Assessment of Nurses ’ Knowledge , Attitude , and Perceived Barriers to Expressed Pressure Ulcer Prevention Practice in Addis Ababa Government Hospitals , Addis Ababa , Ethiopia , 2015

Background. Although pressure ulcer development is now generally considered as an indicator for quality of nursing care, questions and concerns about situations in which they are unavoidable remain. Awareness about the significance of the problem, positive attitude towards prevention, and an adequate level of knowledge are cornerstones to effectively prevent pressure ulcers. Objective. To assess nurses’ knowledge, attitudes, and perceived barriers to expressed pressure ulcer prevention practice in Addis Ababa government hospitals. Methods and Materials. This is a cross-sectional study by design. A total of 217 eligible nurses participated in the study and data were collected through pretested self-administered questionnaire. Results. When queried, 61.2% of the respondents had adequate knowledge on pressure ulcer prevention practices, while 68.4% had favorable attitudes towards prevention practices. Moreover, 67.3% of participants had good pressure ulcer prevention practices. Conclusion and Recommendation.More than half of the nurses were found to have adequate knowledge about pressure ulcer prevention and their attitude towards it was overall favorable. Expressed pressure ulcer prevention practice was affected by the participant’s level of knowledge, attitude, and barriers of care. To provide effective prevention of pressure ulcer, nurses’ level of knowledge and attitude should be enhanced besides resolving these barriers.


Introduction
Pressure ulcer is defined by the National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP) as "localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction."People most at risk of pressure ulcers are those with a medical condition that limits their ability to change positions, requires them to use a wheelchair, or confines them to a bed for a long time [1].
Pressure ulcers result when increased pressure exceeds the local capillary pressure.Depending on patient's severity of illness, less pressure may be adequate enough to obstruct capillary blood flow and can result in decreased oxygen delivery to tissues and as a result pressure ulcers can develop within 2 to 6 hours.If patients who are at risk of pressure ulcer are identified, effective measures will be taken to prevent its occurrence [2].
There are several factors contributing to the development of pressure ulcers.These included prior ulcers, peripheral vascular diseases, diabetic mellitus, smoking, prolonged immobility, poor nutritional status, incontinency, impaired sensation, and aging as intrinsic factors and pressure, shear, friction, moisture, poor moving, and handling as well as therapeutic devices as extrinsic factors.Nurses' knowledge and attitude are also viewed as extrinsic factors for pressure ulcer formation [3].

Advances in Nursing
World stop pressure ulcer day report in 2014 showed that nearly 700,000 patients were affected by pressure ulcers each year.Around 186,617 patients develop a new pressure ulcer in acute care each year.This has shown that in the year January 2012 to December 2013 between 4 and 6% of patients in acute care settings and more than 5-10% of patients in nonacute care had pressure ulcers.Pressure ulcers are accountable for 2% of preventable deaths [4].
According to 2014 Coloplast pressure ulcer summit report, 60,000 people died as a result of the complications of pressure ulcer globally [5].Within the national context, studies that aim to investigate nurses' knowledge, attitude, and perceived barriers towards pressure ulcer prevention practice have not been conducted or could not be found.
A study that was conducted in Felegehiwot Referral Hospital, Bahir Dar, Ethiopia, on hospitalized patients to assess prevalence and associated factors of pressure ulcer revealed that 16.8% of them had pressure ulcer [6].
Nurses still showed poor compliance with the clinical guidelines regarding pressure ulcer prevention practice and put low priority on pressure ulcer prevention.Lack of knowledge is an apparent barrier for using the guidelines in clinical practice [7].Increased knowledge about pressure ulcer prevention among nurses not only improves the practice of pressure ulcer care but also reduces hospital stay [8].One study in Bahir Dar (Northwest Ethiopia) revealed the prevalence of pressure ulcer was 16.8%; this emphasized the need to enhance the knowledge and attitude of nurses regarding pressure ulcer prevention practice [6].
The attitude of nurses towards pressure ulcer prevention refers to their value related to risk assessment, maintaining healthy skin, management of mechanical loads, and education for patient and family [3].Attitude is learned and is affected by knowledge and behavioral intent.It is used to express positive or negative feelings about a person, issue, or object.If a person holds a positive attitude toward an issue, this will increase the possibility of performing a supportive behavior related to that issue and vice versa [9].
If pressure ulcer occurred, it can cause decreased quality of life, infection, pain and disfigurement, alteration to sleep, delayed healing, increased morbidity and mortality rates, an increased need for intensive nursing and medical care, an increased workload for healthcare workers, and, as a consequence, increased healthcare costs [1].A patient with pressure ulcer has a mortality risk that is 2 to 6 times greater than a patient with intact skin [10].Despite its devastating effects, 95% of pressure ulcer can be prevented by managing both intrinsic and extrinsic risk factors as well as repositioning [11].
Although pressure ulcer development is now generally considered as an indicator for quality of nursing care, questions and concerns about situations in which they are unavoidable remain [12].However, pressure ulcers are largely preventable.All patients who are identified as being at risk should have a management plan to prevent development of pressure ulcer, optimize healing, and prevent complications of existing pressure ulcer [13].Even though nurses make prevention part of their routine, there are some barriers to practice and care planning such as inadequate time, inconsistent documentation, lack of staff, lack of equipment, and lack of pressure ulcer related knowledge [3].
Awareness about the significance of the problem, positive attitude towards prevention, and an adequate level of knowledge are cornerstones to effectively prevent pressure ulcers [14].The final sample size was determined as follows by using correction formula:

Methods and Materials
where   is the final sample size,   is the initial sample size 215, and  is the number of staff nurses working in Addis Ababa government hospitals: Considering a 10% nonresponse rate, the total sample size was Hence, 217 staff nurses were included in this study.

Sampling Procedure.
A simple random sampling (SRS) was used to select 3 hospitals from 12 government hospitals in Addis Ababa.After allocating nurses from the 3 selected government hospitals by proportional allocation to size (PAS), the participants were selected by using simple random sampling (Figure 1).

Dependent Variable
(i) Expressed pressure ulcer prevention practice.2.9.Data Collection Methods 2.9.1.Data Collection Tool.Data were collected using structured self-administered questionnaire.The questionnaire was adapted by reviewing literatures of similar studies and guidelines prepared to prevent pressure ulcers [15,16].

Independent Variables
2.9.2.Data Collection Procedure.The data were collected by 6 trained diploma nurses and were supervised by 3 BSc nurses having previous experience in data collection.Continuous follow-up and supervision were also made by principal investigator throughout the data collection period.
2.9.3.Data Quality Assurance.In order to maintain quality of the data, data collectors and supervisors were trained in data collection procedures by the principal investigator.The questionnaire has also been carefully designed and English version was used for data collection.Before actual data collection time, the questionnaire (tool) was checked for clarity, comprehensiveness, and content validity by an expert and pretested for reliability on 10% of the total sample at Debre Markos Referral hospital.Then, based on the finding of the pretest, the questions were modified for wording and clarity.The collected data were then reviewed and checked for completeness and consistency by the principal investigator on a daily basis.

Data Processing and Analysis.
The data were entered in to EPI-data version 3.1, and then the data were cleaned and analyzed by using Statistical Package for Social Science (SPSS) version 21 statistical software.Descriptive statistics were used.Bivariate and multivariate logistic regression were computed to assess statistical association between the outcome variable and independent variables using Odds Ratio; significance of statistical association was assured or tested using 95% confidence interval (CI) and  value (<0.05).

Operational Definitions
(i) Adequate knowledge: nurses who answered greater than or equal to 80% of the knowledge questions correctly.
(ii) Inadequate knowledge: those nurses who answered less than 80% of the knowledge questions correctly.
(iii) Favorable attitude: those nurses who were positively worded and scored points more than the median in the attitude questionnaire.
(iv) Unfavorable attitude: Those nurses who were negatively worded and scored points less than the median in the attitude questionnaire.
(v) Good expressed pressure ulcer prevention practice: nurses who answered greater than or equal to 80% of expressed pressure ulcer prevention practice related questions correctly.
(vi) Poor expressed pressure ulcer prevention practice: nurses who answered less than 80% of expressed pressure ulcer prevention practice related questions correctly.
(vii) Perceived barriers: if nurses answered "agree" or "strongly agree" with the listed barriers in the perceived barrier questionnaire.Hospitals before data collection.The study participants were informed about the objective, rationale, and expected outcomes of the study and written consent was provided for guaranteeing their choice of participation or refusal.All the information was recorded anonymously and confidentiality was assured throughout the study.

Dissemination of the Result.
The final report of the study will be presented and submitted in the form of soft and hard copy to Addis Ababa University, College of Health Sciences, Department of Nursing and Midwifery.In addition, efforts will be made to present the findings on scientific conferences like professional associations and peer reviewed journal publications will also be considered.1).
In addition, about 72 (36.7%) of nurses receive training about pressure ulcer prevention in the form of lecture whereas 70 (35.7%) of them did not receive training (Figure 3).A total of 19 questions were provided for nurses and they got marks out of 19 as follows (Table 2).

Knowledge of Facts about Pressure
Ulcer.The majority, 174 (88.8%), of the participants were aware that pressure ulcer commonly occurred around bony prominences.About 43 (21.9%) of respondents did not know that pressure ulcers contribute to overall hospital costs incurred by the patient (Table 3).4).

Nurses Attitude toward Expressed Pressure Ulcer Prevention Practice.
Scores for each attitude related question were summarized and the responses were then categorized into two variables, namely, favorable attitude and unfavorable attitude.Nurses who were positively worded for each attitude related question were categorized as having favorable attitude whereas respondents who were negatively worded for each attitude related questions were classified in the unfavorable attitude category.Finally, overall attitude score of the respondents were calculated.Those nurses who score above the median were considered as having favorable attitude while those who scored below the median were labeled as having unfavorable attitude.Accordingly, 134 (68.4%) of nurses had favorable attitude while 62 (31.6%) had unfavorable attitude toward expressed pressure ulcer prevention practice.About 89.8% of nurses were positively intended (worded) to care for patients with pressure ulcers and about 56.6% of the participants believe pressure ulcer prevention is not time consuming (Table 5).

Perceived Barriers to Pressure Ulcer Prevention.
Nurses were asked to indicate their agreement about the existence of specific barriers in the work environment.If nurses answered "strongly agree" or "agree" on the listed barrier, it was considered as a perceived barrier and if nurses answered "disagree" or "strongly disagree" on the listed barrier the barrier was not considered as a perceived barrier for expressed pressure ulcer prevention practice.Based on this assumption, disproportionate nurse to patient ratio was the most frequently reported barrier to carrying out pressure ulcer prevention practices (67.9%;  = 133), followed by lack of job satisfaction (64.3%;  = 126) (Table 6).
From the respondents, 180 (91.8%) identified regular turning of patients every 2 hours, 172 (87.8%) identified removing any tightly fitting clothes from the patient, and 168 (85.7%) identified protecting the skin during patient transfer as good pressure ulcer prevention practices (Table 7).

Factors Associated with Expressed
Pressure Ulcer Prevention Practice.In bivariate logistic regression analysis, nurses' overall knowledge, overall attitude, disproportionate nurse to patient ratio, lack of policies and guidelines, lack of evidence supported by research, lack of job satisfaction, and lack of pressure ulcer related knowledge were statistically associated with expressed pressure ulcer prevention practice with  value less than 0.05 at 95% confidence interval (Table 8).
After bivariate analysis, only those variables which were significantly related ( value < 0.05) were entered for further multivariate analysis.By adjusting potential confounders in multivariate logistic regression analysis; only nurses overall knowledge, disproportionate nurse to patient ratio, lack of policies and guidelines, and lack of job satisfaction were significantly associated with expressed pressure ulcer prevention practice.But participants' overall attitude, lack of evidence supported by research, and lack of pressure ulcer related knowledge were not significantly associated with expressed pressure ulcer prevention practice in multivariate analysis.
Overall knowledge level, disproportionate nurse to patient ratio, lack of policies and guidelines, and lack of job satisfaction were negatively associated with expressed pressure ulcer prevention practice.Nurses who have inadequate knowledge were 0.29 times less likely to practice expressed pressure ulcer prevention (AOR = 0.29 (0.010, 0.085)) as compared to knowledgeable nurses.Moreover, nurses who work in settings having disproportionate nurse to patient ratio were 0.294 times less likely to practice pressure ulcer prevention (AOR = 0.111 (0.037, 0.334)) than nurses who reported satisfaction with their job.

Discussion
The main purpose of this study was to assess nurses' knowledge, attitude, and perceived barriers to expressed pressure ulcer prevention practices.Though there are a plethora of studies that were done in an international context aiming to assess the knowledge, attitude, practice, and barriers towards pressure ulcer prevention; there is almost no study that was conducted on a national basis.
This study showed that 38.8% of nurses had inadequate knowledge about pressure ulcer prevention practice.This is less than a study done in Bangladesh, where 57.8% of nurses had inadequate knowledge [17], and in Jordan, where 73% of nurses had inadequate knowledge about pressure ulcer prevention [8].The possible explanation could be lack of trainings and evidences supported by research.
Another factor that affects expressed pressure ulcer prevention practice was knowledge level.Knowledge level was significantly associated with expressed pressure ulcer prevention practice in this study.Nurses who have inadequate knowledge were 0.29 times less likely to practice expressed pressure ulcer prevention (AOR = 0.29 (0.010, 0.085)) as compared to knowledgeable nurses.While a study done in Bangladesh showed that there was no significant association between nurses knowledge and practice [ = 0.14,  > 0.05] [17].This can be explained by differences in methodological approaches.
In this study, only 68.4% of the participants had favorable attitude toward pressure ulcer prevention practice; this is much lower than a survey done in Sweden where nursing staffs as a whole demonstrated positive attitude regarding pressure ulcer prevention [18] and similarly in Iraq where 99% of the nurses had positive attitude toward pressure ulcer prevention practice [19].
This study showed that the attitude of nurses was not significantly associated with expressed pressure ulcer prevention practice.However, a study done in Bangladesh showed a moderately positive relationship between nurses' attitude and practice [17].
Similarly, nurses who work in settings lacking specific policies and guidelines towards pressure ulcer prevention were 0.213 times less likely to practice pressure ulcer prevention (AOR = 0.213 (0.076, 0.596)) than nurses who work in settings having policies and guidelines to pressure ulcer prevention.Besides this, 50% of the respondents reported that lack of policies and guidelines were barriers to practicing pressure ulcer prevention.This was exactly congruent with a study done in Jordan, where about 50% of nurses identified that lack of specific policies and guidelines as an existent barrier to giving care for patients with pressure ulcer [9].This can be explained by the fact that the presence of policies and guidelines that advocate for proper patient care is likely to increase the practice of nursing interventions such as pressure ulcer prevention.
In addition, nurses who are not satisfied by their job were 0.111 times less likely to practice pressure ulcer prevention (AOR = 0.111 (0.037, 0.334)) than nurses who reported satisfaction with their job.In this study, 64.3% of nurses reported that lack of job satisfaction is a barrier to pressure ulcer prevention practice.This was relatively analogous with a study done in Jordan, where 57% of respondents identified lack of job satisfaction as an existent barrier to pressure ulcer prevention [9].This could be due to the fact that if a person is not satisfied by an issue, then the possibility of performing a supportive action related to that issue will also be decreased.
Furthermore, 67.3% of the participants had good expressed pressure ulcer prevention practice, whereas a study in Bangladesh found that staff nurses perceived a moderate level of overall practice regarding pressure ulcer prevention [17].The difference between the healthcare setups of Ethiopia and Bangladesh might explain the relatively discrepant results in pressure ulcer prevention practice.
Consistent with the studies done in Turkey [20] and Uganda [15], participants in this research reported some of the frequently applied pressure ulcer prevention practices.These include patient repositioning (91.8%), keeping patient skins dry and moist (83.2%), balanced diet (80.1%), protecting the skin during patient transfer (85.7%), documenting prevention strategies (83.2%), and removing any tightly fitting clothes from the patient (87.8%).

Strengths of the Study.
The major strength of this research lies in the fact that it has attempted to assess nurses' knowledge, attitude, and perceived barriers to expressed pressure ulcer prevention practice in Addis Ababa, Ethiopia.Thus, it can be first in the country.In addition, three government hospitals were included in the study to make the study representative and the questionnaire was pretested.

Limitations of the Study.
The major limitations of this study include the following: (i) The fact that no study was conducted so far in Ethiopia on this topic; no enough literature was available to discuss in national context.(ii) The practice component may not be well addressed, as observational checklist was not used.(iii) The study may be subjected to response set bias from the respondents.(iv) The study was cross-sectional; therefore, it was difficult to know which occurred first the exposure or the outcome.

Conclusion.
Based on the finding of this study, the following are concluded: (i) More than half of the nurses were found to have adequate knowledge regarding pressure ulcer prevention.(ii) The outlook of nurses in Addis Ababa government hospitals towards pressure ulcer prevention was majorly favorable.

( i )
Sociodemographic characteristics (years of experience and level of qualification).(ii) Knowledge of nurses on (a) risk factors, (b) complications, (c) patients at risk of pressure ulcers.(iii) Attitude of nurses: (a) Interest to give care.(b) Willingness to take responsibility.(iv) Perceived barriers: (a) Unproportionate nurse to patient ratio.(b) Lack of guidelines.(c) Shortage of time.(d) Limited resource.(e) Patient factors.(f) Lack of evidence supported by research.

Figure 2 :
Figure 2: Current area of practice of nurses in Addis Ababa government hospitals, 2015.* Nurses who work as metron, ward head, and triage.

Figure 3 :
Figure 3: How respondents receive training about pressure ulcer prevention in Addis Ababa government hospitals, 2015.
Characteristics.A total of 217 nurses were included in the study.Of these, only 196 nurses voluntarily agreed to participate in this study, and 21 either refused or submitted incomplete questionnaires.This resulted in a response rate of 90.3%.Out of 196 respondents, 133 (67.9%) were females.Moreover, the age of the participants included in this study ranged between 20 and 59 years with mean age of 27.93 (SD = ±6.596)years.From the respondents, 142 (72.4%) were orthodox Christians and 134 (68.4%) were single.The majority, 151 (77%) of nurses, had bachelor degrees (Table

Table 3 :
Distribution of right and wrong responses about facts of pressure ulcer prevention practice among nurses in Addis Ababa government hospitals, 2015.

Table 4 :
Distribution of right and wrong responses about risk factors and patients at risk for pressure ulcer assessment among nurses in Addis Ababa government hospitals, 2015.

Table 5 :
The distribution of attitude towards expressed pressure ulcer prevention practice among nurses in Addis Ababa government hospitals, 2015.

Table 6 :
Perceived barriers to expressed pressure ulcer prevention practice in Addis Ababa government hospitals, 2015.