Nurses’ Knowledge of Pressure Ulcer Prevention in Ogun State, Nigeria: Results of a Pilot Survey

Abstract

  Pressure ulcer (PU) development remains a significant complication among at-risk patients. Optimal prevention strategies start with knowledge about current evidence-based prevention interventions. A pilot study was conducted to describe nurses’ level of knowledge of PU preventive interventions and to test the reliability of the Pressure Ulcer Knowledge Test (PUKT) among Nigerian nurses.

One hundred, eleven (111) nurses were purposively selected from specific wards of a state teaching hospital in South West Nigeria. While 106 nurses (95.5%) correctly identified patients at risk for PU development, 78 participants (70.3%) had low (<59% correct) prevention intervention knowledge scores. No significant differences in PU prevention intervention knowledge scores were observed between nurses with different educational backgrounds (P = 0.317) or years of working experience (P >0.005). The Cronbach’s alpha coefficient for reliability was 0.861. The results of this study confirm that many PU prevention interventions in Nigeria are based on tradition and that a structured educational approach is needed to enable Nigerian nurses to provide evidence-based PU prevention interventions.

 Potential Conflicts of Interest: none disclosed

Introduction

  Pressure ulcer (PU) development is a nursing-sensitive quality indicator. The negative impact of PUs on patients’ quality of life underscores the need to prevent their occurrence in hospitalized patients. The literature suggests that PUs can be prevented or their incidence reduced when appropriate interventions are in place,¹ although the Wound Ostomy and Continence Nurses Society (WOCN)² warns that some ulcers maybe unavoidable — ie, they can develop despite early and accurate risk assessment and provision of appropriate preventive interventions. Despite this position by organizations concerned with PU prevention, nurses are still stigmatized and blamed for poor quality care when PUs occur.³

  The facility for this study is a state-funded teaching hospital in South West Nigeria. It was established in 1986 and provides tertiary healthcare services for people in Ogun State and its environs. The hospital operates 28 specialty and subspecialty disciplines with 240 beds distributed among various specialties. Researchers observed that most nursing interventions to prevent and manage PUs could be considered obsolete and based on tradition rather than empirical evidence. The hospital does not have a dedicated wound clinic. A recent descriptive study⁴ among Nigerian nurses (N = 95) that examined the perception of activities to prevent PUs reported that 32.6% of nurses were massaging bony prominences for 10 to 30 minutes, a practice not supported by evidenced-based recommedations^5,6 and indicative of a gap in the practitioners’ knowledge. The same study also noted that although nurses use turning schedules, consistency in turning frequency was lacking.   Currently, no national guidelines for PU risk assessment, prevention, and treatment exist in Nigeria; recommendations for care are based on international guidelines and caregiver experience. However, despite the lack of a national guideline, PUs are an important concern to care providers, as evidenced by the fact that some hospitals in Nigeria report facility-acquired ulcers. One example is a prospective study⁷ of PU prevalence among spinal cord-injured patients in Gombe state in which the authors reported that 16 out of 28 patients (57%) developed a PU. The authors attributed this high incidence to inadequate knowledge of preventive interventions among practitioners and the absence of a policy requiring the use of pressure-redistributing equipment in the hospital. In a case study conducted in a hospital in Osun state, Onigbinde et al⁸ examined the effectiveness of gentamycin in the management of PUs. He noted that PUs are very common in Nigerian hospitals, particularly among mobility-compromised patients, and affect approximately 9% of hospitalized patients within the first 2 weeks of admission. Furthermore, a 2-year (2004–2006) prospective study⁹ of PU risk factors in spinal cord-injured patients admitted to a spinal cord injury unit in Lagos showed a 57.1% PU incidence rate. The average hospital stay for this group of patients with PU was reported to be 33.1 days. The length of stay for those without PUs was not reported. However, in another prospective study of PUs among traumatic spinal cord-injured patients in the University College Hospital in Ibadan, Nigeria, Iyun et al¹⁰ reported an average length of stay of 73 days. This study reported that 67 patients (87.5%) developed ulcers within the first week of admission. Because no national surveys have been conducted in Nigeria, nationwide prevalence and incidence data are not currently available.

  The international guideline from the Wound Ostomy and Continence Nurses Society⁵ suggests five basic strategies for effective PU prevention: assessment and measurement of risk; pressure redistribution; interventions to reduce or prevent exposure to shear and frictional forces; interventions to alleviate other contributing factors, including moisture and impaired nutrition; and patient, family, and caregiver education. Of these strategies, the most commonly implemented intervention by nurses in the authors’ hospital is pressure redistribution by repositioning. This often is conceptualized as turning the patient from side to side when lying in bed or on similar surfaces; however, current recommendations included in the WOCN guidelines^5,11-13 indicate the need to avoid pressure on the trochanter and lateral malleolus while the patient is in the side-lying position. This recommendation supports use of a 30˚ side-lying position, which is believed to prevent sliding and shear-related injury.¹⁴ Similarly, a systematic review of the literature¹⁵ and consensus meeting concluded that repositioning and the 30˚ side-lying position can relieve pressure from tissues over bony prominences. This recommendation was corroborated in a randomized clinical trial¹⁶ of repositioning using the 30˚ tilt to prevent PU, as well as by a systemic review¹⁷ of evidence on the effectiveness of repositioning in PU prevention. Both studies^16,17 suggested that a 4-hour repositioning schedule used in combination with an appropriate pressure redistribution surface is effective in reducing facility-acquired PU. Although the need to reposition is generally accepted, and most guidelines suggest 2-hour intervals on a standard hospital mattress and 4-hour intervals on a pressure redistribution surface,^5,6 the frequency of repositioning remains a topic of debate. A consensus statement on PU prevention from the National Pressure Ulcer Advisory Panel¹⁸ stated that a patient with normal circulatory capacity should not spend more than 2 hours in one position. Anecdotal evidence⁴ suggests that Nigerian nurses commonly position patients in a complete lateral position and massage the bony prominences of at-risk patients; in addition, adhering to a consistent turning schedule has been found to be quite challenging due to poor staffing levels.

  On the other hand, a prone position using appropriate pillow bridging is advocated to reduce interface pressure in the sacrum whenever possible. Pillow bridging implies placing a pillow between the body surface and the bedding — in particular, between bony prominences — to maintain alignment and enhance comfort. However, when a patient’s comfort, treatment needs, and physiologic conditions are affected, this position is rarely used in practice.

  PU knowledge deficits among nursing staff is a global concern, but its extent among nurses in Nigeria has not been examined. The goals of this pilot study were 1) to assess nurses knowledge of international recommendations for PU prevention, and 2) to test the reliability of the Pressure Ulcer Knowledge Test (PUKT)¹⁹ among Nigerian nurses.

Methods and Procedures

  Study design and participants. A descriptive survey design study was conducted among nurses working in a state teaching hospital in South West Nigeria. Approval to conduct the study was obtained from the hospital’s institutional review board. All eligible participants were directly involved in patient care and were recruited from the medical, surgical, neurological, and orthopedic units of the hospital. With the support of the ward managers, potential participants were approached during their free time in their break rooms or at the beginning of their shift (afternoon and night shift only). After agreeing to participate, nurses were asked to provide written informed consent and to complete the questionnaires. Data were collected for 2 weeks.

  Data collection instrument. An adapted version of PUKT¹⁹ was used for data collection. This instrument has been widely used among nurses in other countries to evaluate knowledge of PU prevention strategies. In its original version, the PUKT is a 47-item test designed to measure knowledge of PU prevention, staging, and wound description. The tool was developed by Pieper and Mott in 1995. An extensive literature search showed no evidence of its use among Nigerian nurses.

  In the current study, the instrument was adapted and some content reworded to suit the care environment. Some items in the original version, such as questions related to the appointment of a governmental panel to study PU risk and prevention and treatment and the use of vascular boots, were removed because they did not pertain to the authors’ hospital environment. Some items were reworded for clarity. For example, because nurses often use water-filled gloves to elevate heels, the item heel protectors relieve pressure on the heels was rephrased to read, “A heel protector such as a water-filled glove relieves pressure on the heels.”

  A split-half reliability test was conducted. Although the PUKT instrument was developed in the US, content validity and reliability (Cronbach’s alpha coefficient 0.861) supported its repeatability and usability in another country such as Nigeria. If an instrument has a high degree of reliability, it can be used in other studies.²⁰ The Cronbach’s alpha coefficient, 0.861, is above the minimum acceptable level of 0.7,²¹ and therefore acceptable for use in this study. It was not necessary to translate the instrument into the local language because Nigerian nurses speak and understand English.

 The PUKT is not included in the nurse training programs in Nigeria, but the nursing curricula both at the diploma and baccalaureate levels include content for PU prevention as part of medical-surgical nursing course, some of which is addressed in the PUKT tool. Questions on PU staging, also included in the original instrument, were answered by participants but are not included in this report, because the focus of this study was knowledge of preventive interventions. The test items reported here include 24 true-or false assertions on PU prevention. Respondents were expected to choose one correct answer from among True (T), False (F), or I don’t know (NK) responses. A correct response was scored as 1. An incorrect or I don’t know response was scored as 0. In the original study of this test,¹⁹ a score of 90% or above was described as adequate knowledge. For this study, the range of scores was categorized as follows: 80% and above: high knowledge; 59% to 79%: moderate; and below 59%: low knowledge.

  Data assessment. Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 15.0 (SPSS, Chicago, IL), for individual items using descriptive statistics. The analysis compared the scores for nurses based on educational level (diploma and BSc nurses) rather than isolated scores for each participant. The Student’s t-test was used to examine the mean correct responses between the professional groups. P value was set at a =0.05. The split-half method of reliability testing was used to ascertain the consistency of the instrument because nursing schedules limited the ability to meet with the same group of nurses at a later date for a retest.

Results

  One hundred, eleven (111) out of a potential 128 nurses participated in the study. Most were women (104, (94%) and most graduated from a diploma program (73, 66%); the majority (49, 44%) had 11 to 20 years’ experience (see Table 1). The average age of participants was 23 (± 0.93) years.  Analysis of knowledge items indicated that 106 nurses (95.5%) correctly identified patients at risk for PU development, and 102 (91.9%) correctly answered the question about the need to assess patient’s skin on admission. However, some obsolete interventions were marked as correct by all participants, including the importance of massaging bony prominences (False), the use of ring and donut devices (False), and use of 3-hour repositioning schedule for persons confined to bed (False) (see Table 2). Similarly, all participants selected the incorrect response on the frequency of repositioning/shifting of weight for chairbound patients. However, the majority of participants (80, 72%) correctly noted that 4- to 6-inch foam material should be placed beneath an at-risk patient. Most participants (90, 81%) were unable to correctly interpret a Braden scale score of 18.

  Overall, 78 participants (70.3%) scored below 59% of correct answers, with a mean score of 13 ± 0.46 for the 24 questions, indicating an inadequate knowledge of evidence-based interventions for PU prevention. No respondents had a score >80% correct (see Table 3).

 Chi-square analysis of the educational category and knowledge score (see Table 4) of respondents indicates some difference between educational level and knowledge of PU preventive interventions, but the differences were not statistically significant (P = 0.317 and P >0.005, respectively). Of the 78 nurses with a low knowledge score, 49 (62.8%) were RNs and 29 (37.2%) were RNs with a BSc degree. Of those with a moderate knowledge score (33), 24 (72.7%) were RNs and nine (27.3%) had a BSc nursing degree (see Table 4). Knowledge scores also did not differ significantly between nurses working in different capacities (P = 0.544) or between those with more or those with fewer years of clinical experience (P >0.005). Only 18% of staff nurses and 18% of nursing officers had moderate knowledge scores. In Nigeria, a Nursing Officer is a rank above the staff nurse. The proportion of nurses with moderate knowledge scores was slightly higher (27%) among the principal and chief nursing officers. Reliability, as demonstrated by Cronbach’s alpha coefficient, was 0.861.

Discussion

  The ability to prevent PUs is a sensitive indicator of nursing care quality and may likely explain Wuster’s²² assertion that excellent skin care is the hallmark of quality nursing care. Achieving this goal demands that practicing nurses possess adequate knowledge of evidence-based interventions, rather than rely on traditional and ritualistic practices. Few studies have examined gaps in nurses’ knowledge of PU prevention in different countries. The goal of this study was to use the PUKT to evaluate nurses’ knowledge of interventions to prevent PU in hospitalized patients.

  Study participants included general nursing graduates with varied responsibilities, skills, and years of experience. Most nurses had basic diploma certificates; none had received specialist training in wound care or were tissue viability nurses. Such specializations are not common in Nigeria. The mean age of nurses in this study was 23 ± 0.928 years and, consistent with general nursing demographics, 104 (93.7%) were women.^23,24

  Knowledge assessment. The need to assess nurses’ knowledge of PU prevention strategies and improve educational programs is increasing with changing trends in healthcare. In Nigeria, PU knowledge studies among nurses are sparse, possibly because the global paradigm shift from PU treatment to prevention has not been identified as a priority at this time. In addition, no government regulations on PU development exist in Nigeria. However, institutional policies emphasize quality nursing care for patients, including the importance of maintaining skin integrity.

  Study results indicated that 106 nurses (95.5%) correctly identified risk factors for PU development. This result is similar to Bostrom and Kenneth’s²⁵ descriptive survey of 245 staff nurses working in multiple settings. The study concluded that despite a good knowledge of risk factors for skin breakdown among nurses, maintaining patient skin integrity was hindered by environmental and clinical impediments.

  In the current study, knowledge of evidence-based preventive interventions was poor, which explained the results of previous studies⁴ and the authors’ observation that most prevention practices are based on tradition. For example, all participants (100%) believed massaging bony prominences of at-risk patients and the use of ring/donut cushions are appropriate. A descriptive, exploratory, cross-sectional survey of the knowledge and practice of PU prevention among Greek nurses²⁶ similarly concluded that although nurses understood PU risk factors and areas at risk, a significant proportion were not aware that interventions such as massage and the use of donut devices were no longer recommended. Halfens and Eggink²⁷ explored the extent of use of some PU prevention interventions among nurses in the Dutch hospitals and found that some interventions that were not recommended in current guidelines were still used. Results of the current study are similar; participants had good knowledge scores on risk factors but poor knowledge scores on evidence-based interventions. Such observations suggest that educational nursing program content should emphasize the interpretation and utilization of research findings.

  The lack of knowledge of current recommendations demonstrated by participants in this study has serious implications for practice and the prevalence of PU in Nigerian hospitals. Interventions used in Nigeria are generally discouraged in almost all international guidelines, suggesting a need for review of that country’s nursing educational curriculum. The persistent use of nonevidence-based interventions also may be attributed to lack of a national guideline or standard of practice for PU prevention in Nigeria.

  Educational level. In the US, Pieper and Mott’s¹⁹ descriptive study to examine nurses knowledge of PU prevention, staging, and description found that participant knowledge scores were not related to either educational level or years of working experience; rather, persons who had attended a recent lecture or read an article on PU prevention had higher scores. In the current study, knowledge scores also did not differ significantly between nurses with different levels of education or years of working experience. As observed in the current results, nurses lacked knowledge of specific areas of PU prevention. The mean number of correct responses was 13 (± 0.46); 70.3% of respondents scored below 59%. Specifically, the percentage of moderate scores among the diploma nurses and graduate nurses were 72.7% and 27.3%, respectively. These findings contradict previous reports of comparable scores between nurse auxiliaries and BSN nurses²⁸ using the same PUKT, suggesting that educational level in Nigerian nurses does not predict knowledge of PU preventive interventions. Therefore, a focused educational program is needed in this area of care.

  Educational intervention. Using a quasi-experimental design, Sinclair et al²⁹ implemented and evaluated an evidence-based education program on PU prevention among two levels of nursing staff (RN= 595, LPN= 59) using the PUKT and observed an increase in knowledge following the educational program. Results showed scores of 42.3% correct responses at pretest and 60.5% following educational intervention, which strongly supports the need for a structured program to improve knowledge of PU prevention among nurses.

  Using the mean score of the two groups (1.24, diploma nurses; and 0.70, BNSc nurses), t-test results indicated a statistically significant difference (P = 0.002). In view of these results, knowledge of PU preventive interventions was deemed inadequate among both diploma and graduate nurses. The result appears to be consistent with results of a descriptive study¹⁹ of 228 American nurses from two hospitals where the tool first was applied. A score of 71.1% of correct responses was reported, and the knowledge level was significantly higher among nurses who had attended PU lectures or read articles during the year before the study, suggesting that an education program can improve knowledge of PU prevention.

  Knowledge of predictive scales. The importance of using validated scales to support nurses’ clinical judgment in predicting PU development in patients at risk has been described in literature. Results of a meta-analysis³⁰ assessing the effectiveness of nurses’ clinical judgment in predicting PU suggested that the predictive validity of clinical judgment alone is low and that a valid risk assessment scale should be used. The majority of participants in the current study (81.1%) are not familiar with the Braden scale or any other PU risk assessment scale, which suggests that nurses depend entirely on their own clinical judgment. This knowledge deficit of the Braden score among these study participants is similar to findings from Miyazaki et al’s³⁰ descriptive, exploratory study that examined PU prevention knowledge among 386 nursing professionals in Brazil. The researchers concluded that an educational program on the use of the Braden scale should be a priority in PU programs because valid scales are considered essential in PU prevention.

Study Limitations

  The limitations of the study include the nonrandomization of the sample and the small sample size; another study involving a larger sample size is warranted. In addition, the PUKT was used for the first time among nurses in Nigeria, and the low scores may be related to their unfamiliarity with such an instrument.

Conclusion

  The value of knowledge in PU prevention cannot be overemphasized. Findings from this study indicate a gap in knowledge of current evidence-based interventions for PU prevention among nurses in Nigeria and confirm that most PU prevention practice decisions are based on tradition, myths, and past experience. A structured educational approach is needed to enable Nigerian nurses to provide evidence-based PU prevention interventions.

 The authors are Lecturers, Department of Nursing, University of Ibadan, Ibadan, Nigeria. Please address correspondence to: Rose Ekama Ilesanmi, RN, MSc, IIWCC (Stellenbosch), FWACN; email: ekamailesanmi@yahoo.com.

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