Original Article

Knowledge and Attitudes of Nurses on Pressure Ulcer Prevention: A Cross-Sectional Multicenter Study in Belgian Hospitals
Dimitri Beeckman, RN, PhD, Tom Deoor, RN, PhD, Lisette Schoonhoven, RN, PhD, Katrien Vanderwee, RN, PhD

ABSTRACT
Background: Evidence-based guidelines for pressure ulcer prevention have been developed and promoted by authoritative organizations. However, nonadherence to these guidelines is frequently reported. Negative attitudes and lack of knowledge may act as barriers to using guidelines in clinical practice. Aims: To study the knowledge and attitudes of nurses about pressure ulcer prevention in Belgian hospitals and to explore the correlation between knowledge, attitudes, and the application of adequate prevention. Methods: A cross-sectional multicenter study was performed in a random sample of 14 Belgian hospitals, representing 207 wards. Out of that group, 94 wards were randomly selected (2105 patients). Clinical observations were performed to assess the adequacy of pressure ulcer prevention and pressure ulcer prevalence. From each participating ward, a random selection of at least five nurses completed an extensively validated knowledge and attitude instrument. In total, 553 nurses participated. A logistic regression analysis was performed to evaluate the correlation between knowledge, attitudes, and the application of adequate prevention. Results: Pressure ulcer prevalence (Category I-IV) was 13.5% (284/2105). Approximately 30% (625/2105) of the patients were at risk (Bradenscore <17 and/or presence of pressure ulcer). Only 13.9% (87/625) of these patients received fully adequate prevention whilst in bed and when seated. The mean knowledge and attitude scores were 49.7% and 71.3%, respectively. The application of adequate prevention on a nursing ward was significantly correlated with the attitudes of the nurses (OR = 3.07, p = .05). No independent correlation was found between knowledge and the application of adequate prevention (OR = 0.75, p = .71). Conclusions: Knowledge of nurses in Belgian hospitals about the prevention of pressure ulcers is inadequate. The attitudes of nurses toward pressure ulcers are significantly correlated with the application of adequate prevention. No correlation was found between knowledge and the application of adequate prevention. KEYWORDS attitude, knowledge, nursing, pressure ulcer prevention, guidelines, hospital, prevalence, correlation

Dimitri Beeckman, Researcher, Nursing Science, Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium; Visiting Professor, Department of Bachelor in Nursing, Artevelde University College Ghent, Gent, Belgium; Lecturer, Florence Nightingale School of Nursing & Midwifery, Kings College London, London, UK; Tom Deoor, Professor, Nursing Science, Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium; Lisette Schoonhoven, Assistant Professor, Nursing Science, IQ Healthcare, Radboud University, Nijmegen, The Netherlands; Katrien Vanderwee, Assistant Professor, Nursing Science, Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium Address correspondence to Dimitri Beeckman, Nursing Science, Ghent University, UZ Blok A2nd oor De Pintelaan 185, 9000 Gent, Belgium; Dimitri.Beeckman@UGent.be Accepted 26 October 2010 Copyright 2011 Sigma Theta Tau International doi: 10.1111/j.1741-6787.2011.00217.x

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INTRODUCTION
ressure ulcers are painful, costly, and often preventable complications that threaten many individuals in hospitals, nursing homes, and home care (Hopkins et al. 2006; Spilsbury et al. 2007). A prevalence study in 2008 indicated an overall prevalence (Category I-IV) of 12.1% in Belgian hospitals. Only 10.8% of the patients at risk received fully adequate prevention in bed as well as while seated (Defloor et al. 2008). In 2001, the National Pressure Ulcer Advisory Panel (NPUAP) reported a prevalence (Category I-IV) of 15% in acute care hospitals in the United States (National Pressure Ulcer Advisory Panel 2001). Pressure ulcers are associated with high morbidity and mortality rates, increased hospitalization, and increased use of health care resources (Hopkins et al. 2006; Essex et al. 2009; Gorecki et al. 2009; Lardenoye et al. 2009). Individuals with activity/mobility limitations are at risk of developing pressure ulcers. These individuals include the elderly, patients who experienced physical trauma, patients with spinal cord injuries or fractured hips, those in long-term care homes or community care, the acutely ill, and patients in intensive care (European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel 2009). Interventions to prevent pressure ulcers should focus on the reduction of the amount and/or duration of pressure and shear (European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel 2009). Prevention in individuals at risk should be provided on a continuous basis during the time that they are at risk (European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel 2009). The application of an appropriate support surface, combined with correct repositioning is recommended (Royal College of Nursing and National Institute for Health and Clinical Excellence 2005). Heels should be free of all pressure because they are particularly vulnerable to pressure injury (European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel 2009; Heyneman et al. 2009). The plantar surface of the heel is well adapted to resisting the forces of standing and ambulation but the posterior heel is not because it is covered with only a thin layer of fat and skin. Specific devices should be placed to elevate the heel so as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon (Donnelly 2001; Wong & Stotts 2003). A wedge-shaped, bedwide, viscoelastic foam cushion or a pillow can be used for this. Evidence-based guidelines for the prevention of pressure ulcers have been developed widely and have been promoted by programs and campaigns of authoritative organizations. However, nonadherence to pressure ulcer guidelines is reported frequently (Hill 1992; Halfens

& Eggink 1995; Wilkes et al. 1996; Panagiotopoulou & Kerr 2002; Meesterberends et al. 2010; van Gaal et al. 2010). Many barriers may influence complianceor noncompliancewith a guideline (van Gaal et al. 2010). It is expected that negative attitudes and lack of knowledge act as barriers to using guidelines in clinical practice (Ajzen & Madden 1986; Grol & Wensing 2004; van Gaal et al. 2010). The number of studies on attitudes of nurses toward pressure ulcer prevention is limited (Bostrom & Kenneth 1992; Hill 1992; Maylor & Torrance 1999; Moore & Price 2004). Bostrom and Kenneth (1992) identified lack of interest and low priority of prevention in nursing care as important barriers to effective pressure ulcer prevention. Maylor and Torrance (1999) emphasize the importance of a lack of individual motivation as a barrier for effective prevention. According to Moore and Price (2004), nurses demonstrated an overall positive attitude toward pressure ulcer prevention. Attitudes seem to be negatively affected by lack of time (Moore & Price 2004), lack of nursing staff (Hill 1992; Moore & Price 2004), lack of knowledge (Hill 1992), and insufficient equipment (Hill 1992). Literature on knowledge about pressure ulcer prevention is often contradictory. Some researchers conclude that overall knowledge is appropriate (Bostrom & Kenneth 1992; Hill 1992; Wilkes et al. 1996; Provo et al. 1997; Maylor & Torrance 1999; Pancorbo-Hidalgo et al. 2007; K allman & Suserud 2009). Others conclude that nurses knowledge about pressure ulcer prevention is inadequate (Halfens & Eggink 1995; Pieper & Mattern 1997; Caliri et al. 2003). Russell (1996) and Panagiotopoulou and Kerr (2002) identified lack of knowledge in specific topics including etiology, pressure ulcer classification, and preventive methods. Hulsenboom et al. (2007) state that knowledge about pressure ulcer prevention in Dutch nurses barely improved in the previous decade. Evidence about the correlation between knowledge and the application of adequate prevention is lacking.

AIMS AND OBJECTIVES

This study aims to: (1) study the knowledge and attitudes of nurses about pressure ulcer prevention in Belgian hospitals and (2) to explore the correlation between knowledge, attitudes, and the application of fully adequate prevention.

METHODS
Study Design A cross-sectional multicenter study was performed. The study included a survey of pressure ulcer prevalence and
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adequacy of pressure ulcer prevention, and an assessment of the knowledge and attitudes of nurses about pressure ulcer prevention. The study was approved by the ethics review committee of Ghent University Hospital. Data were collected in April 2008.

In bed

Non-pressure redistributing mattress

Pressureredistributing mattress

Dynamic mattress

Study Population Adequacy of pressure ulcer prevention and pressure ulcer prevalence. The adequacy of preventive care and pressure ulcer prevalence was studied in all hospitalized patients in a random selection of 94 nursing wards in 14 Belgian hospitals. Patients under the age of 18 were excluded. All patients or their relatives were asked for their consent to participate in the study. Patients in pediatric care, day care, mother/child care, and mental health care wards were excluded from this study. Knowledge and attitudes of nurses toward pressure ulcer prevention. Based on a baseline of 10% of patients at risk receiving fully adequate prevention (Vanderwee et al. 2007) and an expected detectable difference of 20% or more of fully adequate prevention between: (1) wards with satisfactory knowledge (60%) and/or attitudes (75%) and (2) wards with insufficient knowledge (<60%) and/or attitudes (<75%) ( = 0.05, = 0.20), a sample size of 94 wards was determined. Data on knowledge and attitudes of nurses were collected in a random selection of at least five nurses from each participating ward.

+
Repositioning 2 hourly

+
Repositioning 2-4 hourly

+
Repositioning not needed

Heels elevated from the mattress using a wedge-shaped, bedwide, viscoelastic foam cushion or a pillow

In an (arm)chair

No pressureredistributing cushion

Pressureredistributing cushion

+
Repositioning 1 hourly

+
Repositioning 2-3 hourly

Figure 1. Algorithm of adequate preventive measures for patients at risk (Vanderwee et al. 2007). ulcer preventive measures included prevention in bed and while seated. The materials used and the repositioning frequency were recorded. Both evidence-based effective and noneffective measures (based on the 2009 NPUAP/EPUAP International Guideline) were recorded. An algorithm was used to assess the adequacy of the prevention provided Vanderwee et al. (2007) (see Figure 1). The algorithm included the combination of: (1) the use of a pressure redistributing/dynamic surface (mattress or cushion), (2) the frequency of repositioning, and (3) the elevation of the heels from the mattress in patients at risk for pressure ulcers. Prevention was defined as fully adequate if all preventive measures were applied, both in bed and when seated. Prevention was defined as partly adequate if not all required preventive measures were applied in bed and/or armchair. Prevention was defined as not adequate if no prevention was applied in bed and/or armchair in patients at risk. The data collection instrument was developed using the software package SNAP Surveys version SNAP 9 Professional (Snap Surveys Inc., London, UK). Knowledge and attitudes of nurses toward pressure ulcer prevention. For this multicenter study, two

Instruments Adequacy of pressure ulcer prevention and pressure ulcer prevalence. Clinical observations were used to assess the adequacy of pressure ulcer prevention and pressure ulcer prevalence. The procedure as developed by the European Pressure Ulcer Advisory Panel (EPUAP) was used (Vanderwee et al. 2007). This procedure has been evaluated as sufficiently robust to measure and compare pressure ulcer prevalence and prevention in different hospitals. The method consists of a minimum data set and a uniform procedure. The data collection instrument included five categories of data: (1) general data, (2) patient data, (3) risk assessment, (4) skin observation, and (5) prevention. General data contained the type of hospital and ward. Patient data included age, gender, and incontinence. The Braden Scale was used to assess the pressure ulcer risk of each patient. In Belgium, patients with a Braden score <17 are generally considered as being in need of prevention. Skin observation consisted of details on pressure ulcers (category and location) and incontinence-associated dermatitis. Pressure ulcers were categorized according to the EPUAP classification system. Finally, data on pressure
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individual, anonymous, instruments on various aspects of knowledge and attitudes about pressure ulcer prevention were used. Knowledge The Pressure Ulcer Knowledge Assessment Tool was used to assess the knowledge of the participating nurses about pressure ulcer prevention. The instrument includes 26 multiple choice questions with 3 answer options and reflects 6 domains expressing the most relevant aspects of pressure ulcer prevention: (1) etiology and development; (2) classification and observation; (3) nutrition; (4) risk assessment; (5) reduction of the magnitude of pressure and shearing; and (6) reduction of the duration of pressure and shearing. The maximum score on the instrument was 26 and a mean knowledge score of 60% was considered to be satisfactory in this study. The instrument was extensively validated in terms of item difficulty, discriminating index, and quality of the response alternatives (Beeckman et al. 2010b). The internal consistency reliability (Cronbachs ) was 0.77 and the 1-week test-retest intraclass correlation coefficient (stability) was 0.88 (Beeckman et al. 2010b). Attitude The validated Attitude toward Pressure Ulcer tool (APuP) was used to study the attitudes of the nurses toward pressure ulcer prevention (Beeckman et al. 2010a). The instrument includes 13 items and reflects five subscale domains: (1) personal competency to prevent pressure ulcers, (2) priority of pressure ulcer prevention, (3) impact of pressure ulcers, (4) responsibility in pressure ulcer prevention, and (5) confidence in the effectiveness of prevention. A 4point Likert-type scale was designed to collect the data (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree). Sum scores were calculated to obtain the total attitude score. Scores on the negatively worded items were reversed to obtain a total score. Higher scores indicated more positive attitudes. A mean attitude score of 75% was considered to be satisfactory in this study. Previous validation research indicated that the Content Validity Index of the items in the APuP was between 0.87 and 1.00 and Cronbachs ranged from 0.76 to 0.81. The instrument, as well as each of the five domain subscales, can be considered a brief, conceptually sound, rigorously developed instrument with strong evidence supporting the psychometric properties (Beeckman et al. 2010b). Procedure Adequacy of pressure ulcer prevention and pressure ulcer prevalence. In each hospital, a supervisor was ap-

pointed who was responsible for the local organization of the study. Prior to the study, all supervisors attended a training session. This consisted of: (1) a theoretical training (pathology, classification, risk assessment using the Braden Scale, and prevention); (2) an introduction to the study aims and protocol; and (3) the use of the data collection instrument. The purpose of this training was to ensure the correctness and uniformity of completing the data collection instrument. The supervisor created teams of nurses who collected the data on the wards. Each team consisted of two nurses: a nurse from the staff of the ward being surveyed and a nurse from a different ward. The first nurse was able to provide relevant background information about individual patients. Accordingly, all patients were observed by two nurses. Both nurses had to agree on the classification of the pressure ulcer. If they disagreed, the opinion of the nonward nurse was taken into account. The supervisors instructed the teams about the study procedure. For that purpose, the supervisors received a Powerpoint presentation and an information guide on the study procedure to increase the reliability of the data collection. Knowledge and attitudes of nurses toward pressure ulcer prevention. The participating nurses were fully informed by the researcher about the purpose of the study and were asked to complete the instruments individually. In the instrument, the purpose, procedure, assured anonymity, and confidentiality were fully explained. The return of a completed instrument was considered as consent to participate. While completing the instruments, the participants were not allowed to use other resources and were supervised by the researcher. The time to complete both instruments was 30 minutes. Data Analysis Statistical analyses were performed using SPSS 15.0 (SPSS Inc., Chicago, IL, USA). Descriptive data are presented in frequencies (percentages) and means ( standard deviation). One-way analyses of variance and independent sample t-tests were performed to test for differences in scores among groups. Binary logistic regression modeling (Method Enter) was performed to assess the correlation between the application of fully adequate prevention in 30% of the patients at risk (yes/no) and: (1) knowledge, (2) attitude, (3) additional pressure ulcer education on ward level, and (4) the presence of a pressure ulcer nurse on ward level. A correlation analysis was performed to test for multicollinearity between the independent variables. Spearmans needed to be less than 0.80 to be included in the model. Results were considered to be significant if the two-tailed p-value was <.05.
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Pressure Ulcer Prevention TABLE 1 Patient characteristics by ward type SURGICAL n Age 1939 years 4059 years 6069 years 7079 years 8089 years >89 years Genderb Female Male Incontinence Urinary Fecal Risk Braden <17 Total
a

MEDICAL n 33 123 108 200 169 24 325 332 149 111 128 657 (%) (5.0) (18.7) (16.4) (30.4) (25.7) (3.7) (49.5) (50.2) (22.7) (16.9) (19.5) (31.2)

SURGICAL MEDICAL n 11 24 18 31 26 4 59 56 22 23 26 115 (%) (9.6) (20.9) (15.7) (27) (22.6) (3.5) (51.3) (48.7) (19.1) (20.0) (22.6) (5.5)

GERIATRIC n 0 4 18 109 271 55 299 158 219 211 167 457 (%) (0.0) (0.9) (3.9) (23.9) (59.3) (12.0) (65.4) (34.6) (47.9) (46.2) (36.5) (21.7)

INTENSIVE CARE n 2 8 18 29 19 1 27 50 4 28 53 77 (%) (2.6) (10.4) (23.4) (37.7) (24.7) (1.3) (35.1) (64.9) (5.2) (36.4) (68.8) (3.7) n

OTHER (%) (5.6) (17.6) (17.6) (24.8) (32.8) (1.6) (55.2) (44.8) (30.4) (26.4) (21.6) (5.9) n

TOTAL (%) (4.3) (16.0) (14.8) (28.2) (31.6) (5.0) (44.7) (55.3) (25.0) (22.6) (24.8) (100)

(%) (5.6) (23.0) (18.8) (28.8) (20.6) (3.0) (57.3) (42.7) (13.9) (10.2) (18.1) (32.0)

38 155 127 194 139 20 386 288 94 69 122 674

7 22 22 31 41 2 69 56 38 33 27 125

91 336 311 594 665 106 940 1165 526 475 523 2105

a Two missing data, b four missing data.

RESULTS
Pressure ulcer prevalence and adequacy of pressure ulcer prevention. The total sample consisted of 2105 patients from 94 nursing wards in 14 hospitals. Almost 70% of the patients were admitted to surgical and/or medical wards. More than 60% of the patients were aged 70 and about 25% were at risk for pressure ulcers according to the Braden Scale. Demographic data for the patients are presented in Table 1. The overall pressure ulcer prevalence (Category IIV) was 13.5% (284/2105) and of Category II-IV 7.9% (167/2105). Intensive care units and geriatric wards showed the highest prevalence figures (Category I-IV), 18.2% and 22.8%, respectively (Table 2). In intensive care units, 30.9% of the patients at risk received adequate preventive measures in bed as well as while seated in an armchair, whereas on wards with surgical patients the lowest figures for adequate care (4.2% and 3.6%, respectively) were reported. Overall, 13.9% of the patients at risk received fully adequate prevention. In 19.1% of the wards (18/94), all patients at risk received fully adequate prevention, whereas in 56.4% of the wards (53/94), none of the patients at risk received fully adequate prevention. Heels were not elevated in 55.5% of the patients at risk. The majority of patients at risk (71.5%) received partly adequate prevention. More than 70% of the patients not at risk received (some) prevention while lying or when seated. More results on the adequacy
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TABLE 2 Pressure ulcer prevalence by ward type PRESSURE ULCERS CATEGORY I-IV n Surgical wards Medical wards Surgical-medical wards Geriatric wards Intensive care units Other wards Total 58 71 9 104 14 28 284 (%) (8.6) (10.8) (7.8) (22.8) (18.2) (22.4) (13.5) PRESSURE ULCERS CATEGORY II-IV n 27 45 4 64 11 16 167 (%) (4.0) (6.8) (3.5) (14.0) (14.3) (12.8) (7.9)

of the applied prevention by ward type are provided in Table 3. Knowledge and attitudes of nurses toward pressure ulcer prevention. A total of 553 nurses from 94 nursing wards participated in the assessment of knowledge and attitudes toward pressure ulcer prevention. More than half of the nurses were over the age of 35 and 55% of them worked as a nurse for more than 10 years. The sample included staff nurses (86.1%), senior nurses (4.5%), and tissue viability nurses (9.4%). An overview of the basic characteristics of the participating nurses is shown in Table 4.

Pressure Ulcer Prevention TABLE 3 Prevention in patients at risk (Braden <17 and/or pressure ulcer) and not at risk by ward type SURGICAL n (%) Patients at risk Bed + armchair Fully adequate preventiona Partly adequate preventionb No adequate preventionc Fully adequate prevention Partly adequate prevention No adequate prevention Fully adequate prevention Partly adequate prevention No adequate prevention Correct: no prevention Incorrect: prevention Correct: no prevention Incorrect: prevention Correct: no prevention Incorrect: prevention 144 (21.4) 6 (4.2) 124 (86.1) 14 (9.7) 19 (13.2) 120 (83.3) 5 (3.5) 0 (0.0) 15 (16.7) 75 (83.3) 530 (78.6) 154 (29.1) 376 (70.9) 164 (30.9) 366 (69.1) 513 (96.8) 17 (3.2) MEDICAL n (%) 153 (23.3) 18 (11.8) 111 (72.5) 24 (15.7) 43 (28.1) 103 (67.3) 7 (4.6) 3 (2.6) 23 (20.0) 89 (77.4) 504 (76.7) 116 (23.0) 388 (77.0) 119 (23.6) 385 (76.4) 474 (94.0) 30 (6.0) SURGICAL -MEDICAL n (%) 28 (24.3) 1 (3.6) 20 (71.4) 7 (25.0) 2 (7.1) 20 (71.4) 6 (21.4) 0 (0.0) 2 (10.5) 17 (89.5) 87 (75.7) 28 (32.2) 59 (67.8) 29 (33.3) 58 (66.7) 86 (98.9) 1 (1.1) GERIATRIC n (%) 202 (44.2) 39 (19.3) 137 (67.8) 26 (12.9) 90 (44.6) 102 (50.5) 10 (5.0) 21 (13.4) 59 (37.6) 77 (49.0) 255 (55.8) 41 (16.1) 214 (83.8) 44 (17.3) 211 (82.7) 200 (78.4) 55 (21.6) INTENSIVE CARE n (%) 55 (71.4) 17 (30.9) 26 (47.3) 12 (21.8) 18 (32.7) 26 (47.3) 11 (20.0) 0 (0.0) 0 (0.0) 9 (100) 22 (28.6) 4 (18.2) 18 (81.8) 4 (18.2) 18 (81.8) 22 (100) 0 (0.0) OTHER n (%) 43 (34.4) 6 (14) 29 (67.4) 8 (18.6) 13 (30.2) 28 (65.1) 2 (4.7) 2 (6.3) 1 (3.1) 29 (90.6) 82 (65.6) 26 (31.7) 56 (68.3) 27 (32.9) 55 (67.1) 76 (92.7) 6 (7.3) TOTAL n (%) 625 (29.7) 87 (13.9) 447 (71.5) 91 (14.6) 185 (29.6) 399 (63.8) 41 (6.6) 26 (6.2) 100 (23.7) 296 (70.1) 1480 (70.3) 369 (24.9) 1111 (75.1) 387 (26.1) 1093 (73.9) 1371 (92.6) 109 (7.4)

Bed

Armchair

Patients not at risk Bed + armchair Bed Armchair

PU = pressure ulcers, a effective preventive measures, b some preventive measures, and c no preventive measures.

Knowledge The mean knowledge score was 49.6% (12.9/26). An overview of the knowledge scores is described in Table 5. Only 23.5% (130/553) of the nurses had a mean score of 60%. A statistically significant difference was found between the knowledge of staff nurses (48.5%) and tissue viability nurses (58.1%) (t = 4.5, df = 526, p < .001). Nurses who attended additional training on pressure ulcer prevention showed higher knowledge scores than nurses who did not attend any additional training (51.3% vs. 47.7%, t = 3.17, df = 551, p = .002). Certificate nurses showed significantly lower knowledge than nurses with a bachelor degree (47.7% vs. 51.5%, t = 2.97, df = 529, p = .003). The lowest scores were obtained in the themes risk assessment (35.6%), reduction of the magnitude of pressure and shearing (43.9%), observation and classification (48.4%), and etiology and development (50.0%). Only 26.0% of the nurses knew that pressure ulcers were caused by a lack of oxygen in the tissue. Nurses knowledge did not prove to be significantly higher in wards in which over 30% of the patients at risk received fully adequate prevention (49.2% vs. 51.9%, t = 1.297, df = 92, p = 0.198). Attitude The mean attitude score was 71.3% (37.1/52). An overview of attitude scores is provided in Table 5. Approximately half of the nurses (283/553) obtained a mean attitude score

of greater than or equal to 75%. The attitudes of staff nurses (70.4%) were found to be significantly lower than those of tissue viability nurses (76.7%) (t = 2.6, df = 526, p = .01). No difference was found between the attitudes of tissue viability nurses and senior nurses (76.7% vs. 77.9%, t = 0.32, df = 75, p = .75). Nurses who attended additional training on pressure ulcer prevention did not show higher attitude scores than nurses who did not (t = 1.67, df = 526, p = .10). Nurses attitudes proved to be significantly higher in wards in which greater than 30% of the patients at risk received fully adequate prevention (74.2% vs. 70.2%, t = 2.203, df = 92, p = .03). A weak correlation was found between: (1) the attitude of nurses toward their competency and (2) their total knowledge score (r = 0.24, p < .001). A positive correlation was found between the attitude of nurses regarding the priority given to pressure ulcer prevention and: (1) their total knowledge score (r = 0.38, p < .001) and (2) the application of fully adequate prevention (r = 0.25, p = .016). An overall positive correlation was found between total knowledge scores and total attitude scores (r = 0.41, p < .001). The logistic regression analysis showed that the application of fully adequate prevention on a nursing ward was significantly correlated with the attitudes of the nurses (OR = 3.07, p = .05). In this model, no independent correlation was found between knowledge and the application of fully adequate prevention (OR = 0.75, p = .71).
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Pressure Ulcer Prevention TABLE 4 Demographic data of the participating nurses NURSES (n = 553) % (n ) Gender Male Female Education Certicate nursea Bachelor degree MScN degreeb Age category <25 years 2534 years 3550 years >50 years Work experience <5 years 510 years 1020 years >20 years Function Staff nurse Senior nurse Tissue viability nurse Ward Surgical Medical Surgical/Medical Geriatric Intensive care Other 10.3 (57) 89.7 (496) 47.7 (264) 48.3 (267) 4.0 (22) 14.3 (79) 32.9 (182) 41.4 (229) 11.4 (63) 24.6 (136) 20.4 (113) 26.6 (147) 28.4 (157) 86.1 (476) 4.5 (25) 9.4 (52) 29.7 (164) 26.6 (147) 4.3 (24) 19.2 (106) 12.3 (68) 8.0 (44)

This study indicates that pressure ulcer prevalence and the application of fully adequate prevention in patients at risk has not improved over the last few years (Vanderwee et al. 2007). Similar to Vanderwee et al.s (2007) study, approximately 30% of the patients were at risk, and in this group pressure ulcer prevention was found to be mainly inadequate. Only 13.9% of all patients in need of prevention (either in bed or when seated) received fully adequate prevention. Prevention when seated and heel damage prevention were most problematic. Moreover, this study showed that a significant amount of patients not at risk (71.5%) received some kind of prevention, which is unnecessary and inefficient. Knowledge and Attitudes of Nurses toward Pressure Ulcer Prevention Knowledge. Adequate knowledge about pressure ulcer prevention is important to decide: (1) which patients should receive prevention, (2) which prevention should be applied, and (3) how prevention should be applied. This study highlights concerns about nurses knowledge of pressure ulcer prevention. Knowledge on none of the items was satisfactory. Knowledge about: (1) risk assessment, (2) measures to reduce the magnitude of pressure and shearing, (3) observation/classification, and (4) etiology was insufficient. In less than a quarter of the nurses, a desirable level of knowledge was observed. Knowledge was not significantly correlated with the application of fully adequate prevention. Wards with overall higher knowledge scores did not show higher figures on the application of pressure ulcer preventive measures. This may indicate that nurses with more adequate knowledge do not perceive a need to act more adequately in practice. However, the application of prevention as observed in this study might also be influenced by some other barriers. Several researchers explored barriers to guidelines use in clinical practice (Hutchinson & Johnston 2004). The major barriers to the use of guidelines in practice include that guidelines are not available, there is no access to research, poor facilities for implementation, lack of competent colleagues, lack of time for reading and implementation, the characteristics of the nurses, the nurses lack of authority in the organization, the process of utilization, and the organization (Hunt 1997; Nilsson Kajermo et al. 1998; Hutchinson & Johnston 2004). According to Kajermo et al. (2008), senior nurses and nurse managers should create clear/realistic goals and strategies to support nurses professional development and possibilities to implement research findings in clinical practice. Although no significant correlation was found between knowledge and the application of adequate prevention, it is reasonable to suppose that insufficient knowledge does

a The certicate nurse undertakes practical nurse training in the fourth grade

of secondary school after completing secondary school studies. The training is largely based on practice and apprenticeship. b Master of Science in Nursing (advanced-level quaternary education degree for nurses having a Bachelor degree).

The results of the logistic regression analysis are shown in Table 6.

DISCUSSION
This study aims to investigate the knowledge and attitudes of nurses about pressure ulcer prevention in Belgian hospitals and to explore the correlation between knowledge, attitudes, and the application of fully adequate prevention. The results showed that the knowledge of nurses about pressure ulcer prevention in Belgian hospitals was poor. Moreover, only half of the nurses showed attitude scores of equal to or greater than 75%. The application of fully adequate prevention was statistically significantly correlated with the attitudes of nurses.
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Pressure Ulcer Prevention TABLE 5 Knowledge and attitudes of the participating nurses KNOWLEDGE n /26 (%) Overall Gender Male Female Education Certicate nursea Bachelor degree MScN degreeb Age category <25 years 2534 years 3550 years >50 years Work experience <5 years 510 years 1020 years >20 years Function Staff nurse Senior nurse Tissue viability nurse Ward Surgical Medical Surgical/Medical Geriatric Intensive care Other Additional training Yes No 12.9/26 (49.6) 13.6/26 (52.3) 12.8/26 (49.2) F = 4.88, p = .008 12.4/26 (47.7) 13.4/26 (51.5) 13.8/26 (53.1) F = 1.84, p = .14 13.8/26 (53.0) 12.9/26 (49.6) 12.8/26 (49.2) 12.3/26 (47.3) F = 4.47, p = .004 13.9/26 (53.4) 13.0/26 (50.0) 12.6/26 (48.5) 12.4/26 (47.7) F = 11.28,p < 0.001 12.6/26 (48.5) 14.1/26 (54.2) 15.1/26 (58.0) F = 2.28, p = .046 12.4/26 (47.5) 13.5/26 (51.8) 12.6/26 (48.5) 13.6/26 (52.2) 12.5/26 (48.2) 12.4/26 (47.6) t = 3.17, p = .002 13.4/26 (51.5) 12.4/26 (47.7) 37.7/52 (72.5) 36.4/52 (70.0) 36.5/52 (70.2) 36.8/52 (70.8) 38.1/52 (73.3) 37.6/52 (72.3) 36.8/52 (70.8) 39.0/52 (75.0) t = 1.67, p = .10 36.6/52 (70.4) 40.5/52 (77.9) 39.9/52 (76.7) F = 0.72, p = .61 37.1/52 (71.3) 36.4/52 (70.0) 37.1/52 (71.3) 37.6/52 (72.3) F = 5.51, p = .004 37.1/52 (71.3) 36.6/52 (70.4) 37.7/52 (72.5) 36.7/52 (70.6) F = 0.41, p = .75 36.3/52 (69.8) 37.7/52 (72.5) 39.4/52 (75.8) F = 0.59, p = .63 DIFFERENCE NA t = 1.47, p = .14 ATTITUDE n /52 (%) 37.1/52 (71.3) 37.9/52 (72.9) 37.0/52 (71.2) F = 2.62, p = .07 DIFFERENCE NA t = 0.69, p = .49

NA = not applicable. a The certicate nurse undertakes practical nurse training in the fourth grade of secondary school after completing secondary school studies. The training is largely based on practice and apprenticeship. b Master of Science in Nursing (advanced-level quaternary education degree for nurses having a Bachelor degree).

TABLE 6 Binary logistic regression modeling to assess the relationship between the adequacy of pressure ulcer prevention provided and: (1) knowledge, (2) attitude, (3)% of patients at risk, (4) additional training, and (5) the presence of a pressure ulcer nurse on ward level B d (SE)e Application of fully adequate prevention in 30% of the patients at risk 0.284 (0.775) Knowledgea 1.122 (0.565) Attitudeb 0.597 (0.578) % Patients at riskc Additional training provided 0.076 (0.609) Presence of a pressure ulcer nurse 1.013 (0.603) WALD 2 0.134 3.944 1.066 0.16 2.825 P 0.714 0.047 0.302 0.901 0.093 OR (95% CI ) 0.753 (0.1653.442) 3.071 (1.0159.295) 1.816 (0.5855.637) 1.079 (0.3273.559) 2.753 (0.8458.969)

a Reference category: knowledge score <60%, b attitude score <75%, c <30% patients at risk, d B, regression coefcient, e SE = standard error.

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lead to misconceptions about pressure ulcer prevention and subsequently to suboptimal care. Education is necessary to improve knowledge. However, McCluskey and Lovarini (2005) found that continuing professional education can improve knowledge but also found that the subsequent impact on behavior was limited. They state that the ongoing challenge for educators, researchers, and managers is how to support health care workers to establish new routines and priorities around evidence-based practice. This behavior change may probably require a lot of time. In a study by Caliri et al. (2003), nursing students knowledge scores were higher if they had participated in practical training about pressure ulcers or used a Web site about pressure ulcers. It is therefore recommended that educators consider different educational methods, structures, or ways of presenting information on pressure ulcer prevention. More highly educated nurses scored significantly higher in knowledge scores than did those with lower levels of education. These findings are comparable to PancorboHidalgo et al. (2007) who found that nurses holding a university degree obtained higher scores for knowledge and clinical performance. In contrast, other researchers did not find any correlation between educational background and scores for knowledge (Pieper & Mott 1995; Pieper & Mattern 1997). In this study, attending additional training was positively correlated with higher knowledge scores. Pieper and Mott (1995) also found that nurses knowledge was significantly higher when the nurses recently had heard a lecture or read an article about pressure ulcers. In contrast, Pieper and Mattern (1997) found that knowledge was not higher if nurses recently read an article about pressure ulcers. Attitude. A significant correlation was found between knowledge and attitude. This finding indicates the sizeable correlation between what individuals know and how they feel about pressure ulcer prevention. Attitudes were significantly correlated with the application of fully adequate prevention. Wards with overall higher attitude scores showed higher figures on the application of fully adequate prevention. According to Petty and Cacioppo (1996), attitudes are considered important because they give an indication of what to expect from individuals. As stated by Ajzen and Fishbein (2005), a positive attitude toward an issue is an important influencing factor that determines an individuals likelihood of carrying out a positive behavior. This statement is supported by Champion and Leach (1989) and Hicks (1996) who showed the positive impact of more positive attitudes on the quality of nursing practice. In this study, the attitudes of the nurses differed according to their professional role in clinical practice. Tissue
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viability nurses showed significantly higher attitudes than staff nurses. This finding highlights the importance of the presence of a tissue viability nurse on a ward or unit. Better attitude scores in tissue viability nurses may be correlated with higher motivation, and more interest in pressure ulcer prevention. Whether nurses had received any formal training in pressure ulcer prevention did not make a significant difference. This finding is comparable to Moore and Price (2004) who found that attitudes were not influenced by any formal training in pressure ulcer prevention and management. The fact that formal training did not influence the attitude of nurses requires some reflection. Most of the interventions to improve patient care are focused on in-service training and refresher courses, using traditional lectures. The effectiveness of these educational methods to improve attitudes should be questioned. Research in other domains indicate that interventions proposed to improve attitudes and practice should include interactive components and constructive feedback (Pittet et al. 2000; Jenkins & Fallowfield 2002). Interventions to improve attitudes should be focused on novice nurses as well as on senior staff, as the influence of senior staff may be substantial. In this study, the attitude toward the priority of pressure ulcer prevention in care was positively correlated with the knowledge of the nurses and the application of fully adequate preventive care, which is comparable to the findings of Bostrom and Kenneth (1992). In this study, rigorously constructed and psychometrically evaluated instruments were used, increasing reliability of the study results (Vanderwee et al. 2007; Beeckman et al. 2010a, 2010b). Evaluation of knowledge, attitudes, prevalence, and adequacy of prevention should be organized on a frequent basis. In research by Lahmann et al. (2010), repeated participation in pressure ulcer surveys led to: (1) lower pressure ulcer prevalence rates, (2) increased use of all guidelines/risk assessment scales, and (3) increased use of most preventive measures and devices. In contrast, Hulsenboom et al. (2007) found that being employed in an institution that monitors pressure ulcer care hardly affects the knowledge level.

Limitations There are several limitations that should be considered. First, randomly selected participants may have been less motivated to complete the knowledge questionnaire, and the results might be too negative. However, care was taken during recruitment to minimize recruitment bias and obtain a representative sample. Second, participants could have given socially desirable answers during the attitude assessment, despite the anonymous character of the instrument. Possibly, the attitude results may be too positive.

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CONCLUSIONS
The overall adequacy of pressure ulcer prevention in Belgian hospitals was poor and knowledge in nurses was inadequate. Apart from that, only half of the nurses showed attitudes scores of equal to or greater than 75%. Attitudes of nurses toward pressure ulcers were significantly correlated with the application of fully adequate prevention. Knowledge was not significantly correlated with the application of fully adequate prevention. Educators, both involved in basic nursing education and in in-service training, have an important role in developing methods to improve both knowledge and attitudes toward pressure ulcer prevention. References Ajzen I. & Madden T. (1986). Prediction of goal-directed behaviour: Attitudes, intentions and perceived behavioural control. Journal of Experimental Social Psychology, 22(3), 453474. Ajzen I. & Fishbein M. (2005). The influence of attitudes on behaviour. In D. Albarracin, B. Johnson, M. Zanna (Eds.), The Handbook of Attitudes. Mahwah, NJ: Erlbaum, pp. 289311. Beeckman D., Defloor T., Demarr e L., Van Hecke A. & Vanderwee K. (2010a). Pressure ulcers: Development and psychometric evaluation of the Attitude towards Pressure ulcer Prevention instrument (APuP). International Journal of Nursing Studies, 47(11), 14321441. doi:10.1016/j.ijnurstu.2010.04.004. Beeckman D., Vanderwee K., Demarr e L., Paquay L., Van Hecke A. & Defloor T. (2010b). Pressure ulcer prevention: Development and psychometric validation of a knowledge assessment instrument. International Journal of Nursing Studies, 47(4), 399410. Bostrom J. & Kenneth H. (1992). Staff nurse knowledge and perceptions about prevention of pressure sores. Dermatology Nursing, 4(5), 365378. Caliri M., Miyazaki M. & Pieper B. (2003). Knowledge of pressure ulcers by undergraduate nursing students in Brazil. Ostomy/Wound Management, 49, 3. Retrieved 12 April, 2010, from http://www.o-wm.com/article/1436. Champion V. & Leach A. (1989). Variables related to research utilization in nursing: An empirical investigation. Journal of Advanced Nursing, 14(9), 705710. Defloor T., Bouzegta N., Beeckman D., Vanderwee K., Gobert M. & Van Durme T. (2008). Pressure ulcer prevalence in Belgian hospitals in 2008. [Studie van de Decubitusprevalentie In de Belgische ziekenhuizen 2008: Project PUMap]. (p. 120). Brussels: Federal Public Service: Health, Food Chain Safety and Environment. Donnelly J. (2001). Hospital-acquired heel ulcers: A com-

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