The Knowledge of Pressure Ulcer Among Nursing Students and Related Factors
The Knowledge of Pressure Ulcer Among Nursing Students and Related Factors
The Knowledge of Pressure Ulcer Among Nursing Students and Related Factors
Sarmilan a/l Murugiah1, Tukimin bin Sansuwito2, Kosheila Ramuni2*, Urmisha Das3, Hafiza Che Hassan4
1
Clinical Instructor, Faculty of Nursing, Lincoln University College, Malaysia
2
Lecturer, Faculty of Nursing, Lincoln University College, Petaling Jaya, Malaysia
3
Research Scholar, Lincoln University College, Petaling Jaya, Malaysia
4
Dean, Faculty of Nursing, Lincoln University College, Petaling Jaya, Malaysia
Objective
Pressure ulcer has been recognized as a major cause of morbidity, mortality and a burden to healthcare. Pressure
ulcer also is an indicator of quality of the hospital care towards patients. Limited studies have been conducted
regarding the nursing student’s knowledge towards pressure ulcer prevention in Malaysia.
Our aim is comparing the level of knowledge regarding pressure ulcer prevention among final year nursing students
in a Health Campus of Kubang Kerian, Kelantan.
Method
This is a cross-sectional study aimed to determined and compare the knowledge of pressure ulcer prevention among
the nursing students. There are two variables included in this study- independent variables and the dependent
variables are based on the outcomes of knowledge scores among students. Self-administered questionnaire is used
to measure the characteristic and knowledge level of sample towards pressure ulcer prevention. Data including
descriptive statistics and statistical tests was analysed using the SPSS.
Results
Level of knowledge of nursing students for both programs were low since their mean knowledge (degree students=
46.1%; diploma students=37.6%) did not reach the satisfactory level. Besides, mean knowledge scores were
significantly higher in degree than diploma students with p<0.001.
Conclusion
Thus, data from this study can be used to determine the effect of knowledge of the nurses in the implementation of
changes for better care of pressure ulcer. As the findings in this study shows low level of knowledge among nursing
students regardless of their nursing program’s level, knowledge among nursing students become a barrier in
implementation of better changes in care of patients.
NPUAP (2007)1 defined pressure ulcer as a localized injury to the skin and/or underlying tissue usually over a bony
prominence, as a result of pressure, or pressure in combination with shear and/or friction. While EPUAP (1998) 2,
defined it as an area of localized damage to the skin and underlying tissue caused by pressure, shear, friction and or
a combination of these. These two definitions are not very differing in their meanings for pressure ulcer.
Pressure ulcer has been recognized as a major cause of morbidity, mortality and a burden to healthcare 3. Common
comorbidities that can be caused by pressure ulcer are incapacitating chronic and neurodegenerative conditions.
Besides, this study also revealed that there was association between pressure ulcer and fatal septic infections such
as septicemia4.
The effects of pressure ulcer towards patients include physical, social, emotional and mental disturbances among
patients. It also causes pain, discomfort, distress and restricted daily activities 5,6. Besides, pressure ulcer will not only
affect patient but also their family7. These effects of pressure ulcer need considerable time to heal. Thus, it may
disrupt patient quality of life during those times.
Prevalence of pressure ulcer in Europe is unacceptably high ranging from 9.0% to 18.1%8and causes thousands of
deaths every year in the United States 4. In Asian countries, incidence of pressure ulcer was also considered high,
ranging from 2.1% to 31.3% in Intensive Care unit 9.
Meanwhile, in Malaysia the incidence of pressure ulcer ranged from 0 to 27.0 per 1000 per ICU days with mean of
6.810. All this range of prevalence of pressure ulcer should not be an incontrollable occurrence in any hospital settings
since the most of pressure ulcer are avoidable 8. Therefore, there are needs to focus on prevention rather than on
treatment in order to reduce the prevalence or occurrence of pressure ulcer11.
Review of Literature
Pressure ulcer is one of the most common problem that occurs across in the hospital settings 12,13. Pressure ulcer also
is an indicator of quality of the hospital care12 towards patients who are being hospitalized. The occurrence of
pressure ulcer in the hospital must be a main concern among multidisciplinary team such as nurses, physicians,
physical therapists, wound experts, and educators14.
Internationally, there is an evidence-based guideline of pressure ulcer prevention that have been developed and
promoted widely by European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel
(NPUAP)15. However, noncompliance to these guidelines are often reported16. This situation is due to several barriers
face by nurses in practicing what really have been recommended in those guidelines.
The barriers or factors of this noncompliance issue include negative attitudes, lack of knowledge 16, and lack of
nursing staff17,18. coordination of care19, heavy workload 20,21
and nurses paying least attention to pressure ulcer
22
prevention care in hospital wards .
However, limited studies are being conducted regarding the nursing student’s knowledge towards pressure ulcer
prevention in Malaysia. Without the baseline data regarding the knowledge of nursing students regarding pressure
ulcer prevention they will be unable to handle patient with or at risk of pressure ulcer. The available of these
baselines, will make way for improvements of this condition.
Objectives:
To compare the knowledge of pressure ulcer prevention among final year degree and diploma nursing students in a
Health Campus.
METHOD:
Research Design
This study is a cross-sectional study aimed to determined and compare the knowledge of pressure ulcer prevention
among final year degree and diploma nursing students. The collection of information or data in this study was
conducted at one point in time (Levin, 2006) 23.
Sampling Method
Selection of sample in this study involves the assembly of final year nursing student who have learnt about
pressure ulcer in their classroom and are able to practice their knowledge and skills in clinical area. The sampling
method used in this study is purposive sampling of nonprobability sampling method i.e researcher select individuals
or sample with potentially knowledge about the phenomena studied24,25.
Sample Size
Therefore, all undergraduate final year nursing student for degree and diploma nursing program were invited to
complete the survey questionnaire in this study26. Number of final year degree nursing student all together was 31
students at the current time excluding the researcher. While, number of final year diploma nursing student was 77
students. Thus, total sample that available was 108 students.
Variables
Variables Measurement
There are two variables including independent and dependent. Independent variables are variables that will
not be affected by any other variables while the dependent variables are oppositely 27. Independent variables in this
study are selected base on the demographic data of participant. The demographic data are included age, gender,
nursing program, source of learning and the knowledge of pressure ulcer prevention of respondents were enough or
not. All these data have been measured based on the self-reporting by participant. The dependent variables in this
study had been measured based on the outcomes of knowledge scores among students.
The respondents were asked to choose and circle the ONE BEST answer for each of the questions. Level of
knowledge will be divided into three categories, poor knowledge with the score of < 60%, moderate knowledge with
the score of 60% to 79% and good knowledge with the score of ≥ 80%. A mean knowledge score of ≥ 60% will be
considering as satisfactory level28.
Instrumentation
Instrument in this study is a self-administered questionnaire which is used to measure the characteristic of sample
and knowledge level of sample towards pressure ulcer prevention. Thus, the questionnaire can be divided into 2
parts.
Part 1: Demographic data of respondents
The is the first part of the questionnaire. Respondents were asked to tick the appropriate data which are relevant to
themselves and their education. Thus, this part of respondents’ demographic data is related to respondent age,
gender, level of nursing program, source of learning regarding to pressure ulcer.
Then, the item will be satisfactory if the Cronbach’s alpha value was 0.77 or above 28. Therefore, to ensure the validity
and reliability of the questionnaire, the contents of the questionnaire was reviewed by the supervisor and two other
nursing lecturers. After that, a pilot study was conducted on students that share the similar characteristic with the
sample population.
Ethical Consideration
The ethical approval was obtained prior to conducting this study. Permission from programme chairperson of both
nursing program was taken. Informed consent had been obtained from the respondents prior to survey. Nursing
student who are willing to participate in this study had been given oral and written information by researcher. This
include the explanation on the purposes of the study and their rights to choose and decided to withdraw themselves
anytime from the study. Besides, respondents had been informed that the anonymity of the participants will be
maintained throughout the study and confidentially of their information will be kept. All the information in this study will
be used for academic purposes only.
Pilot Study
Pilot study was conducted on 11 students from degree and diploma batch. However, the internal consistency from
this pilot study did not reach satisfactory level. The internal consistency from this pilot study was -0.061 for all items.
The internal consistency was used to examine the inter-item correlations within an instrument and to see how well
the items fits together conceptually29.
In the present study internal consistency can be affected by the length of scales. There were 26 items in this
instrument. At the same time, number of respondents of pilot study conducted was only 11 people. Small number of
respondents in pilot study for length scales may affect the homogeneity of the sample, then it will reduce the variance
of the total scores and cause the lower reliability30.
Data Analysis
The Statistical Package for the social Sciences Version 22.0 (SPSS v 22) for Windows was used for data entry,
storage, and retrieval. Data including descriptive statistics and statistical tests was donw using the SPSS.
Independent variables were described by frequency (n) and percentages (%). Mean scores of knowledge was
calculated by using descriptive statistics. Differences in background characteristics towards knowledge regarding
pressure ulcer prevention between the degree and diploma nursing student was examined by Student’s t-test.
RESULTS
The data collected were in relative to the research objectives. The fundamental goals that drove the collection of the
data and the subsequent data analysis were to gain better insights into knowledge regarding pressure ulcer
prevention among nursing students. Thus, components in this chapter included:
Response rate
One hundred and eight of questionnaires were distributed to nursing students from both degree and diploma
nursing program. Overall questionnaire response rate was 97% (105/108) of which 93% (98/105) were valid
responses for analysis and 7% (7/105) were not valid for analysis. Researcher failed to set 100% of respondents due
to non-return questionnaire and missing where respondents did not fully complete the questionnaire.
Table 1 shows the response rate for the degree and diploma nursing students. The valid response rate for degree
program was 94% (29/31) while for diploma program was 93% (69/74).
The source of learning categories consisted of learning source without extracurricular activities and with
extracurricular activities. Without extracurricular activities means that students are involved with only classroom
teaching, clinical practice and books. However, students with extracurricular activities gain knowledge regarding
pressure ulcer from other additional sources such as web sites, journal and they also interact with their peers.
From Table 2 it was found that most of the students (71.4%, n=70) involved in extracurricular activities they gained
knowledge about pressure ulcer. Only 28.6% (n=28) students who depends solely on curricular activities were mainly
from diploma program (27.5%, n=19). While, 31% (n=9) degree nursing students depends on curricular activities
only.
For the self-perceptions towards own knowledge regarding pressure ulcer, most of the students (66.3%, n=65)
perceived that their knowledge is not enough. Percentage of degree and diploma nursing students perceived that
way were 48.3% (n=14) and 73.9% (n=51) respectively.
Regarding the theme ‘aetiology and causes’, 89.7% of degree and 53.6% diploma students knew that
hypertension has no relationship with pressure ulcer risk. In theme ‘nutrition’, 89.7% and 63.8% of diploma students
correctly answered that optimizing nutrition can improve the patients’ general physical condition which may contribute
to a reduction of the risk of pressure ulcer. Lastly, one question in the theme ‘reduction in the duration of pressure
and shear’, that had major distribution of correct answer shows that 86.2% of degree and 68.1% of diploma students
knew that if patient is mobilized, then fewer patients will develop a pressure ulcer.
Apart from the above three questions that had a slightest distribution of correct answer were two questions in the
theme ‘aetiology and causes’ and one question in the theme ‘classification and observation’. For two questions in
theme ‘aetiology and causes’, only 17.2% of degree and 18.8% of diploma students correctly answered that shearing
increases when the skin sticks to the surface, and only 34.5% of degree and 14.5% of diploma students correctly
answered that recent weight loss i.e. less than his or her ideal weight, increases the risk of pressure ulcer. For one
question in the theme ‘classification and observation’, only 24.1% of degree and 15.9% diploma students knew that
bedridden patients with pressure on redistributing surface should be under regular observation.
Figure 2 below shows the level of knowledge scores regarding pressure ulcer prevention among nursing students.
From the figure it is evident that not even one student had high knowledge score for both nursing program. As can be
seen from graph below, 82.8% of degree and 98.6% of diploma students had low level of pressure ulcer knowledge.
Apart from that, only 17.2% of degree and 1.4% of diploma students had moderate level of pressure ulcer
knowledge. This shows that level of pressure ulcer knowledge among nursing students were low regardless their
nursing program.
INSERT FIGURE 2 HERE
Distributions of nursing students’ level of knowledge regarding pressure ulcer prevention by themes were shown in
Table 4. For theme ‘nutrition’, frequency and percentage of moderate level were not relevant since there is only one
question for this theme and thus students’ were scored either 0% or 100%.
Difference of level of knowledge regarding pressure ulcer prevention between degree and diploma
nursing students.
Table 5 show the pressure ulcer mean knowledge of degree and diploma nursing students. The mean knowledge
score for the students (n=98) was 40.2% (Table 4.12). While for each degree and diploma program, students mean
knowledge score were 46.1% and 37.6% respectively. The p-value for mean differences of knowledge regarding
pressure ulcer between these two groups was p<0.001 (Table 5). Thus, null hypothesis was rejected, and the result
was significant. In other words, there was significant difference of mean knowledge scores between degree and
diploma students.
The highest scores were in themes ‘nutrition’ (71.4%) and ‘reduction in the duration of pressure and shear’ (46.5%).
The lowest scores were in themes ‘reduction in the amount of pressure and shear’ (35.6%) and ‘risk assessment’
(37.3%). Degree students had significantly (p<0.05) higher scores than diploma students on themes include
‘aetiology and causes’ (p=0.024), ‘classification and observation’ (p=0.037), ‘nutrition’ (p=0.002) as shown in Table 5.
Other than differences in mean of pressure ulcer knowledge among students from both program, learning
sources and self-perceptions of students’ knowledge also analysed to identify if there is significant difference
between these two demographic data and level of knowledge. However, there is no significant difference between
these demographic data and level of knowledge.
As a conclusion, level of knowledge of nursing students for both programme were low since their mean
knowledge (degree students = 46.1%; diploma students = 37.6%) did not even reach the satisfactory level (mean
knowledge ≥60%). Besides, mean knowledge scores were significantly higher in degree than diploma students with
p<0.001 (Table 6).
DISCUSSION
The mean scores of knowledge for each degree and diploma nursing students are 46.1% (SD=11.3) and 37.6%
(SD=10.1) respectively. Since the satisfactory level was set at ≥60% for moderate level of knowledge, the level of
knowledge regarding pressure ulcer prevention for both degree and diploma nursing students were low. This finding
matches the findings of previous study28. Findings in this study were also consistent with findings of studies done
among registered nurses31,32).
The findings are also consistently with the current studies done by Qaddumi & Khawaldeh (2014) 33 which found that
Jordanian nurses (N=141) had insufficient knowledge with means scores 10.84 out of 26 (SD= 2.3). Mwebaza et al.,
(2014)34 also found low level of knowledge about pressure ulcer among Ugandan registered nurses (N=56) in a
teaching hospital.
The study findings reflected that nursing students were not equipped with the knowledge of pressure ulcer
prevention. These findings highlighted that lack of knowledge regarding pressure ulcer prevention may lead to
increases of pressure ulcer in the hospital. As a result, patients’ expectation to get a quality care from staff nurses is
declining. Gunningberg et al., (2013)35 and Etafa et al., (2018)36 suggested that Nursing students are must be urged
to improve and gain more knowledge. This is because they are pre-registered nurses and will graduate as fresh
nursing students later. The only thing that they can rely on is their knowledge since they lack clinical experiences
compared to staff nurse with much more working experience. This was also supported by Wangensteen (2010) 37,
who concluded that knowledge factors appear to be more important for fresh graduated nurses than for experienced
nurse.
Based on the Figure 2 most of nursing students from both program (degree nursing students=82.8%, diploma
nursing students=98.6%) had knowledge scores in the range of 59% and below. Both of the nursing program
students did not achieve satisfactory scores. This finding indicates that nursing students from both programs are
lacking in knowledge regarding pressure which needs to be highlighted in their education.
Difference Level of Pressure Ulcer Knowledge among Degree and Diploma Nursing Students
There is significant difference of level of knowledge and practice regarding pressure ulcer prevention among degree
and diploma nursing student (Table 5). Degree nursing students have significantly higher knowledge than diploma
nursing students with significant value of p<0.001.
Beeckman et al. (2011)28 found that nurses with higher levels of education scored significantly higher in pressure
ulcer knowledge scores than those with lower levels of education. Pancarbo-Hidalgo et al. (2007)38 in his study found
that nurses with university degree had high scores in knowledge including clinical performance in pressure ulcer
prevention. Study done by Aydin & Karadag (2010)39 found that there is statistically significant relationship between
mean scores and level of nursing education with p-value=0.004 (significant at p<0.05). Nurses with bachelor’s degree
had higher knowledge than licensed practical nurse program 39. Differences in level of knowledge may be due to
difference methods of learning and dissemination of information regarding pressure ulcer prevention among nursing
students.
. Table 3 shows that nursing students were good in answering the question correctly which is includes theme
‘aetiology and causes’ and ‘nutrition’. Study by Gunningberg et al. (2013)35 also found that nursing students have
higher knowledge than registered nurse and assistant nurse. Other than that, Table 4 shows degree nursing students
also have significantly higher knowledge than diploma students which includes ‘aetiology and causes’ ( p=0.024),
‘classification and observation’ (p=0.037) and ‘nutrition (p=0.002)’ with significant value at p<0.05. However, there are
also themes where nursing students from both programs were unable to scores especially regarding ‘reduction in the
amount of pressure and shear’. Mostly students lack knowledge in this regard. This indicates that knowledge related
to this theme should be highlighted.
Finding of this study was significant with p<0.001 (significant at p<0.05). This indicates the significant
differences of pressure ulcer knowledge between both programs. As degree nursing students was higher knowledge
than diploma nursing students, then it shows that the higher the education, the higher the knowledge. Besides,
instrument used in this study is a recent instrument developed in the year 2009. The developers also highlighted that
this instrument can be used or applied in nursing education, research and practice to assess knowledge regarding
pressure ulcer prevention.
Limitation in this study was time constraints. As a result, the researcher was unable to go back to respondents for
incomplete questionnaire. Thus, this caused missing value in certain questionnaire that makes it invalid for analysis.
The questionnaire only would be accepted if it was 90% answered by the respondents.
Nursing Practice: Ottawa of Research Use is a conceptual framework that can be used as a guideline to improve
nursing practices in providing a better nursing care towards patient 40. Lack of knowledge in pressure ulcer prevention
has being identified as a barrier factor in implementations of good nursing practices 41. Thus, by follow the conceptual
framework other barriers also should be assessed and its effects must be monitored towards the nursing practice to
make changes appropriately before evaluation41. Monitoring and gives feedback on pressure ulcer prevention that
can be implemented to improve the effectives preventive intervention42.
Nursing Education: This study provides the baseline of knowledge level of pressure ulcer prevention among nursing
students of Malaysia. Low level of knowledge for both nursing program’s students indicates the needs to improve
students’ knowledge regarding this matter. Thus, this study provides students with the latest information regarding
pressure ulcer prevention based on evidence-based practice
Nursing Research: This study is aimed for final year nursing students from both programs. This is because it is
important to know their readiness in terms of knowledge that they supposedly had after three to four years of study
before they become registered nurse. Besides, this study provides the baseline for further study as shown in
conceptual framework.
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Table 1: Response Rate
(%)
Age
20-22 59 60.2 0 0 59 85.5
23-25 35 35.7 29 100 6 8.7
26-28 4 4.1 0 0 4 5.8
Gender
Male 11 11.2 2 6.9 9 13.0
Female 87 88.8 27 93.1 60 87.0
Educational program
Degree 29 29.6 29 94 - -
Diploma 69 70.4 - - 69 93
Learning Sources
Without extra- 28 28.6 9 31.0 19 27.5
curricular
With extra- 70 71.4 20 69.0 50 72.5
curricular
Self-perception towards knowledge
Enough 33 33.7 15 51.7 18 26.1
Not enough 65 66.3 14 48.3 51 73.9
Table 3: Distribution of students’ answer to questions evaluating their knowledge regarding pressure
ulcer prevention
Correct answer Incorrect answer
n=98 n=98
(%) (%)
Qs 1 40 40.8 58 59.2
Qs 2 29 29.6 69 70.4
Qs 3 18 18.4 80 81.6
Qs 4 56 57.1 42 42.9
Qs 5 20 20.4 78 79.6
Qs 6 63 64.3 35 35.7
Qs 1
Qs 2 32 32.7 66 67.3
Qs 3 41 41.8 57 58.2
Qs 4 43 43.9 55 56.1
Qs 5 49 50.0 49 50.0
18 18.4 80 81.6
Qs 1 46 46.9 52 53.1
Qs 2 28 28.6 70 71.4
Theme 4: Nutrition
Qs 1 70 71.4 28 28.6
n=98 n=98
(%) (%)
and shear
Qs 1
22 22.4 76 77.6
Qs 2
37 37.8 61 62.2
Qs 3
42 42.9 56 57.1
Qs 4
34 34.7 64 65.3
Qs 5
22 22.4 76 77.6
Qs 6
47 48.0 51 52.0
Qs 7
40 40.8 58 59.2
and shear
Qs 1
24 24.5 74 75.5
Qs 2 72 73.5 26 26.5
Qs 3 39 39.8 59 60.2
Qs 4 48 49.0 50 51.0
Qs 5 45 45.9 53 54.1
Qs, Question
Table 4: Distribution of nursing students’ level of knowledge for pressure ulcer prevention by themes
Level of knowledge of nursing students, (n=98)
Low Moderate High
Frequency (n) Percent Frequency (n) Percent Frequency (n) Percent
(%) (%) (%)
Themes
Theme 1: 83 84.7 11 11.2 4 4.1
Aetiology and causes
Theme 2:
Classification and 72 73.5 16 16.3 10 10.2
observation
Theme 3:
Risk assessment 38 38.8 46 46.9 14 14.3
Theme 4:
Nutrition 28 28.6 NR NR 70 71.4
Theme 5:
Reduction in the 94 95.9 3 3.1 1 1.0
amount of pressure
and shear
Theme 6:
Reduction in the 57 58.2 25 25.5 16 16.3
duration of pressure
and shear
Theme 3:
37.8 34.5 37.9 31.8 37.7 35.8 0.974
Risk assessment
Nutrition
Theme 5:
35.6 18.2 38.0 21.7 34.7 16.5 0.417
Reduction in the amount of
20-22 38.03(10.02)
23-25 44.91(11.0)
26-28 29.75(13.60)
Gender NA NA
Male 40.45(10.63)
Female 40.11(11.21)
Educational program t=3.70 p<0.001
Degree 46.17(11.29)
Diploma 37.62(10.06)
Learning sources t=0.006 p=0.995
Enough 40.76(10.04)