisturising Skin inspection Massage Incontinence prophylaxis Risk assessment Other
Total (%)
RN (%)
EN (%)
p-Value
142 (97.3) 52 (36.1) 25 (17.1) 23 (15.8) 18 (12.3) 16 (11.0) 5 (3.4) 4 (2.8) 86 (59.7)
74 (97.4) 28 (36.8) 19 (25.0) 5 (6.6) 6 (7.9) 6 (7.9) 4 (5.3) 3 (3.9) 53 (69.7)
68 (100.0) 13 (19.1) 6 (8.8) 18 (26.5) 12 (17.6) 10 (14.7) 1 (1.5) 1 (1.5) 33 (48.5)
NS 0.019 0.011 0.001 NS NS NS NS 0.010
Multiple answers possible. NS = non-significant.
Table 4 Correct international categorisation of pressure ulcers for all respondent (n = 139) and registered nurses, RN (n = 73) and enrolled nurses, EN (n = 66), divided.
Correct categorisation Correct category 1 Correct category 2 Correct category 3 Correct category 4 NS = non-significant.
Total (%)
RN (%)
EN (%)
p-Value
65 (46.8) 75 (54.0) 78 (56.1) 109 (78.4) 120 (86.3)
41 (56.2) 48 (65.8) 48 (65.8) 61 (83.6) 62 (85)
24 (36.4) 27 (40.9) 30 (45.5) 48 (72.7) 58 (87.9)
0.019 0.015 NS NS NS
340
T. Strand, M. Lindgren
Table 5
Possibilities and barriers towards pressure ulcer prevention as perceived by nursing staff.
Barriers (n = 128a )
n (%)
Possibilities (n = 121a )
n (%)
Lack of time Priorities/severely ill patient Shortage of staff Lack of knowledge Lack of pressure relieving materials and equipment
74 (57.8) 37 (28.9) 35 (27.3) 23 (18.0) 23 (18.0)
30 (24.8) 5 (4.1) 29 (23.9) 46 (38) 43 (35.5)
Not participating in patient care Uninterested staff Patient not cooperating
7 (5.5) 6 (4.7) 5 (3.9)
Time Patient status Adequate number of staff Knowledge Access to pressure relieving materials and equipment Participating in patient care Interested staff Patient cooperation Skin inspection Routines Adequate report Risk assessment
18 (14.9) 5 (4.1) 3 (2.5) 17 (14.0) 7 (5.8) 7 (5.8) 5 (4.1)
Stressful working situation Nothing hinders No documentation Lack of continuity Do not know
9 (7.0) 7 (5.5) 3 (2.3) 2 (1.6) 2 (1.6)
Do not know
3 (2.5)
a
Multiple answers possible.
The second factor is the subjective norm which is based on the influence leaders or coworkers have on the performance of a certain behaviour such as PU prevention (Ajzen and Gilbert Cote, 2008). If there is a social pressure to perform PU prevention it is more likely that it will be performed. Since the majority of respondents reported lack of routines for risk assessment this may in turn be evidence of a weak social pressure to perform PU prevention. Perceived behavioural control is the third factor and it derives from the presence of barriers or opportunities to perform a certain behaviour (Ajzen and Gilbert Cote, 2008). Knowledge as well as aiding devices, patient status and coworkers are examples of barriers as well as opportunities. The knowledge among nursing staff in this study seemed to be good, a finding consistent with other studies (Halfens and Eggink, 1995; Maylor and Torrance, 1999a; Panagiotopoulou and Kerr, 2002; Tweed and Tweed, 2008). There were however some important significant differences among RN and EN. These findings may be associated with a difference in educational level, a trend seen in earlier studies (Maylor and Torrance, 1999a). In most cases enrolled nurses work much closer to the patient (Socialstyrelsen, 2006) which may generate negative effects like PU not being discovered since EN had significantly more difficulties identifying PU categories. Category 1 and 2 are the most common categories in the ICU with category 1 being an alarm for development of more severe PU (Schuurman et al., 2009). Studies also suggest that category 1 pressure ulcers deteriorate rapidly in the ICU (Bours et al., 2001). Respondent beliefs on what facilitates and hinders PU prevention was related to number of staff, knowledge and access to aiding devices. Lack of time and staff have earlier been reported as common barriers (Källman and Suserud, 2009; Moore and Price, 2004). Severity of patient illness was also seen as a barrier. Positioning of the patient in a 30◦ lateral position may be enough to prevent PU formation (de Laat et al., 2007) and patient status must not be routinely used as a reason for not taking preven-
tive measures.These three factors lead to the formation of intention to perform a certain behaviour (Ajzen and Gilbert Cote, 2008). In this study the aspect of attitude towards the behaviour and perceived behavioural control does indicate that PU prevention is a priority. Maylor and Torrance (1999b) conclude that greater knowledge leads to lower prevalence. However one must not forget that respondents give somewhat paradoxical answers such as PU prevention being an important part of daily care but also describe lack of time, priorities and severely ill patients as barriers. Maylor (2000) identified a feeling that PU prevention is not as important as other aspects of care and this may certainly be the case in the ICU where severe morbidity is often the reason for admission, but nevertheless respondents who have further education in critical care or anaesthesia do not report PU prevention being of lower priority than other aspects of care. In addition the subjective norm seems to be somewhat low and this may well lead to PU prevention not being performed. Earlier studies show that a low feeling of internal control actually leads to lower PU prevalence (Maylor and Torrance, 1999b). This would further stress the importance of care leaders seeing PU prevention as an important part of daily care in the ICU. This also leads to one of the study limitations namely that it did not explore who respondents identified as being responsible for preventing PU or if coworkers or managers saw PU prevention as an important part of daily care. Therefore the subjective norm of the TpB is not fully explored in this study and may be an important topic for future studies. This study did not explore the actual measures carried out, which could have further strengthened the result. The actual behaviour of PU prevention in the ICU may be of interest for further research projects. It would also be of interest to provide a clearer picture of the effects on patient haemodynamics in relation to pressure relief.
Pressure ulcers in intensive care units A study limitation is the response rate of 46% that may be due to the fact that the questionnaire was extensive as well as respondents lacking knowledge. The low response rate may also be due to a lack of interest in this area of care which can have negative effects on the PU prevalence in the ICU as well as the results of this study. If less than half of RN and EN see PU as an important part of care this may have severe implications for patient care and outcome. Respondents may also be the ones that feel they do have sufficient knowledge but since they lack knowledge in some areas this may lead to a false sense of security and preventive measures not being conducted in a correct manner. The data collected was equally distributed between wards as well as RN and EN. When analysing the material it was evident that respondents completed the questionnaire in a similar manner and, for the most part, all questions were answered. With this in mind as well as the fact that 146 questionnaires were collected and due to the even distribution of answers the result is still relevant.
Conclusion The result of this study describes the situation in four ICUs in a Swedish hospital. PU prevention seem to be viewed as an important part of care in these ICUs but on the other hand lack of time and severe morbidity is seen as barriers towards performing PU prevention. The overall knowledge among respondents seems to be acceptable which is in line with earlier studies. When applying the TpB one may assume that PU prevention is conducted in these ICUs. Nevertheless this study also highlights areas where knowledge needs to be improved such as identifying PU categories and respondents reporting important barriers such as lack of time and staff. Raising knowledge among nursing staff as well as making PU prevention a priority in daily care and providing satisfying ability, is an important organisational challenge in these ICUs.
Conflict of interest No personal or financial relations exist between the authors and organisations or respondents involved that may lead to bias.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j. iccn.2010.08.006.
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