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I S S U E S A N D I N N O V A T I O N S I N N U R S I N G P R A C T I C E

Pressure area care: an exploration of Greek nurses knowledge andpractice

Kalliopi Panagiotopoulou BA MN RGN

Deputy Director, Department of Nursing Education, Army General Hospital of Athens, Kanelopoulou, Athens, Greece

and Susan M. Kerr BA MSc RGN HV

Research Fellow, Department of Nursing and Community Health, Caledonian Nursing and Midwifery Research Centre,

Glasgow Caledonian University, Glasgow, UK

Submitted for publication 2 January 2002

Accepted for publication 30 July 2002

Correspondence:

Kalliopi Panagiotopoulou,

Department of Nursing Education,

401 Army General Hospital of Athens,Kanelopoulou 1,

11525, Athens,

Greece.

E-mail: kalliopipanagiotopoulou@

hotmail.com

P A NA G IO T OP O UL O U K & K E R R S M ( 2 00 2 )P A N A G I O T O P O U L O U K . & K E RR S .M . ( 2 0 0 2 ) Journal of Advanced Nursing

40(3), 285296

Pressure area care: an exploration of Greek nurses knowledge and practice

Background. Despite a plethora of information on the prevention of pressure sores,

they remain a significant problem in both hospital and community settings. The

need to reduce the incidence of pressure sores has been well documented; unfor-

tunately there is little evidence to suggest improvement. The reasons for this lack of

improvement have been explored, but the picture remains unclear. While some

studies have suggested that nurses have the appropriate knowledge to prevent

pressure sores developing (but do not use their knowledge), others suggest that

nurses knowledge of preventive strategies is deficient. In Greece, similarly to the

United Kingdom (UK), the incidence of pressure sores is high. There is currently no

evidence on Greek nurses knowledge and practice and therefore no baseline on

which to build, in terms of improving practice.

Aim. The purpose of this study was to explore Greek nurses knowledge of riskfactors, areas at risk and recommended preventive strategies in relation to

pressure area care. In addition, information was sought on nurses current pre-

ventive practice and any barriers to good practice.

Research methods. The study was exploratory and descriptive, adopting a cross-

sectional survey approach. The sample was drawn from the population of nurses

working in a military hospital near Athens. The data were collected over a 4-week

period in June 2000, using a self-completed questionnaire.

Results. Although the knowledge-base of many of the nurses was good in relation

to risk factors and areas at risk, a significant proportion were unaware that

methods such as massage and donuts are no longer recommended. This lack of

knowledge influenced practice with these methods commonly being used. In relation

to barriers to good practice, a significant proportion of nurses reported that they

could not access, read or understand research findings. This has obvious implica-

tions for the implementation of evidence-based practice.

Conclusion. The results of this study suggest that the knowledge and practice of

participants could be improved. It is of particular concern that methods known to be

detrimental were in common use. Finally, there is a need to improve the research

skills of Greek nurses in order to provide them with the appropriate knowledge to

use research findings.

2002 Blackwell Science Ltd 285

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Keywords: pressure sores, knowledge, practice, risk factors, risk, prevention, re-

search utilization, Greece

Introduction

Despite a plethora of information on the prevention of

pressure sores, they remain a significant problem in both

hospital and community settings. The incidence, known to

vary from 4 to 16% (depending on the case-mix and

classification of sores), represents a significant burden of

suffering for patients and is costly to healthcare providers

(Plati et al. 1992, Oot-Giromini 19931 , Clark & Watts 1994,

National Health Service Centre for Reviews & Dissemination

[NHS CRD] 1995, Baltzi-Economopoulou 1997).

The need to reduce the incidence of pressure sores has been

well documented (Department of Health [DoH] 1992). In

considering how this goal might be achieved, nursing care has

been highlighted as a major influence, with good preventive

strategies being central (Land 1995). In order to deliver highquality care, it is essential that nurses base their practice on

the best available evidence, and if they are to function

effectively they must have knowledge of risk factors, areas

at risk and preventive strategies (NHS CRD 1995).

Knowledge, alone, is insufficient, as nurses must actually

use the knowledge they have. Studies that have explored

nurses knowledge and practice in relation to pressure area

care are reviewed below.

Nurses knowledge

Knowledge of risk factors

The number of studies that have explored nurses knowledge

of risk factors is relatively small, and comparisons across

studies are difficult, as different sampling frames and methods

have been used.

A study by Maylor (1999) used a cross-sectional survey

approach to explore nurses knowledge of risk factors. The

study targeted the total population of trained and untrained

nurses (excluding midwives, psychiatric nurses and health

visitors) working in an NHS trust in Wales (n 625). The

nurses were asked to indicate their level of agreement (using a

4-point Likert scale) with a number of statements relating torisk factors (e.g. to state whether a low albumin level is a risk

factor). The 18 items included in the list were compiled with

the assistance of an expert panel. Results from the 439

respondents (70% response rate) suggested that the average

level of agreement with expert opinion was generally good.

Perhaps unsurprisingly, registered nurses mean score was

significantly greater than that of unqualified nurses

(P < 0001).

Another study that found nurses knowledge of risk factors

to be good, was undertaken by Bostrom and Kenneth (1992)

in the United States of America (USA). A cross-sectional

survey approach was used to collect data from a random

sample of nurses (n 398) who were members of the

Nursing Consortium for Research in Practice. In this case,

the nurses were asked to comment on a list of 12 factors

(generated from the literature and expert opinion), stating

whether each factor was or was not considered to be a risk

factor. Data gathered from the 245 respondents (62%

response rate) suggested that the level of knowledge was

good. Seventy-one percent (n 245) answered 10 of the 12

questions correctly. A factor that may limit the generaliz-

ability of these results is that participants were all members of

the Nursing Consortium for Research in Practice. It would

seem reasonable to assume that this group may have beenmore knowledgeable than nurses who were not members of

the consortium.

While the studies discussed suggest that nurses knowledge

of risk factors is good, work by Beitz et al. (1999) suggests

that it is poor. In this study, a survey approach was used to

collect data from a convenience sample of 86 qualified and

unqualified nurses working in a community hospital in the

USA. Data were collected using the Pressure Ulcer Risk and

Treatment Test developed by Hayes et al. (1995). Results

from the 86 respondents (100% response rate) suggested that

the knowledge was limited in the following areas: importance

of pressure relief (45% did not state that this was important);

friction (59% did not recognize that friction is a predisposing

factor); and age (94% did not agree that a patients level of

risk increases with age). A limitation of this work is the fact

that a convenience sample was used, which obviously limits

the generalizability of the results.

Another study that has shown nurses knowledge in

relation to risk factors to be poor was conducted by Parker

et al. (1998) in a general hospital in England. A survey

approach was used to collect data from a purposive sample of

275 nurses selected from a total workforce of 1500. The

results from the 255 respondents (87% response rate) suggestthat their knowledge of risk factors was limited. With regard

to extrinsic factors, the percentage who listed pressure, shear

and friction was small (17, 8 and 8%, respectively). In

relation to intrinsic factors the results were as follows:

nutritional status (39%); body weight (12%); incontinence

(12%); neurological factors (4%) and age (7%). The fact that

the sample was selected purposively again limits the gener-

alizability of the findings.

K. Panagiotopoulou and S.M. Kerr

286 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 40(3), 285296

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Knowledge of areas at risk

Information on nurses knowledge of the areas of the body

most at risk of developing pressure sores is very limited. The

only study that appears to have explored this was the one

conducted by Parker et al. (1998) that was discussed above in

relation to nurses knowledge of risk factors. In this case the

purposive sample of 255 nurses was asked to identify the two

areas of the body that are most at risk of developing sores.

Perhaps unsurprisingly, the level of knowledge was found to

be good, with 95% of nurses identifying the sacrum and 82%

identifying the heels as the most vulnerable areas. This level

of information does not allow the reader to gauge knowledge

levels in relation to other areas, such as the spine, the elbows

and the ischial tuberosities. In addition, no account was taken

of areas at risk in different positions (i.e. semi-recumbent,

supine and lateral).

Knowledge of preventive strategies

The number of studies that have explored nurses know-ledge of preventive strategies is relatively small. Halfens

and Eggink (1995) used a cross-sectional survey approach

to gather data from a sample of qualified nurses in the

Netherlands. In this case the sample was selected randomly

from a group of nurses who received copies of a free

weekly nursing journal (it was estimated that 80% of all

nurses working in the Netherlands received this journal).

The content of the questionnaire was derived from infor-

mation contained in the Dutch2 Consensus Report (1992).

The Consensus Guidelines classify preventive strategies in

three ways: methods that are useful and advised for gen-

eral application in all patients at risk of developing pres-

sure sores; methods expected to be useful in individual

cases, but which are not advised for general application;

and methods which are not considered useful. Nurses

were presented with a list of preventive strategies and

asked to comment on how useful they considered each

strategy to be. Data gathered from the 373 respondents

(76% response rate) suggested that the level of knowledge

in relation to methods that are always useful was good.

The nurses were particularly knowledgeable about the

following: the importance of providing a clean, smooth,

dry bottom sheet (997%), maintaining good hygiene

(997%) and palpating and inspecting the skin daily

(915%). Levels of knowledge were, however, more limited

in relation to methods that are sometimes useful.

Respondents appeared to have difficulty in differentiating

between methods that are always useful and those only

recommended in individual cases. Finally, knowledge of

methods that are not recommended was poor. A substan-

tial percentage stated that methods such as massage,

topical creams and donuts (ring-shaped sitting aids) are

always useful (70, 70 and 46%, respectively).

Studies exploring nurses knowledge of preventive methods

have also been undertaken by Russell (1996) and Hill (1992).

Although these UK studies both demonstrated that know-

ledge was good, the results cannot be generalized as the

samples were small (30 and 15, respectively) and convenience

sampling was used.

Nurses preventive practice

Preventive strategies involve methods used to assess indi-

vidual patients level of risk (i.e. risk assessment tools) and

also interventions used to prevent pressure sores develop-

ing. The number of studies that have explored preventive

practice is relatively small. One of the key studies was

discussed previously in relation to knowledge of preventive

strategies (Halfens & Eggink 1995). Interestingly, despite

the fact that nurses were knowledgeable about particularpreventive strategies, they did not always appear to

translate their knowledge into practice (e.g. where 86%

of nurses were aware that nutritional deficiency should be

treated, only 79% stated that always ensured that a

nutritional deficiency was in fact treated). On the other

hand, poor knowledge about methods that should not be

applied was generally translated into practice, with a

significant proportion of nurses reporting that massage,

topical creams and donuts were used regularly. The fact

that massage is a commonly used preventive strategy was

also found by others (Hill 1992, Wilkes et al. 1996, Beitz

et al. 1999).

A more recent study, undertaken in an NHS hospital in

Scotland, used retrospective document analysis (325 case

notes) to explore whether there was an association between

patients level of risk and specific nursing interventions

(Tolmie 2000). The results suggested that almost half

(42%) of patients identified as being at risk of developing

pressure sores, did not appear to have received care that

included appropriate preventive strategies. Although practice

appeared to be poor, the author highlighted the fact that to

some extent the results may have been due to poor

documentation rather than poor practice.Finally, a number of studies have sought to determine

whether nurses routinely use risk assessment tools (e.g.

Norton 1962, Waterlow 1985, Braden et al. 1987) to predict

which patients are at risk of developing pressure sores.

Accurate prediction of risk status is important, as it should

ensure that nurses intervene, when appropriate. While studies

from the UK suggest widespread use of risk assessment scales

(Maylor 1999, Tolmie 2000), those from other countries

Issues and innovations in nursing practice Pressure area care in Greece

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 40(3), 285296 287

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report that their use is uncommon (Halfens & Eggink 1995,

Mockridge & Anthony 1999).

Barriers to good practice

When exploring nurses implementation of research-based

findings (in relation to pressure area care) it is important to

be aware of any barriers that may inhibit good practice.

Although much has improved since the early 1980s, both

within and across countries, many of the barriers highligh-

ted by Hunt (1981) (i.e. nurses do not know about,

understand, believe or know how to apply research findings)

still exist. Another barrier to good practice is resources.

These can be thought of in two ways: first facilities that

allow staff access to the literature (i.e. adequate library

facilities) and second the provision of sufficient human

resources and equipment (such as pressure relieving surfa-

ces) to allow nurses to provide adequate care. Although

there has been a significant improvement in library facilitiesin the UK in the last 10 years, provision varies across the

country (Clinical Standards Advisory Group (CSAG) (1998).

Nurses in many other countries, including Greece, have a

very limited access to library facilities and electronic

databases.

In Greece, similarly to the UK, the incidence of pressure

sores remains high (68%) (Plati et al. 1992). Unfortunately,

there is currently no evidence on Greek nurses knowledge

and practice and therefore no baseline on which to build in

terms of improving practice. The results of studies underta-

ken elsewhere, although of interest, are not generalisable to

the Greek situation as there are a number of cultural and

health system differences.

The study

This study takes a first step in gathering information that

could improve Greek nurses clinical effectiveness.

Aims

The study aimed to: (1) explore Greek nurses knowledge of

risk factors, areas at risk and preventive strategies; (2)explore preventive practice; and (3) identify any barriers that

may inhibit good practice.

Research methods

Research approach

The study was exploratory and descriptive in nature, adopt-

ing a cross-sectional survey approach.

Population and sample

The target population was all registered and enrolled nurses

working in hospitals in Greece. The sample was selected from

the accessible population, that is, from the population of

438 nurses working in a military hospital near Athens. Gui-

ded by the literature, and in order to facilitate comparisons

across studies, nurses who would be expected to demonstrate

either specialist knowledge and/or who would have little or

no experience of pressure area care were excluded from the

study. In addition, senior nurses with little or no direct

patient contact were excluded. The following inclusion and

exclusion criteria were therefore applied:

Inclusion criteria. Registered and enrolled nurses with roles

and responsibilities connected with direct patient care.

Exclusion criteria. Registered and enrolled nurses working in

intensive care unit (ICU), accident and emergency, theatre or

psychiatric wards.Access was negotiated with the Director of Nursing

Services. Once this had been agreed, nurses who met the

inclusion criteria were identified from the population of

nurses working in the hospital. The total number of eligible

nurses was 166 (69 registered and 97 enrolled nurses).

Instrument

The instrument used incorporated previously validated

instruments developed by Maylor (1999) and Halfens and

Eggink (1995). However, in order to ensure that the study

objectives were met, some questions exploring knowledge

of areas at risk and barriers to good practice were ad-

ded. In addition, a small number of questions were ex-

cluded as they referred to situations that do not apply in

Greece. The main sections of the questionnaire are outlined

in Table 1.

Face and content validity of the instrument were assessed

by a group of experts that included nurse educators,

experienced researchers and tissue viability nurses (n 6).

This group also assessed issues that might have influenced the

reliability of the instrument, such as the wording and order of

questions and layout of the questionnaire. On completion of

this process the instrument was translated into Greek by thefirst author, with the accuracy of the translated version being

ratified by an experienced tissue viability nurse working in

Greece. The Greek version of the instrument was then piloted

with a small group of nurses in Greece (n 10). Several

minor alterations were made to the questionnaire following

the pilot study (e.g. the Greek words used to describe the

ischial tuberosity were altered as participants stated that the

original translation lacked clarity).



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Data collection

Data were collected during a 4-week period in June 2000.

On-site distribution and retrieval of the questionnaires was

achieved with the assistance of a colleague working at the

study site. Each of the 166 questionnaires was addressed

personally and delivered with an information sheet and replyenvelope. Nurses who wished to participate in the study were

asked to complete and return the questionnaire within a

2-week period. They were assured that their responses would

be treated confidentially and that participation was volun-

tary. Following a reminder, the total number of returned

questionnaires was 118; the response rate was therefore 71%.

Data analysis

Data were coded and entered into the statistical software

package SPSS (version 8). Descriptive and inferential statistics

were prepared. When comparing results between two groups,

t-tests were used for outcome measures that could be

assumed to be approximately normally distributed (e.g. total

knowledge scores). When comparing results across more than

two groups, one-way analysis of variance (ANOVA) was used.

Finally, in instances where the data were categorical, the chi-

squared test was employed. The level of significance was set

at P 005.

Results

The results are presented below. As would be expected when

collecting data using a self-completed questionnaire, the dataset is not 100% complete. The level of response for each

question is given.

Sample characteristics and continuing professional

development

The characteristics of respondents are presented in Table 2. As

indicated, the majority were female (871%) and the mean age

was 287 years (SD 374). Fifty-three percent were enrolled

nurses and 583%, had been qualified for more than 5 years.

In relation to continuing professional development

(Table 3), 496% of the nurses reported that they had read

a research-based article on pressure area care in the previous

6 months while 667% had attended in-service training on

pressure area care in the previous 2 years.

Knowledge of risk factors

The nurses knowledge of risk factors is summarized in

Table 4. The question asked was as follows: In your opinion

Table 3 Continuing professional development

Percent

Read a nursing journal/s (n 117)

More than once a month 154

Once every 13 months 274

Once every 46 months 214

Less than once every 6 months 188

I have not read a nursing journal in the last 12 months 171

Read a research-based article on pressure area care (n 117)

Less than 1 month ago 12

13 months ago 205

46 months ago 171

More than 6 months ago 368

Never 137

Attended in service training on pressure area care (n 117)

Less than 1 year ago 411

12 years ago 256

More than 2 years ago 120

Never attended such training 214

Table 2 Sample characteristics

Percent

Gender (n 116)

Female 871

Male 129

Age

2024 100

2529 509

3034 300

3539 91

Basic training (n 117)

Degree (RN) 470

Diploma (EN) 530

Number of years qualified (n 115)

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which of the following can be an important contributory

factor to the development of pressure sores? Respondents

were asked to indicate their answer on a 4-point Likert Scale

(strongly agree, agree, disagree, strongly disagree). The

answers judged as correct in terms of expert opinion

(Maylor 1999) are highlighted in bold for ease of identifica-

tion. As indicated, the level of agreement with expert

opinion was particularly high for the following risk factors:

high pressure over a bony prominence for a long duration

(907%), incontinence (684%), friction (605%) and low

blood albumin (648%). Level of agreement with expert

opinion was limited in the following areas: shearing forces

(179%), analgesics (10

7%), hospital easy chairs (0%) and

confused mental status (263%).

Knowledge score (risk factors)

Following guidelines produced by Maylor (1999), a total

knowledge score was calculated for each respondent. Taking

each of the 24 response-items individually, four points

were awarded for complete consensus with expert opinion

(e.g. expert response strongly agree; participant

response strongly agree), three points for partial agree-

ment (e.g. expert response strongly agree; participant

response agree), two points when there was a weak dis-

crepancy (e.g. expert response strongly agree; participant

response disagree) and finally one point was awarded

when there was a strong discrepancy (e.g. expert

response strongly agree; participant response strongly

disagree). The knowledge score therefore ranged from 24

(lowest possible score) to 96 (highest possible score). This

score was then transformed to produce a percentage

agreement with expert opinion. The average level of

agreement with expert opinion was 71%, with a range of

48684

7%.

Knowledge of areas at risk

Knowledge of areas of the body at risk of developing

pressure sores in the semi-recumbent, supine and lateral

positions is summarized in Table 5. Respondents were pro-

vided with a picture of a patient in each of the three positions

and were asked to indicate which areas of the body they

Table 4 Knowledge of risk factors (answers judged as correct in terms of expert opinion are indicated in bold)

Risk factors

Strongly agree

(%)

Agree

(%)

Disagree

(%)

Strongly disagree

(%)

High pressure over a bony prominence, for a long duration

(n 118)

907 93 00 00

Incontinence (n 117) 684 282 26 09

High blood albumin levels (n 108) 00 120 370 509

Friction (n 114) 605 316 79 00

Shearing forces (n 112) 179 339 415 71

High pressure over a bony prominence, for a short duration

(n 110)

157 463 343 37

Immobility (n 117) 829 171 00 00

Analgesics (n 112) 63 107 500 330

Low pressure over a bony prominence for a long duration

(n 114)

289 474 184 53

Hospital mattresses (standard mattress) (n 117) 325 513 137 26

Hospital easy chairs (n 111) 00 63 559 378

Patients usual home mattresses (n 113) 168 460 292 80

Immobile patient propped up in bed (n 118) 322 466 195 17

Immobile patient sitting up in a chair (n 115) 339 443 183 35

Patients usual home chair (n 111) 144 33

3 44

1 8

1

Patient age of 75 years (n 114) 333 474 175 18

Low pressure over a bony prominence for short duration

(n 115)

43 200 574 183

Low blood albumin levels (n 108) 648 269 65 19

Poor nutritional status (n 117) 556 444 00 00

Body weight (above average) (n 116) 414 379 164 43

Body weight (below average) (n 115) 539 443 17 00

Concurrent diseases (n 117) 675 299 17 09

Confused mental status (n 114) 220 263 432 51

Medications (n 115) 287 539 157 17



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considered were at risk from a choice of 14 alternatives (e.g.sacrum, heels, buttocks). Answers judged as correct in terms

of the Pressure Ulcer Prevention Consensus Group (PUPG

2000) are highlighted in bold for ease of identification. As

indicated, levels of agreement with the consensus guidelines

were particularly high for heels in the semi-recumbent

(949%) and supine (974%) positions. The level of agreement

with the consensus guidelines was also high for the sacrum in

the semi-recumbent (829% and supine (923%) positions. Of

note is the fact that the toes were rarely identified as an area at

risk (semi-recumbent 26%; supine 17%).

Knowledge score (areas at risk)

In order to judge levels of knowledge of areas at risk in each

of the three positions, a total score was calculated. A score of

1 was awarded for each correct response and 0 was awarded

for each incorrect response. As there were 14 response-op-

tions for each position, the possible score ranged from 0

(lowest possible score) to 42 (highest possible score). Fol-

lowing this process, the average level of agreement with

expert opinion was 705% with a range of 452905%.

Knowledge of preventive strategies

The questions contained in this section were derived from the

questionnaire developed by Halfens and Eggink (1995). The

latter is based on guidelines on preventive methods contained

in the Dutch Consensus Report (1992). It should be noted

that the Dutch guidelines are largely consistent with those

produced by the USA [Agency for Health Care Policy

Research (AHCPR) 1992], the most commonly used inter-

national guidelines. The Dutch guidelines grade preventive

methods in one of three ways: methods that are useful and are

advised for general application in all patients at risk;

methods expected to be useful in individual cases, but which

are not advised for general application in patients at risk;

and methods that are not useful.

The results are presented in Table 6. Correct answers are

highlighted in bold for ease of identification. As indicated, the

level of agreement with the Consensus Guidelines in relation

to methods considered as always useful was generally high.

Nurses appeared to have difficulty in identifying methods not

advised for general application, but which may be useful in

individual cases. For example, air mattresses were incor-

rectly considered by a majority (675%) to be always useful.

Finally, level of agreement with the consensus guidelines on

methods considered to be never useful was low. Only 6 9%

of the nurses stated correctly that massage was never

useful, while more than half (569%) considered that it was

always useful.

Knowledge score (preventive strategies)

In order to judge levels of knowledge in relation to preventive

strategies, a knowledge score was calculated. Following the

guidelines provided by Halfens and Eggink (1995), a score of

1 was awarded for every correct response and 0 for every

incorrect response. As there were 20 response-options, the

possible knowledge scores ranged from 0 (lowest possible

score) to 20 (highest possible score). Following this process

the average level of agreement with expert opinion was 50%

with a range of 3075%.

Preventive practice

Results in relation to preventive practice are summarized in

Table 7. Again, this section of the questionnaire was derived

from that developed by Halfens and Eggink (1995). The

questions asked nurses to comment on their practice in terms

of: methods used in their ward (in principle) for every patient

at risk; methods used in individual cases (but not for every

patient at risk); and methods never applied. Again, correct

answers are highlighted in bold for ease of identification.

As indicated (Table 7), the level of agreement with the

consensus guidelines (Halfens & Eggink 1995) with respectto the methods used in principal for every patient at risk of

developing pressure sores was generally high. However,

202% of the sample did not use a risk assessment tool and

214% reported that they did not attempt to prevent or treat

nutritional deficiency for every patient at risk. Again, similar

to the results in relation to knowledge of preventive

strategies, many nurses did not appear to be able to

differentiate between methods that were generally applicable

Table 5 Knowledge of areas at risk (answers judged as correct by

the Pressure Ulcer Prevention Consensus Group are indicated in bold)

Areas at risk

(n 117)

Semi-recumbent

Yes (%)

Supine

Yes (%)

Lateral

Yes (%)

Occiput 385 470 94

Back of head 632 761 17

Ear 145 94 932

Shoulder blades 675 855 282

Shoulders 145 239 769

Elbows 521 778 590

Spine 470 761 26

Hip 436 393 778

Sacrum 829 923 26

Ischial tuberosity 829 778 513

Knee 43 26 376

Heels 949 974 410

Toes 26 17 205

Ankle 179 111 872



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and methods only useful in individual cases. This was

particularly true of use of topical medications (353%) and

air mattresses (328%). Regarding methods considered never

useful, just less than a third (314%) reported that they

always used massage, a strategy considered to indicate poor

practice in pressure sore prevention.

Practice score (preventive practice)

In order to judge nurses level of practice a score was calcu-

lated following the scoring guidelines produced by Halfens

and Eggink (1995). A score of 1 was awarded for practice

that was in accordance with the guidelines and 0 was awar-

ded when practice did not accord with what is recommended.

As there were 20 response-options, possible scores ranged

from 0 (lowest possible score) to 20 (highest possible score).

Following this process the average percentage agreement withexpert opinion was 545% with a range of 2580%.

Factors that may have influenced knowledge and practice

One of the reasons that the sample characteristics and

information on continuing professional development (CPD)

were collected was to allow exploration of whether factors

such as age, gender and in-service training appeared to

influence levels of knowledge. The results demonstrated that

there was a statistically significant difference in relation to

qualifications, with registered nurses exhibiting greater

knowledge and reporting better preventive strategies than

enrolled nurses (knowledge RN mean 105; EN mean 96;

t 230; P 002; practice RN mean 114; EN mean 105,

t 2163; P 0033). A more detailed analysis using the

chi-squared test highlighted that a significantly greater

proportion of enrolled nurses were not aware that donuts

and topical creams should not be used (v2 1406, d.f. 3,

P 0003; v2 94, d.f. 3, P 0024, respectively). This

lack of knowledge was reflected in their practice as enrolled

nurses were more likely to report that they used donuts and

topical creams than registered nurses (v2 894, d.f. 2,

P 0011; v2 1210, d.f. 2, P 0002, respectively).

Overall, the reported preventive practice of registered nurseswas significantly better than that of their enrolled nurse

colleagues (t 2163, P 0033).

Perceived barriers to good practice

The results for barriers to good practice are summarized in

Table 8. Nurses were asked to select barriers that they

considered applied personally or in their work environment

Table 6 Nurses knowledge of preventive strategies (correct answers are indicated in bold)

Always

useful (%)

Sometimes

useful (%)

Never

useful (%)

Dont

know (%)

Methods judged as always useful

Provide clean, smooth and dry bottom sheet (n 118) 983 17 00 00

Maintain good hygiene (n 118) 941 51 08 00

Prevent or treat nutritional deficiency (n 117) 863 137 00 00

Palpate and inspect the skin daily (n 117) 735 248 17 00

Prevent maceration (softening of the skin) (n 116) 974 26 00 00

Involve patient in prevention(n 116) 690 302 09 00

Reposition at least once every 3 hours (n 118) 932 59 08 00

Assess decubitus risk with a risk assessment tool (n 116) 784 190 09 17

Methods judged as sometimes useful

Use foam mattresses and/or pillows (n 113) 301 345 212 142

Use water mattresses and/or pillows (n 115) 278 409 70 243

Use air mattresses and/or pillows (n 118) 675 205 34 85

Use gel mattresses and/or pillows (n 113) 115 221 124 540

Pressure relieving material with adhesive to stabilize heels or elbows (n 117) 350 530 85 34

Cream with topical medication to prevent or treat dry skin ( n 116) 784 216 0 0

Paramedical treatment (e.g. physiotherapy) for mobility and reactivity (n 116) 707 284 0 09

Involve family and friends in prevention (n 114) 658 27

2 6

1 0

9

Methods judged as never useful

Use donut (n 115) 217 383 391 09

Insert catheter (to prevent maceration due to incontinence) (n 118) 492 458 42 08

Massage (n 116) 569 353 69 09

Cream with topical medication to prevent blood flow disturbance caused

by pressure (n 118) 415 314 93 178



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from a list of 17 items (the most commonly cited barriers only

are tabulated). The most frequently identified barriers were as

follows: of lack of staff/manpower (949%), lack of

equipment (788%) and overcrowding in the ward (com-

mon in Greek hospitals) (791%). More than half of the

respondents (60%) reported that research findings were not

user friendly, 462% that they could not access relevant

literature and 313% that they lacked knowledge of relevant

literature.

Finally, chi-squared analyses demonstrated that there was

no statistical difference in barriers to good practice reported

by registered and enrolled nurses.

Discussion

Nurses knowledge

The study sought to explore Greek nurses knowledge of risk

factors, areas at risk and preventive strategies. In relation

to knowledge of risk factors, the average level of agreement

with expert opinion was 71%. Previous studies have sugges-

ted that a level of knowledge (i.e. agreement with expert

opinion) greater than 70% is good (McLay 1998). Results

in this study therefore concur with previous studies that

found nurses knowledge of risk factors to be good (Bostrom

& Kenneth 1992, Maylor 1999). The level of knowledge

obtained by this sample of Greek nurses was greater than that

demonstrated by those who participated in Maylors UK

study (574%).

Nurses level of knowledge of areas at risk was also good,

with the average level of agreement with expert opinion being

705%. This data adds valuable information to the know-

ledge base, as we could identify no previous studies exploring

nurses knowledge of areas at risk in a comprehensive

manner. As discussed previously, the information gathered in

the study by Parker et al. (1998) was very limited.

In relation to overall knowledge of preventive strategies,

nurses level of agreement with expert opinion was only 50%.To some extent this could be attributed to the fact that, while

there is a wealth of research-based evidence in relation to

risk factors and areas at risk (AHCPR 1992), the evidence-

base for preventive strategies is more limited (AHCPR 1992,

NHS CRD 1995). As the instrument used to assess

knowledge of preventive strategies was adapted from the

one developed by Halfens and Eggink (1995), the Greek

nurses knowledge was compared to the level exhibited by

Table 7 Preventive practice (correct answers are indicated in bold)

Always

applied (%)

Sometimes

applied (%)

Never

applied (%)

Methods that should always be applied

Provide clean, smooth and dry undersheet (n 118) 1000 00 00

Maintain good hygiene (n 118) 966 34 00

Prevent or treat nutritional deficiency (n 117) 786 214 00

Palpate and inspect the skin daily (n 117) 778 214 09

Prevent maceration (softening of the skin) (n 118) 975 25 00

Involve patient in prevention (n 118) 720 271 08

Reposition at least once every 3 hours (n 118) 847 153 00

Assess ulcer risk with a risk assessment tool (n 114) 772 202 26

Methods that should be applied in individual cases

Use foam mattresses and/or pillows (n 108) 269 500 231

Use water mattresses and/or pillows (n 109) 119 284 596

Use air mattresses and/or pillows (n 116) 517 328 155

Use gel mattresses and/or pillows (n 105) 67 248 686

Pressure relieving material with adhesive to stabilize heels or elbows (n 116) 216 586 198

Cream with topical medication to prevent or treat dry skin ( n 116) 629 353 17

Paramedical treatment (e.g. physiotherapy) for mobility and reactivity (n 117) 547 444 09

Involve family and friends in prevention (n 118) 610 37

3 1

7

Methods that are never useful

Use donut (n 118) 153 390 458

Insert catheter (to prevent maceration due to incontinence) (n 118) 483 492 25

Massage (n 118) 314 559 127

Cream with topical medication to prevent blood flow disturbance caused

by pressure (n 117) 222 479 299



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nurses in Holland. Dutch nurses average level of knowledgewas less than that of Greek nurses in relation to methods

that are always useful (77% compared to 86%) and it was

considerably greater for methods that are sometimes useful

(54% compared to 31%) and never useful (27% compared

to 15%). This suggests that Greek nurses had more difficulty

than Dutch nurses in differentiating between methods that

are always useful and those not advised for general

application. Further comparisons indicated that the percent-

age of nurses who were regularly using outdated, ineffective

(sometimes detrimental) methods such as massage and

donuts was considerably greater in Greece than Holland.

Nurses perceived practice

Another key aim of the study was to explore nurses reported

practice in relation to pressure area care. Their average level

of agreement with what is suggested as good preventive

practice was 545%. Again, this relatively low score may be

attributed to the rather limited evidence-base on the effect-

iveness of preventive strategies (AHCPR 1992, NHS CRD

1995). Comparisons between these findings and those

obtained in Holland (Halfens & Eggink 1995) were again

undertaken. While Greek nurses practice in relation tomethods that should always be applied was considerably

better (85% compared to 60%), it was worse than that of

Dutch nurses for methods that are sometimes useful (40%

compared to 44%), and considerably worse for those that

should not be applied (22% compared to 40%). Again

therefore Greek nurses were not good at differentiating

between methods advisable for general application and those

only useful in a small number of cases. Practice in relation to

methods that are not recommended reflected level of

knowledge, that is massage, creams and catheterization

were used on a regular basis. These results suggest an overall

inability to provide tailored, individualized care. Our experi-

ence suggests that in the Greek situation, where there are no

formal protocols to guide practice in terms of quality and

cost-effectiveness, nurses generally err on what they consider

is the safe side, often in circumstances where this is not

warranted.

Comparisons with studies other than that of Halfens and

Eggink (1995) are necessarily limited, as different methodo-

logical approaches have been used. However, in relation to

methods that should not be used, the findings on misuse of

massage have been demonstrated elsewhere (Hill 1992,

Wilkes et al. 1996, Beitz et al. 1999).

Factors that may have influenced knowledge and practice

In relation to influences on the nurses knowledge of riskfactors and areas at risk, no statistically significant differ-

ences were found for the demographic variables. The number

of years qualified did not appear to influence level of know-

ledge. A similar finding has been highlighted in previous

research (Maylor 1999, Mockridge & Anthony 1999). In

relation to continuing professional development, exposure to

in-service education on pressure area care did not appear to

increase the nurses level of knowledge in this study. This

finding contradicts that of others, as Maylor (1999) found that

nurses who had been exposed to in-service education on

pressure area care demonstrated significantly greater levels of

knowledge.

When exploring influences on knowledge and practice of

preventive strategies in this study, there were statistically

significant differences in relation to qualifications, with

registered nurses exhibiting a greater level of knowledge and

practice. Maylor (1999), perhaps not surprisingly, found that

registered nurses level of knowledge was greater than that of

nursing care assistants.


The final aim of the study was to determine whether therewere any barriers to good practice in pressure area care. The

most commonly cited factors were work-related, and this

finding has been reported elsewhere. In particular, it has often

been reported that the work environment is unsupportive of

good practice. First, the utilization of research findings is

not always supported at managerial levels and, second,

staffing levels are often so low that it is difficult to provide the

desired level of nursing care (Wilkes et al. 1996, Carroll et al.

Table 8 Barriers to Good practice


Agree/strongly

agree (%)

Lack of staff/manpower (n 118) 949

Overcrowded ward (n 115) 791

Lack of equipment (n 118) 788

Lack of co-operation with other health

professionals (n 118)

695

Lack of disposable material (n 118) 635

Research findings are not user friendly (n 115) 600

Lack of access to relevant literature (n 117) 462

Lack of knowledge of relevant literature (n 115) 313

Unfamiliarity with an existent risk assessment tool

(n 115)

260

Lack of understanding of relevant literature

(n 115)

209

Unfamiliarity with an existent pressure sore

grading scale (n 114)

202



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1997, Walsh 1997, CSAG 1998, Kajermo et al. 1998). More

than three-quarters (79%) of the respondents reported that

overcrowding was a constraint on good practice. This is a

common problem in all Greek hospitals and our findings echo

those of Plati et al. 1992)3 in a civilian hospital in Greece.

Personal barriers, such as lack of awareness and lack of

understanding of the relevant literature, have also been

reported by others (Funk et al. 1991, Hill 1992, Russell

1996, Wilkes et al. 1996, Carroll et al. 1997, Walsh 1997,

CSAG 1998, Kajermo et al. 1998). Research findings have

often been criticised for not being user friendly (Hunt 1981,

CSAG 1998).

Study limitations

The main limitation centres on the use of the self-report

questionnaire. As would be expected, there was a level of

missing data. In addition, although nurses were asked not to

confer with each other and not to consult textbooks whencompleting the questionnaire, we have no way of knowing if

they complied with this request. In addition, of course, we do

not know if their reported practice reflected their actual

practice.

Finally, another limitation is arguably the fact that nurses

who were considered to have specialist knowledge of pressure

area care (i.e. those working in intensive care) were excluded

from the study. This was done in order to facilitate

comparisons across studies. However we believe that future

work should include nurses who are considered to have

specialist knowledge and that subgroup comparisons (e.g.

between those working in ITU and in general medical/

surgical wards) would be informative.

In relation to the generalizability of the findings, we cannot

comment with certainty on the level of knowledge and

practice of nonresponders. However, as the response rate was

high (71%) and the demographic characteristics (including

numbers of enrolled and registered nurses) of the responders

and nonresponders were shown not to be significantly

different, there is no reason to assume that the results cannot

be generalized to all nurses working at the study site who met

the inclusion criteria. In relation to generalization of the

results to the target population (i.e. all hospitals in Greece),this cannot be done with any certainty as we consider that the

population at the study site (nurses working in a military

hospital) is more knowledgeable about pressure area care.

Conclusions and recommendations for practice

Despite the limitations, it is considered that this study takes a

valuable first step in providing information on Greek nurses

knowledge and practice of pressure area care. Although some

practices were questionable, levels of knowledge were gen-

erally good. There is an obvious need to improve the research

skills of Greek nurses in order to provide them with the

appropriate knowledge to understand and implement

research findings. In addition, nurse clinicians should be

encouraged to develop clinical indicators to improve the

quality of nursing practice for the prevention of pressure

sores in the Greek population. This could be done by using

clinical experts in the area of pressure sores as well as

undertaking audits of patient records. Finally, there is a need

for further Greek-based research studies. The first author

(who is a Major in the Greek Army) intends to replicate this

study in other military hospitals in Greece (n 3) and will

encourage colleagues working in civilian hospitals, where

knowledge is likely to be more limited, to do likewise. In

addition, there is a need for observational studies to deter-

mine actual rather than perceived practice.

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