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Received: 4 October 2018    Revised: 9 February 2019    Accepted: 23 March 2019

DOI: 10.1111/jocn.14875

ORIGINAL ARTICLE

Development and validation of the pressure ulcer management

self‐efficacy scale for nurses

Federica Dellafiore MSc, RN, PhD(c), Research Nurse1 | Cristina Arrigoni MSc, RN,

Researcher2 | Greta Ghizzardi RN, Research Nurse1 | Irene Baroni RN, Research
Nurse1 | Gianluca Conte RN, Research Nurse1  | Francesca Turrini RN, Wound care
specialist  | Gianluca Castiello RN, Wound care specialist1 | Arianna Magon RN, Research
1

Nurse1 | Francesco Pittella RN, MSN, MBA, Head of Education1 | Rosario Caruso MSc, RN,
PhD, Head of Health Professions Research and Development Unit1

1
Health Professions Research and
Development Unit, IRCCS Policlinico San
Donato, Milan, Italy
2
Department of Public Health, Experimental
and Forensic Medicine, Section of
Hygiene, University of Pavia, Pavia, Italy
Correspondence
Rosario Caruso, MSc, RN, PhD, Head
of Health Professions Research and
Development Unit, IRCCS Policlinico San
Donato, Via Agadir, 20‐24, 20097 San
Donato Milanese, Milan, Italy.
Email: rosario.caruso@grupposandonato.it
Funding information
This research was partially supported by
“Ricerca Corrente” funding from Italian
Ministry of Health to IRCCS Policlinico San
Donato.
Abstract
Background: Pressure ulcers (PUs) represent a current issue for healthcare delivery.
Nurse self‐efficacy in managing PUs could predict patients’ outcome, being a proxy
assessment of their overall competency to managing PUs. However, a valid and reli‐
able scale of this task‐specific self‐efficacy has not yet been developed.
Objectives: To develop a valid and reliable scale to assess nurses’ self‐efficacy in
managing PUs, that is, the pressure ulcer management self‐efficacy scale for nurses
(PUM‐SES).
Methods: This study had a multi‐method and multi‐phase design, where study re‐
porting was supported by the STROBE checklist (File S1). Phase 1 referred to the
scale development, consisting in the items’ generation, mainly based on themes
emerged from the literature and discussed within a panel of experts. Phase 2 focused
on a three‐step validation process: the first step aimed to assess face and content
validity of the pool of items previously generated (initial version of the PUM‐SES); the
second aimed to assess psychometrics properties through exploratory factorial anal‐
ysis; the third step assessed construct validity through confirmative factorial analysis,
while concurrent validity was evaluated describing the relationships between PUM‐
SES and an established general self‐efficacy measurement. Reliability was assessed
through the evaluation of stability and internal consistency.
Results: PUM‐SES showed evidence of face and content validity, adequate construct
and concurrent validity, internal consistency and stability. Specifically, PUM‐SES had
four domains, labelled as follows: assessment, planning, supervision and decision‐
making. These domains were predicted by the same second‐order factor, labelled as
PU management self‐efficacy.
Conclusion: PUM‐SES is a 10‐item scale to measure nurses’ self‐efficacy in PU man‐
agement. A standardised 0–100 scoring is suggested for computing each domain and
the overall scale. PUM‐SES might be used in clinical and educational research.

J Clin Nurs. 2019;28:3177–3188. © 2019 John Wiley & Sons Ltd |  3177
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3178       DELLAFIORE et al.
Relevance to clinical practice: Optimising nurses’ self‐efficacy in PU management
might enhance clinical assessment, determining better outcomes in patients with
PUs.
KEYWORDS
pressure ulcers, reliability, scale development, self‐efficacy, validation
1 |  I NTRO D U C TI O N
Appropriate management of pressure ulcers (PUs) is pivotal for nurs‐
ing practice, due to its effects on clinical outcomes, length of stay
and overall quality of nursing care delivery (Mesarić, 2016). Nurses’
belief in the ability to succeed in the best management of PUs rep‐
resents an expression of their task‐specific self‐efficacy. Overall,
self‐efficacy is a strong predictor of performance and clinical com‐
petence (Caruso, Fida, Sili, & Arrigoni, 2016; Caruso, Pittella, Zaghini,
Fida, & Sili, 2016). Potential benefits of interventions to promote
specific clinical self‐efficacy were widely discussed in the nursing
literature (Robb, 2012). However, a shared and valid scale to meas‐
ure nurses’ self‐efficacy in managing PUs is not currently available,
despite its possible implications on their performance and educa‐
tion. More precisely, the lack of measures to assess the self‐efficacy
related to PU management could undermine the possibility of re‐
search to address the best educational strategies for clinical nurses,
especially when their self‐efficacy is low, and to explore empirically
the relationships between nurses’ self‐efficacy and outcomes re‐
lated to PUs.
2 |  BAC KG RO U N D
PUs represent an important issue for the healthcare systems world‐
wide (Boyko, Longaker, & Yang, 2018). PUs are defined as localised
injuries of the skin and/or the underlying tissue, usually over a bony
prominence, as the result of pressure and/or shear forces (NPUAP
EPUAP PPPIA, 2014). Despite the availability of widespread risk
assessment tools, the best management of PUs is still an impor‐
tant issue in every healthcare facility (Ricci, Bayer, & Orgill, 2017).
Accordingly, PU prevalence varies between 8.8%–53.2% in long‐
term care settings (Moore & Cowman, 2014), between 2.2%–23.9%
in nursing homes and between 3%–33% among chronic patients
(Courvoisier, Righi, Béné, Rae, & Chopard, 2018).
PUs negatively affect many clinical outcomes as well as patient‐
reported outcomes (PROs), such as quality of life. In fact, patients
with PUs frequently experience pain combined with fear, isolation
and anxiety regarding their healing process (Courvoisier et al., 2018;
Moore & Cowman, 2014). Further, elderly patients with PUs have a
threefold higher risk of dying than those without PUs, although PUs
among these patients are often associated with a poor health status
rather than a cause of death per se (Moore & Cowman, 2014). PUs
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What does this paper contribute to the wider global
clinical community?
• Pressure ulcer (PU) prevalence varies roughly between
9%–53.2%, with some differences related to the clinical
setting, being an important issue for health care.
Outcomes of PUs are theoretically influenced by nurses’
specific self‐efficacy.
• PUM‐SES is a short, valid and reliable scale to measure
nurses’ specific self‐efficacy in managing PUs.
• The measurement of nurses’ specific self‐efficacy in
managing PUs (using PUM‐SES) could address research
to understand how self‐efficacy influences outcomes
related to PUs, detecting the most critical aspects of
nurses’ self‐efficacy and consequently planning their
education.
also contribute to an increase in the economic burden of different
healthcare systems (Bennett, Dealey, & Posnett, 2004; Haalboom,
2000). For instance, 11 billion dollars are spent yearly in the United
States of America (USA) to treat PUs (Sen et al., 2009).
Nurses’ belief in the ability to succeed in the best management
of PUs refers to a task‐specific nurses’ self‐efficacy. The measure
of task‐specific self‐efficacy could be a proxy assessment of their
capacity for the appropriate management of PUs. Accordingly, self‐
efficacy is foundational to nursing education and practice for its role
in influencing performance and behaviours (Caruso, Pittella, et al.,
2016). Precisely, self‐efficacy among nurses occurs when they rise
to the challenge of a difficult task, leading to improved performance
of any given activity (Bandura & Wessels, 1997).
Nurses’ self‐efficacy is a modifiable predictor of performance,
which is susceptible to four main sources influenced by specific
educational strategies, that is, personal mastery, vicarious experi‐
ence, symbolic experience and emotional arousal (Bandura, 2001).
Personal mastery refers to the belief that success can generally be
replicated using a winning behaviour, while vicarious experience is
a social comparison process referring to the experience acquisition.
Further, symbolic experience encompasses verbal motivation by
peers, and emotional arousal refers to the feeling of being able to
master a stressful situation. Overall, self‐efficacy mediates the rela‐
tionship between knowledge and action (Plaza & Draugalis, 2002).

DELLAFIORE et al.
For instance, educational outcomes in patients with chronic diseases
were positively influenced by the nurses’ self‐efficacy in performing
their educational plan (Ylimäki, Kanste, Heikkinen, Bloigu, & Kyngäs,
2015). In other terms, nurses’ self‐efficacy represents a qualifying
condition that reflects their sense of control on the practice.
Despite the high potential of self‐efficacy as a proxy assessment
of their clinical competence in managing PUs, there are no currently
available valid and reliable scales to measure nurses’ self‐efficacy in
managing PUs. In fact, only broad measures of professional self‐effi‐
cacy are described in the literature, which are mainly useful to assess
the nurses’ belief in the ability to succeed in their profession, such
as using the Nursing Profession Self‐Efficacy Scale (NPSES; Caruso,
F I G U R E 1   Gantt chart to illustrate the study process [Colour figure can be viewed at wileyonlinelibrary.com]
13652702, 2019, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.14875 by Ondokuz Mayis Universitesi Kutuphane Ve Dokumantasyon, Wiley Online Library on [10/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
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Pittella, et al., 2016). Overall, NPSES could be helpful to assess the
general professional self‐efficacy, which could have an impact on
the stress perception or the general carrier trajectory (Badolamenti,
Sili, Caruso, & Fida, 2017), but it was not developed to detect the
nurses’ self‐efficacy in relation to their clinical practice (Caruso,
Pittella, et al., 2016). Accordingly, the same authors of the NPSES
stated the importance of the development of task‐specific measures
of self‐efficacy, as the general scales of self‐efficacy are not suitable
to detect the characteristics of the clinical practice (Caruso, Pittella,
et al., 2016). So far, the unavailability of scales to measure nurses’
self‐efficacy in managing PUs undermines the possibility of studies
aimed to identify and test the best educational strategies to enhance

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3180       DELLAFIORE et al.
clinical competence, as well as the understanding of the relation‐
ships between self‐efficacy and PUs. To address these gaps, this
study aimed to develop a valid and reliable scale for the assessment
of nurses’ self‐efficacy in managing PUs, that is, the Pressure Ulcer
Management Self‐Efficacy Scale for Nurses (PUM‐SES).
3 |  M E TH O DS
3.1 | Design
As showed in Figure 1, this study had a multi‐method design, divided
into two main phases, consistent with recommendations for scale de‐
sign and development (Rattray & Jones, 2007). The study reporting
was also consistent with the “Enhancing the Q UAlity and Transparency
Of health Research” (EQUATOR) guidelines, using the “STrengthening
the Reporting of OBservational studies in Epidemiology” (STROBE)
checklist (see File S1). Phase 1 referred to the scale development, con‐
sisting in the items’ generation, mainly based on the themes emerged
from the literature and then discussed within a panel of experts, using
a focus group. Phase 2 focused on a three‐step validation process.
The first step aimed to assess face and content validity of the pool
of items previously generated (initial version of the PUM‐SES). The
second step aimed to determine the psychometrics of the developed
scale (i.e., exploratory factorial analysis) and its reliability (i.e., internal
consistency), and eventually remove or modify ambiguous items. The
third step referred to (a) the assessment of construct validity through
a confirmative factorial analysis of the most plausible factor structure
derived from the previous step, (b) the assessment of the concurrent
validity using a general measure of self‐efficacy (c) and the evaluation
of internal consistency and stability (reliability).
3.2 | Phase 1: developing the initial pool of items
In this phase, the research team conducted a literature review in the
field of wound care to summarise the paramount interventions aimed
to describe the nursing activities in managing PUs. According to
Bandura's recommendations, the literature review specifically aimed
to highlight the main challenges and issues that nurses have to face
in their daily nursing interventions to manage PUs (Bandura, 2001).
Accordingly, the literature review was conducted independently by
three researchers (FD, FT and VB). Then, the main results were labelled,
shared, compared and discussed in a consensus meeting among the
research team members to achieve their final agreement and also solv‐
ing the possible divergences in defining the main results. The consen‐
sus meeting summarised these results into five main themes related to
the management of PUs: (a) prevention; (b) assessment; (c) treatment;
(d) nurses‐specific clinical skills; and (e) health services. These themes
represented the initial framework of the PUM‐SES, shaping the initial
domains to measure self‐efficacy related to PU management.
Subsequently, the results of the literature review were dis‐
cussed in a focus group involving both researchers and expe‐
rienced wound‐care specialists (i.e., specialists with a certified
education in wound care). This approach allowed the comparison
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of the results coming from the literature review with the real‐life
experiences proposed by the wound‐care specialists. Precisely, the
focus group took place in February 2017, and it was conducted by a
researcher (RC) with high expertise in role‐playing and interviews.
Focus group participants were involved using a purposeful sam‐
pling, being selected considering their knowledge and expertise
on management of PUs or research on wound care. Further, the
research team also considered the availability and willingness of
the eligible participants to participate in this research. Accordingly,
seven specialist nurses took part in the focus group, which was
audio‐recorded and verbatim‐transcribed, with the written consent
of all participants. The research team performed a textual content
analysis to investigate the verbatim text and to identify possible
hidden themes (Hsieh & Shannon, 2005). Specifically, two experts
in qualitative research (FD and RC) guided this analysis. The results
from the textual content analysis were represented by statements
aimed to describe the themes of the focus group. Accordingly, the
focus group proposed the first set of items. Referring to PUs, the
initial three main themes (which represent the hypothetical scale
domains) were (a) management (including prevention, assessment
and treatment); (b) clinical skills; and (c) healthcare services (mainly
referred to the devices and their supply). Each statement used to
represent the sub‐themes of the three domains was tested using
member checking and peer debriefing (Lincoln & Guba, 1986). The
resulting 32 statements represented the basis of the initial pool of
items. Accordingly, each developed item referred to the three pre‐
identified main themes of the focus group. These items measured
each presented situation to answer to the following question: “How
confident do you feel when faced with the following situations?”
The responders had to use a five‐point Likert scale (from 1 = com‐
pletely no confident–5 = completely confident).
Overall, items generation followed the recommendations for
avoiding errors in the wording (Dillman, Smyth, & Christian, 2014).
This phase was conducted in April 2017.
3.3 | Phase 2: validation process
The original pool of items was validated following three main steps:
face and content validity, psychometric evaluation and initial relia‐
bility (cross‐sectional data collection) through an exploratory factor
analysis (EFA). Then, construct validity was assessed using a con‐
firmative factor analysis (CFA) (further cross‐sectional data collec‐
tion was needed after the analysis of the previously collected data),
while concurrent validity described the relationships between PUM‐
SES and General Self‐Efficacy Scale, which were expected to be
positively associated. The final reliability was assessed on the data
collected for the CFA through the assessment of stability and inter‐
nal consistency.
3.3.1 | Phase 2: First step
The first step of the validation process was conducted between
May–June 2017, involving a panel of experts in wound care to

DELLAFIORE et al.
ascertain the scale face and content validity (Polit & Beck, 2014).
Experts were enrolled using a purposeful sampling from a list of
fifteen specialists in wound care coming from several university
hospitals of Northern Italy. Face validity explored panellists’ under‐
standing of the items and their views about the overall concept they
purport to measure, assessed through open‐ended questions to the
panellists. Conversely, content validity referred to the “quantitative”
agreement among panellists regarding how pertinent each item was
in relation to the objective of its measurement using Likert scores
(1 = completely no pertinent; 4 = completely pertinent) (Lawshe,
1975). During this phase, some items were modified or deleted, ac‐
cording to the results coming from the validation process.
3.3.2 | Data analysis for face and content validity
As a preliminary analysis, descriptive statistics were performed on
the demographic characteristics for involved panellists and their an‐
swers to the Likert scores. This initial version of PUM‐SES was tested
for face and content validity, computing content validity ratio (CVR)
and Content Validity Index for item level and scale level (I‐CVIs and
S‐CVI; Polit & Beck, 2014). Content and face validity could require
more than one round of panellists’ consultation to achieve adequate
indexes, where amendments to the items had to be integrated at
the end of each round. To obtain the face validity, the authors asked
the same panel of experts to answer three open‐ended questions
and then transcribed verbatim for the textual analysis. The questions
were aimed to explore the difficulty level of the items’ wording, the
desired meanings, and to discuss any ambiguity or misinterpreta‐
tions of the same items.
3.3.3 | Phase 2: Second step
A multicentre cross‐sectional approach was used to collect data for
the psychometric evaluation and the reliability. Nurses coming from
two university hospitals of Northern Italy (Lombardy region) were
enrolled in the study from July–September 2017 using a conveni‐
ence and consecutive sampling (i.e., sample A). Eligible nurses had to
be full‐time hired, working for more than 6 months and with profi‐
cient skills in understanding the Italian language (i.e., foreign nurses
with poor knowledge of Italian language were excluded). Further,
eligible nurses were informed of the study aim, and they had to sign
a written consent form to confirm their willingness to participate.
3.3.4 | Data analysis for EFA
The sample size determination for the EFA on sample A was based
on the recommendation to enrol ten participants for each item in
the scale (Watkins, 2018). Considering that the items in this stage
of scale development were sixteen (desirable sample = 160 nurses),
and also keeping into account a desirable response rate equal to 80%,
we invited 200 eligible nurses. As a preliminary analysis, descriptive
statistics were performed on the distribution of each item, including
the evaluation of skewness and kurtosis to ascertain the normality.
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EFA was preceded by Bartlett's test used to assess the factorability
of the correlation matrix and the Kaiser–Meyer–Olkin (KMO) index
to assess the sample adequacy to factor analysis. Specifically, EFA
was performed using maximum‐likelihood estimator (ML), where the
analysis of the eigenvalues, the scree test and the framework given
by phase 1 (three dimensions) were used for selecting the number of
factors (domains) underlying the items’ answering (Reise, Waller, &
Comrey, 2000). An oblique rotation (Geomin) was used to maximise
the factor loadings on their latent dimension (domain). This rotation
is suggested when items are supposed to be intercorrelated. Only
the items with a factor loading equal or higher than 0.32 and without
cross‐loadings (loadings higher than 0.32 with more than one factor)
were kept for the subsequent validation step (Costello & Osborne,
2005). Cronbach's α coefficient was used to assess internal consist‐
ency of the items grouped into their factor of reference, according
to the EFA interpretation. All statistics were performed using MPlus
7.1.
3.3.5 | Phase 2: Third step
This step of the validation process needed a new data collection
(cross‐sectional) to confirm the results derived from the psychomet‐
ric assessment (phase 2, step 2). Data were collected in two major
hospitals in the greater Milan area (Italy). Accordingly, a sample of
nurses was enrolled (i.e., sample B) between October–December
2017, using a convenience and consecutive sampling approach, and
using the same inclusion/exclusion criteria of the previous step.
Further, a sample of 15 nurses was randomly selected and invited
to re‐take the scale 20 days after their first assessment to determine
the stability of PUM‐SES using the test–retest approach.
3.3.6 | Data analysis for construct, concurrent
validity and reliability
The sample size determination for the CFA on sample B took into
account the factor structure coming from EFA, which suggested
four domains. Accordingly, we followed the recommendation to
enrol 50 participants for each domain (estimated sample = 200
nurses) (VanVoorhis & Morgan, 2007). Further, we also consid‐
ered an optimal response rate equal to 80%; for this reason, we
invited 240 eligible nurses. Then, an ordinal confirmatory facto‐
rial analysis (CFA) was performed on the sample B to validate the
most plausible factor structure model derived from the previous
EFA performed in sample A. The following indices were consid‐
ered to evaluate the fit between the hypothesised CFA model and
the observed covariance matrix: the Satorra–Bentler chi‐square;
the comparative fit index (CFI) (values > 0.90 indicated an accept‐
able fit); the root mean square error of approximation (RMSEA)
(values < 0.06 indicated an acceptable fit); and the weighted root
mean square residual (WRMR; values 1.0 indicated an acceptable
fit). In addition, the possible presence of a single second‐order fac‐
tor was examined, hypothesising an underlying more general fac‐
tor of PU management specific self‐efficacy, which could explain

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3182       DELLAFIORE et al.
the intercorrelations between the first‐order factors. The chi‐
square difference tests were performed to evaluate the adequacy
of possible competing models which may explain the observed re‐
lationships as well. To compute the chi‐square difference tests, we
needed to consider both the difference in the chi‐square values
of the two competing models and the difference in the degrees of
freedom. If the chi‐square difference is significant, the model with
more satisfactory parameters of fit to data is the most suitable
solution. In case the chi‐square difference is not significant, both
models fit the data equally well.
Domains resulting from CFA were assessed again through
Cronbach's α. Further, the two measures of the test–retest were as‐
sociated using Pearson correlation (r), where higher correlation indi‐
cated good stability. A nonprobabilistic sampling (i.e., convenience
sampling) was used for the test–retest, where 15–20 participants
were considered as the minimum sample size based on previous
research to assess stability in self‐report self‐efficacy measures
(Caruso, Pittella, et al., 2016). Pearson correlation (r) was also used to
assess the concurrent validity, describing the relationships between
PUM‐SES and GSE, where a positive association was expected as an
evidence of concurrent validity. All statistics were calculated using
α = 0.05. Statistics were performed using MPlus 7.1 and the IBM
SPSS Statistics for Windows, Version 22.0 (IBM Corp. USA).
3.3.7 | Measurements
Data collected in this study consisted in socio‐demographic char‐
acteristics, answers form the PUM‐SES and General Self‐Efficacy
Scale (GSE). The socio‐demographic characteristics were sex, age
and marital status, level of education, years of experience and clini‐
cal area of belonging. GSE was a monodimensional, self‐report tool
to measure general self‐efficacy. GSE encompassed 10 items, and
its validity and reliability were demonstrated by several studies in
33 different languages (Scholz, Benicio Gutiérrez, Sud, & Schwarzer,
2002). The items of the scale needed to answer to the following
question, using a four‐point Likert scale (from 1 = not true–4 = al‐
ways true): “How much do you agree with this statement?”.
3.3.8 | Ethical considerations
This study obtained the approval from the Institute Review Board
(IRB) (822/int/2017) and the authorisation of each involved centre.
The research was conducted in full accordance with the interna‐
tional ethical principles and the Italian legal requirements for non‐
interventional studies. All the enrolled nurses were informed about
aim and methodology of the study, and they were asked to provide a
written informed consent. Enrolled nurses were also informed about
the confidentiality of their answers.
3.3.9 | Scoring
According to Bandura's recommendations, self‐efficacy should be
measured using 0–100 scores (Bandura, 1997, 2006). Therefore, we
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standardised each domain score to 0–100, as well as the overall scale score.
PUM‐SES did not include items to be reversed. For this reason, to stand‐
ardise each domain score, it is needed to subtract the possible minimum
score from the sum of the items for each domain and then multiply by 100
divided by the difference between the maximum and minimum score.
Accordingly, standardised assessment = [(item1 + item2)‐2]*(100/8);
standardised planning = [(item3 + item4)‐2]*(100/8); standardised deci‐
sion‐making = [(item6 + item8+item9 + item10)‐4]*(100/16); and stand‐
ardised supervision = [(item5 + item7)‐2]*(100/8). To score the overall
scale, it is needed to sum item responses, subtract the number of items
answered and multiply by 2.5.
4 | R E S U LT S
4.1 | Face and content validity
Thirteen nurses participated in phase 2 to test face and content
validity (response rate = 87%). Females represented 60% of the
involved experts (n = 7). They had an average age of 36 ± 9 years,
working from 13 ± 7 years. Four nurses of them had a specialist
postgraduate education in wound care, while the other three were
expert in research. The first content validity round was assessed by
CVR, I‐CVIs indicating that only 16 items (on the 32 proposed by
the initial pool) achieved adequate content validity (i.e., CVRs higher
than 0.70). Accordingly, the analysis of the comments for face va‐
lidity confirmed the redundancy of those items with low CVR and
I‐CVI. Once deleted the redundant items, a second round of face and
content validity achieved satisfactory indices (all CVRs, I‐CVIs and S‐
CVI had scores higher than 0.75). Consistently, the narrative analysis
on the experts’ answers to the second round of consultation of the
experts showed two main themes: “usefulness” and “immediacy of
comprehension.” Finally, these 16 items composed the initial version
of PUM‐SES with adequate face and content validity.
4.2 | Exploratory factorial analysis and internal
consistency
A sample of 150 nurses (response rate = 75%) was enrolled in this
step (sample A). Table 1 shows the demographics of the sample A.
The majority of nurses were females (78%), unmarried (52.7%), em‐
ployed in surgical units and long‐term wards (60.7%). Their average
age was 39.11 ± 9.7 years, and the mean of their years of experience
was 15.3 ± 9.99.
The preliminary analysis on the covariance matrix to assess its
factorability showed that Bartlett's test of sphericity was significant
(p < 0.001) and the Kaiser–Meyer–Olkin (KMO) test was 0.91, indicating
the adequacy of sample A. The study of the scree test, the interpreta‐
tion of fit indices and the theoretical interpretation of the intercorrela‐
tions among items suggested four factors with a good fit to the data:
𝜒(2text  = 51.69; p = 0.005; CFI = 0.982; TLI = 0.972; SRMR = 0.026;
2text9)
total variance = 49.6%. An alternative model testing a three‐factor
solution was run, but it had poor fit to the data, considering the in‐
dices as follow: 𝜒(2text
9text0)
 = 1,488.76; p < 0.001; RMSEA = 0.274; 90%
 13652702, 2019, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.14875 by Ondokuz Mayis Universitesi Kutuphane Ve Dokumantasyon, Wiley Online Library on [10/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
DELLAFIORE et al. |
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TA B L E 1   Samples' demographics (sample A and sample B) model, with all items significantly loading on the respective factors
(Table 2). An alternative three‐factor model based from the first
Sample A (N = 150) Sample B (N = 182)
PUM‐SEM development (phase 1 with three pre‐identified domains)
Phase 2 (Step b) Phase 2 (Step c) was tested, but it showed poor fit to the data (𝜒(2text  = 1,466.71;
8text8)

  n % n % p < 0.001; RMSEA = 0.279; 90% CI [0.225–0.358]; CFI = 0.401;

TLI = 0.306; SRMR = 0.198). This result was also corroborated by
Sex
a statistically significant chi‐square difference between the two
Male 33 22 35 19.2
models (p < 0.001). Hence, the model with four factors was the
Female 117 78 147 80.8
most adequate structure, where assessment, planning, decision‐
Age making and supervision had a good internal consistency (i.e., 0.871;
Years (m; SD) 39.11 9.71 36.21 9.7 0.896; 0.947; and 0.928, respectively). The internal consistency
Marital status for the overall scale was also high, being 0.968. Further domains
Married 71 47.3 72 39.6 were positively intercorrelated, where assessment was corre‐
Unmarried 79 52.7 110 60.4 lated with planning (r = 0.64; p < 0.001), decision‐making (r = 0.72;
Work environment p < 0.001) and supervision (r = 0.76; p < 0.001), planning was also
Outpatient clinic 19 12.7 9 4.9 correlated with decision‐making (r = 0.75; p < 0.001) and supervi‐

Long‐term unit 45 30 45 24.7

sion (r = 0.69; p < 0.001), and finally decision‐making was correlated
with supervision (r = 0.78; p < 0.001). Considering the high internal
Postoperative unit 46 30.7 58 31.9
consistency for the overall scale and the intercorrelation among do‐
Intensive and 27 18 45 24.7
critical care mains, a second‐order factor model resulted to explain data as well
(𝜒(2text  = 60.48; p < 0.001; RMSEA = 0.050; 90% CI [0.034–0.066];
Others 13 8.7 24 13.1 3text3)
CFI = 0.971; TLI = 0.976; SRMR = 0.033). This model is depicted
Years of experience
in Figure 2, where factor loadings were close to the values of the
Means (SD) 15.30 9.9 12.49 10.27
four‐dimension CFA as shown in Table 2. Comparing the four‐fac‐
tor model with the second‐order factor model (chi‐square second‐
CI(0.221–0.451); CFI = 0.421; TLI = 0.386; SRMR = 0.208. Further, order factor model– chi‐square four‐factor model) using likelihood
these two EFA models had a significant chi‐square difference, indicat‐ ratio test resulted in a chi‐square difference of 0.767 with 2 degrees
ing that only one model was suitable to explain data. Accordingly, the of freedom, showing an adequacy to explain the data for both the
model having better indices of fit (the one with four factors) was the models. Overall, as depicted in Figure 3, the standardised scores for
most plausible solution. Then, the extracted four factors were re‐la‐ each domain were as follows, where higher scores indicated higher
belled as follows: assessment; (b) planning; (c) decision‐making; and (d) self‐efficacy: assessment = 57.9 ± 6.6, planning = 66.6 ± 5.9; super‐
supervision. Some of the items showed cross‐loadings, that is, loadings vision = 54.4 ± 4.3; and decision‐making = 73.2 ± 7.0.
higher than 0.30 with more than a single factor (item 3; item 4; item 7; Concurrent validity was also satisfactory, considering that GSE
item 8; item 15; item 16). After a careful analysis of these items’ content had a significant and positive relationship with all the domains and
(File S2), the research team agreed to delete them prior to re‐use the the overall scale. Specifically, higher scores of GSE were associated
PUM‐SEM for further construct validity testing using a new sampling. with higher scores of assessment (r = 0.42; p < 0.001), planning
At the end of this phase, PUM‐SES encompassed 10 items. Cronbach's (r = 0.41; p < 0.001), decision‐making (r = 0.44; p<0.001), supervi‐
α was acceptable for each computed domain (excluding the deleted sion (r = 0.42; p < 0.001) and overall scale (r = 0.45; p < 0.001).
items) and for the overall scale (assessment = 0.871, planning = 0.893; The correlations between first answers and second answers of
decision‐making = 0.867; supervision = 0.930; overall scale = 0.965). the 15 nurses selected for the test–retest were all higher than 0.60
This last version encompassed ten items. (p < 0.001) for the four domains and the overall scale.

4.3 | Construct and concurrent validity and

reliability
A sample of 182 nurses was enrolled in this step (response
rate = 86%). Table 1 shows the demographics of the sample B.
The majority of the enrolled nurses were female (80.8%), unmar‐
ried (60.4%) and employed in surgical units (31.9%). Their average
age was 36.2 ± 9.7 years, with a mean of working years equal to
12.5 ± 10.3. Results from the confirmatory model (𝜒(2text
3text1)
 = 59.7,
p < 0.001; RMSEA = 0.079; 90% CI [0.05–0.11]; CFI = 0.977;
TLI = 0.966; SRMR = 0.38) showed the adequacy of the four‐factor
5 | D I S CU S S I O N
This study was designed to develop a scale to measure the self‐ef‐
ficacy related to PU management among nurses, that is, PUM‐SES.
PUs are currently an important issue for every healthcare setting
(Courvoisier et al., 2018). Accordingly, the possibility to measure
self‐efficacy in managing PUs opens a number of future scenarios
for clinical practice and education, as self‐efficacy acts as a proxy
assessment of nurse capacity for the appropriate management of
PUs. There is a growing interest in the description of the role of
 | 3184      

TA B L E 2   Psychometric assessment and construct validity

Psychometric assessment Construct validity

EFAa  Factor Loadings (Sample A, n = 150) CFAb  Factor Loadings (Sample B, n = 182)

Factor 1: Factor 2: Factor 3: Factor 4: Factor 1: Factor 2: Factor 3: Factor 4:

  Mean SD Assessment Planning Decision‐making Supervision Mean SD Assessment Planning Decision‐making Supervision

Item 1 3.36 0.85 0.894 0.028 −0.012 0.040 3.34 0.76 0.841      
Item 2 3.4 0.79 0.629 0.019 0.154 0.182 3.29 0.71 0.920      
Item 3 3.48 0.88 0.569 0.334 0.042 0.007 – –        
Item 4 3.76 0.78 0.217 0.366 0.438 −0.167 – –        
Item 5 3.81 0.77 0.084 0.932 −0.018 −0.106 3.80 0.71   0.877    
Item 6 3.65 0.89 0.090 0.754 0.051 0.070 3.53 0.82   0.929    
Item 7 3.61 0.82 −0.064 0.500 0.354 0.111 – –        
Item 8 3.53 0.83 0.140 0.387 0.124 0.372 – –        
Item 9 3.24 0.86 0.437 0.002 0.010 0.653 3.07 0.85       0.883
Item 10 3.62 0.78 −0.073 0.053 0.805 0.068 3.54 0.81     0.834  
Item 11 3.07 0.89 0.102 0.067 0.309 0.418 3.28 0.81       0.782
Item 12 3.36 0.88 0.104 0.007 0.745 0.064 3.31 0.75     0.872  
Item 13 3.43 0.81 −0.016 0.001 0.669 0.269 3.38 0.80     0.860  
Item 14 3.48 0.76 0.036 0.133 0.672 0.080 3.48 0.76     0.851  
Item 15 3.62 0.84 −0.098 0.467 0.696 0.051 – –        
Item 16 3.16 1.03 0.060 −0.487 0.421 −0.043 – –        
  Explained variance 12.8 10.7 14.7 11.4 Explained variance 13.6 11.4 16.7 12.7
(%) (%)

Note. Bold values indicate factor loadings greater than 0.32 without cross‐loadings.
a
Factors were extracted by maximum‐likelihood estimator with Geomin rotation to optimise loading interpretations. Factor loadings were all standardised. Overall % of variance for EFA = 49.6%.
b
Estimates for factor loading derived from MPlus STDYX completely standardised solution. Overall % of variance = 54.4%.
DELLAFIORE et al.

13652702, 2019, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.14875 by Ondokuz Mayis Universitesi Kutuphane Ve Dokumantasyon, Wiley Online Library on [10/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
13652702, 2019, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.14875 by Ondokuz Mayis Universitesi Kutuphane Ve Dokumantasyon, Wiley Online Library on [10/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
|       3185

F I G U R E 2   Second‐order factorial analysis

F I G U R E 3   Standardized scores of
DELLAFIORE et al.

self‐efficacy

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3186       DELLAFIORE et al.
self‐efficacy as a performance predictor, acknowledging that self‐
efficacy is a modifiable factor of every person, and nursing out‐
comes could benefit from tailored intervention to enhance nurses’
task‐specific self‐efficacy (Caruso, Pittella, et al., 2016). Within this
frame of literature, the main contribution of this study refers to the
evidence of validity and reliability of PUM‐SES.
The posed model with four different domains of self‐efficacy
showed good fit to the data, as did the second‐order CFA model.
These results confirm the theoretical framework given by Bandura
(2001) that self‐efficacy related to PU management could theoret‐
ically encompass more sub‐measures than a unique more general
measurement. Further, the intercorrelation among specific domains
and the high internal consistency of the overall scale corroborate the
possibility to score the overall measure of PUs’ management self‐effi‐
cacy, as well as the single domains. Reliability was also adequate in re‐
lation to the scale stability. Further, the positive relationships between
PUM‐SES and GSE supported concurrent validity, considering that the
two measurements of self‐efficacy were consistent with the theoret‐
ical expectation where higher levels of specific self‐efficacy are cor‐
respondent to higher levels of general self‐efficacy (Bandura, 2001).
The four domains and each developed item were consistent with
prior research in wound care. Particularly, decision‐making was the
area with higher scores, followed by planning, assessment and su‐
pervision. This trend, showing higher self‐efficacy in performing
proper decision‐making, is consistent with the previously described
endeavours in nursing education, where the approach of problem‐
solving guides the decision‐making (Arrigoni et al., 2017). Further,
decision‐making in PU management encompasses the complexity
of the “team effect,” since it should be based on a model of collab‐
orative approach between family caregivers and many healthcare
providers (Caruso, Magon, Dellafiore, et al., 2018; Schmitt et al.,
2017). It is possible that nurses are more confident in their ability
to perform decision‐making that takes into account problem‐solving
and collaboration, rather than planning, assessment and supervision
investigated by PUM‐SES.
Accordingly, planning, assessment and supervision seem to reflect
the major difficulties underpinning the management of PUs. At this
regard, literature has described that the function of nurses in plan‐
ning PU management does not only referred to their role as wound
care providers, but also refers to their educational role (Eisenberger
& Zeleznik, 2004; Magon et al., 2018). De facto, education of patients
and caregivers is fundamental to achieve the best enhancements in
self‐management, early mobilisations (when it is possible), nutrition,
posture training, etc. (Cameron et al., 2015; Caruso, Magon, Baroni,
et al., 2018; Cooper, Vellodi, Stansby, & Avital, 2015). Further, the
domain of assessment responds to the need of adequate knowledge
related to the available international classification and monitoring of
PUs over time (Cooper et al., 2015; NPUAP EPUAP PPPIA, 2014). In
addition, the domain of supervision does not encompass easy tasks,
because it needs a deep understanding of the role of nurses towards
the activities of the healthcare assistants, which should be particu‐
larly contextualised in the setting where nurses work to avoid missed
care activities or failure in care delivery (Johnson et al., 2015).
13652702, 2019, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.14875 by Ondokuz Mayis Universitesi Kutuphane Ve Dokumantasyon, Wiley Online Library on [10/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
5.1 | Limitations and strengths
This study presented some limitations. Firstly, PUM‐SES was devel‐
oped using two Italian samples, and we expected possible influence
from the national context. However, PUM‐SEM is a valid and reliable
measure for task‐specific self‐efficacy in Italian nurses, which should
be tested with more empirical research in different contexts. Another
limitation was the convenience sampling used to enrol nurses. Further,
the description of PUM‐SEM should not be intended as a representa‐
tive portrait of the Italian population, due to more multicentric and
randomised samplings are needed. Accordingly, the two samples in
this study differed from the overall Italian nursing population, regard‐
ing age and years of experience; specifically, the nurses in our sam‐
ples were slightly younger (Caruso, Rocco, Shaffer, & Stievano, 2019).
Those demographic differences suggest caution when considering our
samples as fully representative of the Italian nursing population for the
inferential meanings of this study. For this reason, we recommend pru‐
dence regarding the generalisability of the study results. Considering
the reliability, we also suggest caution in considering the scale as sta‐
ble, due to our test–retest was performed using a narrow time frame
of 20 days generally used for self‐report scales, while some authors
suggested a broader time frame (at least three months) to ascertain
stability in self‐efficacy measurements (Tonkin, 2008). Another limi‐
tation regarding the evidence of stability is given by the sample size
(n = 15), which is not necessarily representative of the broader nursing
population.
Further, the domains of PUM‐SES were narrowly expressed,
considering that three domains out of four encompassed only two
items. This aspect requires careful consideration, as the number of
items needed to provide optimal coverage of the construct's the‐
oretical domain is commonly suggested to be at least three (Hair,
Black, Babin, & Anderson, 2010). However, according to some re‐
cent indications for domains’ extraction, only two items could be
considered sufficiently reliable to express a latent variable (scale
domain), when those items are highly correlated with each other
but slightly correlated or uncorrelated with other variables, as we
observed in our scale (Yong & Pearce, 2013). That being said, we
suggest further empirical evidence to confirm the factorial struc‐
ture of PUM‐SES.
Lastly, more research should be performed to describe specific‐
ity and sensitivity of PUM‐SES. Particularly, specificity and sensi‐
tivity are required in future research to determine the cut‐offs of
adequate and inadequate self‐efficacy through the study of the
self‐efficacy and dichotomous clinical empirical outcomes (e.g.,
PUs being prevented/healed vs. PUs not being prevented/healed)
under the receiver operating characteristic (ROC) curve. However,
the main strengths were given by the consecutive approach for sam‐
pling to control for selection bias and by the high methodological
consistency with the main recommendations to develop self‐effi‐
cacy measures (Rattray & Jones, 2007). Another important strength
of PUM‐SES was given by the fact that it was actually easy to fill
(its filling requires approximately 3–5 min). This implies easy use of
PUM‐SES in studies that require multiple questionnaires.

DELLAFIORE et al.
6 | CO N C LU S I O N
This study developed and validated a 10‐item scale to measure self‐
efficacy in nurses related to PU management. Our results showed
evidence of internal consistency, stability, content validity, construct
and concurrent validity. We recommend more validity testing in dif‐
ferent countries to allow cross‐national research, and further stud‐
ies to assess the specificity and sensitivity of PUM‐SES, which are
fundamental to establish future cut‐offs for critical levels of self‐ef‐
ficacy. Overall, PUM‐SES could be useful in educational and clini‐
cal research. Educational studies might use PUM‐SES to detect the
weakest areas of self‐efficacy in nurses, also testing which educa‐
tional approach could be more functional to enhance and sustain
their self‐efficacy. Clinical studies might use PUM‐SES to correlate
empirically nurses’ self‐efficacy with clinical outcomes in PU man‐
agement and to develop tailored action plans to optimise outcomes.
7 | R E LE VA N C E TO C LI N I C A L PR AC TI C E
In the general field of wound care, prior studies highlighted that
patients’ higher self‐efficacy was associated with better outcomes
(Hug et al., 2018). However, no empirical evidence is currently avail‐
able showing the relationship between nurses’ self‐efficacy and
outcomes related to PUs. PUM‐SES could be helpful to close this
gap. PUM‐SES may yield further insights to frame educational paths
aimed to enhance nurses’ belief of their ability in managing PUs.
The influence of psychological factors such as self‐efficacy on
outcome was largely described, acknowledging that self‐efficacy
mediates the relationship between knowledge and practice (Andrew,
McVicar, Zanganeh, & Henderson, 2015; Hoffman, 2013). A high
sense of self‐efficacy allows for persevering and acting towards the
achievement of the best outcomes, despite the challenges of daily
practice (Bandura, 2001). As we found in this study, self‐efficacy
varies on several dimensions related to the challenging aspects of
everyday clinical practice. Each dimension is important as it affects
a specific aspect of daily practice in a different way. For instance,
some nurses may feel capable in performing a proper assessment of
PUs, but less capable to plan a care path or to supervise the activ‐
ities of healthcare assistants. These different aspects of the same
broader self‐efficacy could affect the outcomes independently. The
more general domain of self‐efficacy (the scale overall score) rep‐
resents the general proxy assessment of nurses’ belief to succeed in
managing PUs.
AC K N OW L E D G E M E N T S
We wish to thank all the study participants and the data managers
for the support in collecting and record the case form reports.
C O N FL I C T O F I N T E R E S T
The authors declare no conflict of interest.
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|
      3187
AU T H O R C O N T R I B U T I O N S
RC, FD, CA, GG, IB, FT, GC, AM and FP: conception and design, or
acquisition of data, or analysis and interpretation of data; RC, GG,
FD and GC: drafting the manuscript or critical revision of important
intellectual content; RC, FD, CA, GG, IB, FT, GC, AM and FP: final
approval of the version to be published. Each author should have
participated sufficiently in the work to take public responsibility for
appropriate portions of the content; and RC, FD, IB, FT, GC, AM and
FP: accountable for all aspects of the work in ensuring that questions
related to the accuracy or integrity of any part of the work are ap‐
propriately investigated and resolved.
ORCID
Gianluca Conte  https://orcid.org/0000-0002-8171-8203
Rosario Caruso  https://orcid.org/0000-0002-7736-6209
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S U P P O R T I N G I N FO R M AT I O N
Additional supporting information may be found online in the
Supporting Information section at the end of the article.  
How to cite this article: Dellafiore F, Arrigoni C, Ghizzardi G,
et al. Development and validation of the pressure ulcer
management self‐efficacy scale for nurses. J Clin Nurs.
2019;28:3177–3188. https://doi.org/10.1111/jocn.14875