Literature Evaluation Table In nursing practice, accurate identification and application of research is essential to achieving successful outcomes. The ability to articulate research data and summari

An observational study Mohammad Y.N. Saleh a,∗ , Panos Papanikolaou b, Omayyah S. Nassar c, Abeer Shahin d, Denis Anthony e aClinical Nursing Department, School of Nursing, The University of Jordan, Amman, JordanbIndependent Investigator of Nursing Issues, 3 Thrush Close Cardi ff, CF3 0PE, UKcMaternal Child Health Department, School of Nursing, The University of Jordan, JordandCommunity Health Nursing Department, School of Nursing, The University of Jordan, JordaneApplied Health Research, School of Healthcare, G20 Baines Wing, University of Leeds, Leeds, LS2 9UT, UK ARTICLE INFO Keywords:

Pressure ulcer Knowledge Pressure ulcer prevention Pressure ulcer treatment Jordan ABSTRACT Aims and objectives: To assess nurses' knowledge on pressure ulcer (PU) prevention and treatment in Jordan, and the frequency of and factors infl uencing nurses’implementation of PU prevention and treatment interventions.

Background: Highly educated and experienced nurses can provide eff ective PU care; however, previous studies highlighted poor knowledge and implementation of PU care.

Design: A correlational study examining nurses ’knowledge of PU prevention and frequency of PU preventive actions in Jordanian hospitals.

Methods: Participants were 377 nurses and 318 patients from 11 hospitals. Data were collected to quantify the frequency of nurses ’implementation of pressure ulcer prevention and treatment interventions for patients suf- fering from PUs and/or at risk of PU development using a self-reported cross-sectional survey and prospective 8- h observation.

Results: For observed PU prevention while type of hospital and number of beds in units were signi ficant it is not known without further work if this is replicable. For observed PU treatment, linear regression analysis revealed signi ficant negative beta values for more than 50 beds in clinical unit ( β= −2.49).

Conclusion: The study addressed new factors, facilitating the provision of prevention and treatment strategies to PU development, including type of clinical institution and number of beds in clinical unit.

Relevance to clinical practice: There is a need to develop training programmes to improve insufficient nurses ’ knowledge and, thus, clinical practices on PU prevention and treatment. These programmes would assist both junior and senior nurses and other key stakeholders (e.g. hospital managers, policy-makers, and educators) to improve the performance of PU services, thus, minimising patient suff ering. 1. Introduction Pressure ulcers (PUs) are a major health problem, resulting in re- duced quality of life [ 1]and demanding resources from healthcare systems worldwide [ 2]. PUs are seen as an outcome of poor-quality nursing care [ 3]; they are largely preventable [ 4] and clinical guide- lines are available to assist clinicians. In 2017, Anthony et al. reported that there were 854 grade 2 –4 PUs in a single year (2015) in Greater Glasgow and Clyde (an area of Scotland with a population of 1.2 mil- lion), of which 48.4% were assessed as avoidable [ 5]. PU rates continue to increase signi ficantly [ 6]in some regions, but not in all. For example, in Germany, total prevalence fell from 12.5% in 2002to 5.0%in2008, probably due to more e ffective PU prevention strategies [ 7]. Differences in PU prevalence among countries may be attributed to di fferences in the risk levels and/or use of di fferent prevention strategies. Halfens et al. [ 8] compared PU prevalence among Austrian, Swiss, and Dutch hospitals. The PU rate was highest among Dutch hospitals which was probably not due to di fferent risk scores as when only at risk patients were considered the rate remained higher. Preventive measures di ffered among the countries and this may be the explanation for di ffering rates.

https://doi.org/10.1016/j.jtv.2019.10.005 Received 10 October 2018; Received in revised form 31 July 2019; Accepted 21 October 2019 ∗Corresponding author.

E-mail addresses: [email protected] (M.Y.N. Saleh),[email protected] (P. Papanikolaou),[email protected] ,[email protected] (O.S. Nassar), [email protected] ,[email protected] (A. Shahin),[email protected] (D. Anthony). Journal of Tissue Viability 28 (2019) 210–217 0965-206X/ © 2019 Published by Elsevier Ltd on behalf of Tissue Viability Society. T 1.1. Nurses‘knowledge about PU prevention and treatment Nurses ’knowledge about PU prevention and treatment is a pre- requisite to undertake e ffective prevention and therapeutic interven- tions of PU and its complications, which can lead to mortality if not treated e ffectively.

Numerous studies on nurses' knowledge about PU management re- vealed contradictory findings. Nurses ’knowledge about PU prevention is a signi ficant predictor of implementing PU prevention in practice (9).

In 2006, Pancorbo-Hidalgo et al. identi fied that about 65% of nurses implemented PU prevention interventions [ 10]. Aslan and Giersbergen [ 11] con firmed that almost 59% of Turkish nurses implemented PU knowledge in clinical practice. Several studies have shown inadequate knowledge about PU pre- vention and treatment, though Demarré et al. [ 12] revealed that knowledge was not a signi ficant independent predictor for applyingPU prevention toat-risk nursing-home residents. Further, a Jordanian study revealed that 73% of nurses had inadequate PU knowledge and skills, leading to ineff ective prevention and implementation plans [ 13]. Saleh et al. [ 14] showed that, although nurses had adequate PU knowledge, their prevention measures were insu fficient. Thus, there is a gap be- tween theory and practice.

Several factors in fluencing knowledge about PU prevention and treatment indicated con flicting findings. For example, despite nurses with bachelor degrees having better knowledge on PU prevention, this was not associated with providing PU prevention [ 15]. One study re- vealed that highly educated nurses demonstrated less knowledge than those with baccalaureate degrees [ 16]. Additionally, nurses working in orthopaedic, trauma, and emergency departments lacked knowledge about PU prevention, classi fication, and management [ 17,18].

1.2. Factors in fluencing nurses ’implementation of PU management Moore and Price [ 19] con firmed that well-educated nurses, having received additional formal training on skin and PU risk assessment, were aware that early actions would reduce the likelihood of PU oc- currence. Insu fficient documentation and training may have impeded their ability to provide e ffective preventive care-plans. Both factors have been repeatedly recognised as important for e ffective nursing [ 20].

Number of unit beds also a ffects PU prevention and practices. For instance, crowding is a common problem in Greek hospitals [ 21]. In Jordan, however, the number of unit beds was not associated with implementing PU prevention and treatment interventions [ 9].

Nurses' characteristics such as gender, age, and experience may in fluence implementing PU prevention and treatment. There are find- ings such as that male nurses showed better knowledge on PU pre- vention [ 13] that remain to be replicated or substantiated. The litera- ture con firmed no associations with nurses' knowledge and implementation of PU care [ 9,11]. Although having more than 10 years ’experience was signi ficantly associated with PU prevention knowledge, work experience was not in fluential in practising better PU prevention [ 15].

International PU prevention guidelines recommend using an estab- lished risk assessment scale (RAS) [ 6]. The purpose of a RAS (e.g. the Braden scale) is to guide nurses' clinical judgement [ 10] to expand the clinical e ffectiveness of PU prevention (e.g. incidence reduction). The predictive capability of nurses' clinical judgement can be augmented by access to structured PU risk assessment activities [ 22]. This might be expected to improve nurses ’clinical e ffectiveness of PU prevention.

RASs, along with advanced PU prevention measures, have been em- ployed recently in Jordan hospitals, which may explain nurses' lack of PU prevention [ 9].

What is most needed is to explore factors in fluencing PU care, to determine the level of knowledge and observe its implementation in clinical practice [ 19]. Thus, the present study was developed to assess nurses ’knowledge and practice of PU prevention and treatment in Jordan and to observe factors associated with PU care in clinical practice.

2. Materials and methods 2.1. Aims This study aimed to assess: Nurses' knowledge of pressure ulcer prevention and treatment.

Frequency of observed implementation of pressure ulcer prevention and treatment in clinical practice.

Factors in fluencing nurses' implementation of pressure ulcer pre- vention and treatment interventions.

2.2. Study design This is a correlational study examining nurses ’knowledge of PU prevention and frequency of PU preventive actions in Jordanian hos- pitals. First, a self-reported cross-sectional survey was undertaken to assess nurses' knowledge of PU prevention and treatment. Next, a prospective 8-h observation quanti fied the frequency of nurses ’PU prevention and treatment interventions for patients su ffering from, or at risk of PUs.

2.3. Sample and setting Inclusion criteria were hospitals in Jordan with 200 or more beds and medical-surgical, and critical care units. Eleven hospitals (6 gov- ernment, 2 university, 1 military, and 2 private) met the inclusion criteria [ 23].

From these, a list of all units with potential PU patients, including medical-surgical, and critical care units was obtained from the nursing directors. Three clinical units per hospital were randomly selected (33 in total). All selected units implemented the Braden RAS as a require- ment for hospital accreditation [ 24].

Nurses working in the selected units were surveyed. The sample consisted of registered nurses with baccalaureate and/or 3-year di- ploma, and associate degree nurses (2-year diploma). All participants were involved in direct patient assessment and PU prevention and treatment. Senior nurses were excluded. Observed patients were adults (18 years and older), and having at least a mild risk of developing a pressure ulcer- Braden score ≤17. We also included any patient suf- fering from PU grade 1– 4according to EPUAP-NPUAP guidelines [ 25], who had been admitted to critical care or medical-surgical unit for at least 24 h, regardless of their Braden score.

2.4. Power calculation A power analysis using G*power [ 26] gave a required sample size of128 for an independent groups t-test. This figure used power = 0.80, α = 0.05 (2-tailed) and e ffect size = 0.5 (medium e ffect). A sample of 377 nurses and 318 patients was achieved.

2.5. Measures 2.5.1. Nurse demographics and professional characteristics Nurses ' characteristics included gender, age, education, having postgraduate education, experience, hospital type, type of clinical unit number of unit beds, knowledge about PU, having PU training, using PU RAS and PU classi fication system involvement in PU research, and whether they agree with EPUAP-NPUAP's [ 25]definition of PU.

2.5.2. Patients ’demographics Observed patients ’characteristics included gender, age, hospital M.Y.N. Saleh, et al. Journal of Tissue Viability 28 (2019) 210–217 211 type, length of stay, previous hospitalisation, medical diagnosis, and level of PU risk using the Braden scale.

2.5.3. Nurses‘knowledge and implementation of PU prevention and treatment In the first part of the study a questionnaire collected data about Jordanian nurses ’knowledge and practice of PU prevention and treat- ment, based on previous works [ 9,21, 27] and EPUAP-NPUAP's PU prevention and treatment recommendations (6, 25). An initial 60-item questionnaire was subjected to validation by researchers and expert nurses (n = 10), assessing comprehensiveness, clarity, avoidance of ambiguity, and content validity. This involved circulating the draft items until there was consensus on content, order, and wording. The questionnaire contained the following subscales:

PU prevention: 16 interventions considered e ffective/ine ffective according to EPUAP-NPUAP [ 6,25] guidelines and expert panel.

PU treatment: 29 interventions considered e ffective/ine ffective ac- cording to EPUAP-NPUAP [ 6,25] guidelines and expert panel.

For each intervention, participants were asked to indicate its degree of appropriateness according to their knowledge (yes = 1/no = 0).

Eleven items were reverse-coded ( Appendix 1). The total knowledge index scores were reached by adding positive responses in both sub- scales. Cronbach's alpha reliability was as follows: total instru- ment = 0.61, prevention knowledge subscale = 0.47, treatment knowledge subscale = 0.62, observed prevention subscale = 0.61, and observed treatment subscale = 0.71.

The questionnaire was piloted using a sample of 40 nurses after gaining ethical approval. Thirty-two questionnaires were received.

Afterwards, some items were reworded for clarity and the questionnaire was revised to combine similar items and remove misleading or re- peated items. The pilot sample was excluded from the main study.

2.5.4. Observed PU prevention and treatment In the second part of the study, the items assessing nurses' knowl- edge in the first part were used to formulate an observational checklist to measure nurses' implementation of prevention and treatment inter- ventions in clinical practice. For each item, the observer assessed nurses ’performance assisting patients with and/or at risk of PU as follows: always = 2, sometimes = 1, never = 0.

The Braden scale was used to determine the risk of PU occurrence (cut-o ffscore ≤17). EPUAP-NPUAP's classi fication system [ 6,25 ] was applied to distinguish those patients with PU. These checklists were assessed through an inter-rater reliability index. Two trained nurses assessed the performance of one nurse caring for a patient with grade 3PU. These nurses showed an almost 0.90 intra-class correlation coef- fi cient in scoring checklist items and were in agreement with the re- searchers' (Tissue Viability Nurse Specialist) assessment.

2.6. Ethical considerations Ethical approval was sought and granted by the Research and Ethics Committee at the School of Nursing, The University of Jordan, and the Research and Ethics Committee of each participating hospital.

Participation was voluntary. The anonymity and con fidentiality of both nurse and patient participants were ensured by assigning identi fication numbers to participants, restricted to the research team. The ques- tionnaire contained detailed information about the study's objectives, and returned questionnaires implied consent. Written consent was obtained from patients involved in the ob- servation. Patient participants could choose to leave the study at any time, or they could refuse participation and/or inspection for PU de- velopment. 2.7. Data collection 2.7.1. Survey of knowledge A detailed explanation of the study was presented to senior nurses at participating hospitals. A list of available nurses was prepared by se- lected hospitals one day before data collection. Questionnaires were distributed to nurses by the researchers via departmental managers and charge nurses. Each questionnaire had a covering letter explaining the study, its aims, and how to complete and return the form. Self-com- pleted questionnaires were returned in a sealed envelope to the re- searchers.

2.7.2. Observation When the self-reported questionnaires were collected from partici- pants, observational checklists were used to measure nurses' im- plementation of PU prevention and treatment interventions. The ob- servation procedure was implemented in nursing units that had completed the survey. The 8-h prospective observation of nurses' per- formance with patients showed that flexibility, consistency, and ade- quacy of PU prevention and treatment interventions were applied in clinical settings. Each nurse participant was observed separately.

Observation followed an arranged plan with unannounced visits to participating units. To reduce observational bias, 10 nurses were trained for two weeks on the EPUAP-NPUAP [ 6,25] grading system, Braden scale for PU risk assessment, EPUAP guidelines for PU preven- tion and treatment, and using the observational checklists. Trained nurses reviewed patients' medical records to document patients ’de- mographic data and identify eligibility.

Observed nurses who performed care with patients were aware of the observers ’presence but not their speci fic tasks [ 28].

2.8. Data analysis Items that were not practice-recommended were reverse-coded ( Appendix 1). Total scores were computed for prevention knowledge, treatment knowledge, observed PU prevention, and observed PU treatment. Dependent variables were observed PU prevention and ob- served PU treatment (both normalised 0 –100). Independent variables were type of clinical unit (medical-surgical or critical care), institution, number of beds in ward/unit, years of experience, basic education, higher education (yes/no), length of time since last attended PU training session, involvement in PU research (yes/no), knowledge sources about PU, using RAS (yes/no), agreement with de finition of PU, PU grading (yes/no), and demographics (gender, age). Also, knowledge of prevention/treatment was calculated (normalised 0 –100).

Univariate inferential tests were used to determine variables that may in fluence observed PU prevention/treatment (dependent vari- ables). Both were roughly normally distributed by visual inspection using histograms. Finally, linear regression analysis was employed to show associations of independent variables found to be signi ficant under univariate analysis, on observed implementation of PU preven- tion and PU treatment. Additionally, knowledge of prevention was added as a covariate for observed PU prevention, and knowledge of treatment was added as a covariate for observed PU treatment.

Signi ficant results were examined at α= 0.05 (2-tailed) probability, and the beta showed the strength of the relationship between the de- pendent and independent variables.

3. Results 3.1. Descriptive statistics Of 460 questionnaires distributed, 377 were returned (Response rate = 81.9%). In addition, of 360 eligible patients, 318 were observed for PU prevention and treatment intervention (Response rate = 88.3%).

Demographic data of nurse participants are presented in Table 1and M.Y.N. Saleh, et al. Journal of Tissue Viability 28 (2019) 210–217 212 observed patients' characteristics are presented inTable 2. Knowledge sources about PU were largely from formal education or in-service education. Most nurses (89.9%, n = 339) were not involved in research activities on pressure ulcers. Only 34.2% stated using RAS. About 90% of participants (n = 335) agreed on the defi nition of PU and 49.6% acknowledged using the EPUAP-NPUAP classi fication system. Re- garding observed patients, about 168 (52.8%) were aged ≥60 years and most (89.9%, n = 286)had previous hospitalisation. Half had a short length of stay, for 1– 3 days (52.5%, n = 167), and 218 (68.6%) had mild to moderate risk of PU development. Sixty-six percent and 79% of nurse participants disagreed with using ‘doughnuts ’and ‘mas- sage ’, respectively, yet 32% said they always use'doughnuts'to prevent pressure ulcers.

The knowledge and observed implementation scores are shown in Tables 3 and 4. Table 5showsknowledge and implementation indices of PU prevention and treatment. Results showed less than satisfactory knowledge on PU prevention and treatment (74.5% and 72.6%respec- tively, where we would hope to have at least 80%) and very inadequate implementation of PU prevention and treatment (49.2% and 44.9%, respectively).

3.2. Univariate analysis Institution was signi ficantly associated with observed prevention and treatment interventions (p = 0.001), with the military hospital having higher implementation than governmental, university, or pri- vate hospitals in both cases. Type of clinical unit, namely critical care, was signi ficant for observed prevention (p = 0.007), but not signi ficant for observed treatment. Gender was not signi ficant for either im- plementations, nor were experience, age, basic education, knowledge sources, last attended PU training, involvement in PU research, agree- ment with PU defi nition or PU classification. Higher education was signi ficant for implementing treatment (p = 0.005), but was not sig- ni ficant for prevention. Using RAS was signi ficant for treatment (p = 0.031), with higher implementation for those employing a RAS.

Number of beds was signi ficant for both prevention and treatment (p = 0.001 and p = 0.018), with units having fewer beds experiencing higher implementation than larger units in both cases.

3.3. Regression analysis Linear regression used observed prevention as the dependent vari- able. Independent variables included institution, type of clinical unit, number of beds in unit, and knowledge about PU prevention, all were signi ficant under univariate analysis. All categorical independent vari- ables were dummy coded, except for knowledge of prevention. This gave signi ficant negative beta values for the type of institution (uni- versity and private hospitals) and signi ficant positive association for the number of beds in unit (10 –20 beds) ( Table 6).

For observed treatment ( Table 7), linear regression used observed treatment as dependent and independent variables were those sig- ni fi cant under univariate analysis-institution, higher education, using RAS, number of beds in unit, and knowledge about PU treatment. All independent variables were dummy coded, except for treatment knowledge. This gave signi ficant negative beta values for institution (governmental and private hospitals) and also for number of beds in unit (> 50 beds). Table 1 Nurse Participant's characteristics (N = 377). N% Institution Governmental 133 35.3 University 86 22.8 Private 66 17.5 Military 92 24.4 Unit Medical-surgical 175 46.4 Critical care 202 53.6 Unit Beds M=22 SD = 14 R = 5-64 Less than 10 101 26.8 10 –20 102 27.1 21 –30 53 14.1 31 –40 94 24.9 41 –50 3 0.8 More than 50 16 4.2 Experience in Years Less than 1 year 78 20.7 1–4 140 37.1 5 –10 103 27.3 11 –15 32 8.5 16 –20 14 3.7 More than 20 years 10 2.7 Gender Male 189 50.1 Female 188 49.9 Age (years) M = 27.4 SD = 4.5 R = 21-50 21 –26 207 54.9 27 –32 125 33.2 33 –38 31 8.2 39 –44 12 3.2 45 –50 2 0.5 Basic Education BsC 329 87.3 Diploma 3 years 32 8.5 Associate Degree 2 years 15 4.0 Higher education Yes 63 16.7 No 314 83.3 Source of knowledge University Degree 178 47.2 In service education 43 11.4 Conference attendance 4 1.1 Product Promotion 24 6.4 Degree plus in service education128 34.0 Last attended PU training Less than one year ago 113 30.0 1–2 years 57 15.1 More than 2 years 70 18.6 Never attended 136 36.1 Using RAS Yes 129 34.2 No 248 65.8 Involved in PU research Yes 38 10.1 No 339 89.9 Agreement with PU de finition Disagree 42 11.1 Agree 335 88.9 Availability PU classi fication (Grading) Yes 187 49.6 No 190 50.4 M = Mean, SD=Std. Deviation, R (Range) = Min-Max. Table 2 Observed patient's characteristics (N = 318).

Patient's Characteristics n (%) Institution Governmental126 (39.6%) University 80 (25.1%) Private 31 (9.7%) Military 81 (25.5%) Gender Male204 (64.1%) Female 114 (35.8%) Age (in years) 18–39 69 (21.7%) 40 –59 81 (25.5%) 60 –69 82 (25.7%) 70 –79 64 (20.1%) 80 –89 18 (5.7%) ≥ 90 4 (1.2%) Length of stay 1 day-3 Days167 (52.5%) 4 days –6 days 83 (26.1%) 1 week –29 days 49 (15.4%) 1 month-6 months 19 (5.9%) > 6 Months 0 (0.0%) Previous hospitalisation Yes286 (89.9%) No 32 (10.1%) Diagnosis Medical-surgical197 (61.9%) Critically ill 121 (38.01%) Level of PU risk using Braden scale ≤9 (Severe risk) 57 (17.9%) 10-12 (High risk) 43 (13.5%) 13-14 (Moderate risk) 61 (19.2%) 15-17 (Mild risk) 157 (49.3%) M.Y.N. Saleh, et al. Journal of Tissue Viability 28 (2019) 210–217 213 Table 3 Assessed level of prevention knowledge and the actual preventive care provided.

PU prevention knowledge and implementationPrevention knowledge Prevention Implementation Yes (%) No (%) Never (%) Sometimes (%) Always (%) 1. Assess pressure ulcer using risk assessment scale suchas The Braden scale 71.1 28.9 24.9 54.420.7 2. Inspect and document skin condition on daily basis (basically areas at risk and bony prominences such as the Sacrum) for dryness, cracking, erythema (redness), maceration, Fragility, heat and induration. 90.2 9.8 3.7 92.8 3.5 3. Avoid excessive friction (rubbing) and/or friction over bony prominences in patient's movements 88.1 11.9 5.0 94.2 0.8 4. Avoid excessive moisture due to incontinence, perspiration, wound drainage and maintain skin clean and dry. 90.5 9.5 0.8 97.9 1.3 5. Assess, support and maintain nutritionally compromised patients.For example, the need for NGT feeding and serum Albumin level. 85.9 14.1 22.3 77.2 0.5 6. Maintain patient's activity (outside the bed) and mobility (within the bed)according to patient's health condition 92.3 7.7 21.2 76.4 2.4 7. Reposition those patients at risk frequently and on regular basis (if it is safe to do so) 92.8 7.2 0.0 87.013.0 8. Use pillows, foam wedges to relief pressure over bony prominences such as knees, or heels 91.5 8.5 1.9 95.82.3 9. Use principles of safe manual handling during transfer and/or positioning of the patient 90.5 9.5 0.0 97.82.2 10. For those patients seated on chair, they should not exceed 2 h out of the bed 80.1 19.9 5.9 72.321.8 11. Encourage patients to reposition themselves and redistribute weight every 15 min (if this possible) 81.2 16.2 13.0 49.9 37.1 12. Educate nurses and/or care givers the principles of pressure ulcer prevention 88.1 11.9 10.1 88.51.4 13. aUse skin barrier creams to protect reddened skin 13.3 86.7 2.4 91.06.6 14.aUse alcohol solution on the skin 55.4 44.6 37.6 62.40.0 15.aUse donuts-type devices to relieve pressure on areas at risk 34.0 66.0 15.6 52.531.9 16.aMassage reddened areas and/or bony prominences is helpful in pressureulcer prevention 21.0 79.0 10.1 86.23.7 aReverse-coded items. Table 4 Assessed level of knowledge of implementation and the actual treatment implemented.

PU treatment knowledge and implementation Treatment knowledge PU Treatment Implementation Yes (%) No (%) Never (%) Sometimes (%) Always (%) 1. Existence of appropriate pressure ulcer de finition 82.5 17.5 6.1 81.412.5 2. Using valid classi fication system that de fine pressureulcer into four stages (grades) 70.0 30.0 7.5 85.76.8 3. Full assessment and documentation of a pressure ulcer included (location, size, grade, wound bed, exudates, pain, surrounding skin, and undermining) on daily or weekly basis 84.9 15.1 1.6 92.8 5.6 4. Re evaluate a pressureulcer as the patient's condition deteriorates 85.9 14.1 4.2 93.42.4 5. Performing complete physical examination for those patients who are newly developed pressureulcer 82.8 17.2 11.7 84.1 4.2 6. Assess and manage nutritional needs of patients who developed or at risk of pressure ulcer development suchas food ingestion 84.1 15.9 3.7 94.4 1.9 7. Assess for and manage pain related to pressureulcer development 89.7 10.3 1.9 98.10.0 8. Educate nurses and caregivers on pressure ulcer management 85.9 14.1 1.9 95.82.3 9. Manual repositioning ofthe patient of at least 3 h 83.3 16.7 8.8 91.20.0 10. Using special devices inpatient's repositioning suchas sliding sheet, sliding board and/or hoist 68.2 31.8 10.1 58.431.5 11. Assess patient's bed or chair for safety, mobility, and comfortability 88.3 11.7 1.6 96.02.4 12. Avoid positioning of the patient on a developed pressure ulcer 63.7 36.3 22.8 77.20.0 13. Apply pressure ulcer relief, reduction, or redistribution devices such alternating air mattress (bed), low air loss system, foam overlays, gel pads,and/or air fluidized beds 81.4 18.6 2.1 91.2 6.7 14. Debridement (removal of dead tissues) of necrotic tissues using surgical (scalpel), enzymatic agents, and/or hydrocolloid hydrogel dressings 84.1 15.9 1.9 93.9 4.2 15. Clean a pressure ulcer using normal saline 0.9%solution 89.9 10.1 2.1 97.30.6 16. Cover a pressure ulcer with moist primary dressings such as hydrocolloids 76.4 23.6 20.7 77.41.9 17. Wound dressing proto colplanned and supervised by Tissue Viability Nurse Specialist (TVNS) 67.4 32.6 39.6 33.227.2 18. Assess for signs and symptoms of pressure ulcer wound infection such as purulent discharge, odor, pathology findings, and/or osteomyelitis 89.1 10.9 3.2 96.8 0.0 19. Apply aseptic technique (hand washing, sterile dressing) in caring those patients who are having infected pressure ulcer or with signs and symptoms of osteomyelitis 91.8 8.2 1.6 98.4 0.0 20. Collaborate with healthcare professionals to provide adjunctive therapies relevant to pressure ulcer care such as electrotherapy, hyperbaricoxygenation, or laser therapy 60.5 39.5 30.9 43.4 25.7 21. Obtain Tissue culture for infected pressure ulcer 83.2 16.8 26.6 57.815.6 22. aUsing antiseptics frequently to clean pressure ulcer wound suchas iodine povidine, H2O2,chlorohexidine 27.6 72.4 38.0 62 0.0 23.

aDry dressing used ona pressure ulcer such as drygauze or iodine soakedgauze 22.5 77.5 30.9 69.10.0 24.aChange dressing on daily basis regardless the condition of the wound bedand findings of wound assessment 24.4 75.6 7.8 92.2 0.0 25.

aUse topical antibiotics on pressure ulcer with signs of infection 10.1 89.9 18.6 81.40.0 26. Antibiotics are prescribed according to the results of swab culture in an infected pressure ulcer 88.1 11.9 2.2 96.8 1.0 27.

aUse alternative methods in pressure ulcer treatment such as (honey, heat, or other preparations) 57.5 42.5 55.3 22.3 22.4 28.aLeave the necrotic (dead) tissues with nodebridement on ulcers without signs of infection 43.2 56.8 62.8 37.20.0 29.aUse the same type of dressing for all ulcers 36.9 63.1 38.8 61.20.0 aReverse-coded items. M.Y.N. Saleh, et al. Journal of Tissue Viability 28 (2019) 210–217 214 4. DiscussionThe present study assessed nurses ’knowledge and practice of PU prevention and treatment in Jordan and explored factors associated with PU care in clinical practice. Pressure ulcer care was better in the military hospitals, but with only one military hospital included it is di fficult to interpret this result – it may just be that the particular military hospital has high standards not generalizable to other military hospitals. The number of beds in clinical units was only signi ficant for pre- vention interventions for units with 10– 20 beds, neither more nor fewer were signi ficant (though 31– 40 beds approaches signi ficance) and it is possible this result is not replicable. For treatment interventions only beds > 50 was signi ficant. A previous study found no such relation with bed size [ 9]. This may be attributable to limited nursing resources in clinical units with more beds (and far more beds than would be typical in most countries). . Nurses have less than adequate knowledge of PU prevention and very inadequate implementation of PU care. There is a need to increase pressure ulcer training both in nurse education and continuing educa- tion after graduation.

Our study revealed that more educated nurses did not provide better PU treatment. However, highly educated nurses were aware that un- dertaking early actions would reduce the likelihood of PU [ 19].

Training and documentation are recognised as being essential for pro- viding PU care [ 20]. A consideration is the mismatch between supply and demand for highly educated nursing services (19). Additionally, anecdotal evidence suggests that more educated nurses undertake less hands-on care. Poor knowledge of managing PU complications by highly educated nurses was evident compared with those holding a baccalaureate degree [ 16]. Additionally, highly educated nurses may have insu fficient clinical experience; in Jordan, many degree-level nurses continue with postgraduate education at the expense of clinical experience. We suggest that the recent use of RASs (the Braden scale) and clinical employability of PU defi nition and PU staging in Jordan may orient nurses to organise clinically e ffective PU prevention plans. Most nurses agreed with the latest defi nition of PU and that using structured RAS was signi ficant for PU treatment. But no predictive value was evident regarding their impact on undertaking e ffective PU prevention and treatment. A higher Braden score may increase use of PU preven- tion and treatment activities, though there is no evidence that using such scales reduces pressure ulcer incidence. In addition, the validity and reliability of frequently used RASs for PU are questionable due to limited evidence regarding their usefulness [ 22]. However, the pre- dictive capability of nurses ’clinical judgement can be augmented through access to structured PU risk assessment activities. Besides, the usefulness of a structured RAS has no clinical signi ficance once the PU has developed [ 29].

Our study found no in fluence of nurses ’demographics (e.g. age, gender) on their likelihood of undertaking PU care activities. The lit- erature suggests that neither demographics nor experience infl uence PU care [ 30].

4.1. Limitations to the study The observed data on nurses' knowledge were self-reported. The observation approach was applied to at-risk patients and the PU in- terventions were examined. Yet, the unplanned observations were ex- clusive of the prevention and treatment care provided —not all PU in- terventions provided to at-risk patients could be observed. Further, the 8-hourobservation interval may have missed observing changes on patients ’skin and PU interventions.

The questionnaire and its content validity have not been tested other than by its piloting and the team of experts, respectively. Also, familiarity of ward nurses with the investigator may have biased their use of PU management interventions.

5. Conclusions PU treatment is less good in units with > 50 beds which leads one to consider that work load, occupancy rate, availability of resources, and nurse –patient ratios essential to plan e ffective PU care may be di fferent in these units. Additional investigation is required to shed light on the theory –practice gap, perhaps through an experimental approach, to Table 5 Nurses' knowledge index and implementation index of PU prevention and treatment.

Index M SD Min - Max Percentiles 25th 50th 75th Knowledge of PU Prevention 74.5 11.1 31–100 68.7 75.0 81.2 Knowledge of PU treatment 72.6 11.0 38–93 65.5 75.8 79.3 Observed implementation of PU prevention 49.2 8.1 34 –78 43.7 50.0 56.2 Observed implementation of PU treatment 44.9 6.9 29 –64 41.3 43.1 48.2 M = Mean, SD=Std. Deviation.

Table 6 Regression analysis of observed PU prevention interventions (obtained from linear regression using enter method). B Std. Error Standardized Beta t P Value a (Constant) 54.3 3.30 16.4 < 0.001 a Knowledge of PU prevention − 0.01 0.04 −0.02 −0.36 0.711 University Hospital − 4.37 1.32 −0.23 −3.31 0.001 a Private Hospital −3.67 1.48 −0.17 −2.57 0.011 a Military Hospital 0.34 1.44 0.01 0.23 0.812 Critical Care unit −1.21 1.33 −0.07 −0.91 0.362 Number of unit beds < 10 1.8 1.55 0.10 1.17 0.240 10 –20 3.7 1.33 0.21 2.77 0.006 a 21–30 2.9 1.59 0.12 1.83 0.06 41 –50 0.93 4.60 0.13 0.202 0.84 > 50 2.0 2.29 0.05 0.874 0.38 aRegression analysis of PU observed prevention intervention final model produced at a = 0.05, F = 3.65, P < 0.001, R 2= 0.32. Table 7 Regression analysis of observed PU treatment interventions (obtained from linear regression using enter method). B Std. Error Standardized Beta t P Value a (Constant) 44.12 2.66 16.57 < 0.001 Knowledge of PU treatment 0.029 0.034 0.045 0.84 0.39 Governmental Hospital - 7.24 1.009 - 0.493 −7.19 < 0.001 a University Hospital − 2.28 1.25 −0.190 −1.899 0.059 Private Hospital −8.51 1.399 −0.422 −6.08 < 0.001 a Having higher education 0.34 1.006 0.018 0.339 0.735 Using RAS 0.41 0.88 0.027 0.46 0.645 Number of unit beds < 10 1.33 1.01 0.084 1.31 0.19 21 –30 0.38 1.26 0.019 0.30 0.76 31 –40 −1.63 1.09 −0.103 −1.49 0.13 41 –50 −0.30 3.78 −0.004 −0.07 0.93 >50 −5.00 2.04 −0.147 −2.49 0.013 a aRegression analysis of observed PU treatment intervention final model produced at a = 0.05, F = 8.801, P < 0.001, R 2= 0.508. M.Y.N. Saleh, et al. Journal of Tissue Viability 28 (2019) 210–217 215 improve the transformation of knowledge into practice.

5.1. Relevance to clinical practiceSigni ficant gaps of knowledge were identi fied on skin assessments, risk assessment procedures, and management strategies regarding nurses' views towards PU care policies. Therefore, there is a clear need to develop training programmes to improve the clinical utility of nurses' knowledge regarding PU prevention and treatment. These training programmes would assist both junior and senior nurses (e.g. nurse managers) and other key stakeholders (e.g. hospital managers, policy- makers, and educators) to improve PU prevention and treatment ser- vices, thus minimising patients ’su ffering. One form of training would be to arrange courses regarding the e ffective management of PU and its complications. At ward level, senior nurses would update junior sta ff, while promoting best practice. Another form would be to introduce a simulation-based training system for di fferent stages of PU manage- ment, such as debridement of a deep ulcer.

Regular updates on best practice should be shared among ward sta ff and newcomers to ensure excellent standards are maintained, reducing the theory –practice gap and the time-lag between research findings and implementation. Consequently, the well-being of patients and their families would improve, and there would be long-term cost-savings for healthcare organisations due to reduced patients ’stays.

This study's practice implications move beyond the speci fic nursing specialty (i.e. PU management) and are applicable to other specialties.

In palliative care, it is imperative to provide lifelong training to nurses to bridge the theory –practice gap and well-recognised strategies ad- dress this issue (e.g. use of a nurse-link) [ 31]. Similar activities help to improve the translation of knowledge into practice in other specialties (e.g. paediatric nursing) and geographical areas (e.g. Pakistan) [ 32].

Funding This research has been funded by Deanship of Scienti fic Research at the University of Jordan.

Declaration of competing interest No con flict of interest for any of the authors.

Appendix 1. Description of the reverse-coded items used in the analysis Prevention interventions Item no. 13: Use skin barrier creams to protect reddened skin Item no.14: Use alcohol solution on the skin.

Item no.15: Use donuts-type devices to relieve pressure on areas at risk.

Item no. 16: Massage reddened areas and/or bony prominences is helpful in pressure ulcer prevention.

Treatment interventions Item no. 22: Using antiseptics frequently to clean PrU wounds (e.g. iodine providing, H2O2, chlorohexidine).

Item no. 23: Dry dressing used on a PrU such as dry gauze or iodine soaked gauze.

Item no. 24: Change dressing on daily basis regardless of the condition of the wound-bed and findings of wound assessment.

Item no. 25: Use topical antibiotics on PrU with signs of infection Item no. 27: Use alternative methods in PrU treatment such as (honey, heat, or other preparations) Item no. 28: Leave the necrotic (dead) tissues with no debridement on ulcers without signs of infection Item no. 29: Use the same type of dressing for all ulcers.

Source: Original items as adapted from the tool (Saleh et al., 2013).

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