Journal of Tissue Viability 29 (2020) 76–81

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Journal of Tissue Viability

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Factors related to knowledge, attitude, and practice of nurses in intensive T

care unit in the area of pressure ulcer prevention: A multicenter study
Shahrokh Khojastehfarb, Tahereh Najafi Ghezeljeha,b,∗, Shima Haghania
a
Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran
b
Department of Critical Care Nursing, School of Nursing and Midwifery, Iran University of Medical Sciences, Rashid Yasemi St, Valiasr St, Tehran, Iran

A R T I C LE I N FO A B S T R A C T

Keywords: Introduction: As one of the main members of the health team, nurses have an important role in pressure ulcer
Pressure ulcers prevention in health care centers. The aim of this study was to investigate knowledge, attitude, and practice of
Bed sores nurses on the prevention of pressure ulcers and their related factors.
Attitude Methods: This cross-sectional study was carried out in 2018. The total number of ICU nurses employed in
Knowledge
educational-health centers affiliated to Iran University of Medical Sciences were examined. Among a total of 328
Practice
Nurse
nurses, 308 questionnaires were completed by the participants. Pressure Ulcer Knowledge Questionnaire,
Pressure ulcer prevention Attitude Toward Pressure Ulcer, and Practice of Pressure Ulcer Prevention questionnaires were used to collect
data. SPSS software version 16 and independent t-test, Chi-square, Fisher exact, one-way Analysis of variance,
and multiple linear regressions tests were used for data analysis.
Findings: Based on the mean score of knowledge, attitude, and practice of the nurses about the pressure ulcer
prevention were 63.47 ± 10.31, 39.10 ± 40.22, and 32.03 ± 6.17, respectively. There was a positive and
significant relationship between these three variables. Findings revealed that knowledge was increased by 0.051
units, with a one-year increase in work experience of nurses in the ICU. Moreover, women's knowledge and their
attitude were higher than those of men as 3.132 and 1.65 units, respectively. Based on the findings, attitude of
nurses increased by 0.43 units for an hour of extra work per week. Nurses' attitude score in the General ICU and
their practice were higher than scores of other nurses as 2.144 and 2.574 units, respectively. Moreover, practice
of nurses increased by 0.162 unit with one-year increase of their age.
Conclusion: Given the undesirable level of knowledge and attitude and relatively desirable practice of nurses in
the field of pressure ulcer prevention and the importance of improving the safety of patients admitted to the ICU,
it is suggested that appropriate educational planning be developed to raise the level of knowledge, attitude, and
practice of health care providers, especially nurses, in the area of pressure ulcer prevention.

1. Introduction
Pressure ulcer is a common and debilitating problem occurring in all
health care centers [1]. Pressure ulcers are localized tissue damages to
the skin or soft tissue over bony prominence or related to devices as a
result of pressure and/or shear [2]. Every year, 2.5 million people in the
United States are prone to develop pressure ulcers, among which
60,000 people will die due to its complications such as sepsis and os-
teomyelitis [3]. Pressure ulcers can also have adverse effects on families
and care providers of health organizations, impose therapeutic costs to
the family and medical centers, and lower quality of life [4]. To manage
them, the health system spends $18.5 billion a year in America, of
which $129,000 is spent on the treatment of patients whose entire
tissue thickness was affected by the ulcer [3]. Patients admitted to ICU
are more prone to the pressure ulcer resulting from hospitalization
because of aggressive care measures, central vascular lines, and me-
chanical ventilation [5].
Pressure ulcers are amongst the indicators of nursing care quality
[6] and nurses play a vital role in prevention and responding to the
onset of these ulcers [3]. In the ICU, patient's care team have been
assigned to prevent the incidence of pressure ulcer, and its team
members not only have to pay attention to the patient's early illness, but
also to take into account any potential risk of hospitalization that ul-
timately leads to side effects [5].
Basic knowledge and clinical experiences are necessary to improve
the quality and safety of nursing care. Caring patients with pressure
ulcer is one of these issues and its responsibility is on nurses who take
care of patients [7]. However, the nurses' compliance with the

∗
Corresponding author. School of Nursing & Midwifery, Rashid Yasemi St, Valiasr St, Tehran, Iran.
E-mail addresses: khojastehfarshahrokh@gmail.com (S. Khojastehfar), najafi.t@iums.ac.ir (T. Najafi Ghezeljeh), shima_haghani@yahoo.com (S. Haghani).

https://doi.org/10.1016/j.jtv.2020.02.002
Received 19 December 2018; Received in revised form 12 January 2020; Accepted 2 February 2020
0965-206X/ © 2020 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.
S. Khojastehfar, et al.
guidelines of pressure ulcer prevention has been reported to be weak
[8] and nurses' compliance with clinical guidelines is affected by sev-
eral factors, one of which can be lack of knowledge in this area [9]. In
practice, they assign low priority to pressure ulcer prevention and ig-
nore its importance [3]. Nurses' knowledge about pressure ulcer is es-
sential for evaluation, risk factor management, and the implementation
of preventive approaches [8]. Given the fact that nurses' attitude and
knowledge about the pressure ulcer prevention are related to their
caring quality [10], research on nurses’ knowledge and attitude to-
wards the prevention of pressure ulcers may help increase preventive
strategies and their attention to this vital indicator of nursing care
quality [11]. To remove barriers to pressure ulcer prevention in ICUs
and other hospital and therapeutic sections, the authorities and nursing
service policy makers must have more information on knowledge, at-
titude, and practice of nurses regarding the pressure ulcer prevention in
order to plan in-services educational programs. Meanwhile, profes-
sional nurses can be trained to provide nursing care. Nursing managers
should also recognize the caring status and then optimize it [10].
Although, according to recent line of research on pressure ulcers,
knowledge is reported to be good in some studies and inadequate some
other studies [12]. Moreover, the literature review on ICU nurses is
scant. Also, there is diversity in studies related to different sectors with
a small sample size and numerous methodologies, some of which fo-
cused on instrument validation [13]. Ulcers, which are known as in-
ternational problems, often occur in patients with physical disabilities
and immobile patients hospitalized in ICU [4]. Considering the im-
portance of prevention and management of pressure ulcers in ICU, and
the role of nurses' knowledge and attitudes in compliance with the
standards of prevention and treatment of pressure ulcers, this study has
been conducted with the aim of identifying factors related to knowl-
edge, attitude, and practice of nurses regarding the pressure ulcer
prevention in Educational Centers of Iran University of Medical Sci-
ences (IUMS).
2. Methodology
This cross-sectional study with a correlation design was conducted
in ICU of Educational and Therapeutic Centers of IUMS in 2018. This
study was approved by the Ethical Committee of IUMS with the code of
ethics of IR.IUMS.REC/1396.9511449002. Written informed consent
was obtained from all the studied subjects.
2.1. Subjects
In this research, study samples including all of the nurses working in
ICU of Educational Centers affiliated to IUMS, were enrolled through
census. Among 328 nurses working in these centers, 308 nurses com-
pleted the questionnaire.
2.2. Data collection
In this study, data were collected using self-reporting method and
questionnaire. After obtaining written informed consent from the sub-
jects, the researcher submitted the questionnaires to the subjects and
asked them to complete it in the presence of the researcher. The
questionnaires include: Demographic profile form, Pieper Pressure
Ulcer Knowledge Test (PUKT), Attitude towards Pressure Ulcer, and
Practice of Pressure Ulcer Prevention. Subjects needed 15–20 min to
complete these questionnaires. The demographic form, which is de-
veloped by reviewing related literature, has been prepared by the re-
searcher. The content validity of this researcher-made questionnaire
was examined and confirmed by a panel of experts composed of three
faculty members in Department of Nursing and Midwifery at IUMS.
77
Journal of Tissue Viability 29 (2020) 76–81
2.3. Pieper Pressure Ulcer Knowledge Test (PUKT)
PUKT is one of the most reliable knowledge assessment ques-
tionnaire in the case of pressure ulcers and is designed according to the
North American Pressure Ulcer Prediction and Prevention Guide. The
questionnaire includes 47 questions and each question measures the
nurses' knowledge in three areas of pressure ulcer prevention, pressure
ulcers stage, and pressure ulcers description with three options of
“Correct”, “Wrong”, and “I don't know”. Scores were calculated on a
scale of 100. Nurses' knowledge was considered sufficient enough and
they responded “Correct” to 90% of the questions [14]. Validity and
reliability of the questionnaire was confirmed in a study with Ri-
chardson-Kuder coefficient of 0.7 [15]. In this study, the content va-
lidity of this researcher-made questionnaire was examined and con-
firmed by the panel of experts composed of three faculty members in
Department of Nursing and Midwifery at IUMS. Also, in the present
study, internal consistency of knowledge questionnaire was confirmed
by Kuder-Richardson coefficient of 0.97.
2.4. Attitudes questionnaire on pressure ulcers
The Attitude Questionnaire includes 13 items measuring the mental
attitude of individuals towards pressure ulcer prevention. The ques-
tionnaire has five subscales, namely individual competence for the
prevention of pressure ulcer, prevention of pressure ulcers, impact of
pressure ulcers, responsibility to prevent pressure ulcers, and con-
fidence in the effectiveness of prevention. Then, the total score of these
items was calculated using the 5-point Likert scale (“strongly agree”,
“agree”, “slightly agree”, “disagree”, and “strongly disagree”). Negative
items scores were reversed in the calculation of the total score. Several
items (3.5, 7, 10, and 13) had inverse scores. Certainly, higher scores
showed a better and more positive attitude. Average attitude score of
75% or higher was considered satisfactory for describing the samples
[4]. Its content validity was confirmed in Simonetti's study. Cronbach's
alpha coefficient reported to be 0.743 indicating the suitability of the
internal consistency of the tool [8]. In this study, the Attitude Ques-
tionnaire regarding the pressure ulcers was translated using the trans-
lation-back method.
First, an expert translator specialized in medical concepts translated
the text into Persian. Then, the translated text was translated from
Persian to English by another translator (a bilingual specialist). The
second translator was unaware of the original questionnaire. In the next
step, the researcher of this study and her supervisor compared the
translated texts in Persian and English with the original questionnaire
and made the final decisions about the concepts and words. Content
validity of this questionnaire was also examined and approved by the
same panel of experts. In the present study, Cronbach's alpha coefficient
was obtained 0.743 for the studied samples and the internal consistency
of the tool was confirmed as well.
2.5. Practice Questionnaire on pressure ulcers
This self-report questionnaire includes 20 items on a 3-point Likert
scale from Ever (2) to Never (0) measuring the function of individuals
in pressure ulcer prevention. Minimum and maximum scores were
0–40, and the score of 40 shows the nurses' optimal practice in the
prevention of pressure ulcers [16]. Correct answer to 90% of the
questions or more was considered to describe the desirable practice of
nurses. Nurses were asked to complete the questionnaire. In a study on
nurses, Cronbach's alpha coefficient was reported to be 0.91 suggesting
the suitability of the internal consistency of the instrument [17].
Practice Questionnaire regarding pressure ulcer prevention was trans-
lated by the translation-back method. The content validity of this
questionnaire was confirmed by the same panel of experts. In the pre-
sent study, Cronbach's alpha coefficient was reported to be 0.91 de-
termining the internal consistency of the tool.
S. Khojastehfar, et al.
2.6. Data analysis
Descriptive statistics, independent t-test, One-way analysis of var-
iance (ANOVA), Scheffe's Test, Pearson correlation coefficient, and
multiple linear regression analysis were used for data analysis. Multiple
linear regression model enter method was applied to determine which
of the demographic variables had the most effect on each of the vari-
ables of knowledge, attitude and practice. Independent variables were
also introduced into a regression model that was significant by uni-
variate analysis. Categorical variables were transformed into dummy
variables. The residuals have a normal distribution. Collinearity of in-
dependent variables was investigated with the VIF index and it was
between 1 and 2 in all cases. The un-collinearity condition was also
confirmed. Variation Inflation Factor greater than 2 was considered as
cut-off criterion for deciding when a given independent variable dis-
plays “too much” multi-collinearity. The condition for the in-
dependence of residuals examined by Durbin-Watson statistic was ob-
tained between 1.5 and 1.7 in all three regression models, so the
condition for the independence of the residuals was also confirmed.
Therefore, the regression model enter method was used and all in-
dependent variables were entered the equation in “one step”. Collected
Data were analyzed by SPSS version 16. The significance level was less
than 0.05.
2.7. Findings
In the present study, 94% of the participants completed the ques-
tionnaire. Table 1 summarizes the demographic characteristics of the
study subjects.
Based on the results, knowledge of all nurses included in this study
was at an unfavorable level, but the mean score of knowledge gained by
nurses was 63.47 ± 10.31 with a maximum and a minimum of 23.40
and 82.98, respectively, which was higher than the median score of the
tool (i.e. 50). Also, the attitude of 68.5% of the nurses in this study was
undesirable and unsatisfactory (scores were less than 42), and only
31.5% of the subjects had a satisfactory and desirable attitude.
According to the obtained results, the mean score of nurses’ attitude
was 39.40 ± 10.22 with scores ranging from 27.18 to 49 (Table 2).
Moreover, the results showed that, the average practice score was
32.6 ± 3.7 and the range scores were ranged from 17.89 to 49; the
average score obtained by nurses was higher than the median score of
the tool (i.e. 20). The majority of subjects (64.6%) had a practice score
less than 90% and only 35.4% scored above 90%.
Independent t-test results (Table 1) showed that, there was a sig-
nificant relationship between gender and nurses' knowledge (P = 0.04)
in a way that female nurses' knowledge was significantly higher than
that of male nurses. Knowledge about the pressure ulcer prevention in
subjects with training history was significantly higher (P = 0.03). One-
way ANOVA results also showed that, there was a significant relation-
ship between knowledge and work experience of nurses (P = 0.007).
Based on the results of the Scheffe's test, there was a significant dif-
ference in terms of knowledge score between subjects with less than 5
years of work experience and those with 10–14 years of work experi-
ence. The knowledge score in subjects with 10–14 years of work ex-
perience was significantly higher (P = 0.009). Moreover, there was a
significant relationship between the knowledge and experience of the
nurses in the ICU. According to the results of the Scheffe's test, subjects
with work experience more than 10 years in ICU were more knowl-
edgeable (P = 0.003).
Also, independent t-test results (Table 1) showed that, there was a
significant relationship between gender and attitude of nurses
(P = −0.009), female nurses' attitudes were significantly higher than
that of male nurses. Moreover, independent t-test findings showed that,
there was a significant difference in attitude between nurses employed
in the General ICU and those in other sectors (P < 0.001), in such a
way that nurses working in the General ICU had higher attitude scores.
78
Journal of Tissue Viability 29 (2020) 76–81
The results also showed that, there was a statistically significant re-
lationship between nurses' attitude and working hours (P = 0.006);
nurses who worked more than 50 h a week had higher attitude score
towards prevention of pressure ulcer. In the meantime, Table 1 de-
monstrates a significant relationship between attitude and work ex-
perience of nurses (P = 0.02). Based on the results of the Scheffe's test,
there was a significant difference between the attitudes of subjects with
5–9 years of experience and those with 10–14 years of work experience
(P = 0.03); attitude scores were higher in subjects with 10–14 years of
work experience. Also, there was a significant relationship between the
attitude and work experience of the nurses in ICU (P < 0.001). Results
of the Scheffe's test showed that, attitudes of subjects with work ex-
perience of 5–9 years was significantly less than those with less than 5
years of work experience (P = 0.005) and those with more than 10
years (P < 0.001).
One-way ANOVA results showed that, there was a significant re-
lationship between age and nurses' practice (P = 0.03); nursing prac-
tice scores were increased in line with their age. Independent t-test
findings showed that, there was a statistically significant difference
between the practice of nurses working in general ICU (P < 0.001),
those in surgery (P = 0.001) and nurses who did not work in these
sectors, in such a way that subjects working in the General ICU had
higher practice score than nurses working in the surgical ICU.
Reviewing the correlation between quantitative variables and the
practice of the nurses showed that, there was a significant correlation
between nurses' practice and age (P = 0.03, r = 0.15). This coefficient
was less than 0.3 which is considered as a week correlation.
In addition, there was a significant and positive correlation between
knowledge and attitude. By increasing the knowledge score, attitude
scores were also increased (r = 0.365, P < 0.001). The coefficient of
determination was 0.13, meaning that these two variables had 13% in
common variance. In the same way, knowledge and practice had a
significant and positive correlation with each other, and by increasing
the knowledge score, the practice score was also increased (r = 0.38,
p < 0.001). The coefficient of determination was 14%, meaning that
these two variables had 14% in common variance. Practice and attitude
had a significant and positive correlation with each other, and by in-
creasing attitudes, the practice score was also increased (r = 0.32,
p < 0.001). The coefficient of determination was 0.1, which means
these two variables had 10% in common variance.
Table 3 shows that, there is a relationship between nurses' knowl-
edge and variables of work experience in the ICU and gender in the
regression model. Findings revealed that, with a one-year increase in
the work experience of nurses in the ICU, nurses’ knowledge was in-
creased by 0.051 unit. Knowledge of female nurses was higher than that
of male nurses by 3.132 units.
Variables of gender, working hours per week, and the general sec-
tion were related to nurses' attitudes in the regression model (Table 4).
The attitude score of female nurses was higher than that of male nurses
by 1.65 units, and the attitude score of employed nurses in the General
ICU was higher than that of other nurses by 2.144 units. It is also no-
ticeable that, with an hour increase in working hours per week, nurses'
attitudes were increased by 0.043 units.
Variables of age, Surgical ICU, and General ICU were related to
nurses' practice (Table 5). Findings revealed that, with one-year in-
crease in age, nurses' practice was increased by 0.162. Moreover, nurses
working in the surgical ICU had lower practice score than other nurses
by 1.839 unit. But nurses working in the General ICU had 2.574 unit
higher practice score than other nurses.
3. Discussion
The results revealed that knowledge of nurses in this study was at an
unfavorable level. The low level of nurses' knowledge in the field of
pressure ulcers can be related to lack of attention to this issue in nursing
student education programs, in-service training programs, and re-
S. Khojastehfar, et al. Journal of Tissue Viability 29 (2020) 76–81

Table 1
Demographic characteristics of the study subjects and their correlation with knowledge, attitude and practice in the area of pressure ulcer prevention (N = 308).
Variable Frequency (%) Knowledge Attitude Practice

Mean ±SD Test results Mean ± SD Test results Mean ± SD Test results

Age (year) Less than 30 118 (38.3) 61.7 ± 11.09 F = 2.91 38.93± 4.22 F = 2.91 31.44 ± 6.46 F = 3.41
31–40 174 (56.5) 64.36± 9.65 P = 0.056 39.08± 4.27 P = 0.31 32.07± 6.07 P = 0.03
40–50 16 (5.2) 10.10± 66.35 40.63± 3.59 35.71± 3.38
Mean ± SD 32.07± 4.97
Gender Female 257 (4.83) 64.00± 9.97 t = 2.01 39.38± 4.24 32.1± 6.18
Male 51 (16.6) 60.82± 11.64 df = 306 37.69± 3.86 t = 2.63 31.62± 6.18 t = 0.5
P = 0.04 df = 306 df = 306
P = 0.009 P = 0.61
Education BSc 284 (92.2) 63.22± 10.21 t = 1.409 38.96± 4.09 t = 2.09 31.84± 6.08
MSc 24 (7.8) 66.48± 11.22 df = 306 40.83± 5.39 df = 25.28 34.25± 6.92 t = 1.8
P = 0.13 P = 0.1 df = 306
P = 0.07
Type of ICU Internal section Yes 102 (33.1) 63.35± 10.50 t = 0.015 39.08± 4.55 t = 0.056 32.63± 6.36
No 206 (66.9) 63.54± 10.24 df = 306 39.11± 4.06 df = 306 31.72± 6.06 t = 1.2
P = 0.87 P = 0.95 df = 306
P = 0.22
Surgery Yes 109 (35.4) 63.53± 9.79 t = 0.075 38.93± 4.25 t = 0.53 30.49± 6.30
No 199 (64.6) 63.44± 10.61 df = 306 39.20± 4.21 df = 306 32.86± 5.59 t = 3.22
P = 0.94 P = 0.59 df = 306
P = 0.001
Neurosurgery Yes 79 (25.6) 63.93± 10.81 t = 0. 45 38.80± 4.73 t = 0.72 31.25± 6.29
No 229 (74.4) 63.31± 10.51 df = 306 39.20± 4.03 df = 306 32.29± 6.12 t = 1.27
P = 0.64 P = 0.46 df = 306
P = 0.2
General Yes 61 (19.8) 65.29± 9.30 t = 1.54 39.91± 3.56 t = 4.25 34.7± 4.94
No 247 (80.2) 63.02± 10.52 df = 306 38.65± 4.26 df = 106.5 31.34± 6.27 t = 4.47
P = 0.12 P < 0.001 df = 114.48
P < 0.001
Burns Yes 24 (7.8) 62.05± 8.75 t = 0.7 38.57± 3.52 t = 0.63 33.15± 3.53
No 284 (92.9) 63.59± 10.44 df = 306 39.15± 4.28 df = 306 33.93± 6.34 t = 1.49
P = 0.48 P = 0.52 df = 37.42
P = 0.14
Open heart Yes 4 (1.3) 59.57± 9.67 t = 0.76 36.33± 6.12 t = 1.32 33± 6.37
No 304 (98.7) 63.52± 10.33 df = 306 39.14± 4.19 df = 306 32.1± 6.18 t = 1.49
P = 0.44 P = 0.18 df = 306
P = 0.75
Work hour per week 50 and less 258 (83.8) 63.40 ± 10.00 t = 0.79 38.81 ±4.18 t = 2.77 32.6 ±5.70 t = 0.71
More than 50 50 (16.2) 63.82 ± 11.90 df = 306 40.60 ±4.14 df = 306 31.91± 6.26 df = 306
Mean ± SD 47.37 ±9.22 P = 0.26 P = 0.006 P = 0.47
Training history regarding pressure ulcer prevention Yes 133 (63.2) 64.86 ± 10.48 t = 2.07 39.39 ±4.58 t = 1.05 32.08 ± 6.32 t = 0.014
No 175 (56.8) 62.41 ± 10.08 df = 306 38.88 ±3.93 df = 306 31.98 ± 6.07 df = 306
P = 0.03 P = 0.29 P = 0.88
Work experience (year) Less than 5 62 (20.2) 60.74 ± 11.63 F = 5.678 39.11 ±4.25 F = 4.707 31.98 ± 6.61 F = 1.002
5–9 155 (50.3) 62.97 ± 10.29 P = 0.004 38.47 ±4.04 P = 0.01 31.6 ±6.01 P = 0.368
10 and more 91 (29.5) 66.19 ± 8.76 40.17 ±4.34 32.7 ±6.12
Mean ±SD 8.26 ±4.54
Work experience in ICU (years) Less than 5 101 (32.8) 61.49 ± 10.98 F = 5.88 32.71 ±6.37 F = 10.52 39.85 ± 4.01 F = 2.28
5–9 165 (53.6) 63.57 ± 9.98 P = 0.003 31.33 ±5.95 P < 0.001 38.16 ± 4.16 P = 0.1
10 and more 42 (13.6) 67.88 ± 8.61 33.11 ±6.35 40.99 ± 4.03
Mean ±SD 5.70 ±3.41

SD: Standard deviation; ICU: Intensive care unit; ICU: Intensive care unit; MSc: Master of Science; BSc: Bachelor of Science.

training nurses in educational-therapeutic centers. This result can be
due to a great amount of work for nurses and their inability to parti-
cipate in in-person training programs. However, based on the results of
this study, more than half of the nurses had not participated in any
training program for pressure ulcers. These are highly important to be
considered by authorities, policy makers, and nursing curriculum de-
velopers [18,19]. showed that nurses’ knowledge score about the
pressure ulcers was low and below satisfactory level. Another study also
showed that 73% of nurses had inadequate knowledge in the area of
pressure ulcer prevention [9]. The results of these studies were

Table 2
Numerical indicators of attitude and its dimensions for the nurses studied in the area of prevention of pressure ulcers (N = 308).
Attitude and its dimensions Mean SD Lowest score Highest score

Individual competence to prevent pressure ulcers (3-12) 8.77 1.03 5 12

Pressure ulcer prevention (3-12) 8.72 1.40 4 12
Impact of pressure ulcer (3-12) 9.05 1.75 5 12
Responsibility for the prevention of pressure ulcer (2–8) 6.34 1.32 2 8
Confidence in the effectiveness of prevention (3-12) 6.22 1.14 2 8
Attitude (13–52) 39.10 4.22 27.18 49

SD: Standard deviation.

79
S. Khojastehfar, et al. Journal of Tissue Viability 29 (2020) 76–81

Table 3 The results of this study showed that, the nurses' practices were
The results of linear regression analysis to investigate the effect of demographic relatively desirable. One of the reasons for the relatively desirable
characteristics on nurses’ knowledge about prevention of pressure ulcers practice of nurses, in contrary to their knowledge and attitude, can be
(N = 308). related to the tool used in this study. There are a few studies on the
Independent variables B coefficient Standard Statistics p-value psychometric properties of the tool used for evaluating practice in this
coefficient study. However, in the research population, the reliability of the tool
was appropriate and its content validity was approved by panel of ex-
Age 0.198 0.095 1.27 0.205
Work experience −0.205 −0.09 −1.133 0.258
perts. It is necessary to conduct studies for designing appropriate tools
Work experience in ICU 0.051 0.202 2.71 0.007 for evaluating the practice of nurses in the prevention of pressure ul-
Gender Female 3.132 0.113 2.011 0.045 cers. Furthermore, the current results can be related to the issue of
Male Reference category social desirability, and nurses tend to show that their practice deserves
Record of continuous Yes 1.489 0.072 1.243 0.215
social desirability and selected items that have had a positive load
training No Reference category
concerning concerning patients' care. Another reason could be the work routine of
pressure ulcer nurses in executing procedures, despite having this level of knowledge
prevention and attitude. Moreover, in this study a high cut-off point was con-
sidered for knowledge and attitude of nurses towards the prevention of
ICU: Intensive care unit.
pressure ulcer. If the cut-off point is considered high (90%) for practice,
it would be noticeable that the majority of nurses would have un-
Table 4
desirable practice [10]. showed that, 67.3% of nurses had good practice
The results of linear regression analysis to investigate the effect of demographic
in prevention of pressure ulcer prevention. Based on the results of these
characteristics on nurses' attitudes on prevention of pressure wound (N = 308).
studies, nurses had poor practice in the prevention of pressure ulcers
Independent variables B coefficient Standard Statistics p-value [13,16,17].
coefficient
Based on the results of this study, by one-year increase in the work
Age 0.053 0.056 0.793 0.428 experience of nurses in the ICU, their knowledge would be increased.
Work experience 0.001 0.01 0.136 0.892 Moreover, female nurses' knowledge was more than that of male nurses.
Work experience in ICU 0.043 0.111 1.989 0.048 They also had more positive attitude towards the pressure ulcer pre-
Gender Female 1.651 0.146 2.604 0.01
vention compared to that of male nurses. The greater knowledge and
Male Reference category
General ICU Yes 2.144 0.203 0.657 < 0.001 positive attitude of female nurses compared to that of male could be
No Reference category linked to the larger sample size of female nurses. However, in a study by
Ref. [23]; male nurses had more positive attitude towards pressure
ICU: Intensive care unit. ulcer prevention than the female nurses. In contrary to the results of
this study, Qaddumi and Khawaldeh's study showed that, there was no
Table 5 relationship between nurses' knowledge about the pressure ulcer pre-
The results of linear regression analysis to investigate the effect of demographic vention standards and any of the demographic variables [9]. Differ-
characteristics on nurses' practice on prevention of pressure ulcers (N = 308). ences in the results of their study and the current study can be related to
Independent variables B coefficient Standard Statistics p-value the differences in the characteristics of the population under study.
coefficient The findings of this study showed that, nurses' practice was im-
proved by a one-year increase in age. It can also be attributed to an
Age (year) 0.162 0.131 2.328 0.021
Surgical ICU Yes −1.839 −0.143 −2.494 0.013
increase in nursing experience by age. However, more studies are
No Reference category needed in this regard. Based on the current results, positive attitude and
General ICU Yes 2.574 0.168 2.91 0.004 better practice of nurses in general ICUs can be related to the fact that
No Reference category those patients were hospitalized for longer periods and this is an ef-
fective factor in the incidence of pressure ulcers. On the other hand,
ICU: Intensive care unit.
long-term hospitalization resulted in longer-term involvement of the
nurses in providing care for patients. In a study, there was a relation-
consistent with the present study. In contrary to the current study, some
ship between type of the hospital and the nurses’ knowledge with re-
studies have shown that the knowledge of the majority of nurses re-
spect to prevention and treatment of pressure ulcers [24].
garding the prevention of pressure ulcers was acceptable [20–22].
In addition, it was indicated that, with an hour increase in working
Differences between the results of these study and the present study
hour per week, nurses' attitudes increased by small amounts, which can
could be due to the difference in data collection tools and also the low
be linked to more involvement in patient care throughout the week.
cutoff point to categorize the desirability of knowledge.
More work experience helped the nurses to increase their knowledge
The results of this study showed that, most of nurses had in-
[16,17]. [25] showed a positive relationship between attitude towards
appropriate and unsatisfactory attitudes towards pressure ulcers pre-
the prevention of pressure ulcers and work experience. In the present
vention. Low knowledge can justify inappropriate or negatives attitude
study, more than half of the nurses did not attend the training program
of nurses. According to the results of this study, there was a positive
and there was no difference between the two groups in terms of attitude
relationship between knowledge, attitude, and practice. More knowl-
score. It can be said that, in addition to the upholding quantity and the
edge and more positive attitude towards the pressure ulcer prevention
necessity of nurses' participation in pressure ulcer prevention training
can be associated with better practice in the prevention of pressure
programs by facilitating nurses’ attendance in these programs and
ulcers. Therefore, it is essential to take measures such as education in
adopting educational approaches accessible for nurses, special attention
order to make nurses' attitudes positive and satisfactory concerning the
should be paid to the quality of these training courses and considering
prevention of pressure ulcers. Training can affect nurses' attitude,
effective teaching methods. In the study by Ref. [13]; the attitude score
therefore interventions to improve their attitudes are also essential. In a
of nurses who participated in the training for pressure ulcer prevention
study by Beeckman et al. indicated that, the nurses' attitude towards the
was higher than the others.
pressure ulcer prevention was undesirable, and it was also expressed in
This study was a multicenter research conducted on a large number
this study that the nurses’ attitude was different based on their pro-
of ICU nurses. In the current research, PUKT developed in 1995 was
fessional role [13].
used to assess the knowledge of nurses about pressure ulcer. Research

80
S. Khojastehfar, et al.
on pressure ulcers has moved on since that time and maybe it cannot
reflect the latest body of knowledge about pressure ulcer. It is re-
commended to conduct a similar study newly designed instruments.
4. Conclusion
The results of this multicenter research indicated that, knowledge of
nurses included in this study was not at the desirable level. Also, most
of the nurses had inappropriate and unsatisfactory attitudes towards
pressure ulcer prevention. Moreover, nurses' practice was relatively
favorable. Given that the pressure ulcers are threats to patient's safety,
managers of health care centers must develop required plans in line
with the empowerment of the health team, especially nurses. Therefore,
it is essential to develop educational programs for the prevention of
pressure ulcers and managing care services for patients at risk of de-
veloping the pressure ulcer. The results of this study also show the
importance of the support of nursing managers and health care provi-
ders from new guidelines and the evidence-based practice and practical
trainings related to pressure ulcer prevention.
Funding
This project was funded by Iran University of Medical Science,
Tehran, Iran (Grant iD: 97-3-3-12584).
Declaration of competing interest
There is no conflict of interest.
Acknowledgments
This article was a part of Master's Thesis for ICU Nursing of Nursing
and Midwifery Faculty of Iran University of Medical Sciences.
Therefore, hereby we express our gratitude toward all the officials from
the Faculty of Nursing and Midwifery and Nurses who helped us con-
ducting this research.
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