practice
An exploration of fourth-year undergraduate nurses’ knowledge of and attitude towards pressure ulcer prevention l Objective: To determine undergraduate nurses’ knowledge of and attitudes towards pressure ulcer prevention. l Method: A quantitative, cross-sectional survey design was used for this study. Ethical approval was received. A convenience sample of fourth-year undergraduate nurses was selected to participate (n=60). Data were collected using a pre-designed questionnaire. l Results: Overall, the participants showed a positive attitude towards pressure ulcer prevention but displayed poor knowledge of pressure ulcer prevention. Interestingly, having a high level of competency corresponded with having a positive attitude towards pressure ulcer prevention, but did not equate to possessing knowledge of pressure ulcer prevention. l Conclusion: The findings of this study suggest that fourth-year undergraduates have a positive attitude but lack adequate knowledge on the prevention of pressure ulcers. l Declaration of interest: There were no external sources of funding for this study. The authors have no conflicts of interest to declare.
undergraduate; knowledge; attitude; pressure ulcer; prevention
The authors would like to acknowledge Dimitri Beeckmann et al., University of Ghent, Belgium for permission to use his questionnaire tool 618
of this study is to explore fourth-year nursing undergraduates’ knowledge of, attitude towards and competency in pressure ulcer prevention.
Background A recent study investigating undergraduate nurses’ knowledge on pressure ulcer prevention found that students were generally not well educated in this practice, with only 56% of the questions posed answered correctly, suggesting that the participants may not have sufficient knowledge in pressure ulcer prevention.13 This may have significant consequences for the safe delivery of patient care, as knowledge of pressure ulcer risk factors or prevention strategies is a prerequisite for the planning of nursing interventions for vulnerable patients.
Nurses’ attitudes towards pressure ulcer prevention An attitude is an inclination to think positively or negatively about a person, situation, circumstance or object.16 As an attitude is not a tangible and concrete construct, it may only be understood from calculated, measurable answers of a positive or negative nature towards the object or concept of interest.16 In reviewing the literature, there are limited studies exploring the concept of nurses’ attitudes towards pressure ulcer prevention.15 Attitudes are the main impetus or motivation behind an individual’s activities and performance as they assist in decision-making and setting a level of excellence
ltd
P
ressure ulcers are often an adverse event in clinical care and, despite investment in prevention, little impact on incidence is evident.1 Pressure ulcers negatively affect the lives of patients from a physical, social, and psychological perspective.2 In addition, the financial cost of pressure ulcers is significant and is compounded by inflation and litigation costs.3 High incidence of pressure ulcers is closely linked to quality of care.4-6 Furthermore, there is a direct relationship between incidence rates and costs to the individual and society as a whole.7 Despite this, pressure ulcers are a mostly preventable occurrence,8 and research suggests that when nursing staff are well educated on pressure ulcer prevention, nursing practice in this clinical area can be significantly improved.9,10 Previous studies have tended to focus on the knowledge of pressure ulcer prevention in qualified staff nurses or health-care assistants.11,12 As student nurses will become future qualified health-care staff, it is imperative that during their four years of training they receive education and develop skills pertaining to the prevention and management of pressure ulcers.13 However, research investigating undergraduate nurses’ knowledge on pressure ulcer prevention is uncommon.14 Indeed, only one study has been performed examining nursing undergraduates’ knowledge of pressure ulcer prevention.13 Furthermore, there are limited studies exploring their attitudes towards this concept.15 Therefore, the aim
© 2013 MA Healthcare
E. Cullen Gill,1 MSc, PG H.Dip, RGN, Tissue Viability Manager; Z. Moore,2 PhD, MSc, PG Dip, RGN, Associate Professor, Acting Head of School; 1 Al Ain Hospital, Abu Dhabi, UAE; 2 RCSI School of Nursing, Royal College of Surgeons in Ireland, Dublin, Ireland. Email: emmacullengill@ gmail.com
j o u r n a l o f wo u n d c a r e v o l 2 2 , n o 1 1 , n o v e m b e r 2 0 1 3
Journal of Wound Care. Downloaded from magonlinelibrary.com by 137.189.170.231 on October 11, 2015. For personal use only. No other uses without permission. . All rights reserved.
practice
620
Questionnaire Studies investigating nurses’ knowledge of pressure ulcer prevention have traditionally used a questionnaire.23,24 Recently, there has been a questionnaire developed called the Pressure Ulcer Attitude and Knowledge tool.21,22 The first section of the questionnaire consists of basic demographic questions. The second section contains 13 questions on attitudes towards pressure ulcer prevention and is based on a four point Likert rating scale of strongly agree, agree, disagree and strongly disagree. The third section of the questionnaire contains 26 closed-ended questions on pressure ulcer prevention and is divided into six main themes.22 The questionnaire takes approximately 20 minutes to complete. The pressure ulcer attitude and knowledge questionnaire was successfully tested for validity and reliability.21,22
Population and sample The population comprised all the fourth-year undergraduate nurses (n=60) in a specific university as the ‘accessible population’. The method of non-probability convenience sampling was employed.
Results A total of 60 questionnaires were distributed to fourth-year nursing undergraduate students in January 2011 during their orientation to practice module. A return rate of 78% (n=46) was achieved.
Demographics The two categories of students found in the study were direct entry undergraduates (94%, n=43) and entry as a mature student (6%, n=3). Some 78% (n=36) of the participants were under 25 years of age and 22% (n=10) were aged 26–34 years. The last clinical placement of the respondents was at a medical ward (54%, n=25), a surgical ward (44%, n=20) and a renal ward (2%, n=1).
Method
Attitudes
The purpose of this study was to identify undergraduate nurses’ knowledge of and attitudes towards pressure ulcer prevention. Ethical approval for the study was granted by the hospital’s Ethics Medical Research Committee. A quantitative approach was employed, using a survey design to ascertain undergraduates’ attitudes towards and knowledge of pressure ulcer prevention. A pre-designed questionnaire was used to collect data.21,22 The Statistical Package for Social Sciences (SPSS) for Windows was used for
The attitude section of the questionnaire consisted of 12 questions. Five of these items were positively worded (+) and seven of the items were negatively worded (-). In the positively worded items, the score was: strongly agree=4, agree=3, disagree=2, strongly disagree=1. In the negatively worded items, these scores were reverse scored. The lowest achievable score was 12 and the highest achievable score was 48. The higher the score, the more positive the attitude. Conversely, a lower score reflects a more nega-
ltd
1 Elliot, R., McKinley, S., Fox, V. Quality improvement program to reduce the prevalence of pressure ulcers in an intensive care unit. Am J Crit Care 2008; 17: 4, 328–334. 2 Spilsbury, K., Nelson, A., Cullum, N. et al. Pressure ulcers and their treatment and effects on quality of life: hospital inpatient perspectives. J Adv Nurs 2007; 57: 5, 494–504. 3 Tingle, J. Pressure sores: counting the legal cost of neglect. Br J Nurs 1997; 6: 13, 757–758. 4 Department of Health (1993) Pressure sores; a key quality indicator. http:// webarchive. nationalarchives.gov. uk/20130107105354/http:// dh.gov.uk/health/category/ publications/ [Accessed April 3rd 2011]. 5 Gunningberg, L., Stotts, N. Tracking quality over time: what do pressure ulcer data show? Int J Qual Health Care 2008; 20: 4, 246–253. 6 Gallagher, P., Barry, P., Hartigan, I. et al. Prevalence of pressure ulcers in three university teaching hospitals in Ireland. J Tissue Viability 2008; 17, 103–109. 7 Bales, I., Padwojski, A. Reaching for the moon: achieving zero pressure ulcer prevalence. J Wound Care 2009; 18: 4, 137–144. 8 McElhinny, M.L., Hooper, C. Reducing hospital acquired heel ulcer rates in an acute care facility: an evaluation of a nurse-driven performance improvement project. J Wound Ostomy Continence Nurs 2008; 35: 1, 79–83. 9 Beitz, J., Fey, J., O’Brien, D. Perceived need for education vs actual knowledge of pressure ulcer care in hospital nursing staff. Medsurg Nurs, 1998; 7: 5, 293–301. 10 Moore, Z., Price, P. Nurses’ attitudes, behaviours and perceived barriers towards pressure ulcer prevention. J Clin Nurs 2004; 13: 8, 942–951. 11 Maylor, M., Torrance, C. Pressure sore survey. Part 2: Nurses’ knowledge. J Wound Care, 1999; 8: 2, 49–52.
statistical analysis (IBM, New York, NY, USA). Simple descriptive statistics of frequency, central tendency and dispersion were used to summarise the data. Data were further analysed to investigate relationships between attitude, knowledge, experience, age, lecture attendance and competency.
© 2013 MA Healthcare
References
that guides their actions.17 Indeed, examining an individual’s attitude can lead to an understanding of their likely activities and behaviour.18 As research has shown, if a staff nurse has a positive attitude towards pressure ulcer prevention, their practice of prevention will be more directly involved with quicker implementation of risk assessment and prevention measures.15 In a study by Moore and Price, the attitude of nursing staff was identified as being positive towards pressure ulcer prevention, with the majority of nurses (93%) reporting active involvement in pressure ulcer prevention.10 Despite these positive attitudes and active participation, the authors identified inconsistencies in the practice and documentation of pressure ulcer prevention. The study findings suggest that while nursing staff have a positive attitude towards pressure ulcer prevention, the actual practice of prevention was not made a priority. Factors including lack of time and poor staffing levels were cited as reasons, with some nursing staff prioritising other issues of health care over pressure ulcer prevention.10 Concurrent with these observations, Athlin et al. found that staff nurses viewed pressure ulcer prevention in the clinical area as less important compared to other nursing practices.19 Conversely, Samuriwo argued that nurses placed a high importance on pressure ulcer prevention.15 The author identified barriers which prevented nurses from carrying out prevention practice, such as bed transferrals and medicine rounds which were prioritised by the organisation. It is these barriers created by the organisation that appear to impact on the quality of care delivered in the clinical environment and increase pressure and frustration on nursing staff.15 As undergraduate nurses learn all the fundamentals of nursing practice during their four-year degree programme at university, it is important to explore whether they have the knowledge base and are adequately prepared for their future role as a registered nurse in preventing and managing pressure ulcers. Indeed, past research has identified a lack of wound care education within undergraduate nurse training.20 A more up-to-date study is required to determine whether this issue still remains in undergraduate nursing studies.
j o u r n a l o f wo u n d c a r e v o l 2 2 , n o 1 1 , n o v e m b e r 2 0 1 3
Journal of Wound Care. Downloaded from magonlinelibrary.com by 137.189.170.231 on October 11, 2015. For personal use only. No other uses without permission. . All rights reserved.
practice aetiology and development, classification and observation, nutrition, risk assessment, prevention in the amount of pressure and shear and duration of pressure and shear. The 26 questions were closedended. A correct answer was scored as 1 and an incorrect or ‘I do not know’ answer was scored as 0. The maximum score for this section was 26 and the minimum score was 0. The knowledge questionnaire was analysed using descriptive statistics. The maximum score obtained for the knowledge questions was 20 and the minimum score obtained was 7. The mean, median and mode score was 15.22, 15 and 16, respectively, and the standard deviation was 2.756. Some 92% of the fourth-year undergraduates scored less than 18. Overall, the knowledge scores indicate that nursing undergraduates have a poor knowledge of pressure ulcer prevention (Fig 2). The knowledge data were further analysed using the Mann–Whitney U test in relation to a number of key factors such as past experience working as a health-care assistant, previous attendance at a pressure ulcer lecture and age of the undergraduates. The results demonstrate that there is no statistical difference between knowledge of pressure ulcer prevention and past experience as a health-care assistant, previous attendance at a pressure ulcer prevention lecture and age of the undergraduates (p=0.162; p=0.445; p=0.428, respectively).
0.6 56.50%
0.4 0.3
32.50%
0.2 0.1
An exploration of fourth-year undergraduate nurses’ knowledge of and attitude towards pressure ulcer prevention l Objective: To determine undergraduate nurses’ knowledge of and attitudes towards pressure ulcer prevention. l Method: A quantitative, cross-sectional survey design was used for this study. Ethical approval was received. A convenience sample of fourth-year undergraduate nurses was selected to participate (n=60). Data were collected using a pre-designed questionnaire. l Results: Overall, the participants showed a positive attitude towards pressure ulcer prevention but displayed poor knowledge of pressure ulcer prevention. Interestingly, having a high level of competency corresponded with having a positive attitude towards pressure ulcer prevention, but did not equate to possessing knowledge of pressure ulcer prevention. l Conclusion: The findings of this study suggest that fourth-year undergraduates have a positive attitude but lack adequate knowledge on the prevention of pressure ulcers. l Declaration of interest: There were no external sources of funding for this study. The authors have no conflicts of interest to declare.
undergraduate; knowledge; attitude; pressure ulcer; prevention
The authors would like to acknowledge Dimitri Beeckmann et al., University of Ghent, Belgium for permission to use his questionnaire tool 618
of this study is to explore fourth-year nursing undergraduates’ knowledge of, attitude towards and competency in pressure ulcer prevention.
Background A recent study investigating undergraduate nurses’ knowledge on pressure ulcer prevention found that students were generally not well educated in this practice, with only 56% of the questions posed answered correctly, suggesting that the participants may not have sufficient knowledge in pressure ulcer prevention.13 This may have significant consequences for the safe delivery of patient care, as knowledge of pressure ulcer risk factors or prevention strategies is a prerequisite for the planning of nursing interventions for vulnerable patients.
Nurses’ attitudes towards pressure ulcer prevention An attitude is an inclination to think positively or negatively about a person, situation, circumstance or object.16 As an attitude is not a tangible and concrete construct, it may only be understood from calculated, measurable answers of a positive or negative nature towards the object or concept of interest.16 In reviewing the literature, there are limited studies exploring the concept of nurses’ attitudes towards pressure ulcer prevention.15 Attitudes are the main impetus or motivation behind an individual’s activities and performance as they assist in decision-making and setting a level of excellence
ltd
P
ressure ulcers are often an adverse event in clinical care and, despite investment in prevention, little impact on incidence is evident.1 Pressure ulcers negatively affect the lives of patients from a physical, social, and psychological perspective.2 In addition, the financial cost of pressure ulcers is significant and is compounded by inflation and litigation costs.3 High incidence of pressure ulcers is closely linked to quality of care.4-6 Furthermore, there is a direct relationship between incidence rates and costs to the individual and society as a whole.7 Despite this, pressure ulcers are a mostly preventable occurrence,8 and research suggests that when nursing staff are well educated on pressure ulcer prevention, nursing practice in this clinical area can be significantly improved.9,10 Previous studies have tended to focus on the knowledge of pressure ulcer prevention in qualified staff nurses or health-care assistants.11,12 As student nurses will become future qualified health-care staff, it is imperative that during their four years of training they receive education and develop skills pertaining to the prevention and management of pressure ulcers.13 However, research investigating undergraduate nurses’ knowledge on pressure ulcer prevention is uncommon.14 Indeed, only one study has been performed examining nursing undergraduates’ knowledge of pressure ulcer prevention.13 Furthermore, there are limited studies exploring their attitudes towards this concept.15 Therefore, the aim
© 2013 MA Healthcare
E. Cullen Gill,1 MSc, PG H.Dip, RGN, Tissue Viability Manager; Z. Moore,2 PhD, MSc, PG Dip, RGN, Associate Professor, Acting Head of School; 1 Al Ain Hospital, Abu Dhabi, UAE; 2 RCSI School of Nursing, Royal College of Surgeons in Ireland, Dublin, Ireland. Email: emmacullengill@ gmail.com
j o u r n a l o f wo u n d c a r e v o l 2 2 , n o 1 1 , n o v e m b e r 2 0 1 3
Journal of Wound Care. Downloaded from magonlinelibrary.com by 137.189.170.231 on October 11, 2015. For personal use only. No other uses without permission. . All rights reserved.
practice
620
Questionnaire Studies investigating nurses’ knowledge of pressure ulcer prevention have traditionally used a questionnaire.23,24 Recently, there has been a questionnaire developed called the Pressure Ulcer Attitude and Knowledge tool.21,22 The first section of the questionnaire consists of basic demographic questions. The second section contains 13 questions on attitudes towards pressure ulcer prevention and is based on a four point Likert rating scale of strongly agree, agree, disagree and strongly disagree. The third section of the questionnaire contains 26 closed-ended questions on pressure ulcer prevention and is divided into six main themes.22 The questionnaire takes approximately 20 minutes to complete. The pressure ulcer attitude and knowledge questionnaire was successfully tested for validity and reliability.21,22
Population and sample The population comprised all the fourth-year undergraduate nurses (n=60) in a specific university as the ‘accessible population’. The method of non-probability convenience sampling was employed.
Results A total of 60 questionnaires were distributed to fourth-year nursing undergraduate students in January 2011 during their orientation to practice module. A return rate of 78% (n=46) was achieved.
Demographics The two categories of students found in the study were direct entry undergraduates (94%, n=43) and entry as a mature student (6%, n=3). Some 78% (n=36) of the participants were under 25 years of age and 22% (n=10) were aged 26–34 years. The last clinical placement of the respondents was at a medical ward (54%, n=25), a surgical ward (44%, n=20) and a renal ward (2%, n=1).
Method
Attitudes
The purpose of this study was to identify undergraduate nurses’ knowledge of and attitudes towards pressure ulcer prevention. Ethical approval for the study was granted by the hospital’s Ethics Medical Research Committee. A quantitative approach was employed, using a survey design to ascertain undergraduates’ attitudes towards and knowledge of pressure ulcer prevention. A pre-designed questionnaire was used to collect data.21,22 The Statistical Package for Social Sciences (SPSS) for Windows was used for
The attitude section of the questionnaire consisted of 12 questions. Five of these items were positively worded (+) and seven of the items were negatively worded (-). In the positively worded items, the score was: strongly agree=4, agree=3, disagree=2, strongly disagree=1. In the negatively worded items, these scores were reverse scored. The lowest achievable score was 12 and the highest achievable score was 48. The higher the score, the more positive the attitude. Conversely, a lower score reflects a more nega-
ltd
1 Elliot, R., McKinley, S., Fox, V. Quality improvement program to reduce the prevalence of pressure ulcers in an intensive care unit. Am J Crit Care 2008; 17: 4, 328–334. 2 Spilsbury, K., Nelson, A., Cullum, N. et al. Pressure ulcers and their treatment and effects on quality of life: hospital inpatient perspectives. J Adv Nurs 2007; 57: 5, 494–504. 3 Tingle, J. Pressure sores: counting the legal cost of neglect. Br J Nurs 1997; 6: 13, 757–758. 4 Department of Health (1993) Pressure sores; a key quality indicator. http:// webarchive. nationalarchives.gov. uk/20130107105354/http:// dh.gov.uk/health/category/ publications/ [Accessed April 3rd 2011]. 5 Gunningberg, L., Stotts, N. Tracking quality over time: what do pressure ulcer data show? Int J Qual Health Care 2008; 20: 4, 246–253. 6 Gallagher, P., Barry, P., Hartigan, I. et al. Prevalence of pressure ulcers in three university teaching hospitals in Ireland. J Tissue Viability 2008; 17, 103–109. 7 Bales, I., Padwojski, A. Reaching for the moon: achieving zero pressure ulcer prevalence. J Wound Care 2009; 18: 4, 137–144. 8 McElhinny, M.L., Hooper, C. Reducing hospital acquired heel ulcer rates in an acute care facility: an evaluation of a nurse-driven performance improvement project. J Wound Ostomy Continence Nurs 2008; 35: 1, 79–83. 9 Beitz, J., Fey, J., O’Brien, D. Perceived need for education vs actual knowledge of pressure ulcer care in hospital nursing staff. Medsurg Nurs, 1998; 7: 5, 293–301. 10 Moore, Z., Price, P. Nurses’ attitudes, behaviours and perceived barriers towards pressure ulcer prevention. J Clin Nurs 2004; 13: 8, 942–951. 11 Maylor, M., Torrance, C. Pressure sore survey. Part 2: Nurses’ knowledge. J Wound Care, 1999; 8: 2, 49–52.
statistical analysis (IBM, New York, NY, USA). Simple descriptive statistics of frequency, central tendency and dispersion were used to summarise the data. Data were further analysed to investigate relationships between attitude, knowledge, experience, age, lecture attendance and competency.
© 2013 MA Healthcare
References
that guides their actions.17 Indeed, examining an individual’s attitude can lead to an understanding of their likely activities and behaviour.18 As research has shown, if a staff nurse has a positive attitude towards pressure ulcer prevention, their practice of prevention will be more directly involved with quicker implementation of risk assessment and prevention measures.15 In a study by Moore and Price, the attitude of nursing staff was identified as being positive towards pressure ulcer prevention, with the majority of nurses (93%) reporting active involvement in pressure ulcer prevention.10 Despite these positive attitudes and active participation, the authors identified inconsistencies in the practice and documentation of pressure ulcer prevention. The study findings suggest that while nursing staff have a positive attitude towards pressure ulcer prevention, the actual practice of prevention was not made a priority. Factors including lack of time and poor staffing levels were cited as reasons, with some nursing staff prioritising other issues of health care over pressure ulcer prevention.10 Concurrent with these observations, Athlin et al. found that staff nurses viewed pressure ulcer prevention in the clinical area as less important compared to other nursing practices.19 Conversely, Samuriwo argued that nurses placed a high importance on pressure ulcer prevention.15 The author identified barriers which prevented nurses from carrying out prevention practice, such as bed transferrals and medicine rounds which were prioritised by the organisation. It is these barriers created by the organisation that appear to impact on the quality of care delivered in the clinical environment and increase pressure and frustration on nursing staff.15 As undergraduate nurses learn all the fundamentals of nursing practice during their four-year degree programme at university, it is important to explore whether they have the knowledge base and are adequately prepared for their future role as a registered nurse in preventing and managing pressure ulcers. Indeed, past research has identified a lack of wound care education within undergraduate nurse training.20 A more up-to-date study is required to determine whether this issue still remains in undergraduate nursing studies.
j o u r n a l o f wo u n d c a r e v o l 2 2 , n o 1 1 , n o v e m b e r 2 0 1 3
Journal of Wound Care. Downloaded from magonlinelibrary.com by 137.189.170.231 on October 11, 2015. For personal use only. No other uses without permission. . All rights reserved.
practice aetiology and development, classification and observation, nutrition, risk assessment, prevention in the amount of pressure and shear and duration of pressure and shear. The 26 questions were closedended. A correct answer was scored as 1 and an incorrect or ‘I do not know’ answer was scored as 0. The maximum score for this section was 26 and the minimum score was 0. The knowledge questionnaire was analysed using descriptive statistics. The maximum score obtained for the knowledge questions was 20 and the minimum score obtained was 7. The mean, median and mode score was 15.22, 15 and 16, respectively, and the standard deviation was 2.756. Some 92% of the fourth-year undergraduates scored less than 18. Overall, the knowledge scores indicate that nursing undergraduates have a poor knowledge of pressure ulcer prevention (Fig 2). The knowledge data were further analysed using the Mann–Whitney U test in relation to a number of key factors such as past experience working as a health-care assistant, previous attendance at a pressure ulcer lecture and age of the undergraduates. The results demonstrate that there is no statistical difference between knowledge of pressure ulcer prevention and past experience as a health-care assistant, previous attendance at a pressure ulcer prevention lecture and age of the undergraduates (p=0.162; p=0.445; p=0.428, respectively).
0.6 56.50%
0.4 0.3
32.50%
0.2 0.1
