Knowledge and Practices of Student Nurses towards Prevention and Management of Pressure ulcers in Allied Hospitals of Rawalpindi Medical University

Introduction: Pressure ulcer is a common preventable complication of prolonged hospitalization. Although debilitating, but preventable through timely assessment and proper management. This study was conducted to access student nurse’s knowledge and practices towards the prevention and management of pressure ulcers. Materials and Methods: A cross-sectional study was conducted at Nursing Schools of Holy Family Hospital and Benazir Bhutto Hospital Allied with Rawalpindi Medical University. A pre-tested self-designed questionnaire was filled by 264 students selected through the non-probability convenient sampling technique. Data were analyzed using SPSS 21. P-value <0.01 was considered significant. Results: Mean percentage of Student nurse’s knowledge and practices were 58.7% 69.62% respectively. 21.7% of first-year students, 34.1% of second-year students, and 60.2% of third-year students had good knowledge. Correspondingly, 10.89% of first-year students, 32.9% of second-year students, and 56.2% of third-year students had good practice. There was a significant correlation between knowledge and practices i.e. r value is 0.92, the p-


Introduction
A Pressure Ulcer (PU) also known as Bed Sore is a painful injury to a localized area of the skin and underlying tissues due to ischaemia. 1 It usually occurs over bony prominences because of shear, strain, friction, or pressure. Multiple factors play important roles in the development of PUs. Inadequate nutrition, reduced physical activity, impaired sensory perception, faecal and urinary incontinence, inadequate hydration, and immobility are by far considered the most important factors. 2 Advanced age and presence of multiple co-morbid like Diabetes, Hypertension, and Ischaemic heart diseases are considered secondary risk factors. Although multiple disciplines are involved in Pressure Ulcer management, Nurses play a major role in it as they handle the patients primarily. 3 With better nursing care, this debilitating disease can be managed and prevented. Pressure ulcers are recognized worldwide as one of the most common preventable patient safety problems. 4 Also, pressure ulcers are responsible for 2% of preventable deaths in the world. 5 According to our knowledge, no significant data is available in Pakistan regarding the incidence of Pressure Ulcers. It has been estimated that the cost required for the treatment of Pressure Ulcers is almost thrice the cost of prevention. 6 Only in the United States, 2.5 million cases of Pressure Ulcers are reported annually. 7 The incidence of pressure ulcers in Asian countries is considered quite high, ranging from 2.1% to 31.3% in ICUs. 8 In countries like Pakistan, where resources are limited, PUs significantly increase the hospital workload and financial burden. PUs can be prevented by taking simple, cost-effective, and time-saving measures if only one knows how to implement those measures. This research will provide essential information regarding Nurse's knowledge, practices, and the shortcomings in their curriculum and training program. This will lead to a better understanding and management of one of the grave issues we are currently facing. It will provide future guidance to make better strategies for the dissemination and adoption of preventive measures. The objective of our study is to assess the Knowledge and Practices of Nurses towards the prevention and management of Pressure Ulcers and to correlate their Knowledge with their Practices.

Materials and Methods
A descriptive cross-sectional study was conducted among Student Nurses studying at Nursing Schools of Holy Family Hospital and Benazir Bhutto Hospital Allied with Rawalpindi Medical University. The study population comprised of first, second, and third-year Diploma Student nurses directly dealing with the patients and having at least 5 months of clinical experience. 264 students were included in the study. The sample size was calculated by the WHO calculator. Nonprobability convenient sampling technique was used for data collection. A self-designed pre-tested questionnaire (Annexure attached) was used, consisting of 10 knowledge-based and 10 practice-based questions. A questionnaire was appropriately modified according to the pretested result before actual data collection. In knowledgebased questions, there were 3 options: yes, no, don't know. 'Yes' was taken 'true'; 'No' and 'don't know' were taken 'false' for questions: 1, 2, 4, 9, 10. However, for the rest 5 questions, 'No' was taken 'true'; 'Yes' and 'Don't know' were taken 'false'. A score of '1' was given for 'true' and a score of '0' for 'false'. The maximum knowledge score was 10. In practice-based questions, a score of '1' is given for 'never', '2' for 'sometimes', and '3' for 'always'. The maximum practice score was 30. The questionnaire was distributed among student Nurses in their respective classes after they were briefed about the study and taking informed verbal consent. Data were analysed using SPSS 21. Frequency and percentages were calculated for categorical variables. Mean percentage scores for both total knowledge and practice were calculated. The Chi-square test was applied to find the relation between knowledge and practice of students with their academic year. A correlation was made between knowledge and practice (i.e. r=<0.5 is weak, r=0.5-0.7 is moderate and r=>0.7 is a strong correlation). For all purposes p-value <0.01 was considered to be significant at a 99% confidence interval.

Results
Out of 264 students, 101 (38.3%) were from the first year, 85 (32.2%) from the second year, and 78 (29.5%) from the third year. 90% of the students were 19-21 years old. 10 questions were asked to assess the knowledge of students regarding pressure ulcer prevention. Students who got ≤30% score were considered to have 'poor knowledge', who got 40-60% score were considered to have 'average knowledge' and ≥70% score were considered to have 'good knowledge'. Mean knowledge score ± Standard deviation was 5.87 ± 1.82. Mean percentage knowledge score was 58.78%.   10 questions were asked for practice assessment. Students who got score ≤15 were considered to have 'poor practice', who got score 16-23 were considered to have 'average practice' and who got score ≥24 were considered to have 'good practice'. The mean practice score ± Standard deviation was 20.88 ± 3.76. The mean percentage practice score was 69.62%. The correlation coefficient(r) between knowledge and practice of student nurses was 0.92 i.e. strong correlation a p-value was <0.000 i.e. statistically significant. Figure 1: Scattered diagram showing a strong correlation between overall knowledge and practice of student nurses towards prevention and management of PUs.

Discussion
The main purpose of the study was to assess nurse's knowledge and practices regarding pressure ulcer prevention and management and to find the relation between the two variables if any. Although there are multiple types of research done on this topic internationally, little data is present in Pakistan about this grave condition according to our knowledge. The average age of nurses included in the study was between 19-21 years. The study demonstrated that there is a strong relationship between the knowledge of students and their years of practice. Results showed that 60.2% of 3rd year nursing students had good knowledge while 34.1% students of 2nd year and only 21.7% students of the first year could fall in this category.
Similarly, the practice of student nurses was also impacted by their years of study. 56.2% of student nurses of third-year had good practice i.e. average score above 80% while 32.9% students of the secondyear and only 10.89% student nurses of first-year had good practice scores. These results are evidence that one's practice is strongly impacted by one's knowledge of an issue. These findings are similar to a previous study conducted in General Hospital Lahore in which Nurses showed a low level of knowledge (M=35.2%) and correspondingly poor practices (M=36%) regarding pressure ulcer prevention and management. 9 Another study conducted in Belgium showed that the mean knowledge score of the senior nurses was 29.3% while that of assistant nurses was 28.7%; Attitude scores were significantly different between senior nurses and nursing assistants, Senior Nurses showed to have a more positive attitude towards pressure ulcer prevention than nursing assistants. 10 Another study conducted in Northwest Ethiopia showed that 45.6% of nurses had inadequate knowledge and correspondingly 51.6% had unsatisfactory practices regarding pressure ulcer prevention. 11 A study conducted in Korea in 2015 demonstrated that nurses had a moderate level of knowledge of Pressure Ulcer prevention i.e., 60%. 12 These studies demonstrated a close and strong relationship between years of practice, level of knowledge, and practices about PUs prevention and management. In contrast, A study conducted in Bangladesh demonstrated that although mean knowledge score was poor (M = 57.79%, SD = 9.2%), mean practice score was average (M = 77.55%, SD = 11.00%) among nurses. However, significant data regarding discrepancies like these is not present elsewhere, according to our knowledge. The mean knowledge score of nurses was different in the above-mentioned researches. Knowledge is influenced by different factors i.e. quality of education, years of practice, and type of education system. Also, different hospitals around the globe have different curriculum for nursing students. Furthermore, analysis and evaluation methods may also have a role. Despite these discrepancies, most of the research data points toward a strong correlation between knowledge and practice of nurses regarding pressure ulcers. Every research has its limitation. In this study, a sample was taken from diploma students and not the whole nursing staff, and Practice was not assessed based on observations. Furthermore, the study may have been subjected to response set bias from the respondents. A pressure ulcer is a fulminant but preventable complication of prolonged bed rest, immobility, incontinence, and sensory deprivation. For adequate prevention, we must educate our nursing staff and equip them with significant skills. For this, Workshops and awareness seminars should be arranged for them.
The difference in knowledge and practice of students should be assessed before and sometimes after the sessions in order to evaluate the efficiency of these sessions. Knowledge of attendants of high-risk patients regarding the prevention of pressure ulcers should also be assessed. This study will pave a path for future researches about pressure ulcer prevention and its management. Similar studies should be conducted including the whole nursing staff working in the different hospitals across the country.

Conclusion
Knowledge and practice of Student Nurses towards the prevention and management of PUs were found to be average i.e. in between good and poor. There was a statistically significant correlation between knowledge and practices i.e. better the knowledge, better was the practice of Students. In addition to the topic as part of their routine educational course; arranging seminars, workshops, and awareness sessions regarding the prevention of PUs can have a positive impact on the practice of students by the improvement of their knowledge.