European Journal of Cardiovascular Medicine

A pressure ulcer, also known as bedsore, is a localized trauma to the skin or underlying tissue, usually over a bony prominence as a result of pressure alone or pressure in combination with shear force due to rough surface or linen/bedsheets.[1] Pressure ulcer is a very painful condition associated with increase in patient morbidity and financial burden but is a potentially preventable problem by use of some simple measures.   It is common in old age and in patients with limited mobility or those who are bedridden.[2] Pressure ulcer increases the length of the stay in the hospital from 4 to 30 days, negatively impacts the quality of life and increases the chances of morbidity and mortality.[3] Around 1.7 million patients all over world develop pressure ulcer annually. There is variable incidence in occurrence of pressure ulcers amongst developed and developing countries, with an estimated incidence rate of  8.3% to 25.1% in developed countries and 2.1% to 31.3% in developing countries [4-6].There are multiple risk factors for the development of pressure ulcers/injuries which include advanced age, immobility, incontinence, inadequate nutrition and hydration, neuro-sensory deficiency, medical device-induced skin pressure, multiple co-morbidities and circulatory abnormalities [7,8,9]. The basic mechanism of the development of the pressure ulcers is increased pressure in the local capillaries which leads to the rupture of basic skin barrier. Depending on patient’s severity of illness which results in significant immobility, even mild pressure may be sufficient to obstruct capillary blood flow and this can result in decreased oxygen delivery to the tissues and resultantly pressure ulcer can develop in a short span of 2 to 6 hours. We need to identify the patients who are at increased risk of pressure ulcer and deploy effective physical and medical measures to prevent its occurrence .[10] According to 2014 Coloplast pressure ulcer summit report, 60,000 people died globally  as a result of the complications of pressure ulcer.[11] Lack of medical knowledge is a major barrier for not using the standard guidelines in clinical practice for the prevention of pressure ulcer.[12] Increased medical knowledge and training about pressure ulcer prevention amongst nurses and healthcare providers not only improves the practice of pressure ulcer care but also reduces hospital stay and overall cost.[13] One study in Bahir Dar (Northwest Ethiopia) revealed the prevalence of pressure ulcers was 16.8% thus necessitating the need to enhance the knowledge and attitude of nurses with regards to pressure ulcer prevention practices.[14] The attitude of nurses towards pressure ulcer prevention refers to their valued knowledge and practices related to risk assessment of an individual to develop pressure ulcers, maintaining healthy skin barrier, management of mechanical loads which can cause bedsore and education of the patients and their caregiver.[15] Attitude is affected by knowledge and behavioural intent of the  healthcare provider. It is used to express positive or negative feelings about a person, his/her condition, issues concerned like positioning interval, linen used, moist environment etc. If a person holds a positive attitude toward an issue, this will increase the possibility of performing a supportive behaviour related to that issue and vice versa. [16]

The present descriptive cross-sectional study was conducted at ESI-PGIMSR and attached model hospital, a 600 bedded tertiary care hospital in New Delhi, India. The target population for present study comprised of 97 nursing staff working in the medical, surgical, obstetrics and gynaecology, paediatrics, emergency, ICU, otorhinolaryngology and ophthalmology wards of this hospital. Nurses on duty were approached and recruited for the study only after obtaining their consent. A questionnaire comprising of 29 questions was drafted and pre validated prior to enrolment of subjects in the study. The enrolled nurses were informed about the purpose of the research and that participation in it was completely voluntary in nature. The questionnaire was given individually to the nurses and not collectively in groups/association. Participants were able to fill in the questionnaire within approximately 5 minutes and the filled in questionnaire was retrieved immediately. The questionnaire ensured the anonymity of the enrolled subjects and each questionnaire was assigned a unique serial number for compilation of results subsequently. The researcher ensured that the nurses completed the questionnaire in his presence to avoid respondent bias.

Responses To Questions in Questionnaire:

SOCIO-DEMOGRAPHIC CHARACTERISTICS OF SUBJECTS

All of the total of 97 participants completed the questionnaire. The majority of respondents were females viz. 77 (79.38%) and the remaining were males 20 (20.61%) nurses. Out of these 31(31.95%) were 25-29 years old, 63 (64.94%) had bachelors degree in nursing and 62 (63.91%) had 1 to 10 years of experience in nursing practice.The majority of nurses65 (67.01%) had not received any special training on pressure ulcer prevention since they started their nursing career. 

Overall96 out of 97(96.97%) nurses had adequate knowledge regarding etiology of pressure ulcer. All participants knew the importance of turning the posture / side of such patients on regular basis. 92 nursing personnel (94.84%) had knowledge regarding the time interval of turning of patient. 91(93.91%) knew the importance of prompt turning the side of the patient at regular intervals.Majority of nurses 95 (97.93%) had knowledge of importance of nutrition in management of pressure ulcers. All the participants had knowledge of role of nutrition in the healing and prognosis of pressure ulcers. 95 (97.93%) of nurses knew the role of shearing force in bedsore formation. 91(93.81%)  nurses had knowledge about the mechanical measures and measures to reduce the shearing forces which come into play in such patients. 56 (57.73%) nurses knew about the angle of elevation needed for the prevention of bedsore. 45 (46.39%) of the participants had knowledge about the grading of bedsore. 42 (43.29%) of nurses knew about the parameters essential in grading of bedsores. 83 (85.56%) nurses knew importance of foot-end elevation in patients having bedsores. 96 (98.96%) nurses understood and realised the importance of medical education in relation to bedsore management. All 97 (100%) nursing personnel ensured adequate cleaning of the linen / bed after soiling of linen due to exudate from the pressure ulcers. 95 (97.93%) nurses agreed that absence of bedsores in bed ridden patients having prolonged hospital stay is a good indicator of proper nursing care. 50 (51.54%) nurses knew about the incidence of bedsores in the admitted patients of the whole hospital. 67 (69.07%) nurses agreed that the grading assessment is better mechanism in comparison to clinical assessment. 78 (80.04%) participants had enough knowledge to assess and identify the high risk patients who had more chances to develop bedsores. 91 (93.81%) nurses agreed that they can prevent pressure ulcer formation in an admitted patient by appropriate timely nursing care round the clock. 88 (90.72%) nurses informed that they provide necessary advice and instructions to the caregiver for the prevention of bedsores. 93 (95.87%) nurses had knowledge regarding management of pain due to bedsores. 91 (93.81%)nurses had knowledge regarding importance of cleaning the bony prominences in such patients. 30 (30.92%) nurses reported that they have documentary data and evidence regarding patients with bedsores. 27 (27.83%) nurses expressed unwillingness to the use of ring cushion in patients with bedsores. 29 (29.89%) nurses knew the role of ring cushion in management of bedsores. Only 24 (24.74%) participants had knowledge that ring cushion aggravates bedsore. 28 (28.86%) nurses knew the role of massage of bony prominences in prevention of bedsores. 29 (29.89%) participants had knowledge regarding periodic and systematic turning schedule of patient.

Pressure ulcer is also known as bedsore, pressure sore and decubitus ulcer. [17]. It is developed by the prolonged pressure on the skin or when the skin is compressed for long in between any hard or firm surface like bone and longtime soiling of the patient which is usually unattended.[18] There are multiple physical and biological factors contributing to the development of the bedsores. The intrinsic factors include prior ulcer, peripheral vascular diseases, diabetes mellitus, smoking, any systemic illness, poor nutritional status, incontinence for long duration, impaired sensation due to systemic disorders and ageing process. The extrinsic factor commonly includes prolonged immobility, trauma, pressure, shear friction, moisture due to soiling, poor movement and improper handling of mostly bed ridden patients and improper use of therapeutic devices used for the treatment of the other disorder(s). Nurses’ knowledge and attitude regarding the pressure ulcer prevention are also viewed as contributory extrinsic factors for pressure ulcer formation. [19] Multiple morbidities occur due to pressure ulcer formation which can adversely affect quality of life, cause infection of wound, pain, and disfigurement, altered sleep pattern, delayed healing of ulcer, increased morbidity and mortality rates in hospital admitted patients, an increased need for intensive nursing and medical care and lastly enhanced workload on health workers and consequently increased healthcare cost and extra burden on limited health sector resources. [20] Despite its devastating effects, 95% of pressure ulcers can be prevented by managing both intrinsic and extrinsic risk factors as well as periodic regular repositioning of the patient and by obeying the standard guidelines for the prevention of the pressure ulcer.^[21]

Now a days pressure ulcer are recognised worldwide as one of the five most common causes which are harmful to the patient and is preventable by the simple measures including adequate nursing care. Also the prevalence of bedsores is increasingly described as an indicator of the quality of nursing care provided by healthcare organizations in a hospital set up.[22, 23, 24] Pressure ulcer has been described as one of the most expensive and physically debilitating complications since the beginning of the 20th century. The pain and discomfort of pressure ulcer delays rehabilitation, prolongs illness and timing of discharge, also contributes to disability and death of the affected patients and lastly causes unnecessary mental trauma to the patient’s family. These cumulatively raise the healthcare costs owing to increased need of supplies and prolonged nursing care hours. [23] A systemic review of 31 studies found that pressure ulcers significantly limits many aspects of an individual’s well-being including general physical health and adversely affects social, financial and psychological aspects of life of the patients as well as caregiver.[24] According to international literature, it has been identified that the knowledge of nurses with regards to the prevention of pressure ulcers is generally poor all around the world, more so in the developing countries, which is reflected in their practices, as they do not strictly comply and follow the best practice guidelines laid down for the prevention and management of the same. [25] Poor knowledge regarding the pressure ulcer prevention and commonly deployed practices of nurses has its own major contribution for higher prevalence of pressure ulcer in the tertiary care centres. ^[26]

Study conducted in Sweden regarding knowledge and practices of existing guidelines in nurses on prevention of pressure ulcers found that, majority of them had inadequate knowledge and practice to implement guidelines accurately. [27] Awareness about the significance of the problem, positive attitude towards prevention and an adequate level of knowledge are cornerstone to effectively prevent pressure ulcer formation. ^[28]

The main purpose of this study was to assess knowledge, attitude and pressure ulcer prevention practices in the nursing population. Although there are multiple studies available in international context aiming to assess the knowledge, attitude, practices towards pressure ulcer prevention but there are very few studies which have been conducted in tertiary care hospitals in India. This study showed that almost all nurses knew etiology of pressure ulcers and only 5.16% had inadequate knowledge about pressure ulcer prevention practices. This is less than in comparison to a study done in Bangladesh, where 57.8% of nurses had inadequate knowledge and in Jordan where 73% of nurses had inadequate knowledge about pressure ulcer prevention. [29, 30] In this study 93.81% of the participants had favourable attitude towards pressure ulcer prevention practices which is similar to the findings in the survey done in Sweden where nursing staff as a whole demonstrated positive attitude regarding pressure ulcer prevention. [31] Another similar study was carried out in Iraq, in which 99% of nurses revealed that they had positive attitude towards pressure ulcer prevention practices. [32] This study showed that the attitude of the nurses was significantly associated with pressure ulcer prevention practices as seen in the study in Bangladesh.[29] It was noted from our results that nurses showed good mean percentage score of correct answers. This is especially important as good knowledge and practice of nurses has its own significant contribution for decreasing the prevalence of pressure ulcers. This study results showed that nurses have good knowledge (80.41%) regarding risk factors of pressure ulcer development, regarding changing patient’s position every two hours (94.84%), but in contrast another study conducted in Bangladesh showed that the nurses knowledge about factors related to pressure ulcer was very low to low level(33%), but the study of Uganda revealed that nurses knowledge about frequent patient positioning can protect patient from developing pressure ulcers was to the tune of 98.2%, which is slightly higher than the present study.[34] In our study 69.07% nurses had the knowledge of risk assessment scale for pressure ulcer which is significantly higher than the study conducted in Bangladesh which was 12.1%. [29] Even though the study shows that results in present study as regards to Braden scale are better as compared to results in Bangladesh but the fact is that nurses were not having sufficient knowledge about the use of advance measures for pressure ulcer prevention. Using the similar type of questionnaire in a previous study conducted to assess knowledge about pressure ulcers in a group of Iranian nurses handing critical care patients it was revealed that the nurses were not knowledgeable about pressure ulcers.[35] 69 participants out of 97 (71.13%) participants in this present study considered that massaging over bony prominences is not necessary in order to prevent pressure ulcer formation. This finding was similar to the study conducted in Ethiopia wherein the nurses also found that massaging is not an important part in prevention of pressure ulcer formation. [36] However, few participants in Ethopian study were of the opinion that massage was a preventive intervention despite the standard evidence which advises against massage of the prone areas [37] The

study conducted in Ethiopia results found that nurses who didn’t attend seminars on prevention of pressure ulcers (49.7%), avoided using assessment scale to asses pressure ulcer (56.2%) and had inadequate knowledge about use of air cushion in high risk patients (44.3%). Also, it is evident that improper documentation of all data related to pressure ulcer development (42.1%) in the present study is a significant observation [36] which is generally poor in public health setups. But in contrast, present study revealed that the nurses’ practices of pressure ulcer prevention (43.29%) and use of assessment scale is less as compared to the Ethopian study. In the present study 27.83% nurses did not use air mattress for high risk patients in order to prevent pressure ulcer. Also only 30.92% nurses document all data as per the standard scale regarding pressure ulcer assessment which is lower than that found in Ethopian study.

1. .The data obtained in the present study is from self- reported questionnaire and one can’t get accurate information regarding the practical implications of the same.
2. 2.This study was conducted in a single tertiary care government (public health) hospital and there is no data of private hospitals, as the latter have a standard protocol in regards to pressure ulcers (formation, care, assessment etc) whichis followed more judiciously.
3. 3. Study is a cross sectional study and at single point of incidence devoid of follow up assessment

STRENGTH OF THE STUDY

1. A simple approach by the pre-set validated simple questionnaire was used for the study which was easy to understand.
2. This study gives an overall idea about the baseline data of nurse’s knowledge, attitude and practice regarding ulcer prevention which will be helpful for improvement of nursing care regarding pressure ulcer prevention in ESI PGIMSR set up as a tertiary care hospital.
3. This study provides a broad view of the general standard and understanding of the nurses and their knowledge regarding ulcer which is an indicator of nursing care in a health setup.

RECOMMENDATIONS

1. Regular training programmes and seminars for nurses must be conducted to impart knowledge about prevention of pressure ulcers especially those who are working in public health set up in developing nations.
2. Results of the study give idea regarding the knowledge and practices of nurses so we need to disseminate and share the data with administration / concerned authorities so as to improvise the standard of nursing care in interest of patients and the health sector.
3. Knowledge of nurses regarding pressure ulcer prevention is not enough without implementation and adherence to standard protocols into daily practices while caring for the patients.

This study was conducted to assess the level of nurses’ knowledge and practices towards pressure ulcer prevention. On the whole, the study shows:-

1. Overall knowledge of nurses was good as regards to pressure ulcer prevention.
2. Overall practice regarding pressure ulcer prevention was ssatisfactory.
3. Adequate education can bring requisite changes in individual behaviour and this can constructively influence the practices for the betterment of patients and upliftment of the health care services.

In view of the above findings and observations, nurses need to regularly continue upgrading their medical education, clinical skills and train about pressure ulcer prevention and management, which will not only enhance their knowledge and practices but will be of benefit to patients. Further large scale researches over both private and public health platforms about pressure ulcer prevention are needed.

ACKNOWLEDGMENT

My sincere thanks extend to all nurses participated in the study and their positive approach and interest toward the study

1. .The data obtained in the present study is from self- reported questionnaire and one can’t get accurate information regarding the practical implications of the same.
2. 2.This study was conducted in a single tertiary care government (public health) hospital and there is no data of private hospitals, as the latter have a standard protocol in regards to pressure ulcers (formation, care, assessment etc) whichis followed more judiciously.
3. 3. Study is a cross sectional study and at single point of incidence devoid of follow up assessment

STRENGTH OF THE STUDY

1. A simple approach by the pre-set validated simple questionnaire was used for the study which was easy to understand.
2. This study gives an overall idea about the baseline data of nurse’s knowledge, attitude and practice regarding ulcer prevention which will be helpful for improvement of nursing care regarding pressure ulcer prevention in ESI PGIMSR set up as a tertiary care hospital.
3. This study provides a broad view of the general standard and understanding of the nurses and their knowledge regarding ulcer which is an indicator of nursing care in a health setup.

RECOMMENDATIONS

1. Regular training programmes and seminars for nurses must be conducted to impart knowledge about prevention of pressure ulcers especially those who are working in public health set up in developing nations.
2. Results of the study give idea regarding the knowledge and practices of nurses so we need to disseminate and share the data with administration / concerned authorities so as to improvise the standard of nursing care in interest of patients and the health sector.
3. Knowledge of nurses regarding pressure ulcer prevention is not enough without implementation and adherence to standard protocols into daily practices while caring for the patients.

This study was conducted to assess the level of nurses’ knowledge and practices towards pressure ulcer prevention. On the whole, the study shows:-

1. Overall knowledge of nurses was good as regards to pressure ulcer prevention.
2. Overall practice regarding pressure ulcer prevention was ssatisfactory.
3. Adequate education can bring requisite changes in individual behaviour and this can constructively influence the practices for the betterment of patients and upliftment of the health care services.

In view of the above findings and observations, nurses need to regularly continue upgrading their medical education, clinical skills and train about pressure ulcer prevention and management, which will not only enhance their knowledge and practices but will be of benefit to patients. Further large scale researches over both private and public health platforms about pressure ulcer prevention are needed.

ACKNOWLEDGMENT

My sincere thanks extend to all nurses participated in the study and their positive approach and interest toward the study

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