Nurses Knowledge in Presure Ulcers Management Related to the Monitoring of the Incidence and Prevalence of Pressure Ulcers: a questionnaire survey

Summary

Introduction: An effective monitoring of the incidence and prevalence of pressure ulcers necessitates a uniform data collection methodology based on nurses’ knowledge of pressure ulcers.

Aim: The aim of the study was to investigate the knowledge among general nurses in the management of pressure ulcers (prevention, identification and therapy) in connection with monitoring and recording the incidence and prevalence of pressure ulcers.

Method: Quantitative survey was done. The standardised questionnaire “Pressure Ulcer Knowledge Test – PUKT” has been used. Statistical analysis of the data was performed using the Spearman correlation coefficient and Mann-Whitney rank test at the statistical level < 0.05.

Results: General nurses (n=40) from three university hospitals in the Czech Republic involved in the project “Register of Pressure ulcers” undergoing special training, and general nurses (n = 194) not involved in the project activities. The cut-off point for PUKT questionnaire is 90% succesful rate. The overall success rate of correct answers in our sample was 75.5%. The lowest success rate of correct answers was in the category of knowledge related to nursing interventions (57.6% of correct answers). University educated nurses showed better knowledge compared to nurses with secondary education (p = 0.04). There was no significant difference in the level of knowledge between respondents with and without special training and education.

Conclusion: The data analysis showed insufficient respondents’ knowledge of pressure ulcers. The higher level of the undergraduate education the better results in the knowledge test. Nurses with special training were able to better differentiate PUs and IAD.

Keywords:

general nurses – Knowledge – pressure ulcers – Monitoring.

INTRODUCTION

The quality of the prevalence and incidence monitoring and data on the occurrence of pressure ulcers (hereinafter PUs) depends not only on the tool used for data collection, but above all on human resources. The introduction of a single dataset for monitoring the incidence and prevalence of PUs using a single dataset at the national level in clinical practice poses several challenges. The first step is the implementation of software in the digital environment of the health care establishment which must satisfy the condition of universal applicability (Pokorná et al., 2016). The dataset must also include the information relevant for further monitoring and analysis. The data record itself should be simple to understand for the personnel, but at the same time it must provide yield without placing further administrative requirements and it must be compiled in accordance with the clinical best practices based on evidence. The dataset for monitoring of PUs at the national level in the Czech Republic was validated in two pilot studies with the objective to identify shortcomings or unnecessarily monitored data. After the second pilot data collection, the dataset was finalised for use in clinical practice (Saibertová, Pokorná & Mužík, 2018; Pokorná et al., 2018).

The knowledge of personnel in charge of data collection is very important; for the monitored and studied area, in our case, it involves general nurses, who must be able to describe all the parameters of wounds as well as all related aspects of the overall patients’ health condition to choose proper interventions and care plan. For monitoring the incidence and prevalence of PUs using a single data file, continuous education of staff is necessary. It was proven in the implementation of the uniform algorithm for the monitoring of the incidence of PUs developed during the hospitalization in the hospital in Seattle (2010). It is important for the purpose of early identification of PUs and initiating effective care (Zaratkiewicz et al., 2010).

AIM

The main goal was to assess the level of knowledge of nurses on the management (prevention and treatment) interventions related to PUs using the standardised PUKT questionnaire.

METHOD

Design: The cross-sectional survey. Data collection tool: The standardised questionnaire entitled “Pressure Ulcer Knowledge Test (PUKT)” was used (Pieper & Mott, 1995). The PUKT was chosen as the most comprehensively evaluated in terms of psychometry; namely content and design validity, homogeneity, mutual reliability, test-test, and feasibility in comparison with PZ-PUKT and PUKAT (Kielo et al., 2020). The necessary modifications, for extending the collection of information in the field of new classification regarding the PUs and Incontinence Associated Dermatitis (IAD) and regarding socio-cultural conditions in the Czech Republic (questions no. 53 to 55), was done. In these two items the definition of IAD was added. The final questionnaire form contains 55 structured items in identification data of respondents (e.g. sex, age, level of education, type of workplace), PUs classification, general knowledge of PUs and IAD (e. g. classification, category, local symptomatology) and preventative measures and risk assessment of PUs. The cut-off point for PUKT questionnaire is 90% successful rate (the best results is achieved when 90% of the items are answered correctly). Statistical analysis of the data was performed using Spearman correlation coefficient and Mann-Whitney rank test at the statistical level < 0.05. The validity of the presumptions were verified using non-parametric tests, because the distributions of values in the sample of respondents were significantly skewed and do not correspond to the Gaussian curve. Spearman’s correlation coefficient is robust to outliers and generally deviations from normality and work only with the order of the observed values. The Mann-Whitney ranking test, which tests the median matches for two independent samples, was used to statistically calculate the dependence or difference of the variables. Sample and Setting: Nurses from inpatients healthcare facilities. The first group of respondents, identified as the group with a specific training programme, included general nurses, who collected and recorded data for the pilot standardised dataset for PU monitoring in hospitalised patients in the course of “The Register of Decubitus Ulcers - Integration Strategy for Monitoring and Preventive Interventions on the National Level” project activities. Over the period of four years, the respective nurses were repeatedly educated in preventative measures, differential diagnosis of PUs and with appropriate nursing interventions (e.g. positioning, proper pressure relieving tools and devices use). The second group were nurses without the special training in the PUs management.  

RESULTS

The research sample comprised a total of 234 (100%) respondents (n= 226; 96.6% women) and 8 (3.4%) men. It consisted of two groups of respondents:  with a specific training programme (n=40; 17.1%) and a group without specific training (n=194; 82.9%). The summary success rate of correct answers from the entire PUKT questionnaire in our sample was 75.5%. The best results were achieved in the field of assessment of PUs development risk, where the average of the correct answers reached 94.3%; here, we can conclude that the knowledge of nurses in the field of PUs prevention is on a good level, because the number of correct answers exceeded the threshold 90% success rate. See the overview of the correct answers in the table no. 1.

It was confirmed that education is related to the level of knowledge of respondents on preventive and nursing interventions in the field of PUs. University educated nurses demonstrated better knowledge than nurses with secondary education (p = 0.04). The length of work experience as well as type of workplace does not relate to the level of knowledge of respondents on PUs preventative measures. The highest average of the correct answers (75.5%) in all four areas of knowledge was scored by respondents working at anaesthesiology and resuscitation units. There was no statistically confirmed significant difference between the workers from other departments (p = 0.06). The group of respondents working at standard inpatient wards demonstrated an overall average score of correct answers 71.2% and from intensive care units scored 70.3%. The minimum average of correct answers was achieved by the respondents from various other units (e.g., social welfare institutions, after-care, and long-term facilities). The partial goal was to identify the difference in the knowledge level of the issue of PUs between the groups of respondents related to the specific training programme. It was assumed that the long-term educational effect on the group of nurses will be reflected in their higher level of knowledge even without their active motivation. However, no significant difference in the levels of knowledge was identified when comparing the two groups in all four knowledge categories (risk, classification of PUs, general knowledge, nursing interventions). The group of respondents without specific training achieved a slightly higher number of correct answers in the categories of PU classification and knowledge of nursing interventions. On the contrary, the group with the specific training demonstrated a slightly higher score of correct answers in the category of general knowledge on PUs and in the risk assessment of PUs development. Out of 49 knowledge items, the group of respondents with the specific training has demonstrated only slightly higher score of correct answers in 25 items, compared to the group without the specific training. But we must once more stress that the group of “non-specifically trained health care workers” were specialists in quality of care issues; thus, their knowledge should be better in comparison to “ordinary” bed side staff.

DISCUSSION

Our results showed an average of 75.5 % correct answers, which is in line with the results from international studies. The results of the survey from Cyprus from 2015 (Charalambous et al., 2019), which examined the level of knowledge among nurses (n = 102) in inpatient setting also using the standardised PUKT toolkit was almost the same. The average percentage of correct answers was 77.0% and the authors point out the insufficient knowledge, whereas the percentage of correct answers was far from the setpoint of 90%, provided by the authors of PUKT as the threshold for sufficient knowledge (Pieper & Zulkowski, 2014).

In the American study (2017), data analysis revealed a deficit of knowledge for 62 perioperative nurses from 10 hospitals, among which the total score of correct answers reached 72%. The best percentage of correct answers of 77% was achieved in the field of general knowledge about PUs (Tallier, Reineke & Asadoorian, 2017). The Iranian study (2011) identified even lower level of knowledge among nurses (n = 126) and the percentage of all correct answers was only 54.4%. The best answered category regarding the classification of PUs scored 83.3% of correct answers. When compared to the level of correct answers for the respective category of PUs classification, respondents in our study achieved the success rate of only 67.8%. The lower score among Czech nurses could be explained by the insufficient usage of the objective scale for wound assessment (Pokorná & Leaper, 2014; Saibertová & Pokorná, 2016) including EPUAP scale. Another Iranian study published in 2014 once again failed to demonstrate sufficient level of knowledge of nurses (n = 159) working at traumatology departments of two Iranian hospitals, where the total score of correct answers reached 64.6%. The cited study achieved the highest percentage of correct answers in general knowledge about PUs observed, namely 77.3% (Rafiei et al., 2014). Neither of the analyses of the above specialised studies identified sufficient knowledge of nurses on the issue of PUs using the standardised PUKT questionnaire; none of them reached the required success rate of 90% (Iranmanesh, Rafie & Foroogh, 2011; Tallier, Reineke & Asadoorian, 2017; Charalambous et al., 2019; Rafiei et al., 2014). Most of the studies involved slight modifications of the standardised PUKT questionnaire with regard to specific nursing and socio-cultural aspects of the respective country. For this reason, we can identify minor differences in the items included in the research toolkit to test the PUKT knowledge and, thus, the ability to compare the results of the knowledge testing is limited. However, individual non-modified items can be compared well. For the items above, our study has achieved the success rate higher than 90% only for 18 out of 49 items, which is less than half of the total number of items of the questionnaire toolkit. Majority of correctly answered items was from the category of the PUs risk assessment. The lowest score of correct responses in the category aimed at risk assessment was for item no. 42 “A blister on the heel is nothing to worry about.”, where the correct answer NO was provided by 82.5% respondents. In comparison with the other studies, the success rate of correct answers is relatively high, unlike in the Iranian studies, in which success rate was only 12,7% (Iranmanesh, Rafie & Foroogh, 2011) or 16.4% (Rafiei et al., 2014), respectively. This can be explained by the fact that the management at clinics in our study can be more focused on the knowledge of preventative measures or better education of respondents. We assume that there is relatively good availability of evidence-based information at the national portal dekubity. eu (2019) including instructive videos. Active approach to the use of information and motivational factors are an important determinant in the level of knowledge in the field of PUs (Kielo, Saminen & Stolt 2018). In the category of general knowledge on PUs and IAD, the least successfully answered item was no. 55 “Pressure ulcers and IAD moisture lesions differ only in the cause but not symptoms.” with only 30.8% of correct answers. Professionals in clinical practice identify the symptoms of IAD with difficulty, and they also have problems with the differential diagnosis and differentiation from PUs, which is very important for subsequent nursing interventions (Beeckman, 2016).  The lowest score of correct answers in the group of questions related to the knowledge of the new classification of PUs was in item no. 12 “A Stage 3 pressure ulcer is a partial thickness skin loss involving the epidermis and/or dermis.”, where the correct answer NO was chosen only by 20.9% respondents. These items were answered less successfully also in the above-mentioned studies (47.2% or 39.7%, respectively, of correct answers) (Iranmanesh, Rafie & Foroogh, 2011; Rafiei et al., 2014). In clinical practice, differential diagnostics, and determination of the stage of PUs is still problematic. Therefore, it requires continuous training of health care professionals to help them to identify the stage of PUs better and more accurately (Okhovati, Shariat & Esmaeili, 2019; Bredesen et al., 2016). Unified categorisation is also important for better identification of PUs and for monitoring and comparison of incidence on a global scale (National Pressure Ulcer Advisory Panel - NPUAP, 2019). The category of questions focusing on the knowledge related to nursing interventions included the highest number of items with the lowest success rate of correct answers. This was confirmed also in the items related to nursing interventions in the care of the skin in the heel area. Item no. 19 “Heel protectors relieve pressure on the heel.” had a very low score for the correct answer NO (6.8%). Very low number of correct answers was recorded also in other compared studies verifying the knowledge of PUs among nurses using the PUKT questionnaire (Rafiei et al., 2014; Stausberg & Kifer, 2009). Heel protectors are declared by the producers as aids to prevent PUs, but their main purpose is to prevent injuries to skin and subcutaneous tissue, caused by the mechanism of friction and shear forces when moving the feet in the bed (Chaudhary & Singh, 2018; Gleeson, 2016). No special mattresses or contact aids are able to remove the pressure entirely, therefore, it is necessary to ensure regular repositioning of patients and elevating the heels using positioning devices so that they do not touch the bed surface; so called “offloading” or “floating legs” (Bååth, Engström & Gunningber, 2016). The intervention care of the heel area is associated with another item, no. 20 “Donut devices/ring cushions help prevent pressure ulcers.”, also with a very low number of correct answers NO (17.1%). Donut aids have no proven clinical benefit in the prevention of PUs development and should not be used in practice in the opinion of professional organisations (NPUAP, 2019; Davies, 2014). However, international studies have also demonstrated that nurses still consider the use of ring cushions in the prevention nursing interventions as expedient (Tallier, Reineke & Asadoorian, 2017; Akese et al., 2014). The low knowledge was also related to positioning. The score of correct items achieved in item no. 17 “Persons confined to bed should be repositioned every 3 hours.” was only 17.1%. Even though the change in position of the patients belongs among the basic nursing interventions. The results of the studies have confirmed, still, that even the recommended two-hour interval in risk patients is too long and cannot prevent PUs (Sharp, Schulz Moore & McLaws, 2016).

CONCLUSION

Our results showed that the knowledge of selected sample of nurses in the Czech Republic about the PUs management is in line with the results from other international studies. We did not verify statistically significant difference between the two compared groups of Czech respondents (specially trained and without specific training in PUs prevention). Health care professionals with special training who have used a standardised dataset demonstrate better knowledge in identification of IAD and better categorised the PUs.

ETHICAL ASPECTS AND CONFLICT OF INTEREST

The authors declare no conflicts of interest. This article was written at Masaryk university as part of the project “Komplexní přístup k poruchám integrity kůže a sliznic.” number MUNI/A/1559/2020 with the support of the Specific University Research Grant, as provided by the Ministry of Education, Youth and Sports of the Czech Republic in the year 2020.

PhDr. Simona Saibertová, Ph.D.

Department of Nursing and Midwifery, Faculty of Medicine Department, Masaryk University

Saibert@med.muni.cz

Prof. PhDr. Andrea Pokorná, Ph.D.

Department of Nursing and Midwifery, Faculty of

Medicine Department, Masaryk University

apokorna@med.muni.cz