Knowledge and Attitude Regarding Pressure Ulcer Care among Nurses in Saudi Arabia

Pressure Ulcers (PU) are one of the most common hospital-acquired conditions in people with mobility limitations. Such wounds can cause pain and worsen the underlying illness. They can be life-threatening at times and treating them can be costly for both the patient's family and society [1]. A pressure ulcer, also known as a pressure injury, is a specific type of damage that occurs in the skin or underlying tissues due to prolonged pressure. These ulcers typically develop over bony areas, but can also be associated with medical devices [2]. A study conducted in April 2016 by the Commission on Patient Safety estimated that more than 2.5 million patients in acute care facilities had Pressure Injuries (PIs) and that every year, over 60,000 patients pass away from PI-related complications. 10.3% of patients in surgical Intensive Care Units (ICUs) and 12.1% in medical ICUs had Pressure Injuries (PIs), while 3.3% of patients in ICUs developed severe pressure Ulcers (PUs). According to a different Raynaldo (2020), 7.8% of ICU patients developed pressure ulcers during their stay in the ICU, on top of the 9.8% of patients who had them upon arrival [3]. PUs increases hospital care costs, the risk of patient-acquired infections and the rates of morbidity and mortality [4]. The following are some of the several variables that raise the risk of pressure sores: Absence of mobility or movement restricted by a loss of Consciousness and urinary or gastrointestinal incontinence leads to excessive cutaneous wetness, which ruptures skin tissue [5]. Studies have been published on the knowledge and attitude towards pressure ulcers in 2022 by Dr. Ravindra H.N., Balram Kathaliya According to study results, nurses' knowledge of pressure ulcer prevention was extremely low (M = 57.79%, SD = 9.20) and their practice was moderate (M = 72.27%, SD = 14.49). The degree of formal training and the nurses' educational attainment were significantly correlated with their understanding of pressure ulcer prevention [6]Regarding pressure ulcer prevention, there was a positive association between nurses' knowledge and practice (r = 0.459, p>0.000121) [6]. Significant discomfort may follow a pressure ulcer and approximately 60,000 people pass away from pressure ulcers each year [7]. Pressure ulcers are difficult for nurses to properly identify and classify, which raises the risk of wound infection in hospitalized critically ill patients. The purpose of this study was to raise the knowledge of the nurses', attitudes and perceived barriers about pressure ulcer prevention [8].

Factors influencing knowledge about PI prevention and treatment resulted in conflicting results. For example, despite having more knowledge about PI prevention, nurses with bachelor's degrees were not more likely to provide PI prevention. According to one study, highly educated nurses demonstrated less knowledge than those with baccalaureate degrees. Furthermore, nurses in orthopedic, trauma and emergency departments lacked knowledge of PI prevention, categorization and management [9].

The rate of pressure injuries has decreased as more people become aware of them. Large sample size research that collected data from 2006 to 2015 reported that the total frequency of pressure injuries at all institutions decreased from 13.5% (2006) to 9.3% (2015). Each year, 0.31 to 0.7% of adults aged 65 and older who receive basic medical care develop pressure ulcers. The rate of pressure injuries has decreased as more people become aware of them. Large sample size research that collected data from 2006 to 2015 reported that the total frequency of pressure injuries at all institutions decreased from 13.5% (2006) to 9.3% (2015). Each year, 0.31 to 0.7% of adults aged 65 and older who receive basic medical care develop pressure ulcers [6].

Pressure ulcers are a major issue in patient care and they are associated with reduced quality of life, pain, depression, loss of function, lack of independence, an increased risk of infection and sepsis, as well as additional surgeries and longer hospital stays [10]. The current study aims to investigate the knowledge and attitude of nurses in the Kingdom of Saudi Arabia (KSA) regarding the prevention and treatment of pressure ulcers.

Objectives

The current study aims to assess knowledge and attitudes regarding Pressure ulcer care among nurses in Saudi Arabia.

Study Design and Setting

This was a cross-sectional study conducted from July 2024 to February 2025 in Saudi Arabia. All staff nurses and internship-year nurses were invited to participate in the study.

Sample Size

The sample size was determined using Rao soft sample size calculator.

Data collection involved a target sample of 394 nurses (confidence level: 95%; margin of error: 5%). The sample size was estimated using the formula:

• n = P(1-P) * Zα 2/d2 with a 95% confidence level
• n: Calculated sample size
• Z: The z-value for the selected level of confidence (1- a) = 1.96
• P: An estimated prevalence of knowledge
• Q: (1 – 0.50) = 50%, i.e., 0.50
• D: The maximum acceptable error = 0.05
• So, the calculated minimum sample size was: n = (1.96)2 X 0.50 X 0.50/(0.05) 2 = 384

Inclusion and Exclusion Criteria

A basic random sample technique was used to randomly select Saudi Arabian nursing students in the internship year nursing staff and to exclude all students before the internship year.

Method for Data Collection, Instrument and Score System

A structured questionnaire was used as a study tool. This tool consists of 41 questions classified into four main sections. Two questionnaires assess self-reported practice and nursing knowledge about pressure injuries, developed by [11] and Attitude toward Pressure Ulcer Prevention instrument (APUP) [12] and demographic data questionnaire.

Scoring Systems

Section one contained 9 questions which are open-ended and close-ended as personal data such as gender, education, participant state and background, department, source of information and last attended training of pressure ulcer.

The second part asked questions on pressure ulcer knowledge and prevention practice regarding pressure ulcers including ten questions, developed by [11].

The rating using a three-point Likert scale. The participants can choose from one of three options: “true,” “false,” or “don’t know.”

The scoring mechanism of the assessment tool involved allocating a point value of 1 for each correct response, while incorrect answers and "I do not know" responses were given a score of 0. The maximum achievable score was 10, which was then multiplied by 10 to yield a maximum total score of 100, which were subsequently categorized as low (<60%), moderate (60-80%) and high (>81%).

The third assessment tool utilized a self-reported scale to assess engagement in good preventive practices regarding pressure ulcers. The questionnaire developed by [11].

Comprising nine items related to pressure ulcer prevention practices, with a 3-point Likert scale scoring system in which "rarely" responses were assigned a score of 1, "sometimes" responses were given a score of 2 and "always" responses were awarded a score of 3, resulting in a possible total score range of 9 to 27. ⁠The highest scores indicate better engagement in good PI preventive practices, while the lower scores indicate poorer engagement. ⁠The raw score was multiplied by 10 and divided by 27 to convert it to a percentage scale out of 100.

The scores were then categorized as follows: Low, less than 60% (less than 16.2 out of 27), moderate: 60-80% (16.2 to 21.6 out of 27) and high: 81% or more (greater than 21.87 out of 27).

Section four is an APUP (Attitude toward Pressure ulcer Prevention instrument) [12] a Likert scale and it is concerned with five important measures, which are personal competency to prevent pressure ulcers, priority of pressure ulcer prevention and the impact of PI, all of them content of 3 items and a high score of 12 of each of them). And the confidence in the effectiveness of prevention and prevention responsibility, the content of 2 items in each with a high score of 8 in both.

Pilot Test

The questionnaire was distributed to 25 people and they were asked to complete it. This was done to test the questionnaire's simplicity and feasibility for the study. The pilot study data was excluded from the study's results.

Analyzes and Entry Method

The collected data was inputted using the Windows version of Microsoft Excel on a computer (2016). After that data was moved to version 20 of the Statistical Package for Social Science Software (SPSS) to be examined statistically. In this study, both descriptive statistics and the chi-square tests were used.

Table 1 displays various demographic parameters of the participants with a total number of (394). Participants of the study are quite young with a mean age of 32.2 Years and 29.4% of them below the age of 26 years. Most participants are staff nurses (70.3%) suggesting that the workforce specialists are those practicing and not students. Of the participants, the large majority are Saudis, as can be seen by the percentage size of 95.4%. Gender is categorized to show that females dominate the nursing profession accounting for 66.5% of the participants while males are 33.5%. Educational attainment also shows a rich variety, the largest number of employees having a bachelor’s degree (53.6%), close to forty percent have postgraduate education and 4 Table 1: Sociodemographic Characteristics of Participants (n = 394) percent have no formal education, which points at a well-educated workforce. Technical expertise also shows differences; 43.1% of the participants have over 11 years of experience, which indicates that the participants may have a great deal of insight. In addition, the majority (86.3%) of the participants have reported that they have learnt about pressure injuries in the past.

As shown in Figure 1, Based on data collected from a total sample of 394 participants, a conspicuous agreement was witnessed on the part played by immobility in the development of pressure injuries among bedridden patients. Specifically, 323 respondents (82%) of all completed questionnaires indicated immobility was the primary factor developing pressure injuries, thus validating this statement. However, only 7 individuals, or about 1.8%, disagreed with the statement, which means the minority doesn’t perceive the huge significance when they cannot move. In addition, 64 who represent about 16.2% were uncertain and there is an area for educational intervention.

Figure 1: Illustrates patients' immobility is the most important factor for pressure injury formation among participants

Table 2: Parameters related to knowledge regarding pressure ulcer care among nurses in Saudi Arabia (n = 394)

Figure 2: Illustrates assessing the patient’s skin and risk factors among participants

Table 2 shows the findings of the study conducted among 394 respondents on Saudi Arabian nurses’ awareness about pressure ulcer care. Strikingly, the majority of 82,0% answered correctly identifying immobility as the most significant factor in pressure injury development in bedridden patients, which implies adequate knowledge of primary risk factors. A schism in the perception of pressure ulcer preventive measures was evidenced by 61.7% nurses who thought that only nurses could contribute to the prevention of the development of such injuries. Although 54.1% of the respondents recognised the pain assessment scale as a risk assessment tool, still a shockingly high 66.0% agreed with the statement that topical creams are the only safe way the soothe patients’ skin, which indicates that participants do not understand comprehensive care plans. In addition, although most of the respondents agreed on the concept of repositioning (69.0%), 53.0% of the respondents failed to realize the need for repositioning even with the use of the air mattresses for prevention.

As shown in Figure 2, These findings detail a significant trend in the frequency with which such patients were assessed each year with data provided from the evaluation of a total sample of 394 patients. It was found that a total of 292 respondents (approximately 74.1% of the total sample), consistently assess the patient’s skin and monitor for risk factors, indicating high compliance with recommended standard of care with the patient. However, 69 participants, or approximately 17.5%, replied that they do this 'Sometimes,’ indicating a potential variability in the consistency by which assessments are done. In addition, 33 persons, or roughly 8.4% of the sample, stated they "Rarely" engage in this essential evaluation which may pose an opportunity for improvement within clinical practices to improve patient outcomes.

As indicated in Table 3, the study captures various practices of the Saudi Arabian sample of 394 nurses with regards to pressure ulcer care. Peculiarly, detailed assessment of the skin and observation of risk factors were admitted by nurses: 74.1% affirmed they ‘‘always’’ did this. Another element of care that voiced high compliance is the documentation of care, where 78, 7% of the respondents reported that they documented all the relevant data. Other dimensions also received comparable attention with 77.2% of the nurses stating that their organization’s teaching plans include the aspect of pain assessment and management

Table 3: Participants’ Practice Regarding Pressure Ulcer Care Among Nurses in Saudi Arabia (n = 394)

Table 4 indicates the general attitude of nurses in Saudi Arabia to pressure ulcer care with participants grouped from 394. However, a vast number of the respondents show confidence in the prevention of pressure ulcers, 54.6% strongly agreed, while 38.6% agreed with the statement. However, the strength of agreement with the statement that their training is adequate for the tasks assigned is somewhat lower: Only 39.1% strongly agree and 14%. Strongly disagree. However, 28.2% of the respondents strongly agreed that pressure ulcer prevention is challenging, a notion that exists among nurses. Furthermore, the majority associate the need for advancement support with pressure ulcer prevention with 61.4% agreeing with this statement on a strong note.

Evaluating the results shown in Table 5 and referring to the role of nurses within this sphere, the authors delineate a possible decline in the level of professional knowledge concerning pressure ulcer care. However, less than one fourth of the nurses that was surveyed achieved a high level of knowledge at 20.3% with a very high proportion of 42.9% having low knowledge. In addition, 36.8% of the respondents had moderate knowledge regarding the subject.

The finding highlighted in Table 6 is impressive meaning that the nurses are practicing adequate care measures in relation to pressure ulcer in accordance to best practices. Among those of the staff with a high level of practice, 289 or 73.4%, it is safe to say that most of the nurses are adequately prepared in the knowledge and skills in fashioning out ways to avoid pressure ulcers and managing the same. On the other hand, the same figures depict that 84 of the nurses has a moderate level of practice, another 21 have a low level of practice.

Table 4: Participants’ Attitude Regarding Pressure Ulcer Care Among Nurses in Saudi Arabia (n = 394)

Table 5: Shows Knowledge Regarding Pressure Ulcer Care Among Nurses Score Results

Table 6: Shows Practice Regarding Pressure Ulcer Care Among Nurses Score Results

Table 7: Shows Attitude Regarding Pressure Ulcer Care Among Nurses Score Results

Analysing the results shown in Table 7, the attitudes of the nurses towards pressure ulcer care can be described as mainly moderate, although the participants in the study provided higher scores. 67,5% of the surveyed nurses demonstrated a moderate attitude, which indicates a high level of knowledge and responsiveness to the practices of pressure ulcer prevention and treatment. On the other hand, 27.2% displayed a high level of attitude suggesting that there are cracks in knowledge or departments’ commitment towards the delivery of optimal care in this key subspecialty of nursing. In addition, 5.3% of respondents had a low attitude level.

Table 8 shows that knowledge regarding pressure ulcer care among nurses has statistically significant relation to participant state (p value = 0.004), age (p value = 0.0001), residential area (p value = 0.0001), current employment status (p value = 0.0001), education (p value = 0.0001), years of experience (p value = 0.0001), department (p value = 0.0001) and previous pressure injury education (p value = 0.004). It also shows statistically insignificant relation to nationality and gender. People with age 26 years or less, working in the ER or operating room, were all associated with a higher knowledge level.

Table 9 shows that practice regarding pressure ulcer care among nurses has statistically significant relation to participant state (p value = 0.006), age (p value = 0.029), residential area (p value = 0.0001), gender (p value = 0.004), education (p value = 0.022), years of experience (p value = 0.029), department (p value = 0.0001) and previous pressure injury education (p value = 0.029). It also shows a statistically insignificant relation to nationality and current employment status. People aged 35 to 37 years, of female gender, working at ER or operating room and working experience of 5 to 10 years were all associated with a higher practice level.

Table 10 shows that attitude regarding pressure ulcer care among nurses has statistically significant relation to nationality (p value = 0.008), residential area (p value = 0.0001), gender (p value = 0.0001), current employment status (p value = 0.0001),

Table 8: Relation between Knowledge Regarding Pressure Ulcer Care Among Nurses and Sociodemographic Characteristics

*p value was considered significant if ≤0.05

Table 9: Practice Regarding Pressure Ulcer Care Among Nurses in Association with Sociodemographic Characteristics

*p value was considered significant if ≤0.05

Table 10: Attitude Level Regarding Pressure Ulcer Care Among Nurses in Association with Sociodemographic Characteristics

*p value was considered significant if ≤0.05

education (p value = 0.0001), years of experience (p value = 0.0001) and department (p value = 0.0001). It also shows statistically insignificant relation to participant state, age and previous pressure injury education. People with age 27 to 34 years, of female gender, working at ICU or CCU and working experience of 5 to 10 years were all associated with a higher attitude level.

The purpose of the present study was to explore the nurses' knowledge and attitudes about pressure ulcer care in Saudi Arabia because pressure ulcer care is an important aspect of nursing practice closely related to the intra and post operative patients that pose a threat to the patient outcome. Pressure ulcers (also called bed sores) are major healthcare problem that can lead to greater morbidity, prolonged hospital stays and higher healthcare costs. What this study finds is a complex relationship between knowledge, attitude and actual practice, strengths and weaknesses in pressure ulcer management by nurses.

This study shows that a majority of nurses in this study had awareness of immobility as a cause of pressure injury and 82% recognize immobility as a principal risk factor. This finding also fits with previous research substantiating the need for knowledge of risk factors for effective prevention strategies. For example, Bulut et al. [13] has highlighted the fact that risk factors understood by nurses are key to identifying the time appropriate interventions to limit pressure ulcers. However, there was a considerable gap in knowledge regarding the sorts of lesson and safety awareness and 61.7% of respondents thought only nurses could prevent these injuries. This may be because of a lack of interdisciplinary collaboration, which is vital to managing complex patient needs, that Kim and Lee [14] underscored that effective prevention of pressure ulcers necessitates a team approach involving a variety of healthcare professionals.

Furthermore, it was found that nurses did recognize the pain assessment scale as a risk assessment tool (54.1%), yet also held the belief (66%) that topical cream application is the only form of skin care. These findings corroborate the findings of Demarré et al. [15]. who found that nurses fell back on superficial practices instead of the comprehensive care strategies. Additionally, although 69 percent of respondents agreed that patients need to be repositioned, 53 percent did not realize that they had to reposition even when using air mattresses. This disconnect between knowledge and practice is also a common theme in the literature, according to Gunningberg, where good theoretical knowledge was found to fail to be translated into adequate preventive measures actually used in practice [16].

For assessment, the study shows that 74.1% of nurses always check patients’ skin for risk factors and hence adhere to care standards. Though the variability of practice, 17.5% reporting inconsistent evaluations, underscores the need for standardized protocols to standardize care delivery. Findings of Nuru et al. [17] corroborate with this inconsistency, finding that the adherence to assessment protocols by nurses can have significant impact on the pressure ulcer prevention outcomes. High too, was documentation of care, 78.7% of respondents documenting that all pertinent data was recorded. Despite this, practices around the use of water filled gloves and creams were more diverse; only 53.6% of nurses report always using these and 63.7% always apply creams. The variability evidenced in this pilot study suggests an opportunity for targeted educational efforts aimed at reinforcing best practices in pressure ulcer care.

Fifty four point six per cent of nurses were attitudinally confident that they could prevent pressure ulcers and 54.6% strongly agreed with this comment. Yet only 39.1 percent felt well trained for their tasks and a quarter admitted pressure ulcer prevention was difficult. Such sentiment is echoed in the work of Yilmazer et al. [18] who found that despite high confidence levels, many nurses said they did not feel prepared to manage prevention of pressure ulcers effectively due to inadequate training. The overwhelming evidence of the need for continued training and professional development programs, supported by 61.4 percent of the participants, also supported the need of further support to develop skills in this area.

The findings of the study showed apparently, only 20.3% of the nurses had high knowledge for pressure ulcer care while 42.9% had low knowledge level. This finding is analogous to the findings from Kopuz and Karaca, who found out that despite their educational qualification, significant number of the nurses had inadequate knowledge about prevention of pressure ulcer [19]. In spite of that knowledge gap, 73.4% of nurses reported high levels of practice in pressure ulcer prevention, which indicates a separation between the knowledge and the practical application of it. It has been documented in many studiesecute such as Moore and Price [20] describe how nurses’ theoretical knowledge may not match their actual behavior in the prevention or management of pressure ulcers.

It was found that age, gender, education and years of experience were significant for related demographic factors in relation to knowledge, practice and attitude towards pressure ulcer care on the basis of statistical analysis. Younger nurses, those working in emergency or operating room sites and female nurses were also found to have higher knowledge levels, whereas nurses with 5 to 10 years' experience reported higher practice levels. The findings of Vrachni et al. [21] contradict with our findings in that they found demographic variables significantly impacted nurses' knowledge and attitudes to pressure ulcer prevention. Overall attitudes of nurses were predominantly moderate with 67.5% of nurses having a moderate attitude towards pressure ulcer care resulting in need of targeted educational interventions for nurses to improve their knowledge and practice in critical area of nursing care.

It should be acknowledged that the limitations of the present study should also be acknowledged. However, the fact that this is a cross-sectional design precludes drawing causal inferences about knowledge, attitudes and practices being related to one another. It also may be based on self reported data and may be biased because people may overestimate their knowledge and practices. Additionally, the study may limit the generalizability of the findings to other contexts because of its focus on a limited geographical region.

Finally, this study's findings emphasize the need for continuing education and support to close gaps of what nurses know and do about pressure ulcer care in Saudi Arabia. Improving patient outcomes and reducing pressure ulcers through higher standards of care in nursing practice is partly accomplished through increased nurses’ understanding and ability in this critical area.

Acknowledgement

We thank the participants who all contributed samples to the study.

Conflicts of Interest

The authors declare that there are no conflicts of interest:

• Informed Consent: Written informed consent was obtained from all individual participants included in the study
• Data and Materials Availability: All data associated with this study are present in the paper

The study did not receive any external funding.

Ethical Statement

An informed consent was obtained from each participant after explaining the study in full and clarifying that participation is voluntary. Data collected were securely saved and used for research purposes only.

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