Practice on pressure ulcer prevention among nurses in selected public hospitals, Tigray, Ethiopia

Pressure ulcers are localized cellular damages to the skin and underlying tissues caused by pressure, shearing and frictional force. The aim of this study is to assess practices towards pressure ulcer prevention among nurses in the Central Zone of Tigray, Ethiopia, from September 10, 2017 to June 15, 2018. This study has also identified the major barriers that hamper nurses from preventing pressure ulcers. These barriers were heavy workload, inadequate training, and lack of universal guideline and shortage of resource. 17.2% of the participants had a good practice and 82.2% of the respondents had a poor practice of pressure ulcer prevention. Finding of this study showed that respondents have inadequate knowledge which may have led to their poor practice towards pressure ulcer prevention. Immediate intervention should be done on public hospitals of central Tigray to improve nurses’ practice towards pressure ulcer prevention.


Introduction
Pressure ulcers are a type of injury that breaks down the skin and underlying tissue when an area of skin is placed under constant pressure for certain periods causing tissue ischemia, cessation of nutrition and oxygen supply to the tissues and eventually tissue necrosis [1]. Pressure ulcers are caused by a local breakdown of soft tissue as a result of compression between a bony prominence and an external surface [2,3]. A patient with a pressure ulcer suffers from pain and discomfort, and also may have prolonged illness, delayed rehabilitation, increased hospital stay, disability and may even face death resulting from the ulcer and its complications [4,5].
A systematic review reported that the incidence rates of pressure ulcers varied considerably by clinical setting; ranging from 0.4 to 38% in acute care, from 2.2 to 23.9% in long term care, and from zero to 17% in home care [6].
Nurses have poor knowledge regarding risk factors of pressure ulcer development [7].World Stop Pressure Ulcer Day showed that nearly 700,000 patients were affected by pressure ulcers each year and more than 2.5 million people in the USA develops pressure ulcers each year [8,9]. Moreover, a worldwide health care budget that is spent on prevention and treatment of patients with extended hospital stays from pressure ulcer development amounts more than a billion dollars [10][11][12][13].
In Ethiopia, in Felegehiwot Referral Hospital, among 422 patients, the overall prevalence rate of pressure ulcers was 16.8%. Of this, 62%, 26.8% and 2.8% developed stage I, II and stage IV pressure ulcer, respectively [14].
Major barriers that preclude nurses to practice pressure ulcer prevention (PUP) were identified with the notable ones being a heavy workload/inadequate staff, shortage of resources and inadequate training about PUP [15,16] PUP contributes significantly to the occurrence or worsening of the pressure ulcer. Pressure ulcer remains a significant and complex health problem in hospitals in terms of human suffering, tissue necrosis, pain, septicemia, loss of productivity, and financial burden [17].
There is very few published paper regarding nurses' practice towards PUP in Ethiopia [18].

Study area and period
The study was conducted from September 10 to June 15, 2018, in public hospitals of Central Zone Tigray, Ethiopia.

Study design
A cross-sectional study using a quantitative method was employed in the selected public hospitals in Central Zone, Tigray, Ethiopia.

Source of population
All nurses working currently in public hospitals in Central Zone, Tigray, Ethiopia.

Study population
The study population was all nurses working in the three hospitals.

Inclusion and exclusion criteria Exclusion criteria
Nurses who are severely ill and in annual leave during the data collection period were excluded.

Sample size determination
The sample size was calculated using a single population proportion formula with consideration of the following assumptions. The proportion of the prevalence of the pressure ulcer was 16.8% which was derived from a study conducted in Ethiopia, Bahirdar Felegehiwot Referral Hospital [14]; confidence level at 95% and marginal error of 5%. The sample size was calculated as follows: the total calculated samples size was 215. Since the total population is 240, the sample size was determined using correction formula, and adding a 10% non-response rate and the final sample size was 125.

Sampling procedure
There are three general public hospitals in Central Zone of Tigray. From these hospitals, study participants were selected using simple random sampling (lottery method). The list or frame of nurses working in all hospitals was obtained from the monthly work schedule prepared by the head nurse of each ward.

Dependent variable
Practice of nurses towards pressure ulcer prevention.

Independent variables
Socio-demographic factor such as

Operational definitions
Adequate knowledge of PUP For this study, a nurse is said to have an adequate knowledge of PUP if he or she answers correctly greater than or equal to 80% of 20 pressure ulcer prevention knowledge tests.
Inadequate knowledge of PUP For this study, a nurse is said to have an inadequate knowledge of PUP if he or she answers correctly less than 80% of 20 pressure ulcer prevention knowledge test.
Good practice of PUP For this study, a nurse is said to have a good practice of PUP if he or she answers correctly greater than or equal to 80% of 20 PUP practice test.
Poor practice of PUP For this study, a nurse said to have a poor practice if he or she answers correctly less than 80% out 20 possible questions about their practices towards PUP Perceived barriers if nurses answered "yes" or "no" with the listed barriers in the perceived barrier questionnaire.

Data collection tool
The structured questioner for knowledge and practice of pressure ulcer was adopted from a study conducted on general hospital Lahore [19] but, socio-demographic items were modified according the socio-cultural context of the community.

Data collection procedure
The self-administered structural questionnaire was distributed to the nurses following a request for consent from nurses and support from matrons and head nurses. Continuous follow-up and supervision were given by supervisors throughout the data collection period.

Data quality assurance
In order to maintain the quality of the data, the data collectors received training on data collection procedure. The questioner was designed carefully, and the English version was used for the actual data collection. Before the actual data collection, the questioner was checked for clarity, comprehensiveness, and content validity by pretesting on 10% of the sample size (11 nurses working in Shire Suhul hospital, Ethiopia). Finally, possible adjustments or modifications were made on the tools by the group members. Then the collected data was crosschecked for completeness and consistency each day by the principal investigators.

Data process and analysis
The data was entered, and analysis by using the statistical package for social science (SPSS) version 22 statistical software. The association between the dependent and independent variable was analyzed first in the binary logistic regression model. In the second step, predictor variable having a p-value < 0.3 was retained and entered to the multivariate logistic regression analysis. A p-value 0.05 was considered as cut off point for predictors to be significantly associated with outcome variables (CI-95%).

Socio-demographic characteristics of the nurses
A total of 125 professional nurses were invited to participate in the study, and the response rate was 97.6% of which the majority of the respondents (55.7%) were females. The mean ages of the participants were 29 with the minimum age being 22 and maximum 45 years. However, the majority of them (69.7%) were within the age group of 2029 years. More than half (53.3%) were single whereas 45.1% of them were married and 1.6% of respondents were widowed and divorced. Regarding the educational status, the majority of them (79.5%) were first-degree holders, while one-fifth of them (20.5%) were diploma holders.

Knowledge of nurses on pressure ulcer
The overall nurses' knowledge of PUP was 82.75% which indicated that nurses' knowledge regarding pressure ulcer prevention was at the high level. From the study participants, 29.5% (n = 36) had adequate knowledge about PUP (Table 1).

Nurses' practice towards pressure ulcer prevention
From the study, 17.2% (n = 21) of respondents had a good practice PUP and 82.2% (n = 101) of the respondents had a poor practice of PUP.
According to this finding, the nurses' practice test scores showed that 50.33% of nurses always make pressure ulcer prevention practices, 36.46% make pressure ulcer prevention practice sometimes and 15.03% never make pressure ulcer prevention practice ( Table 2).

Nurses' perceived barriers for practicing PUP
Nurses were asked to indicate their agreement about the existence of specific barriers in the work environment. Among the nurses participated in the study, all of them had reported at least one of the following major challenges: heavy workload, inadequate staff, lack of universal guideline on prevention of pressure ulcer, inadequate coverage about PU during training, shortage of resources (equipment, facilities), uncooperative patients, job satisfaction in nursing, lack of time and lack of awareness.
Those who were involved in heavy workload were 2.594 (0.126-0.993) times more risky for pressure ulcer than their counterpart. Moreover, those who have knowledge were less risky (0.354 (0.126-0.993)) than their counterpart (Table 3).

Discussion
The current findings showed that nurses who participated in the study had a good knowledge (82.75%) towards pressure ulcer prevention which is higher than the finding of the study in Alexandria Insurance Hospitals (< 70%) with similar study participants [20] as well as the finding in a study conducted in Bangladesh (57.79%) [13]. But, higher than the study conducted in among 3 public hospitals of AA Ethiopia (Black lion, St Paul's, Ras Desta Damtew) [21] and across 6 public hospitals (Black Lion, Zawuditu Memorial, Alert, Yekatit, Tirunesh Beijing, and Menilik II) which revealed that, the overall nurses knowledge towards PUP was 61.2% and 63.85% respectively [22]. The finding was also higher than the study conducted in Gondar University Teaching Hospital which was at 54.4% [7]. These discrepancies may occur due to a different scoring method and a different sample size.
According to this study, the highest scores of nurses' knowledge on PUP found in the educational program of pressure ulcers (79.5%) which was less than in Ugandan nurses (92.2%) [23]. conversely, there was a lower score of nurses' knowledge of pressure ulcer prevention. the discrepancy may be due to lack of universal training or presence of other priorities as nurses reported lack of universal guideline on prevention of pressure ulcer and presence of other priorities than pressure ulcer which may have become one of their major barrier in PU prevention. Furthermore, 17.2% of the participants had good practice regarding PUP which is consistent with the study conducted in Nigeria (27.68%) [11]. But this figure is different from the study conducted in Gondar University Teaching Hospital [21] in which nearly half of nurses 48.4% have good practice towards PUP practice. This might be due to different evaluation tools and scoring system. Among the practices that nurses always carry out, giving advice for the patient (69.7%), turning patients every 2 h (71.5%) and identifying PU contributing factors (59.0%) were the most practiced. Unlike this, a study conducted in Nigeria [11] showed that turning of patients every 2 h and using of special pillow to prevent PUP were the most practiced care for patients to prevent PUP. The difference between the healthcare setups of Ethiopia and Nigeria might explain the relative discrepant results in PUP practice.
The reason for the very low level of nurses' practice could be supported by Moore and Prince and study in Uganda which means that the reported nurses' barriers may be the reasons for very low level of PU prevention. This study showed that nurses' practice almost reflected by nurses' knowledge towards PU prevention. The heavy workload and shortage of equipment were the most reported barriers to PUP practice. This report is similar to the study conducted in Uganda in which the majority of nurses report a lack of adequate staff as a barrier for implementing effective care practice related to PUP. Similarly, the studies conducted across 6 public hospitals in AA and Gondar University also cited heavy workload as the most reported barrier to practice PUP [7]. Studies have suggested that pressure ulcer development can be directly affected by the number of nurses and the time they spent at the bedside [24].

Conclusion
• More than half of the nurses were found to have inadequate knowledge regarding PUP and • Nurses' levels of practices were found to be very poor concerning prevention of PU.

Limitation of the study
The study was cross-sectional which didn't indicate the precedence of outcome or exposure.