ORIGINAL
ARTICLE
Pressure injury prevention:
attitudes and knowledge of nursing students
Prevenção de lesões por pressão:
atitudes e conhecimento de estudantes de enfermagem
Prevención de lesiones por presión:
actitudes y conocimientos de estudiantes de enfermería
Fernandes, Carla Sílvia; Lima,
Andreia;
Santos, Mariana
ABSTRACT
Objective: the present study aimed to evaluate
attitudes and knowledge in the prevention of pressure injury, from a sample of
Portuguese Nursing students. Method: a quantitative, cross-sectional
study was used. The sampling technique was non-probabilistic and by convenience
with 100 students. The “Attitude Towards Pressure Injury” scale and the
“Pressure Injury Knowledge Assessment Tool” were applied through an electronic
questionnaire. Results: students have, on average, positive attitudes
towards the prevention of pressure ulcers (mean 47.8), with a minimum value of
36 and a maximum value of 62. It is noteworthy that only in the obstacles factor
are data above the mean value (10.4). Conclusions: the knowledge
assessment of nurses and Nursing students allows for the identification of
training needs and priorities, supporting the development of new strategies to
improve the quality of preventive care for pressure injury.
Descriptors: Health knowledge, attitudes, practice;
Students, nursing; Pressure ulcer
RESUMO
Objetivo: avaliar atitudes e conhecimentos na prevenção de lesões por pressão,
de uma amostra de estudantes portugueses de enfermagem. Método: estudo
quantitativo do tipo transversal. A técnica de amostragem foi não
probabilística e por conveniência com 100 alunos. A escala “Attitude Towards
Pressure Injury” e a “Pressure Injury Knowledge Assessment Tool” foram
aplicadas por meio de questionário eletrônico. Resultados: os estudantes
apresentam, em média, atitudes positivas em relação à prevenção de úlcera de
pressão (média 47,8), apresentando um valor mínimo de 36 e um valor máximo de
62. Realça-se que apenas no fator obstáculos se observam dados acima do valor
médio (10,4). Conclusões: a avaliação do conhecimento de enfermeiros e
discentes de Enfermagem permite identificar necessidades e prioridades de
formação, subsidiando o desenvolvimento de novas estratégias para melhorar a
qualidade da assistência preventiva à lesão por pressão.
Descritores: Conhecimentos, atitudes e prática em saúde, Estudantes de enfermagem;
Lesão por pressão
RESUMEN
Objetivo: evaluar actitudes y conocimientos en la prevención de lesiones por presión,
de una muestra de estudiantes portugueses de Enfermería. Método: se
utilizó un estudio cuantitativo y transversal. La técnica de muestreo fue no
probabilística y por conveniencia con 100 estudiantes. La escala “Actitud hacia
las lesiones por presión” y la “Herramienta de evaluación de conocimientos
sobre lesiones por presión” se aplicaron a través de un cuestionario
electrónico. Resultados: los estudiantes tienen, en promedio, actitudes
positivas hacia la prevención de úlceras por presión (promedio 47,8), con un
valor mínimo de 36 y un valor máximo de 62. Cabe destacar que solo en el factor
obstáculos se encuentran datos por encima del valor medio (10,4). Conclusiones:
la evaluación de conocimientos de enfermeros y estudiantes de enfermería
permite identificar necesidades y prioridades formativas, apoyando el
desarrollo de nuevas estrategias para mejorar la calidad de la atención
preventiva de la lesión por presión.
Descriptores: Conocimientos actitudes y práctica en salud; Estudiantes de enfermería,
Úlcera por presión
INTRODUCTION
Pressure injury still represent a significant problem
globally. In addition to being a huge problem in social health with
far-reaching repercussions in deteriorating the quality of life of those who suffer
from them, as well as their families, pressure injury represent a growing care
burden, with high costs to the health system.1-3 In a review study
about the incidence of pressure injury in Europe, the authors identified a high
prevalence of pressure injury (13.7%), with results ranging from 4.6% to 27.2%
in the European countries.3 To improve care quality, nursing
students should possess up-to-date knowledge and change their attitude
concerning the prevention of pressure injury.
Its incidence occurs in the most diverse care
environments,4-5 constituting an interest area for Nursing research,
such for the incidence/prevalence, such for the particularities of treatment,4
as well as in the different impacts resulting thereof, namely the person and their
family,6-8 and other caregivers.
The presence of a pressure ulcer increases the
permanence time in the hospital from four to 30 days, reducing quality of life,
and increasing pain, morbidity and mortality.9 They are considered
as adverse events that affect care safety in health institutions, with a
significant impact on the person, relatives, caregivers and health
organizations.5,9 That is why a pressure ulcer is internationally
evaluated as an adverse event and characterized as a negative indicator of care
actions.10-12
Considering the negative outcomes emerging from the
occurrence of pressure injury, prevention is highlighted as a priority measure
being enhanced at a national and global level. In addition to that, the
prevention of pressure injury is substantially more economical than wound care.9,13
Although pressure injury is related to the quality of the assistance provided,
health professionals must be motivated in a positive way so they can be
involved in the improvement of patient safety, that is, increase access to the
evidence-based guidelines.9
Indeed, the prevalence of pressure injury is an
indicator of the quality of the hospital assistance, widely accepted as a
sensible measure of nursing care.12 Nurses have an important role in
the prevention of pressure injury in health care environments.4,13
The interventions to prevent pressure injury play a central role in the early
identification of patients at risk of developing injuries, and the nurse's
knowledge about the prevention of pressure injury is crucial to evaluate and
treat the risk factors.14
It is emphasized that the need for training is still
present in the prevention of pressure injury for the Nursing team, for the
faculty, and for the Nursing students,12 assuming particular
importance in the training of nursing students.5 That need for
skills development knowledge must be acquired during training, in different
contexts in which it occurs. It is important that, during training, Nursing
students receive sufficient education and develop skills to help to prevent and
treat pressure injury.15-16 The transition from nursing students to
qualified nurses is crucial to skills development at this level, as a result of
teaching and defined in terms of functional adequacy and capacity to integrate
knowledge, skills, attitudes and values in specific situations in the clinical
practice.14
Caring for people with pressures injury requires a high
level of knowledge, for the prevention and management of care actions about
pressure injury, and it might be taught in the nurses' training.15
Inappropriate knowledge about pressure injury can have a harmful effect on the
preventive care strategies.8 A highlight that the studies show is
that the students have relatively limited knowledge on this topic.5,12,15
Nursing students have insufficient knowledge about the prevention,
classification and treatment of pressure injury, which reinforces that more
time must be devoted to wound care (mainly pressure injury) in the training of
nursing students.15
On the other hand, a number of studies show that there
is a close relation between the nurses' attitudes and knowledge as factors that
influence the prevention of pressure injury.2,5,13 The negative
attitudes in relation to the prevention of pressure injury can result in preventive
care actions below the ideal.14 Understanding someone's attitude in
relation to some question is important because it provides an indication of
what can be expected from that person in terms of behavior. Attitudes are
considered as crucially important in Nursing, because they help to comprehend
how people understand questions and processes in care and how they determine
what is important.2 Therefore, given that the prevention of pressure
injury is a multifaceted problem, attitudes can be important and can influence
behavior.2,5 In addition to that, the nurses' attitudes develop
during their academic training.2
The study was guided by the following questions What
are the Nursing students' attitudes and knowledge towards the prevention of
pressure injury? Are there any differences in the Nursing students' attitudes
and knowledge towards the prevention of pressure injury based on
sociodemographic characteristics and academic year? The present study aimed to
evaluate attitudes and knowledge in the prevention of pressure injury, from a
sample of Portuguese Nursing students.
METHOD
A cross-sectional study with a quantitative approach
was carried out. The population under study were all the students attending the
Nursing course from a school in the North of the country. The Strengthening the
Reporting of Observational Studies in Epidemiology checklist for
cross‐sectional studies was used in reporting this study. The sample was
non-probabilistic and for convenience, in which 100 students participated
voluntarily. The following inclusion criteria for the sample were defined: age
over or equal to 18 years old and currently attending the degree course in
Nursing. Compliance with ethical-legal procedures involved an institutional
authorization and, before the beginning of the study, such institutional
authorization was obtained, and it was positive from the ethical commission
(No. 062019). Data confidentiality and anonymity were guaranteed, with the
respective coding of all the data obtained. All of the participants accepted to
participate in the study voluntarily through validation of the informed
consent.
All of the data collection instruments were organized
and forwarded through Google® forms, concomitantly with the virtual Informed
Consent Form, composed by an elicitation page about the research, as well as
the authorization order requested for data use. The request for the Nursing
students to participate in the study was sent through institutional electronic
mail. The application of the inquiries throughout the questionnaire was
conducted during the last quarter of 2019.
The data collection instrument was a questionnaire with
sociodemographic data, including the following: gender, age, academic year and
clinical teachings conducted. To assess the attitude about the prevention of
pressure injury, the “Attitude Towards Pressure Injury (APU)” scale was
used; and, to assess the knowledge about the prevention of pressure injury
prevention, the “Pressure Injury Knowledge Assessment Tool (PUKAT)”
instrument was employed.
APU is an instrument validated for the Portuguese
population,17 adapted from other study,18 composed by 22
items that are organized in 5 factors (importance, responsibility,
obstacles/barriers, confidence in effectiveness and personal competences). The
items are assessed by means of a Likert-type scale – allowing to position in a
continuum of attitude variation: 1) strongly agree; 2) agree; 3) disagree; 4) strongly
disagree. The lower attitude scores are assigned to more positive attitudes
from the respondents. In order to carry out the statistical analysis of the
items formulated in a negative manner, reverse scores were attributed to them,
according to authors.17
PUKAT is a questionnaire with
29 multiple-choice questions, which are intended to assess knowledge on
the prevention of pressure injury. The items were originally elaborated based
on the scientific evidence in the literature,18 and adapted to the
Portuguese version.17,19 It seeks to encompass the most important
aspects about this topic, focusing on six major themes: 1) etiology and
development of pressures; 2) classification and observation; 3) nutrition; 4) risk
assessment; 5) reduction in the amount of pressure; 6) reduction in the
duration of pressure. The number of multiple-choice answers is based on the
relevance of each question, with only one correct answer.
Data analyses were carried out using Statistical
Package for the Social Sciences®, version 25. Descriptive statistics were used
to describe the sample characteristics, and the percentages for the students'
answers were calculated. Non-parametric tests were conducted to assess the
differences between subgroups. The Wilcoxon-Mann-Whitney's U test was used
to compare agreement with statements between the two groups, and the Kruskal-Wallis
test was employed for examining the differences in more than two groups. A
p-value of 0.05 was considered appropriate.
RESULTS
The sample consisted of 100 students; in Table 1 there
is a summary of the data obtained from the participant's characterization.
Regarding gender, females predominate in the sample of students, with a mean of
69.0% (n=69). Regarding age, we can verify that most of the students are
between 22 and 25 years old, 48.0% (n=48). Regarding the academic year,
the majority, 36.0% (n=36) is in third year, followed by 33.0% (n=33)
attending second year, 30.0% (n=30) is in fourth year, and 1.0% (n=1)
is in first year. The majority refers having training about pressure
injury (95.0%, n=95), mostly obtained in theoretical class contexts (86.0%,
n=86). However, the contributions of training are mostly referred to as arising
from practical classes (51.0%, n=51).
Table 1:
Description of the participants, Porto, Portugal, 2019
|
Variables
|
N
|
%
|
|
Gender
(N=100)
Male
Female
|
31
69
|
31.0
69.0
|
|
Age
– Years old (N=100)
18-21
22-25
26-29
≥30
|
29
48
19
4
|
29.0
48.0
19.0
4.0
|
|
Academic
year (N=100)
1st year
2nd year
3rd year
4th year
|
1
33
36
30
|
1.0
33.0
36.0
30.0
|
|
Number
of Clinical Teachings Conducted (N=100)
1 Clinical Teaching Conducted
2 Clinical Teachings Conducted
3 Clinical Teachings Conducted
4 Clinical Teachings Conducted
5 Clinical Teaching Conducted
6 Clinical Teachings Conducted
≥7 Clinical Teachings Conducted
|
0
33
0
1
1
19
46
|
0.0
33.0
0.0
1.0
1.0
19.0
46.0
|
|
Training
on Pressure Injury (N=100)
Yes
No
|
95
5
|
95.0
5.0
|
|
Training
Duration in hours (N=100)
1 Hour
2 Hours
3 Hours
4 Hours
|
4
72
19
5
|
4.0
72.0
19.0
5.0
|
|
Training
Context (N=100)
Theoretical Classes
Practical Classes
Clinical Teachings
Other Contexts
|
86
10
2
2
|
86.0
10.0
2.0
2.0
|
|
Contributions
of Training to Knowledge (N=100)
Theoretical Classes
Practical Classes
Clinical Teachings
Other Contexts
|
41
51
6
2
|
41.0
51.0
6.0
2.0
|
Source:
survey data, 2019.
With regard to inferential statistics, in Table 4, the
relation between the variables and the global score APU scale is verified.
There are significant differences between gender (p=0.001) and more
positive attitudes in the male participants. Statistically significant
differences were found regarding the academic year (p=0.001), but this result
is related to the value of the first year in which there is only one
participant.
Table 4:
Association of the data from the APU SCALE17 – Global score with
variables, Porto, Portugal, 2019
|
APU
Total
|
N
|
Mean
|
Test
Statistics
|
p
|
|
Gender
(N=100)
Male
Female
|
69
31
|
49.5
46.9
|
609.000
|
.001
|
|
Age
– Years old (N=100)
18-21
22-25
26-29
≥30
|
29
48
19
4
|
49.07
47.77
46.42
44.5
|
9.252
|
.002
|
|
Academic
year (N=100)
1st year
2nd year
3rd year
4th year
|
1
33
36
30
|
39.0
49.97
47.33
46.13
|
16.9
|
.001
|
|
Number
of Clinical Teachings Conducted (N=100)
1 Clinical Teaching Conducted
2 Clinical Teachings Conducted
3 Clinical Teachings Conducted
4 Clinical Teachings Conducted
5 Clinical Teachings Conducted
6 Clinical Teachings Conducted
≥7 Clinical Teachings Conducted
|
0
33
0
1
1
19
46
|
0
49.97
0
39.00
49.00
47.11
46.61
|
15.9
|
.003
|
|
Training
on Pressure Injury (N=100)
Yes
No
|
95
5
|
47.84
46.20
|
236.000
|
.981
|
|
Training
Duration in hours (N=100)
1 Hour
2 Hours
3 Hours
4 Hours
|
4
72
19
5
|
45.50
47.90
48.58
44.40
|
3.787
|
.285
|
|
Training
Context (N=100)
Theoretical Classes
Practical Classes
Clinical Teachings
Other Contexts
|
86
10
2
2
|
47.93
47.70
43.50
45.00
|
1.874
|
.599
|
|
Contributions
of Training to Knowledge (N=100)
Theoretical Classes
Practical Classes
Clinical Teachings
Other Contexts
|
41
51
6
1
|
49.29
46.78
44.50
52.0
|
14.082
|
.003
|
|
Number
of Correct Answers (N=100)
9
10
11
12
14
15
16
17
22
23
24
25
26
27
28
29
|
2
1
3
2
6
1
4
4
7
1
4
6
6
15
14
24
|
45.5
52.0
49.0
49.0
42.67
53.00
49.75
51.25
50.29
50.00
48.50
51.33
49.33
47.73
46.71
46.04
|
-0.309
|
.002
|
Source: survey data, 2019.
In addition, the number of clinical teachings conducted
(p=0.003) reflects statistically significant differences. Statistically
significant differences were found regarding the contributions of training to
knowledge (p=0.003). On the other hand, it was possible to identify an
association between knowledge and attitudes, by the number of correct answers
and the global values from the APU scale (p=0.002).
DISCUSSION
The assessment of knowledge and attitudes contributes
to the understanding of the educational needs and priorities, and can help in
the development of specific interventions from the organization of the
curricular plans.5,18,20
The presence of pressure injury has been of extreme
concern because it represents a public health problem, leading to physical and
emotional disorders and influencing morbidity and mortality,21 and
could be prevented in 95% of the cases.22 Their prevention is
fundamental, because the future nurses' knowledge and attitudes can influence
this prevention. It is emphasized that the main responsibility for prevention
lies on the nurse, which evidences the utmost importance of the future
professionals' training.
With regard to the assessment of knowledge on the
prevention of pressure injury by means of the PUKAT instrument, different high
values than the ones obtained by other authors are observed.5,8,14,16,23
As can be seen in Table 2, the values are high, having the lowest point
obtained in the mean of the Etiology and Development factor, with 78%. In
average, the Nursing students obtained 23.8 correct answers from the 29 that
make up the questionnaire. Using the same instrument, this author obtained a
mean of 14.1 in 155 students.17
A systematic review study in different countries with
meta-analysis shows that Nursing students, among others, do not have sufficient
knowledge about the prevention of pressure injury, which, in other words,
evidences that limited knowledge cannot be influenced by demographic regions.8
Similar results were obtained in Belgium, using the same scale, in a sample of
296 Nursing students, in which the authors refer that Nursing students have
lesser knowledge than professionals.5,18 In another study conducted
with 133 Nursing students in Iran, with the use of the same assessment
instrument, the authors also identify insufficient knowledge about pressure
ulcer prevention, classification and treatment.15 Another study
carried out in Sweden mentions that the data show that knowledge was
inacceptable and borderline for nurses, assistants and nursing students.12
In a study conducted in Turkey with 753 students, the authors obtained a mean
knowledge score of 9.95 in the PUKAT questionnaire with 26 items, while
only 2.1% of them had a mean knowledge score ≥60% (acceptable knowledge level).13
These results differ from the ones that we obtained in our study, in which only
23% did not have a mean knowledge score ≥60%.
In a systematic review study with meta-analysis, the
authors refer that the nurses' knowledge was higher than that of the Nursing
students, even so, both below the recommended level, in which the lowest scores
were obtained in the items referring to the reduction of pressure intensity and
torsional forces.8 However, in another study carried out in Turkey,
with the objective of assessing the impact of a simulation standardized program
on 18 Nursing students about the prevention of pressure injury, despite
resorting to a different assessment instrument, the authors obtained a
knowledge increase at the moment of training and up to 3 months after its
conduction, evidencing the importance of other pedagogical strategies to
competence development.16
With regard to attitudes, through the application of
the APU scale, and from the data observed in Table 3, positive attitudes
in relation to the prevention of pressure injury stand out in the students,
except when analyzed in the Obstacles factor dimension, referring to barriers
to prevention, in which the students show, in average, less positive attitudes.
In a Portuguese study conducted with nurses and Nursing students, positive
attitudes from the respondents with regard to the prevention of pressure injury
stand out, with greater focus on the importance of a more efficient prevention.19
In a study with 742 students, the authors refer that, despite the lower
knowledge level of the students, more than two thirds of the respondents showed
high attitude scores (75% or more), which suggests better predisposition to
answer favorably to the prevention of pressure injury.14 Despite
using a different instrument, in a study conducted with 855 Nursing
students in Italy, these authors also mentioned that 73.7% of the respondents
obtained a mean attitude score higher than or equal to 75%, revealing positive
attitudes towards the prevention of pressure injury.14 That aspect
is corroborated in this review study about the theme in which, although
referring to nurses, the authors suggest that, in general, nurses are
positively willing to prevent pressure injury. However, it is important to
highlight those nurses have difficulties in translating that positive attitude
into real strategies for the prevention of pressure injury.2
On the other hand, Table 4 presents statistically
significant relations between the mean APU total score and some variables,
namely: gender, academic year, number of clinical teachings, and contribution
of training to knowledge. The results from the relationship between the number
of clinical practice days and the academic year are reported in other studies.5,13
In fact, these authors also report having observed that the academic year of
the Nursing students, the training experience, and the number of clinical days
attended during the clinical teaching were significantly related to the
attitude total score.14
With regard to the contributions of training to
knowledge, the mean scores put clinical teaching first, followed by practical
classes, and theoretical classes in the last place.16 These data
evidence the importance of the simulated practice in a classroom context or
clinical environment as a way to enhance skills development.16 The
in-person opportunities for the students to improve their attitudes and
knowledge about the prevention of pressure injury included theoretical
teaching, practical and laboratory simulation, in addition to clinical
practice.12,24-26 More details should be covered in the classroom
and laboratories through simulation or clinical practice for improved
management of pressure injuries.27 Currently, with the technological
development, apart from the traditional educational methods, there are
preferable innovative instructional methods for the development of cognitive,
affective and psychomotor skills.16 In many contexts, the teaching
model of pressure ulcers is still based on traditional lecturing, making it
challenging for students to find the connections between knowledge and skills
and learning and practice.28 Certain revisions are needed in the nursing
curriculum to improve attitudes of nursing students toward the prevention and
care of pressure injuries.27 As the attitudes in relation to the
prevention of pressure injury are created during nursing education, it is
important that they are included in the learning activities for the students to
improve their attitudes and to support their prevention competences.13
At last, it was possible to identify an association
between knowledge and attitudes, similarly to the studies conducted by other
authors.5,14,24 That discovery can mean that a student with a higher
level of knowledge can be prone to using strategies to prevent pressure injury.14
A more positive attitude in relation to the prevention of injury might be
developed in Nursing students when the gaps in their knowledge are bridged,
enabling to put Nursing preventive interventions into practice.13
A limitation of the study is convenience sampling,
which limits generalizability. In addition, quite frank positive values in
comparison that contrast with these published studies are observed. Regarding
this theme, and as a limitation, there might be the fact that the questionnaire
has been applied virtually, allowing the student to search for answers,
possibly leading to interpretation bias.
CONCLUSION
Through this study it was possible to assess the
Nursing students' knowledge and attitudes about the prevention of pressure
injury; the findings allow the providers to implement changes in the training
strategies and, with that, improve care actions. From the findings of this
study, the students' attitudes in mean positive values stand out, with lower
values in the Obstacles factor, which translates attitudes that prevent
efficient prevention and that work as prevention strategies for the efficient
performance of the Nursing students in the prevention of pressure injury.
The contributions of the clinical experiences and the
practices to adequate skills development also stand out. In this sense, the
need was perceived to conduct more studies on this theme at a national level.
In addition, the disparity of the instruments used hindered data comparison.
Finally, it is important to emphasize that less knowledge and negative
attitudes in relation to the prevention of pressure injury might exert an undesirable
effect on the preventive care strategies.
ACKNOWLEDGEMENT
We would like to thank the
University for facilitating the study.
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Submission date:
30/03/2021
Acceptance date: 07/10/2021
Publication date: 27/10/2021