Hindawi Publishing Corporation

Advances in Nursing
Volume 2015, Article ID 796927, 11 pages
http://dx.doi.org/10.1155/2015/796927

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

Abebe Dilie1 and Daniel Mengistu2

1
Department of Nursing, Debre Markos University, P.O. Box 269, Debre Markos, Ethiopia
2
Department of Nursing, Addis Ababa University, Addis Ababa, Ethiopia

Correspondence should be addressed to Abebe Dilie; [email protected]

Received 12 August 2015; Revised 22 October 2015; Accepted 24 November 2015

Academic Editor: Ann M. Mitchell

Copyright © 2015 A. Dilie and D. Mengistu. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

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.

1. Introduction capillary blood flow and can result in decreased oxygen

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

World stop pressure ulcer day report in 2014 showed that inconsistent documentation, lack of staff, lack of equipment,
nearly 700,000 patients were affected by pressure ulcers each and lack of pressure ulcer related knowledge [3].
year. Around 186,617 patients develop a new pressure ulcer in Awareness about the significance of the problem, positive
acute care each year. This has shown that in the year January attitude towards prevention, and an adequate level of knowl-
2012 to December 2013 between 4 and 6% of patients in acute edge are cornerstones to effectively prevent pressure ulcers
care settings and more than 5–10% of patients in nonacute [14].
care had pressure ulcers. Pressure ulcers are accountable for
2% of preventable deaths [4].
According to 2014 Coloplast pressure ulcer summit 2. Methods and Materials
report, 60,000 people died as a result of the complications 2.1. Study Design. An institutional based cross-sectional
of pressure ulcer globally [5]. Within the national context, study design was conducted to assess nurses’ knowledge,
studies that aim to investigate nurses’ knowledge, attitude, attitude, and perceived barriers to expressed pressure ulcer
and perceived barriers towards pressure ulcer prevention prevention practices in Addis Ababa government hospitals.
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 2.2. Study Area and Period. The study was conducted in
assess prevalence and associated factors of pressure ulcer Addis Ababa at Black Lion, Ras Desta Damtew, and Saint
revealed that 16.8% of them had pressure ulcer [6]. Paul’s hospitals. There are a total of 1129 nurses in these
Nurses still showed poor compliance with the clinical hospitals, among which 565 are found in Black Lion, 104 in
guidelines regarding pressure ulcer prevention practice and Ras Desta Damtew, and 460 in Saint Paul’s hospitals.
put low priority on pressure ulcer prevention. Lack of The study was conducted from April to May, 2015.
knowledge is an apparent barrier for using the guidelines
in clinical practice [7]. Increased knowledge about pressure 2.3. Source Population. The source population was all nurses
ulcer prevention among nurses not only improves the prac- working as staff in Addis Ababa government hospitals.
tice 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 2.4. Study Population. The study subjects were all nurses
the need to enhance the knowledge and attitude of nurses working as staff in the 3 selected government hospitals in
regarding pressure ulcer prevention practice [6]. Addis Ababa (Black Lion, Saint Paul’s, and Ras Desta Damtew
The attitude of nurses towards pressure ulcer prevention hospitals) and those fulfilling inclusion criteria.
refers to their value related to risk assessment, maintaining
healthy skin, management of mechanical loads, and educa- 2.5. Eligibility Criteria
tion for patient and family [3]. Attitude is learned and is
affected by knowledge and behavioral intent. It is used to 2.5.1. Inclusion Criteria. All staff nurses working in the 3
express positive or negative feelings about a person, issue, or selected government hospitals in Addis Ababa (Black Lion,
object. If a person holds a positive attitude toward an issue, Saint Paul’s, and Ras Desta Damtew hospitals) who were
this will increase the possibility of performing a supportive willing to participate and available during study period were
behavior related to that issue and vice versa [9]. included in the study.
If pressure ulcer occurred, it can cause decreased quality
of life, infection, pain and disfigurement, alteration to sleep, 2.5.2. Exclusion Criteria. Nurses who are in annual leave and
delayed healing, increased morbidity and mortality rates, seriously ill during data collection period in the 3 selected
an increased need for intensive nursing and medical care, Addis Ababa government hospitals were excluded from the
an increased workload for healthcare workers, and, as a study.
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 2.6. Sample Size Determination. The sample size was deter-
devastating effects, 95% of pressure ulcer can be prevented mined by using a single population proportion formula and
by managing both intrinsic and extrinsic risk factors as well considering the following assumptions: prevalence (𝑃) of
as repositioning [11]. pressure ulcer 16.8% [6], 𝑍 = standard normal distribution
Although pressure ulcer development is now generally value at 95% confidence level of 𝑍𝛼/2 = 1.96, and margin of
considered as an indicator for quality of nursing care, error (𝑑) = 5%:
questions and concerns about situations in which they are
unavoidable remain [12]. However, pressure ulcers are largely (𝑍𝛼/2)2 𝑃 (1 − 𝑃)
𝑛=
preventable. All patients who are identified as being at risk 𝑑2
should have a management plan to prevent development of
pressure ulcer, optimize healing, and prevent complications (1.96)2 ⋅ 0.168 (1 − 0.168) (1)
𝑛=
of existing pressure ulcer [13]. Even though nurses make (0.05)2
prevention part of their routine, there are some barriers
to practice and care planning such as inadequate time, 𝑛 = 215.
Advances in Nursing 3

12 government hospitals in Addis Ababa

SRS

Black Lion hospital Saint Paul’s hospital Ras Desta Damtew

nurses (n = 565) nurses (n = 460) hospital nurses (n = 104)

Proportional allocation to size (PAS)

Black Lion Saint Paul’s Ras Desta Damtew

hospital (n = 109) hospital (n = 88) hospital (n = 20)

Total sample size

(n = 217)

Figure 1: The schematic presentation of sampling procedure to select study participants from Addis Ababa government hospitals, 2015.

The final sample size was determined as follows by using 2.8.2. Independent Variables
correction formula:
(i) Sociodemographic characteristics (years of experi-
𝑛𝑜
𝑛𝑓 = , (2) ence and level of qualification).
[1 + 𝑛𝑜 /𝑁]
(ii) Knowledge of nurses on
where 𝑛𝑓 is the final sample size, 𝑛𝑜 is the initial sample size
215, and 𝑁 is the number of staff nurses working in Addis (a) risk factors,
Ababa government hospitals: (b) complications,
𝑛𝑜 215 (c) patients at risk of pressure ulcers.
𝑛𝑓 = = = 197. (3)
1 + 𝑛𝑜 /𝑁 1 + 215/2400
(iii) Attitude of nurses:
Considering a 10% nonresponse rate, the total sample size
was (a) Interest to give care.
10 (b) Willingness to take responsibility.
× 197 = 20,
100 (4)
(iv) Perceived barriers:
20 + 197 = 217.

Hence, 217 staff nurses were included in this study. (a) Unproportionate nurse to patient ratio.
(b) Lack of guidelines.
2.7. Sampling Procedure. A simple random sampling (SRS) (c) Shortage of time.
was used to select 3 hospitals from 12 government hospitals (d) Limited resource.
in Addis Ababa. After allocating nurses from the 3 selected
government hospitals by proportional allocation to size (e) Patient factors.
(PAS), the participants were selected by using simple random (f) Lack of evidence supported by research.
sampling (Figure 1).
2.9. Data Collection Methods
2.8. Variables of the Study
2.9.1. Data Collection Tool. Data were collected using struc-
2.8.1. Dependent Variable tured self-administered questionnaire. The questionnaire was
adapted by reviewing literatures of similar studies and guide-
(i) Expressed pressure ulcer prevention practice. lines prepared to prevent pressure ulcers [15, 16].
4 Advances in Nursing

2.9.2. Data Collection Procedure. The data were collected 70

by 6 trained diploma nurses and were supervised by 3 60
BSc nurses having previous experience in data collection.
50
Continuous follow-up and supervision were also made by
principal investigator throughout the data collection period. 40

(%)
30 63.80%
2.9.3. Data Quality Assurance. In order to maintain quality
20
of the data, data collectors and supervisors were trained in
26%
data collection procedures by the principal investigator. The 10
questionnaire has also been carefully designed and English 10.20%
0
version was used for data collection. Before actual data Outpatient Inpatient Others∗
collection time, the questionnaire (tool) was checked for
Figure 2: Current area of practice of nurses in Addis Ababa
clarity, comprehensiveness, and content validity by an expert
government hospitals, 2015. ∗ Nurses who work as metron, ward
and pretested for reliability on 10% of the total sample at head, and triage.
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 2.12. Ethical Consideration. Ethical clearance was obtained
a daily basis. from Addis Ababa University (AAU), College of Health Sci-
ences, Department of Nursing and Midwifery, Institutional
2.10. Data Processing and Analysis. The data were entered in Review Board (IRB) research committee. After obtaining
to EPI-data version 3.1, and then the data were cleaned and official letter from the department, a permission letter was
analyzed by using Statistical Package for Social Science (SPSS) provided to Black Lion, Saint Paul’s, and Ras Desta Damtew
version 21 statistical software. Descriptive statistics were used. Hospitals before data collection. The study participants were
Bivariate and multivariate logistic regression were computed informed about the objective, rationale, and expected out-
to assess statistical association between the outcome variable comes of the study and written consent was provided for
and independent variables using Odds Ratio; significance guaranteeing their choice of participation or refusal. All the
of statistical association was assured or tested using 95% information was recorded anonymously and confidentiality
confidence interval (CI) and 𝑝 value (<0.05). was assured throughout the study.

2.11. Operational Definitions 2.13. Dissemination of the Result. The final report of the
study will be presented and submitted in the form of soft
(i) Adequate knowledge: nurses who answered greater and hard copy to Addis Ababa University, College of Health
than or equal to 80% of the knowledge questions Sciences, Department of Nursing and Midwifery. In addition,
correctly. efforts will be made to present the findings on scientific
(ii) Inadequate knowledge: those nurses who answered conferences like professional associations and peer reviewed
less than 80% of the knowledge questions correctly. journal publications will also be considered.

(iii) Favorable attitude: those nurses who were positively 3. Results

worded and scored points more than the median in
the attitude questionnaire. 3.1. Sociodemographic Characteristics. A total of 217 nurses
were included in the study. Of these, only 196 nurses volun-
(iv) Unfavorable attitude: Those nurses who were nega- tarily agreed to participate in this study, and 21 either refused
tively worded and scored points less than the median or submitted incomplete questionnaires. This resulted in a
in the attitude questionnaire. response rate of 90.3%.
Out of 196 respondents, 133 (67.9%) were females. More-
(v) Good expressed pressure ulcer prevention practice:
over, the age of the participants included in this study
nurses who answered greater than or equal to 80% of
ranged between 20 and 59 years with mean age of 27.93
expressed pressure ulcer prevention practice related
(SD = ±6.596) years. From the respondents, 142 (72.4%)
questions correctly.
were orthodox Christians and 134 (68.4%) were single. The
(vi) Poor expressed pressure ulcer prevention practice: majority, 151 (77%) of nurses, had bachelor degrees (Table 1).
nurses who answered less than 80% of expressed Concerning current area of practice, about 51 (26%),
pressure ulcer prevention practice related questions 125 (63.8%), and 20 (10.2%) of nurses work in outpatient,
correctly. inpatient, and other departments, respectively (Figure 2).
In addition, about 72 (36.7%) of nurses receive train-
(vii) Perceived barriers: if nurses answered “agree” or ing about pressure ulcer prevention in the form of lec-
“strongly agree” with the listed barriers in the per- ture whereas 70 (35.7%) of them did not receive training
ceived barrier questionnaire. (Figure 3).
Advances in Nursing 5

Table 1: Sociodemographic characteristics of nurses in Addis Ababa Table 2: Mark of the respondents from 19 questions, Addis Ababa,
government hospitals, Ethiopia, 2015 (𝑛 = 196). Ethiopia, 2015.

Variable Frequency (𝑛 = 196) Percent (%) Question Frequency Percent

Sex 1 1 0.5
Male 63 32.1 3 2 1.0
Female 133 67.9 5 4 2.0
Age 6 1 0.5
20–29 years 139 71 8 4 2.0
30–39 years 44 22.4 9 3 1.5
≥40 years 13 6.6 10 2 1.0
Ethnicity 11 6 3.1
Amhara 108 55.1 12 7 3.6
Oromo 45 23 13 12 6.1
Tigre 21 10.7 14 15 7.7
Others∗ 22 11.2 15 19 9.7
Marital status 16 16 8.2
Married 54 27.6 17 24 12.2
Single 134 68.4 18 40 20.4
Divorced 5 2.5 19 40 20.4
Widowed 3 1.5 Total 196 100.0
Religion
Orthodox 142 72.4
Muslim 18 9.2
Protestant 30 15.4
Catholic 4 2
Others∗∗ 2 1
Level of qualification
Diploma 39 19.9 35.70% 36.70%
Bachelor degree 151 77
Master’s degree 6 3.1
Years of work experience
1–4 112 57.1
5–10 58 29.6
>10 26 13.3
Read literature on PU prevention 19.40%
Always 25 12.8 5.60%
Sometimes 120 61.2 2.60%
Never 51 26
Key: ∗ Gurage and foreigners and ∗∗ Jehovah. Lecture Workshop
Course Never received training
Conference

Figure 3: How respondents receive training about pressure ulcer

3.2. Nurses Knowledge about Pressure Ulcer Prevention.
prevention in Addis Ababa government hospitals, 2015.
McDonald’s standard of learning outcome measured criteria
was used to categorize nurses’ level of knowledge regarding
pressure ulcer prevention. Nurses who scored <60, 60–
69, 70–79, 80–89, and 90–100 were considered as having A total of 19 questions were provided for nurses and they
very low, low, moderate, high, and very high knowledge, got marks out of 19 as follows (Table 2).
respectively. Accordingly, 23 (11.7%), 19 (9.7%), 34 (17.3%),
16 (8.2%), and 104 (53.1%) of the participants had very low, 3.2.1. Knowledge of Facts about Pressure Ulcer. The majority,
low, moderate, high, and very high knowledge regarding 174 (88.8%), of the participants were aware that pressure ulcer
pressure ulcer prevention, respectively. Generally, 120 (61.2%) commonly occurred around bony prominences. About 43
of the participants had adequate knowledge about pressure (21.9%) of respondents did not know that pressure ulcers
ulcer prevention practice whereas 76 (38.8%) had inadequate contribute to overall hospital costs incurred by the patient
knowledge. (Table 3).
6 Advances in Nursing

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

Facts about pressure ulcer assessment Response Frequency Percent

(𝑛 = 196)
Right 152 77.6
Pressure ulcer (PU) is marked against the caregiver as poor or nonexistent care
Wrong 44 22.4
Right 161 82.1
Areas of skin are compromised as a result of unrelieved pressure
Wrong 35 17.9
Right 172 87.8
Pressure ulcer occurs in immobile patients
Wrong 24 12.2
Right 170 86.7
Pressure ulcer is developed in stages
Wrong 26 13.3
Right 174 88.8
It commonly occurs around bony prominences
Wrong 22 11.2
Right 160 81.6
Pressure ulcer can lead to permanent disabilities like bone destruction
Wrong 36 18.4
Right 168 85.7
Sepsis is one of the complications of pressure ulcer
Wrong 28 14.3
Right 153 78.1
Pressure ulcer contributes to the overall hospital costs incurred by patient
Wrong 43 21.9

3.2.2. Risk Factors for Pressure Ulcers Development. Nurses Table 4: Distribution of right and wrong responses about risk
were asked to identify possible risk factors for pressure factors and patients at risk for pressure ulcer assessment among
ulcers. Among 196 respondents, 180 (91.8%) identified pro- nurses in Addis Ababa government hospitals, 2015.
longed immobility, 173 (88.3%) identified constant pres-
Risk factors and patients at risk Response Frequency Percent
sure/compression, and 139 (70.9%) identified anemia as a risk assessment (𝑛 = 196)
factor (Table 4).
Right 180 91.8
Prolonged immobility
Wrong 16 8.2
3.3. Nurses Attitude toward Expressed Pressure Ulcer Preven-
tion Practice. Scores for each attitude related question were Right 173 88.3
Constant pressure/compression
summarized and the responses were then categorized into Wrong 23 11.7
two variables, namely, favorable attitude and unfavorable Right 168 85.7
attitude. Nurses who were positively worded for each attitude Friction/shear
Wrong 28 14.3
related question were categorized as having favorable attitude
whereas respondents who were negatively worded for each Moist surfaces in which patients Right 153 78.1
attitude related questions were classified in the unfavorable lie Wrong 43 21.9
attitude category. Finally, overall attitude score of the respon- Right 85.7
Using improper support 168
dents were calculated. Those nurses who score above the materials
median were considered as having favorable attitude while Wrong 28 14.3
those who scored below the median were labeled as having Right 160 81.6
Diabetic mellitus
unfavorable attitude. Accordingly, 134 (68.4%) of nurses had Wrong 36 18.4
favorable attitude while 62 (31.6%) had unfavorable attitude Right 71.9
141
toward expressed pressure ulcer prevention practice. Hypoxemia
About 89.8% of nurses were positively intended (worded) Wrong 55 28.1
to care for patients with pressure ulcers and about 56.6% of Right 165 84.2
Malnutrition
the participants believe pressure ulcer prevention is not time Wrong 31 15.8
consuming (Table 5).
Right 139 70.9
Anemia
Wrong 57 29.1
3.4. Perceived Barriers to Pressure Ulcer Prevention. Nurses
were asked to indicate their agreement about the existence of Right 136 69.4
Ischemic heart diseases
specific barriers in the work environment. If nurses answered Wrong 60 30.6
“strongly agree” or “agree” on the listed barrier, it was consid- Right 164 83.7
ered as a perceived barrier and if nurses answered “disagree” Spinal cord injury
Wrong 32 16.3
or “strongly disagree” on the listed barrier the barrier was
Advances in Nursing 7

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

Attitude component Yes (%) No (%) Total (%)

In your view are all patients at potential risk of developing pressure ulcers (PU)? 105 (53.6) 91 (46.4) 196 (100)
Do you think pressure ulcer prevention is time consuming to carry out? 85 (43.4) 111 (56.6) 196 (100)
Do you have willingness to care for patients with pressure ulcer? 176 (89.8) 20 (10.2) 196 (100)
Do you feel that priority of care is given for patients who are at risk of pressure ulcer? 176 (89.8) 20 (10.2) 196 (100)
Do you believe that most pressure ulcers can be prevented? 179 (91.3) 17 (8.7) 196 (100)
Do you think patients who are admitted receive adequate prevention of pressure ulcer while in 124 (63.3) 72 (36.7) 196 (100)
bed seated?
Do you think pressure ulcer risk assessment should be regularly carried out on all patients during 145 (74) 51 (26) 196 (100)
their stay in hospital?
Do you perceive that nurses hold major responsibilities when patients are vulnerable to pressure 165 (84.2) 31 (15.8) 196 (100)
ulcer?

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

Perceived barrier Yes (%) No (%) Total (%)

Disproportionate nurse to patient ratio 133 (67.9%) 63 (32.1%) 196 (100%)
Shortage of time 100 (51%) 96 (49%) 196 (100%)
Shortage of equipment 105 (53.6%) 91 (46.4%) 196 (100%)
Lack of training and education 110 (56.1%) 86 (43.9%) 196 (100%)
Lack of policies and guidelines 98 (50%) 98 (50%) 196 (100%)
Lack of evidence supported by research 85 (43.4%) 111 (56.6%) 196 (100%)
Patient factors 104 (53.1%) 92 (46.9%) 196 (100%)
Lack of job satisfaction 126 (64.3%) 70 (35.7%) 196 (100%)
Lack of pressure ulcer related knowledge 81 (41.3%) 115 (58.7%) 196 (100%)

not considered as a perceived barrier for expressed pressure overall knowledge, overall attitude, disproportionate nurse
ulcer prevention practice. Based on this assumption, dispro- to patient ratio, lack of policies and guidelines, lack of
portionate nurse to patient ratio was the most frequently evidence supported by research, lack of job satisfaction, and
reported barrier to carrying out pressure ulcer prevention lack of pressure ulcer related knowledge were statistically
practices (67.9%; 𝑛 = 133), followed by lack of job satisfaction associated with expressed pressure ulcer prevention practice
(64.3%; 𝑛 = 126) (Table 6). with 𝑝 value less than 0.05 at 95% confidence interval
(Table 8).
3.5. Expressed Pressure Ulcer Prevention Practice. McDon- After bivariate analysis, only those variables which were
ald’s standard of learning outcome measured criteria was significantly related (𝑝 value < 0.05) were entered for further
used to categorize nurses’ level of practice regarding pressure multivariate analysis. By adjusting potential confounders in
ulcer prevention. Nurses who scored <60, 60–69, 70–79, 80– multivariate logistic regression analysis; only nurses overall
89, and 90–100 were considered as having very low, low, knowledge, disproportionate nurse to patient ratio, lack of
moderate, high, and very high practice, respectively. Accord- policies and guidelines, and lack of job satisfaction were sig-
ingly, 41 (20.9%), 23 (11.7%), 17 (8.7%), and 115 (58.7%) of nificantly associated with expressed pressure ulcer prevention
the participants had very low, moderate, high, and very high practice. But participants’ overall attitude, lack of evidence
practice regarding pressure ulcer prevention, respectively. supported by research, and lack of pressure ulcer related
Generally 132 (67.3%) of the participants had good practice knowledge were not significantly associated with expressed
about pressure ulcer prevention whereas 64 (32.7%) had poor pressure ulcer prevention practice in multivariate analysis.
practice. Overall knowledge level, disproportionate nurse to
From the respondents, 180 (91.8%) identified regular patient ratio, lack of policies and guidelines, and lack of job
turning of patients every 2 hours, 172 (87.8%) identified satisfaction were negatively associated with expressed pres-
removing any tightly fitting clothes from the patient, and 168 sure ulcer prevention practice. Nurses who have inadequate
(85.7%) identified protecting the skin during patient transfer knowledge were 0.29 times less likely to practice expressed
as good pressure ulcer prevention practices (Table 7). pressure ulcer prevention (AOR = 0.29 (0.010, 0.085)) as
compared to knowledgeable nurses. Moreover, nurses who
3.6. Factors Associated with Expressed Pressure Ulcer Preven- work in settings having disproportionate nurse to patient
tion Practice. In bivariate logistic regression analysis, nurses’ ratio were 0.294 times less likely to practice pressure ulcer
8 Advances in Nursing

Table 7: Expressed pressure ulcer prevention practice among nurses in Addis Ababa government hospitals, Ethiopia, 2015.

Prevention strategies assessment Response Frequency Percent

(𝑛 = 196)
Right 180 91.8
Regular turning/repositioning of patients every 2 hours
Wrong 16 8.2
Right 163 83.2
Keeping patients’ skins dry and moist
Wrong 33 16.8
Right 147 75
Ensuring patient is well hydrated
Wrong 49 25
Right 157 80.1
Encouraging patients to have a balanced diet
Wrong 39 19.9
Right 134 68.4
Avoiding hot water when cleansing the skin
Wrong 62 31.6
Right 168 85.7
Protecting the skin during patient transfer
Wrong 28 14.3
Right 172 87.8
Removing any tightly fitting clothes from the patient
Wrong 24 12.2
Right 170 86.7
Providing cushions on areas at risk of pressure ulcers
Wrong 26 13.3
Right 156 79.6
Catheterization in case of incontinence patients
Wrong 40 20.4
Right 163 83.2
Documenting prevention interventions
Wrong 33 16.8

Table 8: Bivariate and multivariate logistic regression analysis of factors associated with expressed pressure ulcer prevention practice in Addis
Ababa government hospitals, 2015.

Expressed pressure ulcer prevention practice

Variables
Response Poor Good COR (95% CI) AOR (95% CI) 𝑝 value
(overall)∗
Inadequate knowledge 52 (81.3%) 24 (18.2%) 0.51 (0.024, 0.111) 0.29 (0.010, 0.085)
Overall knowledge 0.001
Adequate Knowledge 12 (18.8%) 108 (81.8%) 1.00 1.00
Unfavorable attitude 27 (42.2%) 35 (26.5%) 1.00 1.00
Overall attitude 0.508
Favorable attitude 37 (57.8%) 97 (73.5%) 2.022 (1.078, 3.793) 1.387 (0.526, 3.652)
Yes 50 (78.1%) 83 (62.9%) 0.474 (0.238, 0.945) 0.294 (0.093, 0.927)
Disproportionate nurse to patient ratio 0.037
No 14 (22%) 49 (37.1%) 1.00 1.00
Yes 46 (71.9%) 52 (39.4%) 0.254 (0.133, 0.486) 0.213 (0.076, 0.596)
Lack of policies and guidelines 0.003
No 18 (28.1%) 80 (60.6%) 1.00 1.00
Yes 35 (54.7%) 50 (37.9%) 0.505 (0.276, 0.925) 1.629 (0.541, 4.901)
Lack of evidence supported by research 0.385
No 29 (45.3%) 82 (62.1%) 1.00 1.00
Yes 55 (85.9%) 71 (53.8%) 0.190 (0.087, 0.417) 0.111 (0.037, 0.334)
Lack of job satisfaction 0.001
No 9 (14.1%) 61 (46.2%) 1.00 1.00
Yes 33 (51.6%) 48 (36.4%) 0.537 (0.293, 0.983) 0.699 (0.253, 1.932)
Lack of PU related knowledge 0.490
No 31 (48.4%) 84 (63.6%) 1.00 1.00
1.00 = reference; ∗ 𝑝 value < 0.05 (significant) at 95% confidence interval.

prevention (AOR = 0.294 (0.093, 0.927)) than nurses were 0.213 times less likely to practice pressure ulcer preven-
who work in settings having adequate nurse to patient tion (AOR = 0.213 (0.076, 0.596)) than nurses who work
ratio. in settings having policies and guidelines to pressure ulcer
Similarly, nurses who work in settings lacking specific prevention. In addition, nurses who are not satisfied by their
policies and guidelines towards pressure ulcer prevention job were 0.111 times less likely to practice pressure ulcer
Advances in Nursing 9

prevention (AOR = 0.111 (0.037, 0.334)) than nurses who (AOR = 0.111 (0.037, 0.334)) than nurses who reported
reported satisfaction with their job. satisfaction with their job. In this study, 64.3% of nurses
reported that lack of job satisfaction is a barrier to pressure
4. Discussion ulcer prevention practice. This was relatively analogous with
a study done in Jordan, where 57% of respondents identified
The main purpose of this study was to assess nurses’ knowl- lack of job satisfaction as an existent barrier to pressure ulcer
edge, attitude, and perceived barriers to expressed pressure prevention [9]. This could be due to the fact that if a person is
ulcer prevention practices. Though there are a plethora of not satisfied by an issue, then the possibility of performing a
studies that were done in an international context aiming to supportive action related to that issue will also be decreased.
assess the knowledge, attitude, practice, and barriers towards Furthermore, 67.3% of the participants had good
pressure ulcer prevention; there is almost no study that was expressed pressure ulcer prevention practice, whereas a
conducted on a national basis. study in Bangladesh found that staff nurses perceived a
This study showed that 38.8% of nurses had inadequate moderate level of overall practice regarding pressure ulcer
knowledge about pressure ulcer prevention practice. This is prevention [17]. The difference between the healthcare setups
less than a study done in Bangladesh, where 57.8% of nurses of Ethiopia and Bangladesh might explain the relatively
had inadequate knowledge [17], and in Jordan, where 73% discrepant results in pressure ulcer prevention practice.
of nurses had inadequate knowledge about pressure ulcer Consistent with the studies done in Turkey [20] and
prevention [8]. The possible explanation could be lack of Uganda [15], participants in this research reported some of
trainings and evidences supported by research. the frequently applied pressure ulcer prevention practices.
Another factor that affects expressed pressure ulcer These include patient repositioning (91.8%), keeping patient
prevention practice was knowledge level. Knowledge level skins dry and moist (83.2%), balanced diet (80.1%), protecting
was significantly associated with expressed pressure ulcer the skin during patient transfer (85.7%), documenting pre-
prevention practice in this study. Nurses who have inadequate vention strategies (83.2%), and removing any tightly fitting
knowledge were 0.29 times less likely to practice expressed clothes from the patient (87.8%).
pressure ulcer prevention (AOR = 0.29 (0.010, 0.085)) as
compared to knowledgeable nurses. While a study done in 5. Strengths and Limitations of the Study
Bangladesh showed that there was no significant association
between nurses knowledge and practice [𝑟 = 0.14, 𝑝 > 0.05] 5.1. Strengths of the Study. The major strength of this research
[17]. This can be explained by differences in methodological lies in the fact that it has attempted to assess nurses’ knowl-
approaches. edge, attitude, and perceived barriers to expressed pressure
In this study, only 68.4% of the participants had favorable ulcer prevention practice in Addis Ababa, Ethiopia. Thus, it
attitude toward pressure ulcer prevention practice; this is can be first in the country. In addition, three government
much lower than a survey done in Sweden where nursing hospitals were included in the study to make the study
staffs as a whole demonstrated positive attitude regarding representative and the questionnaire was pretested.
pressure ulcer prevention [18] and similarly in Iraq where
99% of the nurses had positive attitude toward pressure ulcer 5.2. Limitations of the Study. The major limitations of this
prevention practice [19]. study include the following:
This study showed that the attitude of nurses was not (i) The fact that no study was conducted so far in
significantly associated with expressed pressure ulcer preven- Ethiopia on this topic; no enough literature was
tion practice. However, a study done in Bangladesh showed a available to discuss in national context.
moderately positive relationship between nurses’ attitude and
practice [17]. (ii) The practice component may not be well addressed,
Similarly, nurses who work in settings lacking specific as observational checklist was not used.
policies and guidelines towards pressure ulcer prevention (iii) The study may be subjected to response set bias from
were 0.213 times less likely to practice pressure ulcer preven- the respondents.
tion (AOR = 0.213 (0.076, 0.596)) than nurses who work (iv) The study was cross-sectional; therefore, it was diffi-
in settings having policies and guidelines to pressure ulcer cult to know which occurred first the exposure or the
prevention. Besides this, 50% of the respondents reported outcome.
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 6. Conclusion and Recommendation
that lack of specific policies and guidelines as an existent 6.1. Conclusion. Based on the finding of this study, the
barrier to giving care for patients with pressure ulcer [9]. This following are concluded:
can be explained by the fact that the presence of policies and
guidelines that advocate for proper patient care is likely to (i) More than half of the nurses were found to have ade-
increase the practice of nursing interventions such as pressure quate knowledge regarding pressure ulcer prevention.
ulcer prevention. (ii) The outlook of nurses in Addis Ababa govern-
In addition, nurses who are not satisfied by their job were ment hospitals towards pressure ulcer prevention was
0.111 times less likely to practice pressure ulcer prevention majorly favorable.
10 Advances in Nursing

(iii) The most reported barriers for expressed pressure [2] C. H. Lyder, “Pressure ulcer prevention and management,”
ulcer prevention practice were disproportionate nurse Journal of the American Medical Association, vol. 289, no. 2, pp.
to patient ratio, lack of policies and guidelines about 223–226, 2003.
pressure ulcer prevention, lack of evidence supported [3] D. Berlowitz, Preventing pressure ulcer in hospitals a tool kit
by research, lack of job satisfaction, and lack of for improving quality of care, pressure injury prevention and
pressure ulcer related knowledge. management clinical guideline in Western Australia, November
2013.
(iv) Pressure ulcer prevention practice was affected by the [4] D. M. Durkin and R. May, Stop the Pressure, February 2015,
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[5] K. Ramkhelawan and N. Boodhram, “Coloplast pressure ulcer
6.2. Recommendations summit,” Journal of Wound and Skin, In press.
[6] H. Gedamu, M. Hailu, and A. Amano, “Prevalence and asso-
To FMOH and Policy Makers ciated factors of pressure ulcer among hospitalized patients at
Felegehiwot referral hospital, Bahir Dar, Ethiopia,” Advances in
(i) The FMOH should give further trainings for nurses Nursing, vol. 2014, Article ID 767358, 8 pages, 2014.
to enhance their knowledge on pressure ulcer preven- [7] “The knowledge of nurses in pressure ulcer prevention and
tion practice. their attitude towards the use of Braden scale,” in Proceedings of
the Sigma Theta Tau International’s 23rd International Nursing
(ii) Policy makers should prepare policies and guidelines
Research Congress, J. C. Maravilla, M. H. Lucero, T. E. Y. Alejo
to prevent pressure ulcer in hospitals. et al., Eds., STTI, July 2012.
To Professional Nurses [8] J. Qaddumi and A. Khawaldeh, “Pressure ulcer prevention
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(i) Nurses need to enhance their attitude and knowledge BMC Nursing, vol. 13, no. 1, article 6, 2014.
on pressure ulcer prevention in order to further [9] A. Tubaishat, M. Aljezawi, and M. Al Qadire, “Nurses’ attitudes
improve nursing practice in this area. and perceived barriers to pressure ulcer prevention in Jordan,”
Journal of Wound Care, vol. 22, no. 9, pp. 490–497, 2013.
(ii) Nurses, who had better knowledge, should also teach [10] American Medical Directors Association, Percentage of
their respective colleagues who had deficits for the patients who develop pressure ulcers while in the facility, 2004,
betterment of nursing care. http://www.qualitymeasures.ahrq.gov/popups/printView
.aspx?id=6435.
To Health Service Managers [11] J. Beckford-Ball, Strikethrough Resistant Technology™ Can Meet
the Demands of Healthcare, vol. 4, Pressure Ulcer Prevention,
(i) Health service managers should identify the per- 2013.
ceived barriers of care and then minimize these [12] J. M. Black, L. E. Edsberg, M. M. Baharestani et al., “Pres-
barriers as much as possible to prevent pressure ulcer. sure ulcers: avoidable or unavoidable? Results of the national
(ii) They also should recruit nurses to balance their num- pressure ulcer advisory panel consensus conference,” Ostomy
bers with the respective patient in order to provide Wound Management, vol. 57, no. 2, pp. 24–37, 2011.
interventions such as pressure ulcer prevention. [13] L. Bell, Scope and Standards for Acute and Critical Care Nursing
Practice, American Association of Critical-Care Nurses, 2008.
[14] D. Beeckman, T. Defloor, L. Schoonhoven, and K. Vanderwee,
Appendix “Knowledge and attitudes of nurses on pressure ulcer preven-
tion: a cross-sectional multicenter study in Belgian hospitals,”
See Tables 1, 2, 3, 4, 5, 6, 7, and 8 and Figures 1, 2, and 3. Worldviews on Evidence-Based Nursing, vol. 8, no. 3, pp. 166–
176, 2011.
Conflict of Interests [15] I. Mwebaza, G. Katende, S. Groves, and J. Nankumbi, “Nurses’
knowledge, practices, and barriers in care of patients with pres-
The authors declare that there is no conflict of interests sure ulcers in a ugandan teaching hospital,” Nursing Research
regarding the publication of this paper. and Practice, vol. 2014, Article ID 973602, 6 pages, 2014.
[16] D. Berlowitz, C. VanDeusen Lukas, V. Parker et al., Preventing
Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of
Acknowledgments Care, Agency of Healthcare Research and Quality, Rockville,
Md, USA, 2011.
The authors would like to thank Debre Markos University
[17] S. Islam, “Knowledge, attitude, and practice on pressure ulcer
and Addis Ababa University for their financial support; the prevention among nurses in Bangladesh,” in Proceedings of the
authors would also like to extend their gratitude to all the 2nd International Conference on Humanities and Social Sciences,
study participants. Faculty of Liberal Arts, Prince of Songkla University, Diseases
Pallative Care, April 2010.
References [18] U. Källman and B.-O. Suserud, “Knowledge, attitudes and
practice among nursing staff concerning pressure ulcer preven-
[1] European Pressure Ulcer Advisory Panel and National Pressure tion and treatment—a survey in a Swedish healthcare setting,”
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Advances in Nursing 11

[19] R. H. Ibrahim, “Nurses’ attitudes, towards bed sores preven-

tion,” College of Basic Education Researchers Journal, vol. 4, no.
2, 2006.
[20] H. Özdemir and A. Karadag, “Prevention of pressure ulcers: a
descriptive study in 3 intensive care units in Turkey,” Journal of
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