ADDIS ABABA UNIVERSITY COLLEGE OF HEALTH SCIENCES ALLIED SCHOOL OF NURSING AND MIDWIFERY DEPARTMENT OF NURSING AND MIDWIFERY

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1 ADDIS ABABA UNIVERSITY COLLEGE OF HEALTH SCIENCES ALLIED SCHOOL OF NURSING AND MIDWIFERY DEPARTMENT OF NURSING AND MIDWIFERY ASSESSMENT OF NURSES KNOWLEDGE, ATTITUDE AND PRACTICE TOWARDS PRESSURE ULCER PREVENTION FOR HOSPITALIZED PATIENTS IN PUBLIC HOSPITALS IN ADDIS ABABA, ETHIOPIA, BY: WERKU ETAFA (BSN) ADVISOR: ZELEKE ARGAW (RN, BSN, MSN) A THESIS SUBMITTED TO SCHOOL OF GRADUATE STUDIES OF ADDIS ABABA UNIVERSITY COLLEGE OF HEALTH SCIENCES ALLIED SCHOOL OF NURSING AND MIDWIFERY DEPARTMENT OF NURSING AND MIDWIFERY IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTERS OF SCIENCE IN CHILD HEALTH NURSING. JUNE, 2015 ADDIS ABABA, ETHIOPIA

2 Approval by the Board of Examiners This thesis is by Werku Etafa accepted in its present form by the Board of Examiners as satisfying thesis requirement for the degree of Masters of Science in Child Health Nursing. Internal Examiner Sr.Zuriyash Mengistu (RN, BSN, MSN) Full name Rank Signature Date Research Advisor/ supervisor Mr. Zeleke Argaw (RN, BSN, MSN) Full name Rank Signature Date Head Department Daniel Mengistu (Assistant Professor) Full name Rank Signature Date

3 Acknowledgement First, I would like to pass my heartfelt gratitude to my advisor Mr. Zeleke Argaw, for his continuous advice and encouragement from the beginning the end of this thesis. I also record my appreciation to Assistant professors Asrat Demissie and Fikadu Aga, and Mr.Engida Yisma for their fruitful suggestions and constructive comments. My special thanks go to Addis Ababa University College of Health Sciences Allied School of Nursing and Midwifery for its financial and material support without which this thesis work would not be successful. My sincere thanks extend to all nurses participated in the study and data collection facilitators with their respective hospitals who paid great contribution for facilitating data collection. I recognize my special respects are offered to my partner Mr.Gammaches Mekonnen (from Oromiya Energy, Mineral and Water Bureau) for his psychological and financial support and my beloved husband Ayantu Belay whose motivation and loving kindness assisted me in completing this post graduate studies. I P a g e

4 Table of contents Contents Acknowledgement... I Table of contents... II List of Tables... IV List of Figures... V List of Abbreviations and Acronyms... VI Abstract... VII 1. INTRODUCTION Background Statement of the problem Significance of the study LITERATURE REVIEW Pressure Ulcer Prevention Points Nurses Knowledge towards Pressure Ulcer Prevention Nurses Attitude towards Pressure Ulcer Prevention Nurses Practice towards Pressure Ulcer Prevention Factors/barriers associated with nurses KAP towards PU prevention Conceptual Framework for Pressure Ulcer Prevention OBJECTIVES General Objective Specific Objectives METHODS AND MATERIALS Study Area and Period Study Design II P a g e

5 4.3 Source and Study Population Source Population Study Population Study Subjects Sample size determination Sampling Procedures Inclusion and exclusion criteria Study Variables Operational definitions Data Collection Tools Data Collection Procedure Data Quality Control Data Processing and Analyzing Ethical Considerations Dissemination of Result RESULTS AND DISCUSSIONS DISCUSSIONS STRENGTH, LIMITATIONS AND IMPLICATIONS OF THE SUDY CONCLUSIONS AND RECOMMENDATIONS REFERENCES APPENDIXES Appendix- A Information Sheet Appendix- B Consent Form Appendix C English version questionnaires Declaration III P a g e

6 List of Tables Title Page Table1: Frequency distribution of nurses socio-demographic variables in the Public Hospitals in Addis Ababa, 2015 (N=356) Table 2: Frequency distribution of nurses knowledge score towards pressure ulcer prevention in Public Hospitals in Addis Ababa, 2015 (N=356) Table 3: Regression analysis of Nurses Knowledge score regarding pressure ulcer prevention with related variables (N=356) Table 4: Frequency distribution of nurses positive and negative attitude score in Public Hospitals in Addis Ababa, 2015 (N=356) Table 5: Frequency distribution of nurses attitude score by Likert scales regarding pressure ulcer prevention in Public Hospitals in Addis Ababa, 2015 (N=356) Table 6: Frequency distribution of nurses practice score in Public hospitals in Addis Ababa, 2015 (N=356) Table 7: Frequency distribution of nurses perceived barriers to prevent pressure ulcer in Public Hospitals in Addis Ababa, 2015 (N= 356) IV P a g e

7 List of Figures Figure 1: Conceptual framework for nurses knowledge, attitude and practice towards pressure ulcer prevention developed by principal investigator after reviewed different literatures Figure 2: Schematic Presentation of Sampling Procedure Figure 3: Nurses attitude score regarding pressure ulcer prevention in Public hospitals in Addis Ababa, 2015 (N=356) V P a g e

8 List of Abbreviations and Acronyms AAU Addis Ababa University AHRQ Agency for Health Care Research and Quality ANA American Nurses Association AOR Adjusted Odds Ratio CI Confidence Interval COR Crude Odds Ratio CSA Central Statistical Agency of Ethiopia EPUAP European Pressure Ulcer Advisory Panel ETB Ethiopian birr Km Kilometer ICU Intensive Care Unit ICC Intensive Care Centers IHI Institute for Healthcare Improvement KAP Knowledge, Attitude and Practice NICE National Institute for Health and Clinical Excellence NPUAP American National Pressure Ulcer Advisory Panel NQF National Quality Forum PUAT Pressure Ulcer Attitude Test PUKT Pressure Ulcer Knowledge Test PUPG Pressure Ulcer Prevention Guide Line PUP Pressure Ulcer Prevention SPSS Statistical Package for Social Sciences St Saint USA United States of America UK United Kingdom $ United States of American Dollar VI P a g e

9 Abstract Back ground: The presence or absence of pressure ulcers has been generally regarded as a performance measure of quality nursing care and overall patient health. The burden of living with pressure ulcers (PUs) significantly limit many aspects of an individual s well-being, including general health and physical, social, financial, and psychological quality of life. Lack of knowledge and skills, and negative attitudes in PU prevention contributes significantly to the occurrence or worsening of PU Objectives: The aim of this study was to examine nurses knowledge, attitude and practice towards pressure ulcer prevention in public hospitals in Addis Ababa, Ethiopia, Methodology: Structured self administered questionnaire using institutional based cross sectional multi-center study design and quantitative method was employed to collect data from staff nurses (N=356) working in the selected public hospitals in Addis Ababa, from April 21- May 28 /2015. Hospitals were selected by Simple Random Sampling and Multi-stage sampling technique was used to select the study subjects from working units of each Hospital by using Probability Proportionate sampling and Simple Random sampling method was conducted to select the study subjects in each hospital working unit. Data was actually collected after ethical clearance has obtained from Black Lion Hospital, Addis Ababa City Administration Health Bureau and Alert Hospital. Totally, 70 questions were administered for each study subjects of which 20 knowledge test questions were adapted and modified from Pressure Ulcer Knowledge Test (Pieper and Mott), 11 attitude test questions from Pressure Ulcer Attitude Test (Moore and Price) and 20 Practice test questions (Bangladesh and Nigeria). Nurses barrier related 11 questions were adapted by modifying from the study conducted in Uganda. Others were sociodemographic questions. Nurses level of knowledge, attitude and practice, socio-demographic factors associated with nurses Knowledge, Attitude and Practice towards pressure ulcer prevention and nurses barriers to prevent pressure ulcers were assessed using means, medians, percentage, frequency and logistic regression. Data was entered in to computer using Epi data version 3.1 statistical packages and analyzed using Statistical Package for Social Science version 20. Results: The study has assessed nurses level of knowledge, attitude, and practice towards Pressure ulcer prevention. The overall nurses level of knowledge was at low level (63.85%), majority of them had negative attitude (52%) and their Practice was at very low level (33.42%). VII P a g e

10 The study has also showed that nurses with longer working experience were more knowledgeable than those with shorter duration of working experience. Additionally, the study identified the major barriers of nurses for preventing pressure ulcers: Heavy workload and inadequate staff (83.1%), shortage of resources (67.7%) and inadequate training (63.2%). Conclusions and recommendations: The results of the current study showed inadequate knowledge which suggests poor dissemination of their practice and negative attitude regarding pressure ulcer prevention. Immediate intervention should be made at for Public Hospitals found in Addis Ababa to improve nurses Knowledge, Attitude and Practice towards pressure ulcer prevention. Keywords: Nurses Pressure Ulcer Knowledge, pressure ulcer Attitude, pressure ulcer Practice. VIII P a g e

11 1. INTRODUCTION 1.1 Background Pressure ulcers are defined as 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 [1]. The National Pressure Ulcer Advisory and European Pressure Ulcer Advisory Panel (NPUP- EPUAP)category I through IV are characterized by intact skin with non-blanchable erythematic, partial thickness loss of dermis presenting as a shallow open ulcer, full thickness skin loss in which case subcutaneous tissues are visible with no exposed bone, tendon or muscle, full thickness tissue loss with exposed bone, tendon or muscle respectively, whereas two additional categories of United States of America (USA) were unclassified/ unstagable and suspected deep tissue injury characterized by full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed, and purple or maroon localized area of discolored intact skin or bloodfilled blister due to damage of underlying soft tissue from pressure and/or shear, respectively. In both cases the true depth cannot be determined until enough sloughs and/ or scar is removed [1]. The survey conducted across 26 hospitals in Belgium, Italy, Portugal, Sweden and the United Kingdom (UK) reported pilot pressure ulcer prevalence 1078 (18.3%) among 5947 patients. By country, the proportion of patients surveyed who had pressure ulcers were varied- Italy (8.3%), Portugal (12.5%), Belgium (21.0%), UK (21.9%), Sweden (22.9%) [2]. In Germany, the study suggested total number of cases of hospitalized with the principal diagnosis pressure ulcer (PU) increased from 9,941 in 2005 to 12,581 in 2011 (increase of 26.5 %) with a disproportional increase of PU grade 4 (from 46 % in 2005 to 59 % in 2001). Patterns of co morbidity did not change in the period from 2005 to Urinary and fecal incontinence play a major role in those with the principal diagnosis PU whereas fracture of femur, heart failure and pneumonia are the most frequent diagnoses coded with the additional diagnosis of PU [3]. The study in West Scotland revealed that the prevalence of pressure ulcers was 7% with the majority EPUAP Grade one and two. The majority of ulcers were on the sacrum, hips and Ischia 1 P a g e

12 tuberosities with 33% on the foot area [4]. Similarly, the study surveyed over 14,000 patients from 45 health care institutions in Canada reported the prevalence of pressure ulcers in Acute Care Hospitals (25.1%), Non-Acute Facilities (Long-term care, Nursing Homes, etc) 29.9%, Mixed Health Care Facilities (acute and non-acute) 22.1%, Community Care 15.1% [5]. The study conducted in Bahir Dar, Ethiopia among 422 patients found that 71 pressure ulcers with the prevalence rate of 16.8% and stages of pressure ulcer based on EPUAP grading scale, 62%(44) and 26.8% (19) patients developed stage I and stage II pressure ulcer, respectively while prolonged length of stay in hospital, slight limit of sensory perception, and friction and shearing forces were among significantly associated with the presence of pressure ulcer [21]. Several factors were contributed to pressure ulcer development. These were intrinsic factors such as advanced age (> 65 years), limited mobility, poor nutrition, co morbidities, incontinence (urinary more than fecal), impaired sensory perception, altered tissue perfusion, organ system failure, and infection and extrinsic factors like intensity and duration of pressure,shearing, friction and macerations [6]. Nurses knowledge, attitude and practice are also viewed as extrinsic factors for pressure ulcer development [39]. Development of pressure ulcers is complex and multi-factorial. Despite advances in medical technology and the use of formalized prevention programs based on clinical practice guidelines, the prevalence of pressure ulcers during hospitalization continues to increase by 80%. Among all hospitalized patients, prevalence rates of acquired pressure ulcers are the highest in patients in the intensive care unit (ICU), from 14% to 42%. Mortality is also associated with pressure ulcers. Several studies noted mortality rates as high as 60 percent for older persons with pressure ulcers within 1 year of hospital discharge [7, 8]. According to the American Nurses Association (ANA), pressure ulcer prevention is primarily a nursing responsibility. Nosocomially acquired pressure ulcers are among the nurse sensitive outcomes adopted by the National Quality Forum (NQF) and considered to be within the domain of patient-centered outcomes. A targeted preventive approach will be less costly than one that is focused on treating already established ulcers [9, 10]. 2 P a g e

13 1.2 Statement of the problem The presence or absence of pressure ulcers has been generally regarded as a performance measure of quality nursing care and overall patient health [11]. In United States nearly 1 million people develop pressure ulcers annually, while approximately 60,000 acute care patients die from related complications [12]. The prevalence of pressure ulcers in European hospitals ranges from 1% to 11% in medical wards and 4.7% to 66% in surgical wards [13]. Pressure ulcer (PU) can leads to ischemia, cell death, and tissue necrosis, as capillaries are compressed and the blood flow is restricted. Even though, preventing pressure ulcer can be nursing intensive, studies have suggested that pressure ulcer development can be directly affected by the number of nurses and time they spent at the bedside [6]. Pressure ulcers occur across all health care settings, with the highest incidence in the hospital. More recent data, however, estimated 57%- 60% of ulcers occur in the hospital, usually within the first two weeks of admission. The incidence differs by care area, with patients in orthopedics and intensive care at greatest risk [14]. Prevalence rates for PUs are 11.9% in acute care, 29.3% in long term acute care, 11.8% in long term care, and 19.0% in rehabilitation. A key to prevention is early detection of a patient s risk factors which includes using a valid and reliable PU risk assessment tool and timely implementation of prevention interventions [6]. By 2008, the Institute for Healthcare Improvement (IHI) of United States of America (USA) estimated a total national cost of $11 billion per year to treat pressure ulcers. The IHI also estimated that the cost of treating a single full-thickness pressure ulcer to be as high as $70,000 per ulcer and explained the cost of treatment of pressure ulcer increase from 21.4% to 74.6% in between 2006 and 2008 [15]. The burden of living with pressure ulcers (PUs) extends beyond costs to the healthcare system and loss-of-life. A systematic review of 31 studies found PUs significantly limit many aspects of an individual s well-being, including general health and physical, social, financial, and psychological quality of life [16]. 3 P a g e

14 Nurses are often found to demonstrate poor adherence to the PU prevention guidelines. The compliance of nurses to the guidelines was found to be influenced by several barriers. Limited application of knowledge is a common problem in clinical practice [17]. Nurses are not fully aware the importance of using up-to-date pressure ulcer prevention protocols and may not have been exposed to current evidence-based practices; sometimes their practices can be influenced by intuition, experience, or habit [6]. Lack of knowledge and skills, and negative attitudes in PU prevention contributes significantly to the occurrence or worsening of PU. Therefore, nurses require regular training and education in this area of practice [6]. Moreover, increased knowledge about PU prevention among nurses not only improves the quality of PU care but also reduces hospital stays, and the number of patients suffering from this condition [18]. The study in Uganda suggested that inadequacies of supplies for pressure ulcer management and prevention and shortages of human resource for health, particularly nurses, were the most cited barriers to carrying out appropriate pressure ulcer management [19]. Today s nurses are prepared for the sick patients with the most advanced treatments. But there s one thing that hasn t changed: basic bedside care, which can prove especially challenging in light of increasing patient acuity and staffing shortages [6]. The nurses knowledge, attitudes and practices regarding pressure ulcer prevention are enhanced through provision of effective education, willingness to change, clinical practice, availability of resources, sufficient equipment supplies, administrative support, and increased multidisciplinary team collaboration [20]. There are no sufficient and published researches regarding nurses knowledge, attitude and practice towards pressure ulcers in Ethiopia. Therefore, this study was emphasized to assess nurses knowledge, attitude and practice and associated barriers towards pressure ulcer prevention for hospitalized patients in public hospitals in Addis Ababa. 4 P a g e

15 1.3 Significance of the study The treatment of pressure ulcer is more expensive than its prevention. It is believed to be preventable if appropriate measures are early implemented to maintain skin integrity. Once it occurred it may extend from pain and suffering to end of life (mortality). Even though pressure ulcer prevention is a multidisciplinary team approach, nurses are the first line health professionals to provide adequate care for hospitalized patients. To date, no similar studies have been conducted in Ethiopia to examine nurses level of knowledge, attitude and practice regarding pressure ulcer prevention. Therefore, this study assessed nurses knowledge, attitude and practice towards pressure ulcer prevention; which the researchers, nurses, community, planners and policy makers use it as a base line for their future interventions and activities. Another importance of this study is it focused on prevention which is the key for developing countries like Ethiopia. Additionally, it also minimizes the gap in the titled protocol. 5 P a g e

16 2. LITERATURE REVIEW 2.1 Pressure Ulcer Prevention Points According to International Guide Line of National Pressure Ulcer Advisory Panel pressure ulcer prevention practices classified in to Risk assessment, Skin care, Nutrition for pressure ulcer prevention, Education, Mechanical loading and support surfaces [1]. Risk assessment is an integral component of pressure ulcer prevention and its use is recommended by international guidance National Institute for Health and Clinical Excellence (NICE) in combination with nurses clinical judgment [22]. Risk assessment scales are not a replacement for good clinical judgment, and it is essential that patient assessment includes a combination of nursing knowledge, clinical judgment and risk assessment scales to prevent the development of pressure ulcers [23]. A number of instruments have been developed to assess for risk of pressure ulcers. The three most widely used instruments are the Braden scale (6 items; total scores range from 6 to 23) which is commonly used in America whereas the Norton scale (5 items; total scores range from 5 to 20); and the Water low scale (11 items; total scores range from 1 to 64) are commonly used in European countries. All three scales include items related to activity, mobility, nutritional status, incontinence, and cognition, although they are weighted differently across studies [24]. NICE recommended that nurses should be aware that all patients are potentially at risk of developing a pressure ulcer, carry out and document an assessment of pressure ulcer risk for adults, encourage adults who have been assessed as being at risk and at high risk of developing pressure ulcers should be encouraged to change their position frequently and every 6 hours, and frequently and every 4 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required [25]. Similarly, Agency for Health Care Research and Quality (AHRQ) recommended clinical practice guideline risk should be completed on admission. Similarly, it stated total skin assessment is done every 24 hours, with special attention to bony prominences (should not be massaged), especially 6 P a g e

17 the coccygeal/sacral skin and heels. If pressure ulcer found, should be staged and documented [26]. According to the NPUAP for patient in acute term care skin should be assessed on admission, reassess at least every 24 hours or sooner if the patient s condition changes and for long-term care assess on admission, weekly for 4 weeks, then quarterly and whenever the resident s condition changes. Similarly, it recommended maintaining the head of the bed at or below 30 0 avoiding hot water, excessive rubbing and massaging over bony prominences, positioning directly on the trochanter when using side lying position and avoided donut-type devices and sheepskin for pressure redistribution. Moreover, it suggested implementing pressure ulcer prevention educational programs that are structured, organized, comprehensive and directed at all of heath care providers, patients, family, and caregivers[27]. One study found that increasing energy, protein, zinc, vitamins like A, C and promotes wound healing though the mechanism was unknown. Of the micronutrients zinc and vitamin C were the two most commonly nutrients used in wound healing. Vitamin C aids wound healing by increasing collagen synthesis, neutrophil function and angiogenesis. Collagen production also serves to produce a barrier to pathogens. Zinc is an essential trace mineral that is required for cellular growth and replication; zinc deficiencies are thought to affect wound healing by decreasing protein and collagen synthesis [28]. A cohort study in New Zealand tertiary referral hospital assessed the knowledge of nurses 3 times: before educational intervention, within 2 weeks after educational intervention and 20 weeks later using multivariate analysis found that the mean score on the assessment test 84% at baseline, 89% following educational program and 85% after 20 week follow up. This showed that educational provision/intervention had improved the nurses level of knowledge even though returned to base line score later [29]. One descriptive comparative study in Brazil in Intensive Care Centers (ICC) among registered nurses (n=7) who participated in pre intervention phase only and scored 86.4%, and the nursing assistants and technicians (n=25) who participated in both pre, and post intervention (n=36) obtained 74.3% of correct answers, and 81.2%, respectively. Although there was improvement of 7 P a g e

18 knowledge after intervention, it suggested that new intervention might be used to obtain greater staff adhesion and improve their knowledge [30]. Study by Pieper recommended frequent turning and repositioning schedule at least 2 hours and head of bed should be maintained at 30 degree in lateral and supine position alternatively which should be kept one hour after meal or nasogastric tube feeding [31]. The code of conduct for nurses states that all nurses are obliged to maintain accurate and up to date patient records. The evidence from pressure ulcer studies suggests that nurses are not delivering an appropriate level of care to prevent pressure ulcers and they are not keeping the pressure ulcer related documentation of their patients up to date [32]. According to Stechmiller, J the effects of massage or scrubbing the skin is more harmful than helpful as it increases the exposure to friction and sheer. It causes repetitive friction which can lead to rubbing off the epidermis and thereby friction damage to the tissue in patients with risk for pressure ulcer [33]. The study by Beeckman and his colleagues declared that adequate knowledge about PU prevention is important for deciding which patients should receive prevention, which prevention should be applied, and how prevention should be applied [34]. Although PU education improves knowledge, studies have also shown that regular educational updates are needed to maintain and improve PU knowledge and practice standards [35]. 2.2 Nurses Knowledge towards Pressure Ulcer Prevention A cross sectional multi-center study in England, South Hampton Belgian hospitals suggested Knowledge of both nurses and nursing assistants in nursing homes about pressure ulcer prevention was low. The lowest scores found in the themes nutrition (9%), etiology and development (25.9%), classification and observation (23.7%) and reduction in the amount of pressure and shear (26.8%) where as the highest score found on risk assessment (57.9%). Only 16% of the participants indicated that repositioning while seated in a chair is important and should be performed on a regular basis [36]. However, a Dutch hospital nurses knowledge 8 P a g e

19 about the usefulness of measures to prevent pressure ulcers seems to be moderate. This study also investigated nurses employed in organizations that monitored pressure ulcers did not display greater knowledge than those employed in organizations that did not do so [37]. A survey conducted in Spain displayed professional nurses had knowledge deficit (scored, 50%) regarding pressure ulcer prevention related to positioning the patient with regard to the head of the bed (27.7%), air/water, the time period for repositioning while sitting in a chair (28%), donut devices or ring cushions (35.2%), side lying positioning (37.3%), the use of massage (39.6%) and water or air-filled gloves (47.9%). Conversely, it found nurses had sufficient knowledge (scored > 90%) related to skin should remain dry and clean (98.2%), patient /care giver should be educated for pressure ulcer prevention(98.4%), education reduce the incidence of pressure ulcer prevention (98.7%) and all bed should be assessed for pressure ulcer risk [38]. According to the study conducted in Bangladesh the nurses knowledge regarding pressure ulcer prevention was at very low level (Mean=57.79%, SD=9.20). It was found the highest levels of nurses knowledge were; turning thepositionevery2hourstoprotectskindamage (100%),scheduling turning positions for reducing pressure ulcer formation (94.5%), recognizing the value of vitamin C&E to maintain healthy skin (92.3%) a n d elevating the head of bed at<30 0 to reduce shearing force(85.7%), respectively. Conversely, lowest percentages of nurses answered correctly were; applying a risk assessment scale for pressure ulcer development (12.1%) and determining low albumin to be the critical determinant for pressure ulcer development (23.1%) [39]. Cross sectional study conducted among Jordanian nurses revealed that majority (n = 141, 73%) of them had inadequate knowledge about pressure ulcer prevention with the lowest knowledge score related to PU etiology, preventive measures to reduce amount of pressure/shear, and risk assessment [40]. The descriptive cross sectional study conducted in Alexandria health insurance hospital among 122 nurses stated the overall nurses knowledge about prevention of pressure ulcer was below the minimum acceptable level (<70%). It also found the correct answers for non-useful measures for preventing pressure ulcers accounted for 66% of the non-useful measures [41]. 9 P a g e

20 A survey conducted in Uganda found almost all nurses (98.2%) identified regular turning of patients as a preventive measure. It also found that nurses knowledge pressure ulcer risk factors in immobile patients (92.9%), around bony prominences (91.1%), due to skin compression as a result of unrelieved pressure (83.9%), develop in stages (42.9 %), commonly occur management requires interdisciplinary collaboration (39.3%), can lead to permanent disabilities like bone destruction (50%), Sepsis is one of the complications (89.3%). Similarly, the study suggested nurses knowledge regarding pressure ulcer such as immobility (96.4%), pressure/compression (92.9%), friction/shear (64.3%) hypoxemia (28.6%), malnutrition (66.1%), anemia (10.7), ischemia (42.9%), and neurologic disease (50%) [19]. 2.3 Nurses Attitude towards Pressure Ulcer Prevention A cross sectional survey in Swedish health care setting among the municipal, hospital registered nurses and assistant nurses revealed nurses had demonstrated positive attitude towards pressure ulcer prevention irrespective of the study sites. It found that there was no significant difference between the groups (p = ). Similarly, the majority (95%) of the nursing staff felt that they should concern themselves with pressure ulcer prevention in their work and just as many (94%) considered that most pressure ulcer could be avoided, while they demonstrated negative attitudes by preferring their own clinical judgment rather than using risk assessment scale to assess patients at risk from pressure ulcers[42]. Also, the study conducted in Belgian nurses stated nurses have more positive attitude (78.3%) regarding patient care and less positive regarding the impact of pressure ulcer on patient [36]. In Ireland the study revealed the mean overall under graduate nurses attitude towards pressure ulcer prevention was positive [46]. A descriptive study in Bangladesh found most of the nurses achieved neutral levels of overall attitude, whereas, nearly one-fifth (63.7%) and approximately (18.7%) of nurses achieved negative and positive attitude towards pressure ulcer prevention, respectively. It also found nurses have positive attitude towards cleansing patient immediately after soiling themselves (69.7%), attending educational activities on pressure ulcer prevention (63.7%) and a few nurses 10 P a g e

21 strongly agreed as clinical judgment was not better than pressure ulcer risk assessment (9.9%) and all patients were not at risk for developing pressure ulcers (13.2%) [39]. The study conducted among (N= 197) Jordan hospital nurses declared that the overall nurses attitude towards pressure ulcer prevention was positive. It stated that 82% believed that most pressure ulcers were preventive, around three-quarter (74%) thought patients tended not to get pressure ulcer these days and 79% percent thought they should concern themselves with PU prevention during their practice [43]. 2.4 Nurses Practice towards Pressure Ulcer Prevention The survey conducted in Swedish also found 9% (n=14) used the risk assessment scale making judgment on risk potential in patients, 40% (n=95) on admission and/or when patient condition changed. Also concerning documentation it found 42% they always write an individual pressure ulcer prevention care plan daily, 25% reported that they updated patient care plan daily where as 35% used EPUAP classification system in their documentation when pressure ulcer had occurred [42]. In addition to knowledge and attitude of nurses, from the study conducted in Bangladesh the staff nurses overall level of practice regarding pressure ulcer prevention was moderate (M = 77.55%). and five out of six sub-dimensions were at the moderate levels. Those five sub-dimensions were: identifying factors for pressure ulcer formation (77.65%), risk assessment tool (74.17%), nutrition to maintain healthy skin (77.41%), management of mechanical load (77.65%), and educational program for patient, family, and staff (75.09%). In contrast, only one sub-dimension of skin care (82.05%) was at high level [39]. A Qualitative study conducted in Ghana declared that nurses used massage as a salient intervention in pressure ulcer prevention considering because it increases the circulation. Further the nurses explained that they achieved their knowledge in school by practical demonstrations and examinations [44]. The study in Uganda revealed only 28.6% of the nurses had turned patients they found at risk of pressure ulcers on a two-hourly basis. Whereas, none of the nurses reported using any risk assessment tool for pressure ulcers assessment. But on a daily basis they were conducting patient 11 P a g e

22 education (96.4%), encouraging a balanced diet (58.9%), and using pressure reduction devices (33.9%) [19]. 2.5 Factors/barriers associated with nurses KAP towards PU prevention The study in Spain stated Spanish nurses with university degrees and specific education or who had been involved in research had better knowledge and higher implementation of clinical practice in pressure ulcer prevention. Even though it found a positive relationship between nurses knowledge and practice, nurses had higher level off knowledge than practice. Therefore, the level of knowledge is not accord with the level of practice in case of pressure ulcer prevention [38]. Conversely, the Swedish nurses knowledge was not related to their practice in which case nurses level of practice may be affected by were lack of time (57.8%) and severely ill patients (28.9%); while opportunities for knowledge were (38%) and access to pressure relieving equipment (35.5%) [42]. The study conducted by Hulsenboom, Bours, and Halfens found that the demographic variables including age and experience of nurses had no significant influence on PU prevention [37]. In contrast, Choa, Parkb, and Chunge analyzed nurses characteristics in relation to PU Prevention and found that more PU prevention was documented by those who were younger, less experienced, and more educated [45]. The study in Jordan stated that the only significant demographic variable associated with nurses attitude towards pressure ulcer prevention was the experience of the nurses; which showed there was a statistically- significant difference in the mean of the three experience groups levels (p=0.041). The nurses with more than 10 years experience had the most positive attitude (mean 4.3 ± 0.3) compared with those with 1 4 years experience (mean 3.1 ± 0.5), and those with 5 10 years experience (mean 3.7 ± 0.4). Similarly, it found variables such as academic level, age groups and whether they received training on PU and reading research articles on about PU prevention had no association with nurses attitude towards pressure ulcer prevention [43]. The statistical analysis of study conducted by Qaddumi and his colleague declared that there was no significant relationship between nurses knowledge of PU prevention and their age, clinical nursing experience, current higher education, PU research participation, and last attendance at PU 12 P a g e

23 training. In contrast, gender had a significant relationship with nurses knowledge of PU prevention. It also revealed that most of the participants 51% (n = 99) did not receive any type of education on PU after graduation from university, 32% (n = 63) in-service training is the second source of education on PU, 51% (n=91) coming after university. Additionally, they also commonly cited factors affecting nurses for implementing PU prevention were lack of time (34.1%, n = 46), shortage of staff (24.4%, n = 33), the patient s condition (17.8%, n = 24), and lack of resources or equipment(19.3%, n = 26).Lack of training and lack of aides (15.6%, n = 21) were also perceived as important [40]. Across sectional multicenter study in Jordan stated half of subjects regarded barriers for pressure ulcer prevention lack of policies and guidelines about PU prevention (50%; n=120), lack of cooperation with other health professionals (51%; n=121) and lack of job satisfaction (57%; n=137) [43]. Across sectional study conducted in Uganda suggested that shortage of nurses (heavy workloads, 94.6%) the most cited potential and actual barriers to carry out pressure ulcer prevention and management. In addition, the study also found that inadequacies of supplies for pressure ulcer prevention and management (80.4%), uncooperative patient (62.5%), lack of pressure ulcer prevention guide line (50%), poor access to literature (37.5%), inadequate training about pressure ulcer (23.2%) and lack of multidisciplinary initiative (46.4%) [19]. The study by Moore and Price stated that social and organizational factors (barriers or obstacles) could prevent nurses positive attitude from being reflected in practice and incorporating their knowledge into practice. Among these factors were inadequate leadership, lack of education and training program, lack of evidence-based practice guide line, patient over load, shortage of staff and time, lack of multidisciplinary among staffs, lack of equipments and facilities, inadequate pain management. Similarly, the study also found that nurses attitude was not affected by the nurses level of experience [48]. The study in Spain (by Pancorbo-Hindalgo and his colleagues) found that lack of updating in nurses education decreases the level of knowledge among nurses with many years experience. It 13 P a g e

24 also stated that nurses who were not being trained in PU prevention possessed lower level of knowledge and practice as compare to those being trained in PU prevention program. Similarly, it found that incorporating research finding in PU care will significantly improve the practical implementation of PU knowledge [49]. One new and late study conducted in Nigeria in University of Maiduguri Teaching Hospital declared that the overall nurses knowledge and practice of PU prevention low and nurses had positive attitude towards PU prevention. The study result also showed that nurses who had long years of experience had higher levels of knowledge. Similarly, it stated that among the study participants 27.68% do practices of PU prevention always, 31.8% of the nurses practice it sometimes while the rest never do PU prevention practice [50]. 14 P a g e

25 2.6 Conceptual Framework for Pressure Ulcer Prevention This conceptual frame work has four main factors which may affect nurses knowledge, attitude and practice towards pressure ulcer prevention: Socio-demographic factors, organizational/hospital factors, patients and nurses factors. Socio demographic factors -Age, sex, income, level of education, year of experience Organizational/Hospital factors -Guide line for PU prevention -Equipments - In-service training -Clinical practice area/ward -Poor access to literature Knowledge, attitude and practice of nurses towards pressure ulcer Nurses factors -Heavy work load -Job satisfaction -Multidisciplinary initiative Patient factors -Uncooperative patient/ unaided -Presence of other priorities other than PU nt Figure 1: Conceptual framework for nurses knowledge, attitude and practice towards pressure ulcer prevention developed by principal investigator after reviewed different literatures. 15 P a g e

26 3. OBJECTIVES 3.1 General Objective The general objective of this study was to assess the level of nurses knowledge, attitude and practice towards pressure ulcer prevention for hospitalized patients in Public Hospitals in Addis Ababa from April 21-May28, Specific Objectives The specific objectives of this study were: 1) To assess the level of nurses knowledge towards pressure ulcer prevention. 2) To assess the level of nurses attitude towards pressure ulcer prevention. 3) To assess the nurses practice towards pressure ulcer prevention. 4) To assess socio-demographic factors associated with knowledge, attitude and practice of nurses towards pressure ulcer prevention. 5) To assess perceived barriers of nurses to prevent pressure ulcer. 16 P a g e

27 4. METHODS AND MATERIALS 4.1 Study Area and Period The study was conducted in the capital city of Ethiopia, Addis Ababa. The data obtained from the Agenda Addis Ababa City Administration printed in 2007 EC/ 2015 GC described Addis Ababa is located almost in the centre of Ethiopia with a total population of 3,195,000 of whom 1,515,002 males and 1,679,998 females which includes until Hamile,2006 EC/ July,2014 GC. Administratively the city comprises of 11 sub-cities, 99 districts and 116 kebeles. The printed Agenda also described that the city covers the total area of Kari kilometers (km) with an average of 5,814 people living on one Kari kilometer. The data obtained from the city profile of Addis Ababa City Administration stated that the city located at an altitude of about 2,400 meters above sea level, N E, and has complex mix of highland climate zones, with temperature difference of up to 10 0 C depending on elevation and prevailing wind patterns. Although all Ethiopian ethnic groups are represented in Addis Ababa, the city composed of Amhara (47.04%), Oromo (19.51%), Gurage (16.34%), Tigre (6.18%), Silte (1.82%) and others. Languages spoken include Amharic (71.0%), Afan-Oromo (10.7%), Guragigna (8.37%), Tigrigna (3.60%), Siltegna (1.82%) and others are also spoken and used for communications. The religion with the most believers in Addis Ababa is Ethiopian Orthodox with 74.7% of the population, while 16.2% are Muslim, 7.77% Protestant, and 0.48% Catholic. There are 13 public hospitals (4 run by Addis Ababa City Health Bureau, 4 run by ministry of health, 2 by ministry of defense, 1 run by police force and 1run by Addis Ababa University), 34 private hospitals, 86 health centers and various NGOs and health institutions in the city. The public hospitals in Addis Ababa are: 1) Black Lion Specialized Hospital 2) St. Pauls Hospital 3) Zawuditu Memorial Hospital 4) Alert Hospital 5) Yekatit 12 Hospital 6) Ras Desta Damtew Memorial Hospital 7) St. Peters Hospitals 8) Menilik II Hospital 9) Tirunesh Beijing Hospital 10) Armed Forces Hospital 11) Bella Defense hospital12) Federal Police hospital 13) Amanuel Hospital and 14) Gandhi Hospital 17 P a g e

28 The study was conducted from April 21 to May 28, 2015 in selected public hospitals (Black lion, Zawuditu, Alert, Yekatit12, Tirunesh Beijing and Menilik II Hospitals. 4.2 Study Design Institutional based cross sectional multi-center study using quantitative method was employed in the selected public hospitals in Addis Ababa, Ethiopia, Source and Study Population Source Population All nurses working currently in public hospitals in Addis Ababa Study Population The study population was all nurses working in admission wards (units) in the selected hospitals Study Subjects The study subjects were the selected and consented nurses to participate in the study. 4.5 Sample size determination The sample size was determined using a formula of estimating a single population proportion for cross sectional study. n = (Z α/2) 2 P (1- P) d 2 Where: Z= 1.96, the confidence limits of the survey result (value of Z at α/2 or critical value for normal distribution at 95% confidence interval). P= 0.5, the proportion of nurses knowledgeable for pressure ulcer prevention d= 0.05, the desired precision of the estimate n= the total sample size. Thus, n= (1.96) 2 (0.5) (0.5) = 384 (0.05) 2 Since the total number of study population is < 10,000 (N=534) using the correction formula the final sample size was: 18 P a g e

29 nf = nxn = 384x 534= =224 n+n The final sample size using design effect (1.5) and including 10% non response rate was =369. Finally, the number of nurses participating in each hospital was determined using the population proportionate sampling (PPS). n= nf * N in a health facilities N total Where, n= Proportion of nurses participate in the study in a given public hospital, nf= Final sample size obtained using correction formula (369), N=is the total number of nurses in selected public hospitals (534) i.e. N total = Total number of nurses in the selected public hospitals, 1) Black Lion Specialized Hospital=292, 2) Zawuditu Memorial Hospital=43, 3) Alert Hospital=56, 4) Yekatit 12 Hospital =53, 5) Tirunesh Beijing Hospital=38 6) Menilik II Hospital =35 1) Black Lion Hospital = 369x =203 2) Zawuditu Hospital =369x =30 3) Alert Hospital =369x =39 4) Yekatit 12 Hospital = 369x =36 5) Tirunesh Beijing Hospital =369x =32 6) Menilik II Hospital =369x = Sampling Procedures Multi stage sampling technique was employed to select the study subjects in each hospital. Six public hospitals were selected by simple random sampling and the study subjects in each Hospital. The total number of study participants from each hospital was obtained by the PPS. Simple Random Sampling (Lottery method) was employed to obtain the participant from each working unit from monthly work schedule obtained from the head nurse of each ward. It is illustrated below (Fig.2). 19 P a g e

30 PUBLIC HOSPITALS IN ADDIS ABABA By Simple Random Sampling 6 Selected Hospitals By Simple Random Sampling N=203 N=30 N=39 N=36 N=32 N=29 N= 369 Figure 2: Schematic Presentation of Sampling Procedure Keys: 1= Black Lion Specialized Hospital, 2= Zawuditu Memorial Hospital, 3= Alert Hospital, 4= Yekatit 12 Hospital, 5= Tirunesh Beijing Hospital, and 6= Menilik II Hospital 4.7 Inclusion and exclusion criteria Inclusion criteria 20 P a g e

31 Nurses having at least one year of experience in clinical nursing service Having roles and responsibilities with admitted patient care units Nurses working as full time staff and consented Exclusion criteria Nurses who are severely ill and not available in working area during data collection 4.8 Study Variables Dependent (Outcome) Variables Knowledge of nurses towards pressure ulcer prevention Attitude of nurses towards pressure ulcer prevention Practice of nurses towards pressure ulcer prevention Independent Variables Socio demographic factors Hospital factors (equipments, training, guide line, poor access to literatures ) Nurses factors (heavy work load, lack of time, job satisfaction, multidisciplinary) Patient factors (uncooperative patient). 4.9 Operational definitions Knowledge Score [51] Very low knowledge: Nurse who scored the correct answers for knowledge related questions regarding pressure ulcer prevention is < 60%. Low knowledge: Nurse who scored the correct answers for knowledge related questions regarding pressure ulcer prevention is %. Moderate knowledge: Nurse who scored the correct answers for knowledge related questions regarding pressure ulcer prevention is %. High knowledge: Nurses who scored the correct answers for knowledge related questions regarding pressure ulcer prevention is %. Very high knowledge: Nurse who scored the correct answers for knowledge related questions regarding pressure ulcer prevention is 90%. 21 P a g e

32 Attitude Score Positive attitude- nurses who scored the correct answers for attitude related questions above the mean. Negative attitude- nurses who scored the correct answers for attitude related questions below the mean. Practice Score [51] Very low practice: Nurse who scored the correct answers for practice related questions regarding pressure ulcer prevention is < 60%. Low practice: Nurse who scored the correct answers for practice related questions regarding pressure ulcer prevention is between %. Moderate practice: Nurse who scored the correct answers for practice related questions regarding pressure ulcer prevention is between %. High practice: Nurse who scored the correct answers for practice related questions regarding pressure ulcer prevention is between %. Very high practice: Nurses who scored the correct answers for practice related questions regarding pressure ulcer prevention is 90% Data Collection Tools The questionnaire was prepared by selecting, modifying and adapting relevant and standard evaluation tools from Pressure Ulcer Knowledge Test (PUKT) (Pieper and Mott, 1995) [47] contains 47 questions with 3 options (True, False and I don t know), Pressure Ulcer Attitude Test (PUAT) (Moore and Price, 2004) contains 11 questions evaluated by using Likert scale from strongly agree to strongly disagree [48], Practice test questions from study conducted in Bangladesh by (Sharif Islam,2010) and in Nigeria [2014] contains 25 questions with three options (practice always, sometimes and never) and 13 items were barriers related questions from study conducted in Uganda [19] and [43] Data Collection Procedure 22 P a g e

33 Self-administered structured questionnaires were administered to collect data. The questionnaires contain variables related to: Socio-demographic, Knowledge, Attitude and Practice of nurses towards pressure ulcer prevention and perceived barriers. The questionnaires were prepared in English and translated in to Amharic by Saleh Translation Service (around Addis Ababa stadium); then, distributed for the Research Review Ethics Committee of Addis Ababa City Administration Health Bureau, Alert Hospital and St. Peter s Hospital. After approval paper is taken from related hospitals, the data was distributed for the study subjects in English version. The data collection was facilitated by matrons, head nurses, and the staff nurses and supervised by principal investigator (PI). The training was provided by the principal investigator for data collection facilitators before the actual data collection time Data Quality Control Training was given for data collection facilitators 5 days before the actual data collection period on the purpose of the study, how to get informed consent, on technique of selecting the study subjects from each working units. As a result of the pretest necessary corrections was made as per its requirement to some of the questions of the questionnaires. Moreover, during data collection PI checked in the field how the data facilitators do their task and closely supervised the field activity on daily basis. At the end of each data collection day the principal investigator checked the completeness of filled questionnaires and quality of the recorded information. Besides this, the principal investigator carefully entered and thoroughly cleaned the data before the commencement of the analysis. To evaluate the consistency of the questionnaires, pretest was conducted on 9% (N=33) of the sample size 1 week before the actual data collection using self-administered questionnaires. This pretest study was conducted among nurses working in St. Peter hospital which is not included in the study settings selected by lottery method among the hospitals not included in the study settings. The study subjects were selected by simple random sampling and included those who full fill the inclusion criteria Data Processing and Analyzing After data collection, the response was coded and entered in to computer using EPI data version 3.1 statistical packages, and 10% of the response was randomly selected and checked for the consistency of data entry. SPSS version 20 was used for data analysis. Frequencies and 23 P a g e