Assessment of nurses’ knowledge and practice of pressure injuries prevention for critically ill patients in Rwanda: a cross-sectional study
verfasst von:
Sophie Mukantwari, Emmanuel Bikorimana, Liberatha Rumagihwa, Ime U. Akaninyene, Christian Ntakirutimana, Joseph Mucumbitsi, Thierry Claudien Uhawenimana, David Ikwuka
Pressure injuries are costly and can lead to mortality and psychosocial consequences if not managed effectively. Proper management of pressure injuries is crucial for quality nursing care. However, there is limited research on nurses’ knowledge and practices in preventing and managing pressure injuries among critically ill patients in Rwanda. In addition, barriers affecting nurses’ practices in this area also need further investigation in order to inform the interventions to improve nursing care of patients with pressure injuries in Rwandan hospitals.
Methodology
A cross-sectional study involving 129 health nurses was conducted to determine their knowledge and practice levels regarding the prevention of pressure injuries in critically ill patients, and barriers impeding practice in this area. The research modified the Pieper-Zulkowski Pressure Ulcer Knowledge Test to evaluate the knowledge of nurses concerning the prevention of pressure injuries. A 33-item instrument drawn from pressure ulcer risk assessment and prevention toolkits established by the Agency for Healthcare Research and Quality was used to assess nurses’ practices. Additionally, barriers influencing nurses’ knowledge and practices related to the prevention of pressure injuries were evaluated through questions derived from a comparable study conducted in Ethiopia. Descriptive statistics were computed for each variable. Mean scores were computed to categorize nurses’ level of knowledge and practice. Logistic regression analysis was employed to examine the influence of sociodemographic factors and training on the nurses’ knowledge and practice, with a statistical significance set at a p-value less than 0.05.
Results
The study found that 40.0% of nurses had inadequate knowledge towards pressure injury prevention, and 60.0% reported that they inadequately practiced pressure injury prevention among critically ill patients. Nurses who have not been trained in pressure injury prevention have a 52.4% reduction in the odd of having adequate practice compared to those who have been trained (OR 0.476; 95% CI 0.211–0.996). Heavy workload, inadequate staff, shortage of equipments, presence of other priorities than pressure injury prevention, inadequate training coverage of pressure injury prevention were the most prevalent barriers reported.
Conclusion
The evaluation of nurses’ knowledge and practices on pressure injury prevention in critically ill patients at the study setting found that while nurses have satisfactory knowledge, their practical application is lacking due to factors like high workloads and insufficient staffing. The study recommends caution in interpreting the results due to a limited sample size, suggesting further research to guide improvements in nursing practices.
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Introduction
Hospital acquired pressure injuries are bedsores or decubitus ulcers due to patients’ restricted mobility [1, 2]. During the hospital stay, several factors may contribute to pressure injures but most commonly pressure ulcer development, limited mobility/activity, perfusion, and skin/pressure ulcer status increase the likelihood of pressure injuries [2, 3].
Pressure injuries represent a significant yet often overlooked issue impacting hospitalized patients, contributing to prolonged recovery times and diminished quality of life [4]. Every year, it is estimated that around 700,000 individuals worldwide experience pressure injuries, with over 10% of all adult patients admitted to healthcare facilities developing such injuries on a global scale [5, 6]. This static indicates a global prevalence of pressure injuries, with point prevalence ranging from 11.6 to 14.8%, and a mean incidence rate of 6.3% [6, 7]. Despite the scarcity of evidence from Sub-Saharan Africa, existing systematic reviews indicate that prevalence rates for pressure injuries in medical, surgical, and general hospital units range from 3.4 to 18.6%, with a pooled prevalence of 11% for grades II-IV pressure injuries at 5% [8]. The consequences of pressure injuries in this region may be particularly pronounced due to constrained healthcare resources and diverse socioeconomic factors. Therefore, further research is essential to develop effective interventions aimed at preventing pressure injuries in hospitalized patients by addressing low levels of knowledge and adherence to pressure injury prevention protocols among nurses in some parts of Sub-Saharan region [9].
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In Rwanda, there is a lack of comprehensive national studies that document the prevalence and incidence of pressure injuries. Nevertheless, findings from a case report study at Kigali University Teaching Hospital indicate that hospitalized patients may experience pressure injuries. However, the overall burden and associated risk factors of these injuries require further research. A study carried out at the Intensive Care Unit (ICU) of Kigali University Teaching Hospital revealed that pressure injuries continue to pose a considerable challenge. Among the 41 patients evaluated, 11 individuals (27%) presented with preexisting injuries, while 6 patients (15%) acquired new pressure injuries during their stay in the ICU [10]. Kigali University Teaching Hospital, a prominent healthcare institution, sees its vulnerable patient population at risk for developing pressure injuries due to various factors, including immobility, chronic health conditions, and surgical interventions [10]. A clinical report conducted at one of the level teaching hospitals in Kigali revealed that only 11 (24.4%) nurses did not receive training about pressure injury prevention [11]. The majority of respondents (86.7%) in this hospital had inadequate knowledge regarding pressure injury prevention [11]. The most cited barriers to carrying out pressure injury prevention practices were the lack of staff/heavy workload (82.2%) and shortage of pressure relieving devices (40%) [11]. The results obtained from this study may not accurately represent the circumstances at Kigali University Teaching Hospital, which receives numerous referrals from secondary teaching hospitals and district hospitals throughout the nation. The skills and competencies of the staff from the cited study may vary from those at Kigali University Teaching Hospital. Therefore, it is essential to evaluate the knowledge, practices, and obstacles that nurses encounter in their efforts to prevent pressure ulcers within this institution.
Limited research has been conducted at Kigali University Teaching Hospital regarding pressure injuries in Rwanda, highlighting a significant gap in the literature. The prevention of pressure injuries is a critical responsibility for nurses, who serve as the primary healthcare providers. Given that nurses are integral to the prevention of pressure ulcers, their duties encompass various aspects of patient care, including the repositioning of patients, maintaining skin hygiene, and educating patients on methods to prevent pressure injuries. Therefore, it is crucial to evaluate their existing knowledge and practices related to pressure ulcer prevention, as well as the factors that influence their ability to implement these practices effectively. This study was conducted to evaluate nurses’ knowledge and practice of pressure injuries prevention at CHUK as a most important public referral hospital in Rwanda. The findings from this study are crucial for developing initiatives to improve knowledge, practice, quality of care for critical ill patients and address barriers towards the prevention of pressure injuries.
Methods
Clinical trial number
Not applicable.
Study design
This cross-sectional study was carried out over a three-month timeframe, from February 2024 to April 2024. The aim was to provide an overview of nurses’ knowledge and practices related to the prevention of pressure injuries in critically ill patients at one of the University Teaching Hospitals in Rwanda located in Kigali, as well as to identify barriers influencing nurses’ knowledge and practices. Employing a cross-sectional design was deemed the most appropriate method to fulfill the objectives established for this research.
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Study setting
The present research was carried out at Kigali University Teaching Hospital, widely recognized as Centre Hospitalier Universitaire de Kigali (CHUK). This institution stands as the largest referral hospital in Rwanda, admitting approximately 17,986 new patients for inpatient care and serving around 114,060 patients in its outpatient departments each year. CHUK encompasses a variety of specialized departments, including Trauma and Emergency Services, Surgical Ward, Pediatrics, Orthopedics, Internal Medicine, Neurosurgery, Gynecology and Obstetrics, Outpatient Services, Operating Theatre, and Intensive Care Units, among others. Notably, CHUK distinguishes itself from other referral hospitals by receiving a significant number of patients referred from other facilities or directly from accident scenes, many of whom may require extended hospitalization lasting several weeks.
Regarding the pressure injuries prevention and management, CHUK has established detailed protocols that delineate the roles of nursing personnel in the evaluation and management of patients susceptible to pressure ulcers. These protocols encompass routine skin evaluations, scheduled repositioning, and thorough documentation practices to ensure adherence to preventive measures. While the hospital employs various assessment tools, including the Norton Scale and Waterlow Scale, the Braden Scale is predominantly utilized at CHUK for evaluating a patient’s risk of developing pressure ulcers. The Braden Scale assesses six key factors: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each factor receives a score, and the cumulative score aids in identifying the risk level, thereby informing preventive strategies. It is within this context that CHUK was chosen as the site for this study.
Study population
The research encompassed registered nurses from various departments within CHUK, including the Trauma and Emergency Services (TES), Intensive Care Unit (ICU), High Dependency Unit (HDU), Neurosurgery, Internal Medicine, General Surgery, and Orthopedic Surgery, where critically ill patients typically experience extended hospital stays. The participants consisted of nurses from the aforementioned departments who were present during the data collection phase. Additionally, nurses and midwives who expressed a willingness to voluntarily participate in the research were also considered. However, those who were absent due to annual or maternity leave, as well as individuals who declined to take part during the data collection period, were excluded from the study.
Sample size and sampling approach
To determine the sample size, the researcher employed the Yamane Taro formula, which is applicable for finite populations. Upon identifying the population size, the formula for calculating the sample size is expressed as follows: where n represents the sample size, N denotes the population size, and e signifies the margin of error (MoE), with e set at 0.05 according to the research parameters. Consequently, the sample size was established at 129 nurses, as detailed in the formula provided below.
In this research, probability sampling methods were implemented to guarantee that every participant had an equal opportunity to be selected for further analysis. A stratified sampling approach was adopted, categorizing the population into six distinct groups: internal medicine ward, neurosurgery, orthopedic surgery, emergency department, intensive care unit, and intensive care unit. To achieve a proportionate stratification, the researcher applied the formula sample size/population size x stratum size. The sample consisted of 129 nurses, while the total population included 190 nurses. Following this, the investigator utilized a stratified sampling technique to select participants from each stratum, ensuring that each individual within the stratum had an equal likelihood of being chosen. The researcher randomly drew numbers from a box to obtain the necessary sample size and the strata were as follows as outlined in Table 1.
Table 1
Sample size determination process
Departments
Intensive care
Emergency
Neurosurgery
Internal medicine
General surgery
Orthopedic ward
Number of nurses in the department
55
49
23
31 Nurses
20
12
Number of nurses sampled
129 × 55/190 = 37
129 × 49/ 190 = 33
129 × 23/190 = 16
129 × 31/190 = 21
129 × 20/190 = 14
129 × 12/190 = 8
Data collection tools
The study adapted the Pieper-Zulkowski Pressure Ulcer Knowledge Test to assess nurses’ knowledge level on pressure injuries prevention [12]. This test was available as an open access through the publishing journal. To assess nurses’ practices regarding pressure injuries prevention, a 33-item tool was developed using the previous studies about the subject was used [13‐17], and pressure ulcer risk assessment and prevention toolkits found at the website of the Agency for Healthcare Research and Quality. To identify the barriers affecting nurses’ knowledge and practices of pressure injuries prevention, we used questions from a similar study conducted in Ethiopia [18]. The final compiled self-report questionnaire comprised four sections: (i) Sociodemographic characteristics, (ii) nurses’ knowledge regarding pressure injury prevention with 39 items with True or False response options, (iii) nursing practices related to pressure injury prevention with 33 items with Yes or No response options, and (iv) barriers encountered by nurses in the effective prevention of pressure injuries.
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A panel of specialists was convened to evaluate the content validity of the modified instrument. This panel comprised two clinical experts in the management of pressure injuries, one research specialist, one intensivist, and one anesthesiologist affiliated with the study site. Additionally, three academic professionals, including supervisors and educators from the University of Rwanda’s College of Medicine and Health Sciences, participated in the review. Their collective assessment confirmed that the tool is pertinent for evaluating nurses’ knowledge and practices in the prevention of pressure injuries, thereby establishing its validity for the intended application. Additionally, a preliminary study was conducted to assess the comprehensibility of the instrument among participants, aiming to yield reliable results. A pre-test was conducted within the study setting, involving 14 nurses who consented to participate in the pilot study; however, these individuals were later excluded from the primary research group. The Cronbach’s alpha coefficients for the knowledge assessment component from the study referred to was 0.80 and for the practice component, studies that contributed to the items included in the practice assessment for this study had a Cronbach’s coefficient that was above 0.50.
Questionnaire administration
Participants completed a self-report questionnaire provided to them by the researcher. They independently responded to the questions contained within the questionnaire, which was anticipated to require approximately 30 min for completion. The researcher distributed copies of the questionnaire to eligible participants following the regular staff meeting and one hour prior to the conclusion of the standard working hours. A designated box was made available for participants to submit their completed questionnaires, from which the research team subsequently collected the responses every day.
Data analysis
Data analysis was conducted utilizing Statistical Package for Social Sciences (SPSS) version 26.0 [19]. Descriptive statistics were employed for each variable, with results presented in tables and frequency distributions. Mean scores and standard deviations were calculated to encapsulate data concerning nurses’ knowledge and practices related to pressure injuries prevention. A bivariate analysis was performed to evaluate the relationship between sociodemographic characteristics and the levels of knowledge and practice. Variables demonstrating significant associations in the bivariate analysis were subsequently included in a multiple logistic regression analysis to examine their impact on knowledge and practice. Variables yielding a p-value of less than 0.05 in the multiple logistic regression were deemed statistically significant.
McDonald’s standard of learning outcome measured criteria [20] was used to categorize nurses, level of knowledge and practice regarding pressure injuries prevention. This set of criteria was developed in order to measure the actual performance of students’ learning in the educational institution. This criterion was categorized into five groups as shown in Table 2.
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Table 2
Process of categorization of knowledge and practice levels
Level of knowledge and practice
Composite percent of scores
Very low level
< 60%
Low level
60 to 69.99%
Moderate level
70 to 79.99%
High level
80 to 89.99%
Very high level
90 to 100%
The relationship between sociodemographic characteristics and knowledge and practice levels were assessed using a bivariate approach. To investigate their effects on knowledge and practice, variables that had significant connections in the bivariate analysis were added to a multiple logistic regression. In the multiple logistic regression analysis, variables with a p-value of less than 0.05 were deemed statistically significant.
Data management
The hard copies of completed questionnaires were stored securely in a locker. Electronic data was stored on a computer and the researcher was the sole individual with access to a password-protected computer where digital copies were maintained. Data security measures were implemented to uphold the integrity and privacy of the study data. Only authorized personnel could access the password-protected computers used for storing electronic data. Additionally, sensitive hardcopy documents were secured in locked file cabinets located in a safe area.
Ethical considerations
Ethical considerations played a pivotal role in this study to safeguard the privacy and rights of participants. The study adhered to the Declaration of Helsinki regarding research carried out on humans [21]. Approval was obtained from the University of Rwanda (Ref. CMHS/IRB/051/2024) and the Ethical Review Board of Kigali University Teaching Hospital (Ref. EC/CHUK/011/2024). Participants confirmed their voluntary participation in the study by signing a consent form given to them. Any inquiries or concerns were addressed before consent was secured. To ensure the anonymity and confidentiality of participants, codes were assigned to the questionnaires eliminating the risk of using participants’ names which would breach their confidentiality.
Results
As reflected in Table 3, a total of 129 participants were recruited in the study. Of them, the majority (n = 91,70.5%) was female. From the respondents a large number (n = 99,76.7%) were married. The age of participants recruited in the study was between 20 and 60 with the mean age of 36.34 years (SD = 7.11), and most of participants (n = 60,46.5%) were aged between 30 and 39 years. Regarding participants’ working experience, 38.8% had been working as nurses between 5 and 9 years and the mean work experience was 9.62 years (SD = 4.943). Over half of participants (n = 64,49.6%) had a Bachelor’s degree and only 29.5% (n = 38) were trained in pressure injury prevention and management.
Table 3
Socio-demographic characteristics of study participants
Variables
N
%
Sex
Female
91
70.5%
Male
38
29.5%
Marital status
Single
25
19.4%
Married
99
76.7%
Divorced
2
1.6%
Widow
3
2.3%
Age
20–29
22
17.1%
30–39
60
46.5%
40–49
43
33.3%
50–60
4
3.1%
Over 60
Mean = 36.34 years (SD = 7.11)
0
0.0%
Working experience
Under 5 years
23
17.8%
5 to less than 10 years
50
38.8%
Between 10–20
36
27.9%
Over 20
Mean = 10.22 years (SD = 5.432)
20
15.5%
Highest education level obtained
Advanced diploma
62
48.1%
Bachelors’ degree
64
49.6%
Masters
3
2.3%
Yes
38
29.5%
Trained about pressure injury prevention and management
No
91
70.5%
Below one hour
7
18.4%
Nurses’ knowledge towards pressure injury prevention
As shown in Table 4, the majority of participants (80.5%) responded correctly to questions related to knowledge of injury prevention. The lowest scoring item pertained to the effectiveness of ‘heel protectors in alleviating pressure on the heels’, which received a mean score of 26.3. This was closely followed by the understanding that ‘donut devices or ring cushions’ can help prevent pressure injuries, with a mean score of 27.9, and the recommendation that ‘individuals confined to bed should be repositioned every three hours’, which had a mean score of 32.5. Conversely, the highest score was achieved in identifying risk factors associated with the development of pressure injuries, with an average score of 100. This was succeeded by knowledge of the signs of a stage IV pressure injury, which had a mean score of 99, along with adequate dietary intake and the documentation of all care provided to prevent or treat pressure injuries, both also scoring a mean score of 99.
Table 4
Scores on the knowledge towards pressure injury prevention
Variables
Response
N
%
Mean
SD
1. Stage I pressure injuries are intact skin with non-blanch able erythema in lightly pigmented persons.
Right
120
93.0
0.93
0.22
Wrong
9
7.0
2. Risk factors for development of pressure injuries are immobility, incontinence, impaired nutrition, and altered level of consciousness.
Right
129
100.0
1
0.0
Wrong
0
0.0
3. All hospitalized individuals at risk for pressure injuries should have a systematic skin inspection at least daily and those in long-term care at least once a week.
Right
109
84.5
0.84
0.33
Wrong
20
15.5
4. Hot water and soap may dry the skin and increase the risk for pressure injuries.
Right
80
62.0
0.62
0.47
Wrong
49
38.0
5. It is important to massage bony prominence.
Right
58
45.0
0.45
0.49
Wrong
71
55.0
6. A Stage III pressure ulcer is a partial thickness skin loss involving the epidermis and/or dermis.
Right
76
58.9
0.59
0.49
Wrong
53
41.1
7. All individuals should be assessed on admission to a hospital for risk of pressure ulcer development.
Right
126
97.7
0.98
0.26
Wrong
3
2.3
8. A Stage IV pressure ulcer is a full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structure.
Right
128
99.2
0.99
0.20
Wrong
1
0.8
9. An adequate dietary intake of protein and calories should be maintained during illness.
Right
128
99.2
0.99
0.20
Wrong
1
0.8
10. Persons confined to bed should be repositioned every 3 h.
Right
44
34.1
0.34
0.47
Wrong
85
65.9
11. A turning schedule should be written and placed at the bedside
Right
127
98.4
0.98
0.08
Wrong
2
1.6
12. Heel protectors relieve pressure on the heels.
Right
33
25.6
0.26
0.45
Wrong
96
74.4
13. Donut devices/ring cushions help to prevent pressure injuries.
Right
35
27.1
0.27
0.44
Wrong
94
72.9
14. In a side lying position, a person should be at a 30-degree angle with the bed unless inconsistent with the patient’s condition and other care needs that take priority.
Right
95
73.6
0.74
0.42
Wrong
34
26.4
15. The head of the bed should be maintained at the lowest degree of elevation (hopefully, no higher than a 30-degree angle) consistent with medical conditions.
Right
96
74.4
0.74
0.44
Wrong
33
25.6
16. A person who cannot move him or her should be repositioned every 2 h while sitting in a position angle.
Right
69
53.5
0.53
0.50
Wrong
60
46.5
17. Persons who can be taught should shift their weight every 30 min while sitting in a chair.
Right
77
59.7
0.59
0.49
Wrong
52
40.3
18. Chair-bound persons should be fitted for a chair cushion.
Right
94
72.9
0.73
0.27
Wrong
35
27.1
19. Stage II pressure injuries are a full thickness skin loss.
Right
81
62.8
0.63
0.48
Wrong
48
37.2
20. The epidermis should remain clean and dry.
Right
121
93.8
0.94
0.24
Wrong
8
6.2
21. The incidence and prevalence of pressure injuries are so high that it would be better if the institution appoints a team to study risk factors, prevention, and treatment.
Right
116
89.9
0.90
0.21
Wrong
13
10.1
22. A low-humidity environment may predispose a person to pressure injuries.
Right
119
92.2
0.92
0.24
Wrong
10
7.8
23. To minimize the skin’s exposure to moisture on incontinence under pads should be used to absorb moisture.
Right
116
89.9
0.92
0.24
Wrong
13
10.1
24. Slough is yellow or creamy necrotic tissue on a wound bed.
Right
128
99.2
0.87
0.32
Wrong
1
0.8
25. Bony prominences should not have direct contact with one another.
Right
114
88.4
0.88
0.32
Wrong
15
11.6
26. Every person assessed to be at risk for developing pressure injuries should be placed on a pressure redistribution bed surface.
Right
108
83.7
0.95
0.21
Wrong
21
16.3
27. Blanching refers to whiteness when pressure is applied to a reddened area.
29. Skin macerated from moisture tears more easily.
Right
117
90.7
0.94
0.19
Wrong
12
9.3
30. A pressure ulcer scar will break down faster than unwounded skin.
Right
123
95.3
0.95
0.21
Wrong
6
4.7
31. A good way to decrease pressure on the heels is to elevate them off the bed.
Right
126
97.7
0.90
0.28
Wrong
3
2.3
32. All care given to prevent or treat pressure injuries must be documented.
Right
116
89.9
0.99
0.08
Wrong
13
10.1
33. Devices that suspend the heels protect the heels from pressure
Right
128
99.2
0.88
0.31
Wrong
1
0.8
34. Shear is the force that occurs when the skin sticks to a surface and the body slides.
Right
114
88.4
0.84
0.36
Wrong
15
11.6
35. Friction may occur when moving a person up in bed.
Right
108
83.7
0.83
0.37
Wrong
21
16.3
36. A low Braden score is associated with increased pressure injury risk.
Right
107
82.9
0.92
0.26
Wrong
22
17.1
37. Stage II pressure injuries may be extremely painful due to exposure of nerve endings.
Right
118
91.5
0.91
0.28
Wrong
11
8.5
38. For persons who have incontinence, skin cleaning should occur at the time of soiling and at routine intervals.
Right
117
90.7
0.95
0.21
Wrong
12
9.3
39. Educational programs may reduce the incidence of pressure injuries.
Right
126
97.7%
0.97
0.15
Wrong
3
2.3%
SD standard deviation, N number, % percentage
Nurses’ level of knowledge towards pressure injury prevention
The distribution of scores presented in Fig. 1 below shows that two participants (1.6%) exhibited very low knowledge, nine (7%) demonstrated low knowledge, 41 (31.8%) showed moderate knowledge, 48 (37.2%) had high knowledge, and 29 (22.5%) possessed very high knowledge regarding pressure injury prevention. Consequently, a total of 77 participants (60.0%) were found to have adequate knowledge in this area, while 52 participants (40.0%) displayed inadequate knowledge related to pressure injury prevention practices.
Association between demographic characteristics and level of knowledge
Association between demographic characteristics and the level of knowledge was carried out. As reported in Table 5, the results showed that all independent variables were not associated with level of knowledge P-value ˃0.05.
Table 5
Association between demographic characteristics and level of knowledge
Variables
Level of Knowledge
Inadequate
Adequate
χ2
P-Value
Sex
Female
35(38.5%)
56(54.3%)
0.439
0.558
Male
17(44.7%)
21(55.3%)
Married
38(38.4%)
61(61.4%)
Divorced
0(0.0%)
2(100.0%)
Widow
1(33.3%)
2(66.7%)
Age
20–29
10(45.5%)
12(54.5%)
3.428
0.331
30–39
28(46.7%)
32(53.3%)
40–49
30(69.8%)
30(69.8%)
50–60
3(75.0%)
3(75.0%)
Accident and Emergency
11(32.4%)
23(67.6%)
Neurosurgery ward
9(52.9%)
8(47.1%)
General Surgical ward
9(64.3%)
5(35.7%)
Orthopedic ward
2(25.0%)
6(75.0%)
Internal medicine
3(15.0%)
17(85.0%)
Working experience
Under 5 years
9(39.1%)
14(60.9%)
3.221
0.367
Between 5–9
24(48.0%)
26(52.0)
Between 10–20
14(38.9%)
22(61.1%)
Over 20
5(25.0%)
15(75.0%)
Highest education level obtained
Advanced Diploma
26(42.6%)
36(57.4%)
0.985
0.927
Bachelors ‘degree
25(39.1%)
39(60.9%)
Masters
1(33.3%)
2(66.7%)
Trained about pressure injury prevention and management
Yes
16(42.1%)
22(57.9%)
0.072
0.845
No
36(36.7%)
55(60.4%)
Nurses’ practices towards pressure injury prevention
Table 6 shows that a total of 76.4% of participants engaged in at least one preventive measure against pressure injuries. Each implemented measure was assigned a score of 1 point. The average score for pressure injury prevention practices was 78.6. The lowest scoring area was the assessment of patients at risk for developing pressure injuries using the Waterlow scale, which yielded a mean score of 10.0. This was followed by the assessment using the Norton scale, which had a mean score of 12.4, and the assistance provided to patients with impaired mobility through turning and repositioning every two hours, which received a mean score of 31.7. Conversely, the highest scores were recorded in areas such as assisting with hygiene during soiling, managing urinary incontinence through wet checks, and improving nutritional needs by providing feeding assistance, all of which achieved an average score of 99.
Table 6
Nurses’ practices towards pressure injury prevention
Variables
Response
N
%
Mean
SD
Do you screen all patients for pressure ulcer risk at the following times?
Upon admission
Yes
125
96.9%
0.97
0.17
No
4
3.1%
Upon readmission
Yes
59
45.7%
0.46
0.50
No
70
54.3%
When condition changes
Yes
58
45.0%
0.44
0.49
No
71
55.0%
Do you assess the skin condition particularly on prominent areas?
Intactness
Yes
124
96.1%
0.96
0.19
No
5
3.9%
Color
Yes
95
73.6%
0.73
0.44
No
34
26.4%
Sensation
Yes
86
66.7%
0.68
0.48
No
43
33.3%
Temperature
Yes
54
41.9%
0.42
0.49
No
75
58.1%
Moisture
Yes
107
82.9%
0.83
0.21
No
22
17.1%
Assessing patient at risk of developing pressure injuries using the following scale
Braden scale
Yes
81
62.8%
0.63
0.48
No
48
37.2%
Norton scale
Yes
16
12.4%
0.12
0.33
No
113
87.6%
Water low scale
Yes
13
10.1%
0.10
0.30
No
116
89.9%
Relieving pressure by using:
Support surfaces: Bed (foam, air, and waterbed mattresses)
Yes
93
72.1%
0.72
0.24
No
36
27.9%
Support surfaces: Chair
Yes
69
53.5%
0.53
0.40
No
60
46.5%
Pressure-relieving devices: Trapeze, Pillow (e.g.: Put pillow under patients‟ leg from mid-calf to ankle to keep heels off the bed)
Yes
108
83.7%
0.84
0.32
No
20
15.5%
Repositioning
Yes
122
94.5%
0.94
0.40
No
8
6.2%
Assisting patient with impaired mobility with
Turning & changing position every 2 h
Yes
42
32.6%
0.33
0.27
No
87
67.4%
Rising the head from the bed below 300
Yes
110
85.3%
0.85
0.39
No
19
14.7%
Encourage ambulation (within the patient’s limit)
Yes
123
95.3%
0.95
0.42
No
6
4.7%
Managing fecal incontinence by:
Toileting plan
Yes
125
96.9%
0.97
0.32
No
4
3.1%
Checking for dirtiness and dampness
Yes
126
97.7%
0.98
0.22
No
3
2.3%
Assisting with hygiene at the time of dirtiness
Yes
128
99.2%
0.99
0.27
No
1
0.8%
Treating the causes
Yes
120
93.0%
0.93
0.24
No
9
7.0%
Managing Urinary incontinence by:
Toileting plan
Yes
125
96.9%
0.96
0.19
No
4
3.1%
Checking for dirtiness and dampness
Yes
128
99.2%
0.99
0.16
No
1
0.8%
Treating the causes
Yes
124
96.1%
0.96
0.19
No
5
3.9%
Assisting with hygiene at the time of dirtiness
Yes
123
95.3%
0.95
0.42
No
6
4.7%
Using of the skin barriers and protectants
Yes
107
82.9%
0.82
0.23
No
22
17.1%
Improving nutritional needs by providing
Supplements (protein, Vitamin A and C for malnourished patients)
Yes
100
77.5%
0.77
0.42
No
29
22.5%
Feeding assistance
Yes
128
99.2%
0.99
0.08
No
1
0.8%
Adequate fluid intake
Yes
127
98.4%
0.98
0.12
No
2
1.6%
Dietitian consultation as needed
Yes
116
89.9%
0.90
0.30
No
13
10.1%
Patients’ & care givers health education on pressure ulcer preventive measures
During hospitalization
Yes
116
89.9%
0.89
0.30
No
13
10.1%
Before discharge
Yes
69
53.5
0.53
0.50
No
60
46.5
SD standard deviation, N number, % percentage
Level of practice among nurses towards pressure injury prevention
The criteria established by McDonald’s for assessing learning outcomes were employed to classify the levels of practice related to pressure injury prevention among nursing professionals. Participants were categorized based on their scores: those scoring below 60 were deemed to have a very low level of practice, scores between 60 and 69 indicated a low level, 70–79 represented a moderate level, 80–89 signified a high level, and scores from 90 to 100 were classified as a very high level of practice. Figure 2 presents the distribution of participants’ level of practice as follows: (n = 7, 5.4%) exhibited a very low level, (n = 29, 22.5%) a low level, (n = 41, 31.8%) a moderate level, (n = 24, 18.6%) a high level, and (n = 28, 21.7%) a very high level of practice in pressure injury prevention. Consequently, (n = 52, 40%) of the nurses demonstrated an adequate level of practice in this area, while (n = 77, 60.0%) were found to have inadequate practices concerning pressure injury prevention.
Fig. 2
Nurses’ level of practice regarding pressure injuries prevention
×
Association between demographic characteristics and level of practice
Association between demographic characteristics and the level of practice was carried out and the results showed that the highest education level obtained, trained about pressure injury prevention and management P-value < 0.05 (Table 7).
Table 7
Association between demographic characteristics and level of practice
Variables
Level of Practice
Inadequate
Adequate
χ2
P-Value
Sex of participants
Female
59(64.8%)
32(35.2%)
3.399
0.065
Male
18(47.4%)
20(52.6%)
Married
62(62.6%)
37(37.4%)
Divorced
1(50.0%)
1(50.0%)
Widow
0(0.0%)
3(100.0%)
Age
20–29
15(68.2%)
12(31.8%)
1.671
0.658
30–39
36(60.0%)
24(40.0%)
40–49
23(53.5%)
20(46.5%)
50–60
3 (75.0%)
1 (25.0%)
Accident and Emergency
23(67.6%)
11(32.4%)
Neurosurgery ward
11(64.7%)
6(35.3%)
General Surgical ward
5(35.7%)
9(64.3%)
Orthopedic ward
2(25.0%)
6(75.0%)
Internal medicine
20(100.0%)
6(75.0%)
Working experience
Under 5 years
14(60.9%)
9(39.1%)
3.369
0.345
Between 5–9
30(60.0%)
20(40.0)
Between 10–20
18(50.0%)
18(50.0%)
Over 20
15(75.0%)
5(25.0%)
Highest education level obtained
Advanced Diploma
35(57.4%)
27(42.6%)
6.398
0.048
Bachelors ‘degree
42(65.6%)
22(34.4%)
Masters
0(0.0%)
3(100.0%)
Trained about pressure injury prevention and management
Yes
17(44.7%)
21(55.3%)
5.006
0.025
No
60(65.9%)
31(34.1%)
Factors associated with level of practice among participants
Table 8 below shows that participants holding a bachelor’s degree are four times more likely to engage in adequate practices for the prevention of pressure injuries when compared to those with an advanced diploma (OR: 4.122, 95% CI: 2.001–7.632, P-value: 0.004). Furthermore, individuals who have not received training in pressure injury prevention and management exhibited a 52.4% decrease in the odds of demonstrating adequate practices relative to those who have undergone such training (OR: 0.476, 95% CI: 0.211–0.996, P-value: 0.012).
Table 8
Factors associated with level of practice among participants
Variables
OR
95%CI
P-value
Working service
ICU/HDU
Accident and Emergency
1.911
1.121–3.221
0.3222
Neurosurgery ward
0.943
0.231–1.355
0.722
General Surgical ward
1.755
1.144–4.344
0.324
Orthopedic ward
1.621
0.844–2.211
0.129
Internal medicine
2.111
1.876–5.567
0.078
Highest education level obtained
Advanced Diploma
Bachelors
4.122
2.001–7.632
0.004
Trained about pressure injury prevention and management
Yes
No
0.476
0.211–0.996
0.012
Barriers faced by nurses in the prevention of pressure injury
As shown in Table 9, a significant proportion of respondents reported challenges related to heavy workloads and insufficient staffing (n = 114, 88.4%). Additionally, a notable number indicated a lack of resources, including equipment (n = 106, 82.2%). Furthermore, the presence of competing priorities beyond the management of pressure injuries was acknowledged by many (n = 94, 72.9%). Lastly, inadequate training in the area of pressure injury prevention was highlighted by a considerable group of participants (n = 84, 65.1%).
Table 9
Barriers faced by nurses in the prevention of pressure injury
Barrier
N
%
Poor access to literature and reading facilities
Yes
54
41.9%
No
75
58.1%
Heavy workload and inadequate staff
Yes
114
88.4%
No
15
11.6%
Lack of guideline on prevention of pressure injury within the workplace
Yes
34
26.4%
No
95
73.6%
Inadequate training coverage of pressure injury prevention
Yes
84
65.1%
No
45
34.9%
Uncooperative patients
Yes
28
21.7%
No
101
78.3%
Lack of job satisfaction in nursing profession
Yes
30
23.3%
No
99
76.7%
Presence of other priorities than pressure injury
Yes
94
72.9%
No
35
27.1%
Shortage of resources (equipments)
Yes
106
82.2%
No
23
17.8%
Inadequate knowledge about pressure injury among nurses
Yes
24
18.6%
No
105
81.4%
Limited involvement of a multidisciplinary team in the prevention of pressure injuries among hospitalized patients
Yes
29
22.5%
No
100
77.5%
Discusson
Our study did not find any statistically significant association between demographic characteristics and the level of knowledge about pressure injuries prevention. In spite of this, we found that 85% of nurses (17 out of 20) working daily in internal medicine had the most adequate knowledge about PI prevention compared to nurses from other departments. Additionally, nurses with over 20 years of experience in nursing services scored better in knowledge compared to other groups. This contrasts with a survey of 16 Ethiopian hospitals, which reported that the younger age group (< 25 years) had significantly higher mean scores in PI prevention knowledge compared to other age categories [9]. Our study found that only 29.5% of nurses at the study setting received training on PI prevention and management, yet these nurses surprisingly scored well in knowledge about PI prevention. This finding corroborates the findings from studies from Ethiopia, Nigeria, Turkey, in which nurses’ lack of training about pressure injuries prevention and management was highlighted [15, 18, 22].
Our study found that the majority of nurses had a theoretical knowledge about pressure injuries prevention; a result we found promising. However, this finding needs to be interpreted with caution because it only reflects nurses’ self-reports which may contradict what they practice. Compared to the findings of a similar study conducted in one level two hospital in Rwanda [11], our findings suggest an improved level of knowledge hence they do not corroborate with that previous study about the topic in Rwanda. However, further research involving large sample of hospitals at all levels is needed to determine the trends in nurses’ level of knowledge regarding the prevention of pressure injuries among hospitalized patients in Rwanda.
Our study found that over three quarters of nurses surveyed took at least one measure to prevent pressure injuries though only 28% of nurses demonstrated an excellent level of practice in pressure injuries prevention among hospitalized patients. These findings are consistent with a study conducted at Korkata University which found nurses’ level of practice to be inadequate in preventing pressure injuries among hospitalized patients [23].
Our study found that higher education levels among nurses were positively and significantly correlated with PI prevention practices. Nurses with a bachelor’s degree (n = 64, p-value = 0.004) were four times more likely to have adequate practices compared to those with only an advanced diploma (n = 61). CHUK has a significant number of nurses with bachelor’s degrees, thanks to opportunities for upgrading their qualifications and this may influence nurses’ practices in the prevention of pressure injuries. The influence of advanced education on nurses’ practice of preventing pressure injuries has been reported elsewhere and for example a study conducted from Ethiopia reported nurses with bachelor’s degrees were 2.6 times more likely to engage in PI prevention practices than those with diplomas [24]. Our study found that nurses who had not received training in pressure injury prevention and management had a 52.4% (p = 0.012) reduction in the likelihood of adequate practice compared to those who had been trained. This finding is supported by a cross-sectional study in Western China, which demonstrated that nurses’ practices improved with increased work experience and training in PI prevention [25].
Our study found that heavy workload, insufficient number of staff, and prioritization of other tasks over pressure injury prevention were the major barriers that affected nurses’ implementation of pressure injuries prevention among hospitalized patients. Similar barriers were reported elsewhere across the globe particularly in low and middle income settings [18, 26‐28]. These findings suggest that understaffing and inadequate equipment contribute to heavy workloads and reduced quality of care in preventing PIs among critically ill patients.
Limitations
It focused on a single referral hospital, limiting the generalizability of the findings nationwide. Data on nurses’ knowledge about pressure injuries were collected using a self-administered questionnaire, which may not accurately reflect the respondents’ actual knowledge if observational methods of data collection were applied. This limitation could be addressed by incorporating pre- and post-tests to evaluate knowledge more effectively. Furthermore, the study was a quantitative, cross-sectional study, which did not aim to provide an in-depth understanding of the participants’ feelings about the barriers to pressure injury prevention.
A further limitation of this study is the absence of an examination of the relationship between nurses’ knowledge and their practical application, as we did not observe nurses in practice settings. As a result, any potential discrepancies between knowledge levels and practical application may be influenced by bias, particularly since we utilized a self-report questionnaire. We recognize this limitation and suggest that future research should employ observational data collection methods to investigate the correlations between nurses’ self-reported knowledge and their actual practice levels.
Conclusion
The primary objective of this study was to evaluate the knowledge and practices of nurses regarding pressure injury prevention among critically ill patients at CHUK. The findings revealed that while nurses generally had adequate knowledge about pressure injury prevention, their practical application of this knowledge was insufficient. This discrepancy might be attributed to the data collection methods used in the study. The results can inform strategies to enhance nurses’ practices in preventing pressure injuries. The study also identified that the most significant barriers to effective PI prevention were heavy workloads and insufficient staffing. This calls on the Ministry of Health in Rwanda and other stakeholders to sustain training and workshops for nurses on pressure injury prevention, as well as to update guidelines and protocols for ongoing education. Policymakers and nursing managers should enhance nurses’ practices by formulating policies, providing training program in -service, and developing guidelines that address the factors influencing nurses’ knowledge and practices in PI prevention. Future research should investigate deeper into qualitative aspects, investigating the obstacles nurses encounter when implementing prevention strategies.
Acknowledgements
N/A.
Declarations
Ethics approval and consent to participate
The study adhered to the Declaration of Helsinki regarding research carried out on humans. Approval for the execution of this study was granted by the University of Rwanda (Reference: CMHS/IRB/051/2024) and the Ethical Review Board of Kigali University Teaching Hospital (Reference: EC/CHUK/011/2024). Upon arrival at the research location, the researcher interacted with participants within their respective departments to clarify the aims of the study. Prior to filling out the questionnaire, informed consent was sought from participants, and they confirmed their participation in the study by signing on a consent form given to them. Any questions or concerns raised by the participants were addressed prior to obtaining their consent. To maintain the anonymity and confidentiality of the participants, unique codes were assigned to the questionnaires, thereby avoiding the use of personal names. The filled questionnaires were securely stored in a locked box, and the researcher was the only person with access to a password-protected computer where digital versions were kept.
Consent for publication
N/A.
Competing interests
The authors declare no competing interests.
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Assessment of nurses’ knowledge and practice of pressure injuries prevention for critically ill patients in Rwanda: a cross-sectional study
verfasst von
Sophie Mukantwari Emmanuel Bikorimana Liberatha Rumagihwa Ime U. Akaninyene Christian Ntakirutimana Joseph Mucumbitsi Thierry Claudien Uhawenimana David Ikwuka
