Journal of Tissue Viability 26 (2017) 277e281

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Journal of Tissue Viability

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Attitudes of surgical nurses towards pressure ulcer prevention*

€
Seher Ünver a, *, Ümmü Yıldız Fındık a, Zeynep Kızılcık Ozkan a la Sürücü b
, Çag
a
Trakya University, Faculty of Health Sciences, Department of Surgical Nursing, Edirne, Turkey
b
Trakya University, Faculty of Health Sciences, Department of Nursing, Edirne, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Study aim: Nurses play the key role in prevention of pressure ulcers, and negative attitudes of them may
Received 20 January 2017 affect preventive care strategies. This research aimed to identify surgical nurses' attitudes towards
Received in revised form pressure ulcer prevention.
11 July 2017
Materials and methods: A descriptive and cross-sectional study design was used to collect data between
Accepted 1 September 2017
March 31-May 16, 2016 on 101 voluntary nurses (66.01% of all nurses) working in surgical units of a
university hospital in Turkey. “Attitude towards Pressure Ulcer Prevention Instrument” and “Nurse In-
Keywords:
formation Form” were used to investigate nurses' attitude toward preventing pressure ulcer. Descriptive
Attitude
Nurse
statistics, Mann-Whitney U test, independent samples t-test, Pearson's chi-squared, and correlation tests
Pressure ulcer were used to analyse the data.
Surgical Results: The mean age of nurses' was 32.0 ± 6.3 years and, the average duration of clinical experience
was 72.3 ± 61 months. A total of 54.5% were working in surgical wards and, 40.6% gained additional
education about pressure ulcer care. The mean total attitude score was found to be 80.5% (41.8 ± 4.8).
Previous education significantly affected the total attitude score of nurses (p < 0.05).
Conclusion: The total scale score showed that surgical nurses had a positive attitude towards pressure
ulcer prevention and nurses who had previous education about pressure ulcer care has higher attitude
score than who had not. It is recommended that effective in-service education programs be developed at
hospitals or that nurses be required to attend courses to help them to improve their pressure ulcer care.
© 2017 Published by Elsevier Ltd on behalf of Tissue Viability Society.

1. Introduction Diseases (ICD) 11 [1,2].

The National Pressure Ulcer Advisory Panel (NPUAP), a profes-
sional organization dedicated to the prevention and management
of pressure ulcers, defines pressure ulcer as ‘localized damage to
the skin and/or underlying soft tissue usually over a bony promi-
nence or related to a medical or other device’. Formerly, ‘pressure
ulcer’ was the term used for this type of ulcer, but NPUAP
announced a change in the terminology from ‘pressure ulcer’ to
‘pressure injury’ on April 13, 2016, as European Pressure Ulcer
Advisory Panel (EPUAP) continues to use ‘pressure ulcer’ in line
with forthcoming revisions at International Classification of
*
This study was presented as an oral presentation (virtually) at the 20th Inter-
national Nursing Research Conference, Coruna-Spain between 15 and 18 November
2016.
* Corresponding author.
E-mail addresses: seher.unver@hotmail.com (S. Ünver), uyildizfindik@mynet.
€
com (Ü.Y. Fındık), zeynepkizilcik26@hotmail.com (Z.K. Ozkan), caglasurucu@
gmail.com (Ç. Sürücü).
Pressure ulcers are recognized as a common problem in
healthcare that contribute not only to increased health care costs,
but also to high morbidity and mortality rates, prolonged hospi-
talization and emotional problems in patients [3e5]. In a study
from England that researched pressure ulcer-related pain, of the
176 patients, 75.6% reported pain [6]. In Turkey, studies showed
that the prevalence of pressure ulcers in hospitals ranged from 7.2%
to 10.4% and the incidence was reported as 20.56% [7e9]. Addi-
tional research which focused on surgical patients reported that
there was a 54.8% incidence of pressure ulcers in surgical patients
[10]. In Schoonhoven et al.’s study [11] from Netherlands, the
incidence of pressure ulcer development during surgery was re-
ported as 21.2% in a university hospital. In a study from Germany,
Feuchtinger et al. [12] reported that 49% of the patients developed a
pressure ulcer during cardiac surgery in the operating room. In
another study from Sao Paulo [13] that searched the incidence of
pressure ulcers in surgery patients, it was found that 20.6% of the
patients had pressure ulcer. Shokati et al. [14] found that pressure
ulcer was developed by 45.7% of cardiac intensive care unit patients

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0965-206X/© 2017 Published by Elsevier Ltd on behalf of Tissue Viability Society.
278 S. Ünver et al. / Journal of Tissue Viability 26 (2017) 277e281
during 3 months in Boali hospital, in Iran. The incidence rate was
found as 21.5% for stage I or higher stage pressure ulcers among
postoperative six days at Schultz et al.’s study [15]. Spector et al.
[16] estimated the cost of surgery related pressure ulcers and
showed a ~44% addition to the cost of surgical stays. According to
an analysis done in Turkey, Koç et al. [17] calculated the cost of
pressure ulcer treatments and stated that the total cost ranged from
$340.077 to $2.452.686 over a one year span. A systematic review
reported that the cost of pressure ulcer treatment of a patient per
day ranged from 1.71V to 470.49V and varied between 2.65V to
87.57V for pressure ulcer prevention of a patient per day [18].
There are many extrinsic (shear, friction, pressure, etc.) and
intrinsic factors (anaemia, oedema, immobilization, etc.) that play a
role in the development of surgery-related pressure ulcers. Some of
the factors that occur during surgery are related to the duration of
continued pressure, low core temperature, length of surgery,
anaesthesia and circulatory changes related to the surgical pro-
cedure itself [5,19,20].
Prevention of pressure ulcers is necessary to reduce their inci-
dence, and guidelines are available to help clinicians make appro-
priate decisions about pressure ulcer prevention [20,21]. Studies
showed that allied health professions such as occupational thera-
pists and physiotherapists had a positive and strong attitude to-
wards the importance of preventing pressure ulcer as they have an
important role among using some rehabilitation techniques for
positioning and mobilizing the patients [22e24]. Based on multi-
disciplinary approach to pressure ulcer prevention, physical ther-
apists use advanced techniques to redistribute the pressure and
ensure safe exercises; dietitians access and manage the nutritional
status of patients; and surgeons carry out surgical interventions or
debridement that are needed during wound care management
[25]. Nurses play the key role among these healthcare professions
and have a great responsibility in the approach [26]. It is reported
that with evidence-based nursing care the incidence of pressure
ulcer can be reduced by up to 50% [27]. Thus, nurses should be
aware of the risk factors associated with pressure ulcer develop-
ment when examining at-risk patients, follow the guidelines and
apply them to their clinical interventions through pressure ulcer
prevention and treatment [20,28]. In the literature, many studies
have been conducted to evaluate nurses' knowledge and preven-
tion methods [29,30], and results showed their improved knowl-
edge was not consistently linked with improved care [31e33]. In
their study, Beeckman et al. [34] explored the correlation between
knowledge, attitudes and the application of prevention, but found
no independent correlation between knowledge and adequate
prevention; however, there was a significant correlation between
the application of adequate prevention and the attitudes of ward
and non-ward nurses. Thus, not only knowledge, but also the
nurses' attitudes are important in pressure ulcer prevention.
Attitude is defined as ‘a summary evaluation of an object of
thought’ [35] and includes feelings, thoughts or beliefs that lead to
specific action so that attitude may influence the decisions or guide
the behaviour of an individual [36]. Determining nurses' attitudes
towards pressure ulcer prevention may identify their behaviours
and beliefs about pressure ulcer care. Moreover, negative attitudes
towards pressure ulcer prevention may affect preventive care
strategies [37]. It is widely accepted that clinical nurses are
responsible for providing safe and evidenced-based care [38], and
Grimshaw et al. [39] highlighted that negative attitudes are the
principal barriers to evidence-based practice. Aslan and Van
Giersbergen [40] studied nurses' prevention attitudes towards
pressure ulcer that work in intensive care units, medical and sur-
gical units and found the attitude score as 84.12%, as to be positive.
Evaluating attitudes of surgical nurses' towards pressure ulcer is
important to determine the attitude changes over time, to improve
the current attitude status of nurses, and to keep this subject up to
date. However, in Turkey, there are very few studies which examine
the attitudes of nurses in relation to the prevention of pressure
ulcers and which draw attention to this issue by publishing their
results. Thus, the objective of the study was to identify surgical
nurses' attitudes towards pressure ulcer prevention.
2. Material and methods
2.1. Study design and sample
This descriptive, cross-sectional study was carried out at a
university hospital in Eastern Thrace, Turkey. During data collec-
tion, convenience sampling method was used and participation
was based on voluntary basis. We aimed to reach all the research
population consisted of a total of 153 nurses working in surgical
units; nine surgical wards, three intensive care units and the
operating room. The sample consisted of 101 nurses (66.01%) who
volunteered to participate in this study and who were actively
working in the units.
2.2. Data collection
Data were collected from March 31 to May 16, 2016 using two
instruments: the ‘Nurse Information Form’ and the ‘Attitude to-
wards Pressure Ulcer Prevention Instrument’. Nurses were
informed about the study and were given approximately 15 min to
complete the individual data collection forms.
2.2.1. Nurse information form
This form developed as a result of the literature review by the
researchers and consisted of nine questions used to collect data on
the characteristics of the nurses (six items). The questions gathered
data regarding gender, education level, specific work unit, age,
previous education about pressure ulcer care and duration of
clinical experience.
2.2.2. Attitude towards pressure ulcer prevention (APuP)
instrument
This instrument was developed by Beeckman et al. [41] at Ghent
University, Belgium. The validity and reliability of the instrument
for the Turkish population was conducted by Üstün [42] at Ege
University, Turkey, and it was found adequate to use with Cron-
bach's alpha of 0.714. This instrument is a four-point Likert-type
scale rated as follows: (1) strongly disagree, (2) disagree, (3) agree
and (4) strongly agree. It consists of 13 items collected for five
factors: attitude towards personal competency to prevent pressure
ulcers (items 1e3), attitude towards the priority of pressure ulcer
prevention (items 4e6), attitude towards the impact of pressure
ulcers (items 7e9), attitude towards personal responsibility in
pressure ulcer prevention (items 10e11) and attitude towards
confidence in the effectiveness of prevention (items 12e13). Items
3, 5, 7e10 and 13 contain negative expressions and are reversely
calculated in the scoring. The minimum score is 13 and the
maximum score is 52. The higher scale scores show more positive
attitudes [41,42]. The satisfactory level for attitude score was
considered to be
75% in Beeckman et al.’s study [41]. Cronbach's
alpha was found to be 0.799 for this study.
2.3. Data analysis
Descriptive statistics (mean, standard deviation, frequency, and
numbers with percentages), the Mann-Whitney U test, indepen-
dent samples t-test, Pearson's chi-squared and correlation tests
were used to analyse the data. The one way analysis of variance
 S. Ünver et al. / Journal of Tissue Viability 26 (2017) 277e281 279

(ANOVA) test was used for the normally distributed data of the Table 1
three groups. Non-parametric tests were used for the not normally Attitude scores of nurses according to nurses' characteristics and taking additional
education about pressure ulcers.
distributed data, and p < 0.05 was considered significant. The IBM
SPSS Statistics ver. 21.0 (IBM, Armonk, NY, USA) software package Variables n (%) Score (%) P value-Test
was used for coding and analysing the data. Gender
Female 92 (91.1) 80.4 P: 0.667
Male 9 (8.9) 81.8 t: 0.431
2.4. Ethical consideration Education level
High school degree 25 (24.8) 77.5 P: 0.060
Permission to use the Turkish version of the instrument in this Bachelor's degree 76 (75.2) 81.5 t: 1.90
study was obtained via mail. The study was approved by the Ethics Work units
Surgical ward 55 (54.5) 80.5 P: 0.386
Committee of the Trakya University Medical Faculty (TÜTF-BAEK
Intensive care unit 30 (29.7) 81.9 F: 0.960
2016/168-decision number 05/24), and permission to conduct the Operating room 16 (15.8) 78.0
study was obtained from the directorate of the hospital. The Previous education
participating nurses were thoroughly informed about this study, Yes 41 (40.6) 83.2 P: 0.017
and their informed verbal consent was obtained to have their data No 60 (59.4) 78.7 t: 2.428
Age 32.0 ± 6.3 years P: 0.378
published. To ensure confidentiality, they were instructed not to rp: 0.089
write their names on the forms. Clinical experience 72.3 ± 61 months P: 0.101
rs: 0.164

3. Results t: Independent t-test, F: ANOVA test; rp:Pearson correlation, rs: Spearman

correlation.
The majority of the participants were female 91.1% (n ¼ 92),
75.2% (n ¼ 76) had bachelor's degrees and 24.8% (n ¼ 25) had a high
pressure ulcer prevention, and the mean attitude score was 80.5%
school degree. A total of 54.5% (n ¼ 55) were working in surgical
(41.8 ± 4.8). In keeping with previous studies [29,43,44], nurses
wards, 29.7% (n ¼ 30) were working in intensive care units and
exhibited a positive attitude towards pressure ulcer prevention. In
15.8% (n ¼ 16) were working in operating rooms. The mean age was
Ireland, Moore et al. [45] also researched nurses' attitudes; they
32.0 ± 6.3 years, and the average duration of clinical experience was
reported a positive attitude of nurses towards pressure ulcer pre-
72.3 ± 61 months.
vention. Beeckman et al. [34] stated that only half of the nurses
The mean total attitude score was above the satisfactory level
showed attitude scores of
75% concerning pressure ulcer pre-
for attitude score and found to be 80.5% (41.8 ± 4.8). According to
vention in Belgian hospitals. Similarly, another study assessed
the scale factors, the mean score of ‘impact of pressure ulcers’ was
nurses' attitudes towards pressure ulcer prevention in Turkey, and
the highest (85.7%), and the mean score of ‘confidence in the
the mean total score was 84.1% [40]. This result showed that sur-
effectiveness of prevention’ was relatively lower than other scores
gical unit nurses have positive attitudes, and this may reflect that
(53.7%) (Fig. 1).
their thoughts are also positive about pressure ulcer prevention.
The attitude score of nurses who had previous education (a
Based on the results, nurses who took an education about
course/conference they have attended or an in-service education
pressure ulcer care in the past had higher attitude scores than those
etc) about pressure ulcer prevention was significantly higher than
who did not. In Gunningberg's study [46], education programme
those who did not (p ¼ 0.017; p < 0.05). The statistical analysis of
about pressure ulcer prevention was found encouraging for
the nurses' characteristics revealed that there was no significant
Swedish nurses to change clinical practice. Beeckman et al. [34]
difference between the mean attitude score of nurses and their
reported that the mean attitude score of nurses in Belgian hospi-
gender, education level and work units. No statistically significant
tals was not correlated with pressure ulcer education, but knowl-
correlation was found between the attitude scores and age or
edge scores were significantly increased. In Australia, McCluskey
clinical experience duration (Table 1).
and Lovarini [47] found that the impact of the targeted education
intervention on behaviour was limited, but that the knowledge of
4. Discussion individuals could be improved. A study conducted on intensive care
unit nurses working at a Turkish state hospital also reported that
Nurses in the present study had a positive attitude towards

Personal competency to prevent pressure ulcers 75.4%

Priority of pressure ulcer prevention 83.4%

Impact of pressure ulcers 85.7%

Personal responsibility in pressure ulcer prevention 50.8%

Confidence in the effectiveness of prevention 53.7%

Total score 80.5%

0 10 20 30 40 50 60 70 80 90 100

Mean %

Fig. 1. Total and factor scores received from the Attitude toward Pressure Ulcer Prevention Instrument.
280 S. Ünver et al. / Journal of Tissue Viability 26 (2017) 277e281
45% of the nurses who had received education about pressure ulcer
did not use this new information at patient follow-up [48]. This
may be related to the different teaching methods used and the
content of that education. The fact that lack of education may be a
barrier of preventing pressure ulcers and previous education in-
fluences the attitude of nurses but not their knowledge requires
some further investigation. Future studies may research the effec-
tiveness of educational interventions on both the attitudes and
knowledge levels of nurses.
According to the scale factors, the mean score of ‘attitude to-
wards the impact of pressure ulcers’ was highest, while the mean
score of ‘confidence in the effectiveness of prevention’ was rela-
tively lower than the other factors. In a study conducted by Aslan
and Van Giersbergen [40], nurses disagreed (81.2%) with the
statement that pressure ulcers do not have negative impacts on
patients, and ‘attitude towards personal competency to prevent
pressure ulcers’ had the lowest mean score. This may reflect the
low competency and self-confidence levels of nurses in Turkey and
the reasons may be explored through future studies. Confidence in
the effectiveness of prevention (53.7%) was also substantially
different to those reported by Aslan & Yavuz van Giersbergen
(85.55%) [40] in a similar setting in Turkey. We think that this result
is due to the difference in the professional characteristics (educa-
tion, study year, etc.) and working conditions of the nurses who
make up the sample of the research. Demarre et al. [43] examined
the attitudes of nurses about pressure ulcer prevention, and the
lowest attitude scores among nurses were found in ‘attitude to-
wards impact of pressure ulcer’. This was in contrast to the present
study findings. It appears that nurses in the present study do not
have confidence in pressure ulcer prevention, although they have a
highly positive attitude about the impact of pressure ulcers.
In this study, the statistical analysis of the nurses' characteristics
revealed no significant difference between mean attitude scores
and their education level. In Kallman and Suserud's study [49], they
assessed the attitudes of nursing staff towards pressure ulcer pre-
vention in Sweden and did not find any statistically significant
difference between the attitude scores of registered nurses and
nursing assistants. Similarly, Demarre et al. [43] reported that
nurses had a more positive attitude towards pressure ulcer pre-
vention than nursing assistants, but there was not any correlation
between knowledge of the two groups and attitudes. As formal
education is essential in the nursing profession, limited training
and formal educational background concerning wound care may
affect the attitude level of nurses. Additional in-service education
and training courses about specific topics, such as wound care,
pressure ulcers, etc., may need to be added as continuing education
options.
In terms of attitude scores found with the instrument, a statis-
tically significant difference was not determined among the work
units of the nurses, but nurses working in intensive care units had a
higher attitude score than the others. Similarly, according to a study
conducted in Belgian hospitals, a statistically significant difference
was not found between nurses' attitudes on pressure ulcer pre-
vention and the wards they worked in, but intensive care nurses'
attitude score was 70.8%, while surgical ward nurses' was 70.2%
[34]. In another study, Iranmanesh et al. [50] assessed the knowl-
edge of nurses regarding pressure ulcers in Iran, and they reported
that critical care nurses had a higher level of knowledge than or-
thopaedic nurses. Chianca et al. [51] examined Brazilian nurses'
knowledge about pressure ulcers in different wards and deter-
mined that nurses working in clinical nursing units had signifi-
cantly better scores. As patients in long-term care and in intensive
care are at risk of developing pressure ulcers [20], this may
contribute to the high attitude scores of nurses working in intensive
care units. This was also expressed in a study by Beeckman et al.
[34] that intensive care units showed the highest prevalence of
pressure ulcer. The results showed that the effect of individual
characteristics of the nurses (as gender, age, education level,
working units and clinical experience) on attitudes to prevent
pressure ulcers was controversial.
The study had some limitations that should be considered. First,
data of this study are limited to the surgical departments of one
Turkish university hospital. Thus, results cannot be generalized to
all nurses. Second, the use of a self-reported questionnaire may
allow nurses to give socially and institutionally desirable answers
during the attitude assessment.
5. Conclusions
As a result of this study, the total scale score shows that surgical
nurses had a positive attitude towards pressure ulcer prevention
and nurses who had previous education about pressure ulcer care
has higher attitude score than who had not. It is recommended that
effective in-service education programs be developed at hospitals
or that nurses be required to attend courses to help them to
improve their pressure ulcer care.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Conflict of interest
None.
Acknowledgments
Special thanks to the nurses participated this study and saved
their time.
References
[1] National Pressure Ulcer Advisory Panel (NPUAP). NPUAP announces a change
in terminology from pressure ulcer to pressure injury and updates the stages
of pressure injury. 2016. http://www.npuap.org/national-pressure-ulcer-
advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-
ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/.
[Accessed November 2016].
[2] European Pressure Ulcer Advisory Panel (EPUAP). Pressure ulcer terminology.
2017. http://www.epuap.org/news/pressure-ulcer-terminology/. [Accessed 26
May 2017].
[3] Bennett G, Dealey C, Posnett J. The cost of pressure ulcers in the United
Kingdom. Age Ageing 2004;33(3):230e5. http://dx.doi.org/10.12968/
jowc.2012.21.6.261.
[4] Landi F, Onder G, Russo A, Bernabei R. Pressure ulcer and mortality in frail
elderly people living in community. Arch Gerontol Geriatr 2007;44(1):
217e23.
[5] Lindgren M, Unosson M, Fredriksson M, Ek AC. Immobility-a major risk factor
for development of pressure ulcers among adult hospitalized patients: a
prospective study. Scand J Caring Sci 2004;18(1):57e64.
[6] McGinnis E, Briggs M, Collinson M, Wilson L, Dealey C, Brown J, et al. Pressure
ulcer related pain in community populations: a prevalence survey. BMC Nurs
2014;13(16):1e10. http://dx.doi.org/10.1186/1472-6955-13-16.
[7] Enamul Hug AKM, Unalan H, Karamehmetoglu SS, Tuzun S, Gurgoze M,
Tuzun F. Prevalence and risk factors of pressure ulcers in a tertiary hospital.
Turk J Phys Med Rehabil 2001;47(6):3e11.
€
[8] Inan DG, Oztunç G. Pressure ulcer prevalence in Turkey: a sample from a
university hospital. J Wound Ostomy Cont Nurs 2012;39(4):409e13. http://
dx.doi.org/10.1097/WON.0b013e31825825b1.
[9] Katran B. The research on the incidence of pressure sores in a surgical
intensive care unit and the risk factors affecting the development of pressure
sores. JAREN 2015;1(1):8e14.
[10] Karadag M, Gümüskaya N. The incidence of pressure ulcers in surgical pa-
tients: a sample hospital in Turkey. J Clin Nurs 2006;15(4):413e21. http://
dx.doi.org/10.1111/j.1365-2702.2006.01369.x.
[11] Schoonhoven L, Defloor T, Grypdonck MH. Incidence of pressure ulcers due to
surgery. J Clin Nurs 2002;11(4):479e87.
 S. Ünver et al. / Journal of Tissue Viability 26 (2017) 277e281
[12] Feuchtinger J, Halfens R, Dassen T. Pressure ulcer risk assessment immediately
after cardiac surgeryedoes it make a difference? A comparison of three
pressure ulcer risk assessment instruments within a cardiac surgery popula-
tion. Nurs Crit Care 2007;12(1):42e9. http://dx.doi.org/10.1111/j.1478-
5153.2006.00198.x.
[13] Scarlatti KC, Michel JLM, Gamba MA, Gutierrez MGRD. Pressure ulcers in
surgery patients: incidence and associated factors. Rev Esc Enferm USP
2011;45(6):1372e9. http://dx.doi.org/10.1590/S0080-62342011000600014.
[14] Shokati AM, Rafiei H, Alipoor HM, Bokharaei M, Amiri M. Incidence of pressure
ulcer in patients who were admitted to open heart cardiac surgery intensive
care unit. IJER 2016;3(1):12e8.
[15] Schultz A, Bien M, Dumond K, Brown K, Myers A. Etiology and incidence of
pressure ulcers in surgical patients. AORN J 1999;70(3):434e49. http://
dx.doi.org/10.1016/S0001-2092(06)62325-9.
[16] Spector WD, Limcangco R, Owens PL, Steiner CA. Marginal hospital cost of
surgery-related hospital-acquired pressure ulcers. Med Care 2016;54(9):
845e51. http://dx.doi.org/10.1097/MLR.0000000000000558.
[17] Koc S, Bakoglu N, Bardak A. Cost analysis of pressure ulcers cases in Acibadem
Healthcare Group. AJMPS 2014;2(6):125e30.
[18] Demarre L, Van Lancker A, Van Hecke A, Verhaeghe S, Grypdonck M, Lemey J,
et al. The cost of prevention and treatment of pressure ulcers: a systematic
review. Int J Nurs Stud 2015;52(11):1754e74. http://dx.doi.org/10.1016/
j.ijnurstu.2015.06.006.
[19] Pender LR, Frazier SK. The relationship between dermal pressure ulcers,
oxygenation and perfusion in mechanically ventilated patients. Intensive Crit
Care Nurs 2005;21(1):29e38. http://dx.doi.org/10.1016/j.iccn.2004.07.005.
[20] National Pressure Ulcer Advisory Panel. European pressure ulcer advisory
panel and Pan Pacific pressure injury alliance. In: Haesler Emily, editor. Pre-
vention and treatment of pressure ulcers: quick reference guide. Osborne
Park, Australia: Cambridge Media; 2014. https://cascomfg.com/wp-content/
uploads/2016/04/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-
Jan2016.pdf/. [Accessed 12 December 2016].
[21] Clark M. Developing guidelines for pressure ulcer prevention and manage-
ment. J Wound Care 1999;8(7):357. http://dx.doi.org/10.12968/
jowc.1999.8.7.26180.
[22] Worsley PR, Clarkson P, Bader DL, Schoonhoven L. Identifying barriers and
facilitators to participation in pressure ulcer prevention in allied healthcare
professionals: a mixed methods evaluation. Physiotherapy 2017;103(3):
304e10. http://dx.doi.org/10.1016/j.physio.2016.02.005.
[23] Guihan M, Hastings J, Garber SL. Therapists' role in pressure ulcer manage-
ment in persons with spinal cord injury. J Spinal Cord Med 2009;32(5):560e7.
http://dx.doi.org/10.1080/10790268.2009.11754561.
[24] Sprigle S, Sonenblum S. Assessing evidence supporting the redistribution of
pressure for pressure ulcer prevention: a review. J Rehabil Res Dev
2011;48(3):201e14. http://dx.doi.org/10.1682/JRRD.2010.05.0102.
[25] Norton L, Parslow N, Johnston D, Ho C, Afalavi A, Mark M, et al. In:
Rosenthal Sue, editor. Best practice recommendations for the prevention and
management of pressure injuries. Canada: Canadian Association of Wound
Care; 2017. https://www.researchgate.net/profile/Afsaneh_Alavi/publication/
313808796_BPR-prevention_and_management_of_pressure_injury/links/
58a707c892851cf0e3b96995/BPR-prevention-and-management-of-pressure-
injury.pdf/2017. [Accessed 29 May 2017].
[26] Yavuz M, Kır S, Yücesoy F. Basınç Yarası Prevalansı. In: 7. Türk Cerrahi ve
Ameliyathane Hemşirelig i Kongresi, Kongre Kitabı; 2011. p. 266e71.
[27] Cuddigan J, Berlowitz D, Ayello E. Pressure ulcers in America: prevalence,
incidence and implications for the future. An executive summary of the Na-
tional Pressure Ulcer Advisory Panel monograph. Adv Skin Wound Care
2001;14(4):208e15.
[28] Compass C, Brown RL. Pressure ulcer prevention: who's responsible? J Ark
Medl Soc 2009;105(10):228e9.
[29] Saleh MY, Al-Hussami M, Anthony D. Pressure ulcer prevention and treatment
knowledge of Jordanian nurses. J Tissue Viabil 2013;22(1):1e11. http://
dx.doi.org/10.1016/j.jtv.2013.01.003.
[30] Qaddumi J, Khawaldeh A. Pressure ulcer prevention knowledge among Jor-
danian nurses: a cross-sectional study. BMC Nurs 2014;13(6):1e8. http://
dx.doi.org/10.1186/1472-6955-13-6.
[31] Dunleavy K. Putting a dent in pressure ulcer rates. Nursing 2008;38(1):20e1.
281
http://dx.doi.org/10.1097/01.nurse.0000305900.2704.1.49.
[32] Athlin E, Idvall E, Jernfalt M, Johansson I. Factors of importance to the
development of pressure ulcers in the care trajectory: perceptions of hospital
and community care nurses. J Clin Nurs 2009;19(15e16):2252e8. http://
dx.doi.org/10.1111/j.1365-2702.2009.02886.X.
[33] Moore Z. Bridging the theory-practice gap in pressure ulcer prevention. Br J
Nurs 2010;19(15):15e8. http://dx.doi.org/10.12968/
bjon.2010.19.Sup5.77703.
[34] Beeckman D, Defloor T, Schoonhoven L, Vanderwee K. Knowledge and atti-
tudes of nurses on pressure ulcer prevention: a cross-sectional multicenter
study in Belgian hospitals. Worldviews Evid Based Nurs 2011;8(3):166e76.
http://dx.doi.org/10.1111/j.1741-6787.2011.00217.x.
[35] Vogel T, Wanke M. Attitudes and attitude change. second ed. London: Psy-
chology Press; 2016. p. 2.
[36] Pickens J. Attitudes and perceptions. In: Borkowski N, editor. Organizational
behavior in health care. Sudbury: Jones and Bartlett Publishers; 2005. p. 44.
[37] Simonetti V, Comparcini D, Flacco ME, Di Giovanni P, Cicolini G. Nursing
students' knowledge and attitude on pressure ulcer prevention evidence
based guidelines: a multicenter cross-sectional study. Nurse Educ Today
2015;35(4):573e9. http://dx.doi.org/10.1016/j.
[38] Nursing and Midwifery Council. The code. Standards of conduct, performance
and ethics for nurses and midwives. London: NMC; 2015. https://www.nmc.
org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf/.
[Accessed 12 December 2016].
[39] Grimshaw J, Eccles M, Tetroe J. Implementing clinical guidelines: current
evidence and future implications. J Contin Educ Health Prof 2004;24(Suppl 1):
31e7.
[40] Aslan A, Van Giersbergen MY. Nurses' attitudes towards pressure ulcer pre-
vention in Turkey. J Tissue Viabil 2016;25(1):66e73. http://dx.doi.org/
10.1016/j.jtv.2015.10.001.
[41] Beeckman D, Defloor T, Demarre  L, Van Hecke A, Vanderwee K. Pressure ul-
cers: development and psychometric evaluation of the attitude towards
pressure ulcer prevention instrument (APuP). Int J Nurs Stud 2010;47(11):
1432e41. http://dx.doi.org/10.1016/j.ijnurstu.2010.04.004.
[42] Üstün Y. Adapting the “attitude towards pressure ulcer prevention instru-
ment” into Turkish and studying its validity and reliability. Ege Üniversitesi
Saglık Bilimleri Fakültesi; 2013 [Master’s Thesis].
[43] Demarre L, Vanderwee K, Defloor T, Verhaeghe S, Schoonhoven L,
Beeckman D. Pressure ulcers: knowledge and attitude of nurses and nursing
assistants in Belgian nursing homes. J Clin Nurs 2012;21(9e10):1425e34.
http://dx.doi.org/10.1111/j.13652702.2011.03878.x.
[44] Uba MN, Alih FI, Kever RT, Lola N. Knowledge, attitude and practice of nurses
toward pressure ulcer prevention in university of Maiduguri teaching hos-
pital, Borno State, North-Eastern, Nigeria. Int J Nurs Midwifer 2015;7(4):
54e60. http://dx.doi.org/10.5897/IJNM2014.0155.
[45] Moore Z, Price P. Nurses attitudes, behaviors and perceived barriers towards
pressure ulcer prevention. J Clin Nurs 2004;13(8):942e51. http://dx.doi.org/
10.1111/j.1365-2702.2004 00972.x.
[46] Gunningberg L. Pressure ulcer prevention: evaluation of an education pro-
gramme for Swedish nurses. J Wound Care 2004;13(3):85e9. http://
dx.doi.org/10.12968/jowc.2004.13.3.26587.
[47] McCluskey A, Lovarini M. Providing education on evidence-based practice
improved knowledge but did not change behaviour: a before and after study.
BMC Med Educ 2005;5(40):5e12. http://dx.doi.org/10.1186/1472e6920-
5e40.
[48] Sarı E. Information level of intensive care unit nurses about pressure ulcer.
J Acad Geriatr 2013;5(3):73e9.
[49] Kallman U, Suserud B. Knowledge, attitudes and practice among nursing staff
concerning pressure ulcer prevention and treatment-a survey in a Swedish
healthcare setting. Scand J Caring Sci 2009;23(2):334e41. http://dx.doi.org/
10.1111/j.1471-6712.2008.00627.x.
[50] Iranmanesh S, Tafti AA, Rafiei H, Dehghan M, Razban F. Orthopaedic nurses'
knowledge about pressure ulcers in Iran: a cross-sectional study. J Wound
Care 2013;22(3):138e40. http://dx.doi.org/10.12968/jowc.2013.22.3.138.
[51] Chianca TCM, Rezende JFP, Borges EL, Nogueira VL, Caliri MH. Pressure ulcer
knowledge among nurses in Brazilian university hospital. Ostomy Wound
Manag 2010;56(10):58e64.