The knowledge and attitude on the prevention of pressure ulcers in Chinese nurses: A cross-sectional study in 93 tertiary and secondary hospitals
Abstract
Although pressure ulcers are related to substantial health burdens, they may be preventable. Since nurses play a fundamental role in pressure ulcer prevention, their knowledge and attitude are of great importance. This study aims to investigate the current situation and associated factors of nurses' knowledge and attitude on the prevention of pressure ulcers from both tertiary and secondary hospitals. A total of 11 347 nurses were recruited including 7108 nurses (62.6%) from tertiary hospitals and 4239 nurses (37.4%) from secondary hospitals. The median (interquartile range) of the pressure ulcer knowledge score was 51% (38%, 90%) for all the participants with the lowest scores on prevention of pressure ulcers (51.33%). The mean (standard deviation) of attitude towards pressure ulcer prevention was 39.64 (4.65) with the lowest scores on personal competency to prevent pressure ulcers (mean 3.09). The results of multivariate linear regression showed that hospital level, nurses' age, years of work experience, initial education level at work and time of last training significantly associated with nurses' knowledge of pressure ulcer prevention. Meanwhile, hospital level, job title, previous training, time of last training and subjective needs for further training had significant association with nurses' attitude towards pressure ulcer prevention (all p < 0.05). Results showed inadequate knowledge but relative positive attitudes in nurses indicating the importance to deliver continuing education and training regarding pressure ulcer prevention in practice to improve the quality of care.
1 INTRODUCTION
Pressure ulcers are a prevalent complication for hospitalized patients who are confined to physical activities. Pressure ulcers refer to localized injuries in the skin and/or underlying tissues due to pressure or a combination of pressure and shearing forces.1 According to a systematic review and meta-analysis, the international prevalence of pressure ulcers was 12% across different regions and settings, with a wide range of 4%–45%.2 In addition, pressure ulcers are costly as the related prevention and treatment would yield greater quality-adjusted life years at higher cost from the perspective of healthcare and societal sector.3
However, previous studies have shown insufficient knowledge and contradictory attitudes among nurses with respect to pressure ulcers in practice.4-8 To be specific, 91.5% nurses in Wollega demonstrated inadequate knowledge to pressure ulcer prevention with the lowest score in the reduction of pressure duration.6 Similarly, the weakest areas of knowledge including addressing pressure-reducing interventions, aetiology and risk assessment were reported from UK nurses.7 Although positive attitudes towards pressure ulcer prevention could be found, it was overshadowed by significant knowledge deficiency.7 On the contrary, Ethiopian nurses revealed negative attitude to pressure ulcer prevention and several barriers were identified such as heavy workload, shortage of resources and equipment.8 Since nurses take major responsibility of pressure ulcer prevention in clinical practice, it is important to explore the areas where measures can be taken to reduce the incidence of pressure ulcers.
As there is a lack of evidence of nurses' knowledge and attitudes of pressure ulcers in China, more research is needed to inform the education and training regarding pressure ulcers in nursing practice. A provincial digital platform in Zhejiang province China was established in 2022 involving more than 100 hospitals of different levels with the purpose to monitor the incidence of pressure ulcers and implement standard training in a large scale. In this study, we investigated the current situation of nurses' knowledge and attitude on the prevention of pressure ulcers from 93 hospitals in the platform and analysed the influencing factors, which would help develop targeted training programs for nurses, enhance their knowledge and improve the quality of nursing care.
2 METHODS
2.1 Study design and participants
This study was a multicentre cross-sectional study using convenient sampling. Participants were recruited from a provincial platform where more than 100 hospitals of different levels were involved voluntarily. We reached out to the nurse managers who took responsibility of pressure ulcer prevention in each hospital. The included criteria were those who (a) were registered nurses with licence, (b) worked in clinical setting, (c) had working experienced for more than 1 year and (d) participated in the research voluntarily. We excluded the nurses who were having an internship or training program. The informed consent of each participant was obtained.
2.2 Measurement
2.2.1 Basic information
Participants' basic information was collected via self-developed survey including hospital level, gender, age, years of working, job position, education level and training in pressure ulcer prevention.
2.2.2 Knowledge of pressure ulcer prevention
The Pressure Ulcer Knowledge Assessment Tool (PUKAT) 2.0 was adopted to assess participants' knowledge of pressure ulcer prevention. The original instrument was developed by Manderlier et al. with 25 items six dimensions including aetiology, classification and observation, risk assessment, nutrition, prevention of pressure ulcers and specific patient groups.9 The Chinese version of PUKAT 2.0 has been revised into 21 items, and the items that did not align with the culture and conditions in China were deleted. A correct answer was scored 1 point and a wrong answer was scored 0, with an overall score ranging from 0 to 21. The final score for each participant was transferred to a percentage (equal to overall score/total score). <60% was set as a cutoff for low level of knowledge of pressure ulcer prevention.10 The Kuder–Richardson Formula 20 and test–retest reliability of the Chinese version of PUKAT 2.0 were 0.713 and 0.893 in previous literature.11 The Cronbach's α in our study was 0.889.
2.2.3 Attitude towards pressure ulcer prevention
The Attitude towards Pressure ulcer Prevention instrument (APuP) was used.12 It includes 12 items five dimensions including personal competency to prevent pressure ulcers, priority of pressure ulcer prevention, impact of pressure ulcers, responsibility in pressure ulcer prevention and confidence in the effectiveness of prevention, measured on a 4-point Likert scale ranging from ‘very strongly disagree’ (1) to ‘very strongly agree’ (4). Seven items were rated reversely. The total score of APuP was 12–48. Higher scores indicate greater importance was attached by the nurses. The Cronbach's α and test–retest reliability of the Chinese version of APuP were 0.814 and 0.842 in previous literature.11 The Cronbach's α in our study was 0.755.
2.3 Data collection
We explained the purpose of the study and obtained permission from the nurse managers who took responsibility of pressure ulcer prevention in each hospital. One of the nurses in each hospital was selected as research staff and received training prior to the study. Informed consent was obtained from each participant online. Questionnaires were distributed via a web-based link, which required an answer for every question to avoid missing data (online platform: Questionnaire Star, https://www.wjx.cn). We set the minimum time for completing the questionnaire to avoid invalid data. All the participants completed the anonymous questionnaires independently. The research staff could make explanation for better understanding of the participants but without leading information. We collected 13 078 questionnaires and excluded the questionnaires with all the same answers. Finally, 11 347 questionnaires from 93 hospitals were used for analyses, with an eligible rate 86.76%.
2.4 Statistical analysis
Data analyses were performed using Stata V.17.0 for Windows. The normality of the distribution of continuous variables was tested using the Kolmogorov–Smirnov test. In descriptive statistics, continuous variables were presented as mean and standard deviation (SD) or medians and interquartile range according to the distribution of the quantitative variables, and categorical variables were shown as the frequency and percentage. We performed the chi-square test, t test and Mann–Whitney U test to compare the differences of nurses' knowledge and attitude between the tertiary hospitals and secondary hospitals. Multivariate linear regression was performed to test the associated factors of nurses' knowledge and attitude towards pressure ulcers. The level of significance was set as p ≤ 0.05. We followed the STROBE guideline to report the study.
2.5 Ethical consideration
This study was approved by the Ethics Committee of Sir Run Run Shaw Hospital Affiliated to Zhejiang University School of Medicine (20220199). The ethical principles of voluntary participation, anonymity and confidentiality were guaranteed. This study was conducted according to the Declaration of Helsinki.
3 RESULTS
3.1 Participant characteristics
Among the 11 347 nurses, 7108 nurses (62.6%) were recruited from tertiary hospitals and 4239 nurses (37.4%) were from secondary hospitals. Most of them were female (97.5%), 31–40 years (36.6%), held baccalaureate degree as highest education level (75.9%) and had less than 10 years critical care experience (62.1%). 91.7% of the nurses had attended pressure ulcer-related training. Further information is presented in Table 1.
| Variables | Total number (%) (n = 11 347) | Number in tertiary hospitals (%) (n = 7108) | Number in secondary hospitals (%) (n = 4239) | X2 | p value |
|---|---|---|---|---|---|
| Gender | 0.12 | 0.731 | |||
| Male | 287 (2.5) | 177 (1.6) | 110 (0.9) | ||
| Female | 11 060 (97.5) | 6931 (61.1) | 4129 (36.4) | ||
| Age (years) | 7.89 | 0.162 | |||
| 18–25 | 2908 (25.6) | 1801 (15.9) | 1107 (9.7) | ||
| 26–30 | 3141 (27.7) | 1937 (17.1) | 1204 (10.6) | ||
| 31–40 | 4156 (36.6) | 2635 (23.2) | 1521 (13.4) | ||
| >40 | 1142 (10.1) | 735 (6.5) | 407 (3.6) | ||
| Work experience (years) | 13.63 | 0.003 | |||
| <5 | 3587 (31.6) | 2174 (19.2) | 1413 (12.4) | ||
| 5–10 | 3462 (30.5) | 2172 (19.1) | 1290 (11.4) | ||
| 11–20 | 3302 (29.1) | 2101 (18.5) | 1201 (10.6) | ||
| >20 | 996 (8.8) | 661 (5.8) | 335 (3.0) | ||
| Job title | 92.26 | <0.001 | |||
| Nurse | 2854 (25.1) | 1614 (14.2) | 1240 (10.9) | ||
| Nurse practitioner | 4257 (37.5) | 2634 (23.2) | 1623 (14.3) | ||
| Nurse-in-charge | 3643 (32.1) | 2478 (21.8) | 1165 (10.3) | ||
| Nurse manager | 519 (5.2) | 382 (3.3) | 211 (1.9) | ||
| Initial education level at work | |||||
| Certificate | 8278 (73.0) | 4681 (41.3) | 3597 (31.7) | 687.34 | <0.001 |
| Baccalaureate | 3034 (26.7) | 2392 (21.1) | 642 (5.6) | ||
| Master or above | 35 (0.3) | 35 (0.3) | 0 | ||
| Highest education level | 406.96 | <0.001 | |||
| Certificate | 2663 (23.5) | 1278 (11.3) | 1385 (12.2) | ||
| Baccalaureate | 8612 (75.9) | 5760 (50.8) | 2852 (25.1) | ||
| Master or above | 72 (0.6) | 70 (0.6) | 2 (0.0) | ||
| Previous pressure ulcer-related training | 5.23 | 0.022 | |||
| Yes | 10 401 (91.6) | 6548 (57.7) | 560 (4.9) | ||
| No | 946 (8.3) | 3853 (33.9) | 386 (3.4) | ||
| When was the last training | 26.30 | <0.001 | |||
| Within 1 year | 9380 (82.7) | 5831 (51.4) | 3549 (31.3) | ||
| 1–2 years ago | 1064 (9.4) | 712 (6.3) | 352 (3.1) | ||
| 3–5 years ago | 288 (2.5) | 206 (1.8) | 82 (0.7) | ||
| >5 years ago | 615 (5.4) | 359 (3.2) | 256 (2.2) | ||
| Subjective needs for further training | |||||
| Yes | 10 759 (94.8) | 6745 (59.4) | 4014 (35.4) | 0.22 | 0.640 |
| No | 588 (5.2) | 363 (3.2) | 225 (2.0) | ||
3.2 Knowledge of pressure ulcer prevention
The median (interquartile range) of the PUKAT score was 51% (38%, 90%) for all the participants. 62.56% of the nurses scored below 60%. The average scores from the highest to the lowest on the six dimensions were risk assessment (69.44%), specific patient groups (69.10%), classification and observation (66.50%), aetiology (62.90%), nutrition (52.30%) and prevention of pressure ulcers (51.33%). Nurses in secondary hospitals showed significant lower scores than those in tertiary hospitals in the items of aetiology, classification and observation, risk assessment, prevention of pressure ulcers and specific patient groups. The detailed scores are shown in Table 2.
| Item | Total number of correct answers (%) (n = 11 347) | Number of correct answers in tertiary hospitals (%) (n = 7108) | Number of correct answers in secondary hospitals (%) (n = 4239) | X2 | p value |
|---|---|---|---|---|---|
| Dimension 1: Aetiology | |||||
| Item 1 [factors … development of PU] | 6559 (57.8) | 4123 (58.0) | 2436 (57.5) | 0.31 | 0.574 |
| Item 2 [What happens … head of bed elevated to 60°] | 5818 (51.3) | 3830 (53.9) | 1988 (46.9) | 51.85 | <0.001 |
| Item 3 [When … highest risk] | 10 493 (92.5) | 6614 (93.1) | 3879 (91.5) | 9.07 | 0.003 |
| Item 4 [situations … risk of PU] | 5683 (50.1) | 3759 (52.9) | 1924 (45.4) | 59.68 | <0.001 |
| Dimension 2 Classification and observation | |||||
| Item 5 [blister] | 6202 (54.7) | 3979 (56.0) | 2223 (52.4) | 13.40 | <0.001 |
| Item 6 [pictures of PU category I] | 8687 (76.6) | 5479 (77.1) | 3208 (75.7) | 2.91 | 0.088 |
| Item 7 [necrotic tissue PU] | 7733 (68.2) | 4934 (69.4) | 2799 (66.0) | 14.01 | <0.001 |
| Dimension 3 Risk assessment | |||||
| Item 8 [clinical judgment … risk screening tool] | 6783 (59.9) | 4338 (61.0) | 2445 (57.7) | 12.40 | <0.001 |
| Item 9 [frequency of skin assessment] | 8960 (79.0) | 5729 (80.6) | 3231 (76.2) | 30.64 | <0.001 |
| Dimension 4 Nutrition | |||||
| Item 10 [nutritional supplementation … risk of PU] | 5807 (51.2) | 3716 (52.3) | 2091 (49.3) | 9.25 | 0.002 |
| Item 11 [most essential nutritional elements] | 4132 (36.4) | 2621 (36.9) | 1511 (35.6) | 1.73 | 0.188 |
| Item 12 [body weight … risk of PU] | 7864 (69.3) | 4886 (68.7) | 2978 (70.3) | 2.85 | 0.091 |
| Dimension 5 Prevention of pressure ulcers | |||||
| Item 13 [angle of semi fowler position] | 6144 (54.1) | 3948 (55.5) | 2196 (51.8) | 14.94 | <0.001 |
| Item 14 [most effective repositioning protocol] | 7813 (68.9) | 4970 (69.9) | 2843 (67.1) | 10.08 | 0.001 |
| Item 15 [ring cushion … wheelchair] | 5240 (46.2) | 3431 (48.3) | 1809 (42.7) | 33.43 | <0.001 |
| Item 16 [bed linen … prevent PU] | 4470 (39.4) | 2831 (39.8) | 1639 (38.7) | 1.50 | 0.220 |
| Item 17 [most effective … seated] | 4783 (42.2) | 3003 (42.2) | 1780 (42.0) | 0.07 | 0.788 |
| Item 18 [PU on heels] | 7632 (67.3) | 4761 (67.0) | 2871 (67.7) | 0.67 | 0.412 |
| Item 19 [repositioning prevent PU] | 4672 (41.2) | 2972 (41.8) | 1700 (40.1) | 3.19 | 0.074 |
| Dimension 6 Specific patient groups | |||||
| Item 20 [PU in operating room] | 6334 (55.8) | 3981 (56.0) | 2353 (55.5) | 0.26 | 0.605 |
| Item 21 [location … baby…highest risk] | 9346 (82.4) | 5990 (84.3) | 3356 (79.2) | 47.58 | <0.001 |
- Abbreviation: PU, pressure ulcers.
3.3 Attitude towards pressure ulcer prevention
The mean (SD) of APuP was 39.64 (4.65). The average scores per item from the highest to the lowest on the five dimensions were priority of pressure ulcer prevention (mean 3.59), responsibility in pressure ulcer prevention (mean 3.50), confidence in the effectiveness of prevention (mean 3.41), impact of pressure ulcers (mean 3.12) and personal competency to prevent pressure ulcers (mean 3.09). Nurses in secondary hospitals showed significant lower scores than those in tertiary hospitals in personal competency to prevent pressure ulcers, priority of pressure ulcer prevention and impact of pressure ulcers. The detailed scores are shown in Table 3.
| Item | Total mean scores (SD) (n = 11 347) | Mean scores in tertiary hospitals (SD) (n = 7108) | Mean scores in secondary hospitals (SD) (n = 4239) | t | p value |
|---|---|---|---|---|---|
| Dimension 1 Personal competency to prevent PU | 9.27 (1.51) | 9.34 (1.52) | 9.15 (1.48) | 6.58 | <0.001 |
| Item 1 [confident] | 3.30 (0.63) | 3.31 (0.63) | 3.29 (0.64) | 1.83 | 0.067 |
| Item 2 [well trained] | 3.26 (0.65) | 3.27 (0.64) | 3.21 (0.65) | 4.96 | <0.001 |
| Item 3 [should be a priority] | 2.72 (0.81) | 2.75 (0.80) | 2.64 (0.81) | 6.86 | <0.001 |
| Dimension 2 Priority of PU prevention | 7.18 (1.06) | 7.20 (1.05) | 7.15 (1.06) | 1.98 | 0.047 |
| Item 4 [too much attention] | 3.54 (0.81) | 3.55 (0.79) | 3.51 (0.82) | 2.40 | 0.016 |
| Item 5 [not important] | 3.65 (0.55) | 3.64 (0.55) | 3.64 (0.53) | 0.29 | 0.764 |
| Dimension 3 Impact of PU | 9.37 (1.79) | 9.44 (1.77) | 9.26 (1.80) | 5.01 | <0.001 |
| Item 6 [never … discomfort] | 3.53 (0.81) | 3.55 (0.79) | 3.50 (0.83) | 3.05 | 0.002 |
| Item 7 [financial … patient] | 2.87 (1.02) | 2.89 (1.01) | 2.81 (1.03) | 4.02 | <0.001 |
| Item 8 [financial … society] | 2.97 (0.86) | 2.98 (0.85) | 2.94 (0.86) | 2.77 | 0.005 |
| Dimension 4 Responsibility in PU prevention | 7.00 (1.07) | 7.00 (1.06) | 7.00 (1.07) | 0.23 | 0.814 |
| Item 9 [not responsible] | 3.45 (0.72) | 3.45 (0.70) | 3.44 (0.73) | 0.29 | 0.765 |
| Item 10 [important task] | 3.56 (0.62) | 3.56 (0.63) | 3.55 (0.61) | 0.06 | 0.952 |
| Dimension 5 Confidence in the effectiveness of prevention | 6.81 (1.07) | 6.82 (1.06) | 6.78 (1.07) | 1.79 | 0.072 |
| Item 11 [high risk patients] | 3.42 (0.61) | 3.42 (0.60) | 3.41 (0.61) | 0.64 | 0.520 |
| Item 12 [never preventable] | 3.39 (0.72) | 3.40 (0.71) | 3.37 (0.73) | 2.11 | 0.034 |
- Abbreviation: PU, pressure ulcers.
3.4 Multivariate linear regression of PUKAT and APuP
The results of multivariate linear regression showed that hospital level, nurses' age, years of work experience, initial education level at work and time of last training had significant influences on nurses' knowledge of pressure ulcer prevention. Meanwhile, hospital level, job title, previous training, time of last training and subjective needs for further training was significant associated with nurses' attitude towards pressure ulcer prevention (all p < 0.05, Table 4). Specifically, nurses who worked in secondary hospital, were older, had less work experience, had lower level of initial education and received training 1–2 years ago demonstrated poor knowledge of pressure ulcer prevention. In addition, less positive attitude towards pressure ulcer prevention could be found in nurses who worked in secondary hospital, had lower job title, not received training previously, received training longer time ago and did not have subjective needs for further training. There were not significant differences regarding the associated factors in the subgroups of nurses from tertiary and secondary hospitals (data not shown).
| Independent variable | Dependant variable | β | Standard error | t | p value | Dependant variable | β | Standard error | t | p value |
|---|---|---|---|---|---|---|---|---|---|---|
| Secondary hospital (ref. Tertiary) | PUKAT | −0.02 | 0.01 | −3.68 | <0.001 | APuP | −0.36 | 0.09 | −3.94 | <0.001 |
| Female (ref. Male) | 0.01 | 0.02 | 0.29 | 0.77 | 0.45 | 0.27 | 1.64 | 0.10 | ||
| Age (ref. 18–25) | ||||||||||
| 26–30 | −0.02 | 0.01 | −2.34 | 0.02 | −0.03 | 0.12 | −0.22 | 0.82 | ||
| 31–40 | −0.04 | 0.01 | −6.32 | <0.001 | 0.04 | 0.11 | 0.33 | 0.74 | ||
| >40 | −0.04 | 0.01 | −4.60 | <0.001 | 0.10 | 0.16 | 0.63 | 0.53 | ||
| Work experience (years) (ref. < 5) | ||||||||||
| 5–10 | 0.02 | 0.01 | 2.75 | 0.01 | 0.09 | 0.15 | 0.55 | 0.58 | ||
| 11–20 | 0.04 | 0.01 | 3.68 | <0.001 | 0.04 | 0.20 | 0.20 | 0.84 | ||
| >20 | 0.09 | 0.02 | 5.52 | <0.001 | 0.17 | 0.28 | 0.62 | 0.54 | ||
| Job title (ref. Nurse) | ||||||||||
| Nurse practitioner | 0.01 | 0.01 | 1.27 | 0.21 | 0.06 | 0.16 | 0.37 | 0.71 | ||
| Nurse-in-charge | 0.01 | 0.01 | 0.59 | 0.56 | 0.61 | 0.22 | 2.75 | 0.01 | ||
| Nurse manager | 0.01 | 0.02 | 0.02 | 0.98 | 1.46 | 0.32 | 4.52 | <0.001 | ||
| Initial education level at work (ref. Certificate) | ||||||||||
| Baccalaureate | 0.01 | 0.01 | 1.70 | 0.09 | 0.07 | 0.12 | 0.58 | 0.57 | ||
| Master or above | 0.04 | 0.01 | 4.70 | <0.001 | 0.15 | 0.14 | 1.09 | 0.27 | ||
| Highest education level (ref. Certificate) | ||||||||||
| Baccalaureate | 0.01 | 0.02 | 0.19 | 0.85 | 0.24 | 0.33 | 0.72 | 0.47 | ||
| Master or above | 0.01 | 0.02 | 0.52 | 0.60 | 0.62 | 0.33 | 1.86 | 0.06 | ||
| No previous pressure ulcer related training (ref. Yes) | −0.02 | 0.01 | −1.58 | 0.11 | −1.83 | 0.21 | −8.61 | <0.001 | ||
| When was the last training (ref. Within 1 year) | ||||||||||
| 1–2 years ago | −0.02 | 0.01 | −2.33 | 0.02 | −1.39 | 0.15 | −9.41 | <0.001 | ||
| 3–5 years ago | −0.01 | 0.02 | −0.23 | 0.82 | −1.41 | 0.27 | −5.16 | <0.001 | ||
| >5 years ago | −0.01 | 0.02 | −0.01 | 0.99 | −1.55 | 0.39 | −3.98 | <0.001 | ||
| No subjective needs for further training (ref. Yes) | −0.02 | 0.01 | −1.61 | 0.11 | −0.85 | 0.19 | −4.39 | <0.001 | ||
4 DISCUSSION
To our knowledge, this is the first study that investigated the current status and associated factor nurses' knowledge and attitude regarding pressure ulcer prevention in Chinese with a large multicentre sample size. The results showed that nurses had a poor level of knowledge but relative positive attitude in the prevention of pressure ulcer. Nurses in secondary hospitals demonstrated significant lower scores both in knowledge and attitude compared with their counterparts in tertiary hospitals. The associated factors included hospital level, nurses' age, years of work experience, initial education level at work, job title, previous training, time of last training and subjective needs for further training, indicating the importance to enhance education and training as well as the target population.
Pressure ulcers are preventable based on adequate knowledge and positive attitude of nurses. However, we found that nurses from both tertiary and secondary hospitals still had insufficient knowledge in this field with a median score 51% and 62.56% of the nurses scoring below 60%. This result was consistent with the evidence from a previous meta-analysis (pooled estimate 51.5%),10 higher than the average score in Indonesian nurses (35.0%)13 but lower than that in Korean nurses (60.1%).14 Although previous researchers had examined the knowledge of nurses about pressure ulcers prevention using PUKAT in China, the studies were either conducted in early year15 or limited in intensive care nurses16 or tertiary level hospital.17 Since the knowledge level of nurses might change due to the increasing awareness of pressure ulcers and implementation of prevention guidelines, it is necessary to update the research evidence in the general nurse population. We found that nurses' knowledge level scored lowest in the dimension of prevention of pressure ulcers, followed by nutrition. This may be because the core curriculum in school still focuses on development (aetiology), classification and assessment of pressure ulcers, but rarely on how to prevent them. Additionally, nurses in China are less likely to be involved in patient's nutrition management due to lack of discretion, thus may have a poor background in this field. This evidence could therefore be used to guide future curriculum development to increase nurses' knowledge level of pressure ulcers prevention.
As for nurses' attitude towards pressure ulcer prevention, our results showed that nurses had lowest scores in the dimensions of personal competency to prevent pressure ulcers and highest scores in priority of pressure ulcer prevention. This indicated that while nurses attached great importance to pressure ulcer prevention, they might lack the competence to carry it out. Our findings were aligned with previous literature identifying lowest scores in competence14, 18 and were similar to the situations in Indonesia where nurses recognize their responsibility but often failed to perform it adequately.13 Therefore, improvement of nurses' competence should be prioritized in terms of developing effective training programs.
Furthermore, we performed multivariable regression to identify the associated factors, aiming to explore what nurses most need to strengthen their knowledge and attitude level. Notably, the results revealed that nurses in secondary hospital still had significant lower levels of both knowledge and attitude regarding pressure ulcer prevention controlled for other demographic covariates. This implied a need to improve the level of knowledge and attitude, especially those working in disadvantaged settings. Older nurses showed lower level of knowledge which might be explained that they were not as good as their younger counterparts to get a good result in a test-like questionnaire. This was similar to the findings in Indonesian nurses but contradicted to another previous study in China.19 However, longer work experience was significantly associated with higher knowledge level, which may be because nurses accumulated experience of pressure ulcers prevention in practice. In addition, initial education level at work with a master's degree or above also indicated a higher level of knowledge, suggesting an essential need for hospitals to develop continuous educational programs to increase nurses' degree/diploma and provide up-to-date knowledge regarding pressure ulcer prevention.
On the contrary, the effects of age, work experience and education level were not found in nurses' attitude towards pressure ulcer prevention. Instead, job position was a strong factor of nurses' attitude. Nurse-in-charge and nurse manager tended to have favourable attitude than staff nurses. One explanation may be that the presence of pressure ulcer is generally considered as an indicator of poor nursing quality, and therefore, nurses with higher job position are more likely to be concerned and they are expected to perform better in the workplace than staff nurses. Importantly, training related variables including whether received previous training, exact time and subjective needs for further training were another strong factors to influence nurses' attitude towards pressure ulcer prevention. Those without previous training received longer time ago and without subjective needs for further training demonstrated poorer attitude. This highlighted the importance of regular training or workshop incorporating pressure ulcer prevention in clinical nursing practice.
There were also some limitations in our study. Firstly, the cross-sectional study design eclipsed in drawing causal relationship. Future longitudinal research is needed to examine the predictors of later knowledge level and attitude regarding pressure ulcer prevention. Secondly, there may be other factors that have not been considered but may contribute to pressure ulcer prevention knowledge and attitude in Chinese nurses. Factors beyond individual level such as nursing leadership, hospital climate as well as cultural and contextual influence should be tested as well. Despite the limitations, our study provides evidence that can be used to develop education and training strategies to improve the knowledge and attitude of nurses with regard to pressure ulcer prevention. Further intervention studies should be done to examine the effectiveness of such training and explore potential mechanisms with the purpose to improve the quality of patient care.
5 CONCLUSION
Nurses demonstrated relative poor knowledge of pressure ulcer and positive attitude. Hospital level, nurses' age, years of work experience, initial education level at work, job title, previous training, time of last training and subjective needs for further training may be associated with nurses' knowledge and attitude. Our findings illustrate the importance for nurse administrators, authorities and policy makers to work together to develop and implement effective nursing curriculum and training programs.
ACKNOWLEDGEMENTS
We would like to thank all the participants for joining the study.
FUNDING INFORMATION
This research received funding from the Medical Science and Technology Project of Zhejiang Province (2024KY1125) in China.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
Open Research
DATA AVAILABILITY STATEMENT
Data is available upon reasonable request from the authors.
