Nursing Students’ Attitudes Toward the Medical Device-Related Pressure Ulcer in Iran

Introduction

In the last definition of pressure ulcer by the National Pressure Ulcer Advisory Panel, a medical device-related pressure ulcer was also added to it.¹ These ulcers are different from the conventional pressure ulcers that occur most often due to immobility and the bony prominence of the body. Medical device-related pressure ulcers are caused by the pressure exerted by the medical devices attached to the patients’ skin.² Because the use of medical devices is often inevitable, it is more difficult and complicated to prevent medical device-related pressure ulcers than conventional pressure ulcers.^3,4 Medical device-related pressure ulcers can cause many problems such as pain, infection, tissue necrosis, and increased costs for the patient, the patient’s family, and health care systems.^3,5 Although some reports regarding medical device-related pressure ulcers have been seen in the scientific literature for about 50 years,⁶ a focus on such ulcers has increased significantly over the past 10 years.^2,7 In a meta-analysis study by Jackson et al, in 2019, the incidence of medical device-related pressure ulcers was reported as about 12%.⁸ Study in Iran about medical device-related pressure ulcers is limited to a few case reports^9–13 and one cross-sectional study. In the only cross-sectional study, Rashvand et al surveyed the incidence of medical device-related pressure ulcer in three hospitals. The incidence of medical device-related pressure ulcers in Rashvand et al's study was reported as 20.5%.² Currently, the occurrence of medical device-related pressure ulcers can be considered as one of the indicators of the quality of nursing and medical care.¹⁴

Final-year nursing students spend adequate time in clinical settings. In addition, they are giving many nursing cares independently, including caring for patients with pressure ulcers or at risk of pressure ulcers. Given the importance of the issue of pressure ulcers, many previous studies have investigated the knowledge, attitude, and performance of nursing students about conventional pressure ulcers.^15–19 Several studies have examined the nursing students’ attitudes toward conventional pressure ulcers; however, to our knowledge, no study has examined nursing students’ attitudes toward medical device-related pressure ulcers. Medical device-related pressure ulcers are different from conventional pressure ulcers. Medical device-related pressure ulcers are caused by the use of a medical device that has put too much pressure on the patient’s skin. The risk factors for conventional pressure ulcers, including immobility, are usually not related to medical device-related pressure ulcers. Also, the intervention for the prevention of conventional pressure ulcers and medical device-related pressure ulcers are different.^1,2 Frequent change of position is the main intervention in preventing conventional pressure ulcers, while other interventions should be used for the prevention of medical device-related pressure ulcers.

Due to the differences between the conventional pressure ulcers and medical device-related pressure ulcers, it is therefore necessary to evaluate the nursing students’ attitudes toward the medical device-related pressure ulcers. Till today, no studies have been conducted on the same topic. Therefore, the present study was conducted to fill this gap and improve knowledge and skill on prevention of medical device-related pressure ulcers.

Materials and Methods

The present study was conducted from May to June 2020. This study was carried out in the two faculties of Nursing and Midwifery in Qazvin and Yasuj. Nursing education in Iran consists of a 4-year course (8 semesters). Students are posted at hospital in the 7th and 8th semesters of nursing. Nursing students in their 5th and 6th semesters also have about 70% of their training practices in a hospital setting.

The study population consisted of all nursing students who were in the 5th, 6th, 7th, and 8th semesters at Qazvin University of Medical Sciences and Yasuj University of Medical Sciences. At the time of the study, about 270 students were studying in the 5th, 6th, 7th, and 8th semesters at the two universities. The convenience sampling method was adopted for the present study. The inclusion criteria for the participants were as follows: 1) those who were studying in 5th or higher semesters; 2) knowledge to access and use of the Internet; and 3) giving informed consent and willing to participate in the study.

First, the study protocol was approved by the Research Deputy of Yasuj University of Medical Sciences. After obtaining the approval code, the researchers went to the education department of Qazvin School of Nursing and Midwifery and Yasuj School of Nursing and Midwifery and received the names and telephone numbers of the students studying in the 5th or higher semesters of nursing. The study was conducted simultaneously with the prevalence of the coronavirus in Iran. Therefore, the questionnaires were distributed through the Web. For smoothing of the study, the electronic version of the questionnaires was designed by the researchers. Students were contacted by telephone and asked to participate in the study. After obtaining verbal informed consent, the questionnaires were sent to the students via email or WhatsApp, and they were asked to fill out the questionnaires as per guidelines. The average time taken to complete the questionnaire was about 5 minutes. Students completed the questionnaires in 5 minutes (approx.).

Tool Consisted of Two Sections for Data Collection

Section 1: Checklist of Demographic Variables

This checklist includes items such as age, gender, semester, education about medical device-related pressure ulcers, receiving sufficient training on medical device-related pressure ulcers, and there was a need to hold training courses on medical device-related pressure ulcers.

Section 2: Attitude Questionnaire Regarding Medical Device-Related Pressure Ulcers

There is no standard tool available which can examine the attitudes toward medical device-related pressure ulcers. Therefore, a tool was designed and tested by the researchers in the present study. For this purpose, first, the texts were reviewed and the psychometric steps of the tool including formal validity, content validity, and structural validity were performed. The content validity ratio (CVR) for each item was above 0.8 and the whole questionnaire was 0.89. Also, the Cronbach’s alpha value (α=0.77) showed an acceptable level of internal consistency of the questionnaire. The attitude questionnaire of medical device-related pressure ulcer consists of 11 questions, which are divided into two dimensions: medical device-related pressure ulcer prevention (6 questions) and medical device-related pressure ulcer care (5 questions). Question responses ranged from 1 (strongly agree) to 5 (strongly disagree). The final score ranged from 11 to 55.

The questionnaire is scored based on the 5-point Likert scale, ranging from 1 to 5. The minimum possible score is 11 and the maximum score is 55. A higher score indicates a more positive attitude toward the pressure ulcer caused by medical equipment. Scores of 11–25 indicate a negative attitude, 26–40 neutral attitude, and scores of 41–55 a positive attitude to medical device-related pressure ulcers. It should be noted that the article related to the questionnaire design is under review in the Wound Prevention and Management Journal.

Ethical Considerations

The present study was approved by the ethical committee of Yasouj University of Medical Sciences (ethical code: IR.YUMS.REC.1398.156). Verbal informed consent was obtained from the subjects to participate in the study. Verbal informed consent was acceptable and approved by the Ethic Committee of Yasouj University of Medical Sciences. Participation in the study was voluntary. Any information obtained in this study that could be identified with participants remained confidential.

Data Analysis

The obtained data were entered into SPSS version 16 software. Tests such as mean, standard deviation, and frequency were used to describe students’ responses to attitude questionnaire items. Pearson's correlation test was used to investigate the relationship between mean attitude scores and the students' mean age. An independent t-test was used to evaluate the difference between the mean scores of attitude score between participants' sex. A P-value of less than 0.05 was considered statistically significant.

Results

A total 187 nursing students participated in the present study. The mean age of the participants was 23.7±3.9. Of 187 nursing students, 101 (54%) were females and 86 were males. With regards to educational semester, 23, 50, 43, and 71 students were in semester 5, 6, 7, and 8. Eighty-eight participants (41.7%) reported that they received training on medical device-related pressure ulcers. A total of 163 participants (88%) stated that their training was not sufficient for medical device-related pressure ulcers. A total of 155 students stated that they need to hold a training workshop on medical device-related pressure ulcers.

The mean score of attitude toward medical device-related pressure ulcers was 42.1±5.2. The mean score of the prevention dimension was 21.8. In this dimension, the highest and lowest scores were related to the items “preventing medical device-related pressure ulcers is not a nurse’s priority” and

“It is more difficult to prevent medical device-related pressure ulcers than conventional pressure ulcers, such as those that occur in the patient’s sacrum due to lying on the bed for long periods“

respectively (Table 1). The mean score of care dimension was 20.2. In this dimension, the highest and lowest scores were related to the items “nurses don’t play an important role in the care of medical device-related pressure ulcers” and “medical device-related pressure ulcers occur only in patients admitted to special wards, such as intensive care unit“ respectively (Table 1). No significant relationship was found between the mean score of the attitude and its dimensions with the student’s demographic variables such as age, sex, semester, training on medical device-related pressure ulcers, and participating in workshops related to medical device-related pressure ulcer (p < 0.05). Table 2 shows this in detail.

Table 1 Students' Responses to Attitude Questionnaire Items

Table 2 Relationship Between Mean Score of Students' Attitude Toward Medical Device-Related Pressure Ulcer and Their Demographic Variables

Discussion

It is important for health care workers to pay attention to medical device-related pressure ulcers. In this study, the attitude of final-year nursing students is assessed toward medical device-related pressure ulcers. The results of the present study showed that nursing students, despite not receiving sufficient education, have a positive attitude toward the prevention and care of medical device-related pressure ulcers.

To our knowledge, no study has examined nursing students' attitudes toward a medical device-related pressure ulcer. This is the first study that examined the nursing students’ attitudes toward medical device-related pressure ulcers. In the present study, the positive attitude of nursing students toward medical device-related pressure ulcers is very valuable. This can positively affect their practice. According to Ajzen’s theory of planned behavior, a person’s performance in a subject is influenced by three factors, one of which is attitude. This theory states that one of the prerequisites for correct behavior and performance is to have a positive attitude in that field.²⁰ By applying the concepts of this theory to the performance of nursing students about medical device-related pressure ulcers, it can be concluded that the nursing students’ attitudes toward medical device-related pressure ulcers can affect their behavior in this regard. Given the positive attitude of nursing students towards medical device-related pressure ulcers, it seems that their proper training during their studies can lead to a very good performance in this field.

The study participants obtained a high score on both dimensions of medical device-related pressure ulcers. However, some issues need to be addressed and students’ attitudes need to be corrected in those areas. Students believed that medical device-related pressure ulcers were more likely to occur in intensive care units. However, previous studies showed that patients in other wards of the hospital are also at risk for such ulcers.² Students also believed that a medical device-related pressure ulcer is not preventable in many cases. Although the use of medical devices is necessary in many cases, it cannot be said that the prevention of such wounds is not preventable in many cases. In this regard, we can apply the recommendations of the National Pressure Injury Advisory Panel to prevent medical device-related pressure ulcer such as not using devices on edematous and damaged skin, choosing the right size of the device, using prophylactic dressing under the devices, assessing the skin under the used device, moving the device over specific periods if possible, such as moving the pulse oximeter probe, and training health care team members about medical device-related pressure ulcers.¹

Another finding of the present study was that more than half of the study participants said that they received no training on medical device-related pressure ulcers. At the same time, more than 80% of the students who received the training stated that the training they received was not enough. In a study conducted in 2018, we examined nursing students’ knowledge and attitude toward conventional pressure ulcers in Qazvin, Iran²¹ and 32% of participants said that they did not receive the necessary training on conventional pressure ulcers, which is less than the amount obtained in the present study. The findings of the present study and the previous study showed that in Iran, less attention has been paid to the training on medical device-related pressure ulcers for nursing students. To our knowledge, the first research study conducted on the medical device-related pressure ulcer in Iran was published in 2019.² It seems that training on medical device-related pressure ulcers, in particular, should be considered by nursing educators and planners in Iran.

Conclusion

Nursing students exhibited a positive attitude toward the prevention and care of medical device-related pressure ulcers; it seems that if they receive enough training in this regard, an important step can be taken to reduce medical device-related pressure ulcers. Given the lack of studies, it is therefore recommended that similar studies can be performed on nursing students. Also, it is necessary to study the knowledge and performance of nursing students about medical device-related pressure ulcers.