|Year : 2019 | Volume
| Issue : 7 | Page : 1014-1021
Caregivers' knowledge and practice toward pressure ulcer prevention in national orthopedic hospital, Enugu, Nigeria
JA Ingwu, AH Nwaordu, H Opara, OE Israel, C Ogbogu
Department of Nursing Sciences, Faculty of Health Sciences and Technology College of Medicine, University of Nigeria, Enugu Campus, Nigeria
|Date of Acceptance||01-May-2019|
|Date of Web Publication||11-Jul-2019|
Dr. J A Ingwu
Department of Nursing Sciences, Faculty of Health Sciences and Technology, College of Medicine, University of Nigeria, Enugu Campus
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Globally, nurses are known to care for hospitalized patients and the presence or absence of pressure ulcers is being regarded as a performance measure of quality nursing care. The study aims to determine the knowledge and practice of caregivers towards pressure ulcer prevention for hospitalized patients in National Orthopaedic Hospital, Enugu. Method: A cross sectional descriptive survey design was adopted among eighty-five (85) caregivers who met the inclusion criteria and participated in the study. Ethical approval and informed consent of participants was obtained before data collection using a pre-tested semi-structured questionnaire and checklist. Descriptive analysis and Chi-square statistical test was used to test for association between variables. Result: Results revealed poor knowledge 67.3% of pressure ulcer prevention among caregivers. Inadequate staffing 93.5%, heavy workload 92.9%, were highest perceived barriers to pressure ulcer prevention. The test of hypothesis showed that there is a significant relationship between years of service of caregivers and knowledge of pressure ulcer P = 0.000. Conclusion: It was concluded that in-service training, recruitment of more staff and ensuring availability of the necessary equipment are some of the important steps to improve nurses' knowledge and practice regarding prevention of pressure ulcer.
Keywords: Caregivers, knowledge, practice, pressure ulcer
|How to cite this article:|
Ingwu J A, Nwaordu A H, Opara H, Israel O E, Ogbogu C. Caregivers' knowledge and practice toward pressure ulcer prevention in national orthopedic hospital, Enugu, Nigeria. Niger J Clin Pract 2019;22:1014-21
|How to cite this URL:|
Ingwu J A, Nwaordu A H, Opara H, Israel O E, Ogbogu C. Caregivers' knowledge and practice toward pressure ulcer prevention in national orthopedic hospital, Enugu, Nigeria. Niger J Clin Pract [serial online] 2019 [cited 2019 Sep 22];22:1014-21. Available from: http://www.njcponline.com/text.asp?2019/22/7/1014/262522
| Background|| |
Globally, nurses are known to care for hospitalized patients and the presence or absence of pressure ulcers is being regarded as a performance measure of quality nursing care. This is in line with declaration of American Nurses Association (ANA) which says that pressure ulcer prevention is primarily a nursing responsibility. According to the National Pressure Ulcer Advisory Panel (NPUAP), a pressure ulcer is localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device. It can present as intact skin or an open ulcer and may be painful. Pressure ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear.
Nowadays, pressure injuries are recognized worldwide as one of the most common causes of harm to patients and preventable patient safety problem. Also, it is increasingly described as an indicator of the quality of care provided by health care organizations. Pressure ulcers are common conditions among patients hospitalized in acute and chronic care facilities and impose a significant burden on patients, their relatives, and caregivers.
Pressure ulcers have been described as one of the most costly and physically debilitating complications since the 20th century. The pain and discomfort of pressure ulcer delays rehabilitation, prolongs illness, and timing of discharge, and also contribute to disability and death. These dramatically raise health care costs as a result of the need for supplies and nursing hours. Moreover, health care budgets expend billions of dollars worldwide on prevention and treatment of patients with extended hospital stays from pressure ulcer development. It has been estimated that the cost of treating pressure ulcer is 2.5 times higher than the cost of its prevention. In USA, pressure ulcers remain a major health problem affecting approximately 3 million adults. A systematic review of 31 studies found that pressure ulcers significantly limit many aspects of an individual's wellbeing, including general health and physical, social, financial, and psychological quality of life. So, the burden of pressure ulcers goes beyond increasing health care costs to loss of life.
According to an international study by Gunningberg et al., it has been identified that nurses' knowledge of the prevention of pressure ulcers is poor, which reflected in their practices as they do not comply with best practice guidelines. Descriptive study conducted by. in Sweden on nurses' knowledge and practice of existing guidelines on prevention of pressure ulcer found that majority of them had inadequate knowledge and practice to implement guidelines. Similarly, a study in Belgian Hospital found that knowledge of nurses about the prevention of pressure ulcers was inadequate. Poor knowledge and practice of nurses have its own contribution for higher prevalence of pressure ulcers.
There were several factors that contributed to pressure ulcer development. These included advanced age, immobility, dehydration, comorbidities, impaired sensory perception, altered tissue perfusion, malnutrition, anemia, organ system failure, and infection as intrinsic factors and intensity and duration of pressure, friction, shearing, and maceration as extrinsic factors. Some reasons for the high incidence of pressure ulcer might be related to nurses' knowledge and practice in terms of risk assessment and prevention methods. Knowledge, attitude, and practice increased nurses' awareness of the problem of pressure ulcer and provided the basis for informed decision making and the framework to develop and maintain competency of delivering high quality of nursing care.
Nurses' knowledge and practice are also viewed as extrinsic factors for pressure injury development; this is because, even if the prevention of pressure ulcers is a multidisciplinary responsibility, usually nurses play a major role and is considered to be an essential part of nursing care. Thus, preventing ulcer should be the goal of all nurses. Considering nursing services as a tool for the prevention of pressure ulcers, it informed the researcher's decision to investigate nurses' knowledge and practice regarding pressure prevention if it is adequate or inadequate for quality nursing care as regards PU prevention.
Anecdotal observation at National Orthopedic Hospital, Enugu (NOHE), Nigeria found a high incidence of pressure ulcers among patients confined to bed despite the numerous guidelines that have been developed and implemented in health care systems to assist nurses to take appropriate decisions to improve pressure ulcer prevention, pressure ulcer still remains prevalent among hospitalized patients. Episodes of pressure ulcers are common phenomenon in the Nigerian clinic setting. The findings of the study were expected to describe the nurses' knowledge and practice regarding pressure ulcer prevention. The outcomes of this study will contribute to nursing education, nursing practice, and future research in Nigeria.
| Methods|| |
The aim of the study was to assess the caregivers' knowledge and practice toward pressure ulcer prevention for hospitalized patients in National Orthopedic Hospital Enugu, (NOHE) Nigeria.
A self-reported cross-sectional descriptive survey design was used to collect data from nurses in NOHE.
The study utilized total population of nurses working in the five selected inpatients wards of the hospital; male ward 1, female ward 1, female ward 3, male ward 4, and acute burns ward. These wards were purposively selected for the study because the patients in these wards have reduced activity and stay for a relatively longer time due to the severity of their conditions than the patients in other wards. The total number of nurses in the inpatients wards was 93 but only 85 participated. The inclusion criteria include:
- Being available at the time of administering the questionnaire.
- Willingness to participate and consented to the study verbally.
- Having worked in the selected wards for at least 3 months.
The instrument used for data collection is structured questionnaire developed based on extensive literature review. The questionnaire consists of four sections:
Section A: Socio-demographic data: This section consists of six (6) items.
Section B: Caregivers' Knowledge of Pressure Ulcer Prevention: This section is composed of 21-item multiple choice questions which had been developed and modified from the Pressure Ulcer Prevention Guideline (PUPG).
Section C: Caregivers' Practice of Pressure Ulcer Prevention: This isa 15-item structured questionnaire developed using a checklist of Yes/No.
Section D: Caregivers' perceived barriers to Pressure Ulcer Prevention: This section comprised of ten items which the respondents were allowed to tick as many as possible.
Ethical clearance letter was obtained from the Health Research Ethical Committee of National Orthopedic Hospital, Enugu, after having met their prerequisites and was giving approval to obtain information from the Nursing service division and also to carry out the study. The principles of confidentiality, anonymity, and voluntary participation were applied.
The researcher and one trained research assistant administered the copies of the questionnaire directly to the respondents in various wards. Distribution and collection of questionnaire lasted for 5 days. The researcher and the trained research assistant divided themselves each to distribute the questionnaires to the nurses on morning, afternoon, and night duties in order to make sure that all the respondents were reached. One day in the week was used for the distribution of the questionnaires in one ward to avoid preinformation among the participants. After 3 hours of distribution, the copies of the questionnaire were retrieved. A total of 93 questionnaires were administered and only 85 questionnaires retrieved for data analysis.
Data collected were analyzed and interpreted with IBM Statistical Package for the Social Sciences (IBM SPSS) version 23 and descriptive statistics of frequency counts, percentages and mean were used to answer research questions relating to sociodemographic characteristics, knowledge and practice of caregivers regarding pressure ulcer prevention, and caregivers' perceived barriers to pressure ulcer prevention care.
| Results|| |
[Table 1] shows that the mean age of the nurses was 37.6 years with a minimum and maximum age of 25 and 56 years, respectively. The age range of most nurses was between 31 and 40 years 54.1%. A majority of them were female 87.1%. Majority of the nurses were married 76.5%. Most of them 69.4% had a Diploma in nursing. The average length of service of the nurses was 11.62 years, and this ranged from 1 year to 23 years. Majority of participants came from acute burns unit 27.1%.
|Table 1: Frequency and percentage of nurses' sociodemographic characteristics (n=85)|
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[Table 2] shows the distribution of the caregivers' knowledge on PU prevention. It shows that 59 (69.4%) indicated that immobility is the most important factor for pressure ulcer formation in a patient with fractured hip and bedridden. 73 (85.9%) of them indicated that low albumin is the critical determinant for pressure ulcer formation. 81 (95.3%) believe that head to toe skin assessment is an assessment for a patient with spinal cord injury who is at high risk for PU development, while 66 (77.7%) of the respondents are of the opinion that the assertion that risk assessment scale is an appropriate method for assessing an individual who is at risk for PU development is incorrect. 61 (71.8%) indicated that nonblanchable redness or blue–gray discoloration is the sign for PU development. Majority 63 (74.1%) of them believe that application of topical cream is not the appropriate method for skin care. Majority 78 (91.8%) are in agreement that turn position for every 2 hours is significant activity for preventing skin damage. Most of them 71 (85.5%) of them indicated that use of pillow under the patient's leg to prevent heel ulcer. Above average 67 (78.8%) of the respondents indicated that vitamin C and E is important to maintain healthy skin, 76 (89.4%) agree that turn position is an appropriate nursing care for managing mechanical load. 69 (81.2%) indicated that lifting patient without dragging is appropriate activity to reduce to reduce friction for an elderly patient having fractured hip with skeletal traction. While 67 (78.8%) of them are against the assertion that elevate the head of bed <30° is the activity for reducing shearing force, and 65 (76.5%) of them believe that scheduling of turning position is necessary educational information for reducing PU formation. This shows that the overall nurses' knowledge regarding pressure ulcer prevention was poor (M = 67.25%) with minimum and maximum scores of 21.18% and 95.29%, respectively.
|Table 2: Distribution of the caregivers' knowledge on PU prevention (n=85)|
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[Table 3] above shows caregivers' practice on prevention of PU. It shows that 79 (92.9%) of the respondents indicated that identification of common contributing factors for PU development is a practice on prevention of PU. Majority 73 (85.9%) indicated that skin assessment is a practice on prevention of PU. Majority 80 (94.1%) of them indicated that the assertion that use of risk assessment scale as a practice on prevention of PU is incorrect. Also, 69 (81.2%) of them indicated that documentation of all data relating to PU development is not a practice on prevention of PU. And 77 (90.6%) of them agree that placing pillow under the patient's leg is a practice on prevention of PU. Majority 74 (87.1%) believe that monitoring a protein and calorie diet is not a practice on prevention of PU. Also, 72 (84.7%) indicated that to avoid using donut – shape (ring) cushion is not a practice on prevention of PU. Most 81 (95.3%) of the respondents agree that turning a patient position every 2 hours is a practice on prevention of PU. And 76 (89.4%) believed that always attending seminars for PU prevention is not a practice on prevention of PU, while 83 (97.7%) of them indicated that giving advice to the patient or caregiver regarding PU preventive care as a practice on prevention of PU. This shows that the overall nurses' practice regarding pressure ulcer prevention was poor (M = 51.0%) with minimum and maximum scores of 5.9% and 97.7%, respectively.
[Table 4] shows that majority 95.3%, 92.9%, and 90.6% reported that inadequate staffing, heavy workload, and shortage of pressure relieving devices respectively as barriers to prevention of pressure ulcer. More than two-third of them 87.1%, 81.2%, 77.7%, 75.3% identified inadequate coverage on PU during training, uncooperative patients, inadequate knowledge about PU among nurses, and lack of time respectively as barriers. More than half of them 62.4%, 58.8% revealed barriers to be presence of other priorities, and lack of guidelines on PU prevention, respectively. However, majority (72.9%) disagreed on lack of job satisfaction in nursing as being a barrier to pressure ulcer prevention care.
Hypothesis one H
O: There is no significant relationship between respondents' characteristics (professional level and years of service) and caregivers' knowledge toward pressure ulcer prevention.
[Table 5] above shows the relationship between respondent's characteristics (professional level, years of service) and caregivers' knowledge toward pressure ulcer prevention. The result of the table indicated that there is a significant relationship between professional level and below average (r = 11.227; P =0.000), average (r =0.014; P =.000), and above average (r =.776; P =.000). Also, a significant relationship was identified between years of service and below average (r = 11.444; P =.000), average (r =.782; P =.000), and above average (r =.782; P =.000). This shows that professional level and years of service of the respondents may influence their knowledge of pressure ulcer prevention among the respondents.
|Table 5: Relationship between respondent's characteristics and knowledge toward pressure ulcer prevention|
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| Discussion|| |
Regarding the sociodemographic characteristics of the nurses, findings from the study revealed that, majority 54.1% of the nurses were within the age range of 31 and 40 years, while the least group of the nurses 5.9% fall between the age ranges of 51 to 60 years. This shows that majority of the nurses were at the middle age of their working career. 87.1% of them are females; more than half 76.5% of the nurses are married. The greater percentage of nurses 55.1% were working for more than one year in NOHE. This is a clear indication that the respondents were not novices in the nursing profession.
Findings revealed poor knowledge 67.3% of pressure ulcer prevention among nurses. This level of knowledge is below the anticipated, because as nurses working in a recognized specialist tertiary referral hospital, they are expected to be well experienced. The finding of this study is comparable with other studies conducted in different parts of Nigeria. In a study conducted in Ogun south western Nigeria, where 78 (70.27%) of nurse respondents had low (<59% correct) prevention knowledge scores  and the study done in Bornu state, North Eastern, Nigeria where findings revealed overall low level of knowledge among nurses on pressure ulcer prevention. This poor level of knowledge may not be unconnected to their formal educational and training experience. This study found out most of the nurses 69.4% had nursing diploma, this limited formal educational background and training may be a factor related to nurses' poor knowledge. Item analysis supports this explanation. This revealed that the items that the lowest percentages of nurses answered correctly were questions that related to updated information about pressure ulcer prevention. These included that the risk assessment scale is an appropriate method to assess pressure ulcer risk, or Braden scale is the risk assessment scale for pressure ulcer development. The findings of this study are similar to a previous study in adequate training on pressure ulcer prevention care in Irish nurses was one barrier to nurses accessing to updated information about pressure ulcer prevention.
The lack of learning resources for nurses to update their knowledge would be another reason for the poor knowledge. In Nigeria, there is a lack of learning resources for nurses to update their knowledge. Current nursing journals are not available even at the nursing institutes or hospitals; only some old nursing journals are available at the nursing libraries. These facts indicate that nurses still have an inadequate knowledge in some areas of pressure ulcer prevention due to their knowledge not being up-to-date either by lack of formal training or reading text books or journals.
Result also indicated that the practice toward pressure ulcer prevention among nurses was poor 51.0%. The level of knowledge was higher than the level of their practice. In this study, nurses' practice was not reflected by their knowledge. This result is not in accord with the finding of a study in Bangladesh, where the practice of nurses on pressure ulcer prevention was higher than their knowledge. A possible reason for explaining this poor level of practice may be due to certain factors. First, the shortage of nursing staff and heavy workload may be factors that make them stressed up, thus making them have poor attitude to practice of prevention of pressure ulcer despite their higher knowledge. The current ratio of nurses to patients in Nigeria is 1: 15, this inadequate nurse to patient ratio may limit the implementation of quality care to prevent pressure ulcers development. A previous study indicated that a majority of nurses reported lack of staff and lack of time as barriers to carry out pressure ulcer prevention care into effective practice.,
Education and training, administrative support, and supplies of equipment are particularly essential for nurses to prevent the development of pressure ulcers. In this study hospital, no in-service education or training or adequate supplies of equipments are available for preventing pressure ulcer development. For example, there is inadequate pressure relieving equipment. One study found that nurses in Nigeria intervention for pressure ulcer prevention are based on tradition and not evidenced-based interventions. The provision of guidelines for practice to prevent pressure ulcers is an important factor for nurses in providing standard nursing care. The researcher's experience in Nigeria suggests that nurses have limited access to up-to-date evidence-based guidelines for practice in pressure ulcer prevention. No organizational policy or guidelines have yet been developed for nurses to prevent pressure ulcers. The researcher assumed that there were other important factors that might contribute to nurses' practice regarding pressure ulcer prevention. These were not explored in this current study. Those factors include values, beliefs, social norms, purpose, and awareness. Future studies should explore these factors to determine whether they are related to practice or not.
An item analysis of the results showed that only 15.3% of nurses did not use donut shape cushion at bony prominences and only 18.8% document all information related to pressure ulcer risk. Overwhelming 94.1% of nurses in this current study did not use a risk assessment scale to assess pressure ulcer, which implies that, more than three fourth of nurses did not use a risk assessment scale. This is in accord with the study conducted in South Eastern, Nigeria which found that 88% of the nurses did not use any risk assessment tool to identify patients at risk of pressure ulcer. Approximately three-fifths of the nurses 84.7% used donut shape cushion at bony prominences. These results indicate that nurses lacked current updated knowledge and information regarding nursing care activities for pressure ulcer prevention. Extensive education and in-service training, and evidence-based nursing practice about pressure ulcer prevention are required to develop their competencies and might improve nurses' practices in this field.
Though more than half of the respondents reported all the items as barriers to pressure ulcer prevention besides lack of job satisfaction in nursing profession, but a greater majority reported inadequate staffing, heavy work load, uncooperative patients, and inadequate pressure relieving equipment in the wards as barriers to nurses' practice in pressure in prevention of pressure ulcer. This study also favored the above claim in which, respondent's practice of pressure ulcer prevention was found to be poor which was less than 70%. Similarly, study conducted in England showed that majority of the nurses reported lack of staff and time as barriers to implementing effective care practices related to prevention of pressure ulcer. The poor practice can be explained by the fact that shortage of nursing staff limits the working time available for each patient's care. Especially in countries like Nigeria where there is inadequate nurse to patient ratio may limit the implementation of quality care related to pressure ulcer prevention.
Develop a system for assessing nurses' knowledge and practice routinely as regards patients care particularly on pressure ulcer prevention.
Implement guidelines for quality care as regard pressure ulcer prevention practices.
Organize seminar and workshop for nurses to enhance their knowledge and practice.
| Conclusion|| |
Nurses' knowledge and practice toward prevention of pressure ulcer was found to be poor which is unsatisfactory for professional caregivers. Inadequate staffing, heavy workload, and inadequate pressure relieving equipment were some of the barriers to effective practices of pressure ulcer prevention reported by the nurses. In-service training, upgrading courses, and ensuring availability of the necessary equipment are some of the important steps to improve nurses' knowledge and practice regarding prevention of pressure ulcer.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Baharestani M, Black J. Dilemmas in measuring and using pressure ulcer prevalence and incidence: An international consensus. Int Wound J 2009;62:97-104.
Mersal F. Caregivers' knowledge and practice regarding prevention of immobilization complication in El-demerdash Hospital, Cairo, Egypt. Am J Res Commun 2014;2;78-98.
Bours G, Halfens R, Abu-Saad H, Grol R. Prevalence, prevention, and treatment of pressure ulcers: Descriptive study in 89 institutions in the Netherlands. Res Nurs Health J 2012;25:99-110.
Shiny V. Prevention of pressure ulcer for immobilized patients among care givers in Bapuji Hospital. Med Surg Nurs 2010;48:6.
Bansal C, Scott R, Stewart D, Cockerell C. Decubitus ulcers: A review of the literature. Int J Dermatol 2015;44:805-10.
Beeckman D, Defloor T, Schoonhoven L, Vanderwee K. Knowledge and attitudes of nurses on pressure ulcer prevention: A cross-sectional multicenter study in Belgian hospitals. Worldviews Evid Based Nurs 2011;8:166-76.
Thomas D. Prevention and treatment of pressure ulcers. J Am Med Dir Assoc 2010;7:46-56.
Black J, Girolami S, Woodbury M, Hill M, Contreras-Ruiz J, Whitney J. Understanding pressure ulcer research and education needs: A comparison of the association for the advancement of wound care pressure ulcer guideline evidence levels and content validity scores. Ostomy Wound Manage 2015;57:22-35.
Gunningberg L, Lindholm C, Carlsson M, Sjoden P. Risk, prevention and treatment of pressure ulcers-nursing staff knowledge and documentation. Scand J Caring Sci 2010;15:257-63.
Beeckman D, Defloor T, Schoonhoven L, Vanderwee K. Knowledge and attitudes of nurses on pressure ulcer prevention: A cross-sectional multicenter study in Belgian hospitals. Worldviews Evid Based Nurs 2011;8:166-76.
Kimberly C, Cheryl H, Polly J, Michelle M, Molly M, Misty O. PUPPI: The pressure ulcer prevention protocol interventions. Am J Nurs 2010;107:44-52.
Sewchuk D, Padula C, Osbome E. Prevention and early detection of pressure ulcers in patients undergoing cardiac surgery. AORN 2006;84:75-96.
Islam S. Knowledge, attitude and Practice of pressure ulcer prevention for hospitalized patients at Rajshahi Medical College Hospital in Bangladesh. A thesis submitted in Faculty of Nursing, Prince of Songkla University, Bangladesh; 2014.
Ladan A, Garba N, Sani K, Sani H, Muhammad F. Pressure ulcer stages among bed-ridden patients in Ahmadu Bello University Teaching Hospital (ABUTH), Zaria-Nigeria. J Nurs Health Sci 2014;3:61-8.
Ikechukwu E, Ayodipo I, Emeka A, Kayode A, Michael N, Deborah O. Prevalence and factors associated with healing outcomes of hospital acquired pressure ulcers among patients with spinal cord injury. J Public Health Epidemiol 2012;4:44-7.
Ilesanmi R, Ofi B, Adejumo P. Nurses' knowledge of pressure ulcer prevention in Ogun state, Nigeria: Results of a pilot survey. J Ostomy Wound Manage 2012;58:24-32.
Uba M, Alih F, Kever R, Lola N. Knowledge, attitude and practice of nurses towards pressure ulcer prevention in University of Maiduguri Teaching Hospital, Borno state, North-Eastern, Nigeria. Int J Nurs Midwifery 2015;7:54-60.
Moore Z, Price P. Pressure ulcer prevalence and prevention practices in care of older person in the Republic of Ireland. J Clin Nurs 2014;21:362-71.
Federal Ministry of Health. Health Sector Reform Program: Strategic Thrusts and Long Framework. Abuja: Federal Ministry of Health; 2015
Ingwu JA, Ayanor N, Ohaeri B. Factors influencing nurses' use of risk assessment scale for preventing pressure ulcer among patients in National Orthopaedic Hospital, Enugu State, South Eastern, Nigeria. Int J Nurs Midwifery 2015;7:146-53.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]