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Original Article

Knowledge and Attitudes of Nurses on PressureUlcer Prevention: A Cross-Sectional MulticenterStudy in Belgian Hospitals

Dimitri Beeckman, RN, PhD, Tom Defloor, RN, PhD, Lisette Schoonhoven, RN, PhD, Katrien Vanderwee, RN, PhD

A B S T R A C TBackground: Evidence-based guidelines for pressure ulcer prevention have been developed and pro-

moted by authoritative organizations. However, nonadherence to these guidelines is frequently reported.Negative attitudes and lack of knowledge may act as barriers to using guidelines in clinical practice.

Aims: To study the knowledge and attitudes of nurses about pressure ulcer prevention in Belgianhospitals and to explore the correlation between knowledge, attitudes, and the application of adequateprevention.

Methods: A cross-sectional multicenter study was performed in a random sample of 14 Belgianhospitals, representing 207 wards. Out of that group, 94 wards were randomly selected (2105 patients).Clinical observations were performed to assess the adequacy of pressure ulcer prevention and pressureulcer prevalence. From each participating ward, a random selection of at least five nurses completedan extensively validated knowledge and attitude instrument. In total, 553 nurses participated. A logisticregression analysis was performed to evaluate the correlation between knowledge, attitudes, and theapplication of adequate prevention.

Results: Pressure ulcer prevalence (Category I-IV) was 13.5% (284/2105). Approximately 30%(625/2105) of the patients were at risk (Bradenscore

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Pressure Ulcer Prevention

INTRODUCTION

Pressure ulcers are painful, costly, and often preventablecomplications that threaten many individuals in hos-pitals, nursing homes, and home care (Hopkins et al. 2006;Spilsbury et al. 2007). A prevalence study in 2008 indicated

an overall prevalence (Category I-IV) of 12.1% in Belgianhospitals. Only 10.8% of the patients at risk received fullyadequate prevention in bed as well as while seated (Deflooret al. 2008). In 2001, the National Pressure Ulcer AdvisoryPanel (NPUAP) reported a prevalence (Category I-IV) of15% in acute care hospitals in the United States (NationalPressure Ulcer Advisory Panel 2001). Pressure ulcers areassociated with high morbidity and mortality rates, in-creased hospitalization, and increased use of health careresources (Hopkins et al. 2006; Essex et al. 2009; Goreckiet al. 2009; Lardenoye et al. 2009). Individuals with activ-ity/mobility limitations are at risk of developing pressureulcers. These individuals include the elderly, patients whoexperienced physical trauma, patients with spinal cord in-

juries or fractured hips, those in long-term care homes orcommunity care, the acutely ill, and patients in intensivecare (European Pressure Ulcer Advisory Panel & NationalPressure Ulcer Advisory Panel 2009).

Interventions to prevent pressure ulcers should focuson the reduction of the amount and/or duration of pres-sure and shear (European Pressure Ulcer Advisory Panel &National Pressure Ulcer Advisory Panel 2009). Preventionin individuals at risk should be provided on a continu-ous basis during the time that they are at risk (EuropeanPressure Ulcer Advisory Panel & National Pressure Ul-

cer Advisory Panel 2009). The application of an appropri-ate support surface, combined with correct repositioningis recommended (Royal College of Nursing and NationalInstitute for Health and Clinical Excellence 2005). Heelsshould be free of all pressure because they are particularlyvulnerable to pressure injury (European Pressure UlcerAdvisory Panel & National Pressure Ulcer Advisory Panel2009; Heyneman et al. 2009). The plantar surface of theheel is well adapted to resisting the forces of standing andambulation but the posterior heel is not because it is cov-ered with only a thin layer of fat and skin. Specific devicesshould be placed to elevate the heel so as to distribute the

weight of the leg along the calf without putting pressure onthe Achilles tendon (Donnelly 2001; Wong & Stotts 2003).A wedge-shaped, bedwide, viscoelastic foam cushion or apillow can be used for this.

Evidence-based guidelines for the prevention of pres-sure ulcers have been developed widely and have beenpromoted by programs and campaigns of authoritativeorganizations. However, nonadherence to pressure ul-cer guidelines is reported frequently (Hill 1992; Halfens

& Eggink 1995; Wilkes et al. 1996; Panagiotopoulou& Kerr 2002; Meesterberends et al. 2010; van Gaal etal. 2010). Many barriers may influence complianceornoncompliancewith a guideline (van Gaal et al. 2010).It is expected that negative attitudes and lack of knowl-edge act as barriers to using guidelines in clinical practice(Ajzen & Madden 1986; Grol & Wensing 2004; van Gaalet al. 2010).

The number of studies on attitudes of nurses towardpressure ulcer prevention is limited (Bostrom & Kenneth1992; Hill 1992; Maylor & Torrance 1999; Moore & Price2004). Bostrom and Kenneth (1992) identified lack of in-terest and low priority of prevention in nursing care asimportant barriers to effective pressure ulcer prevention.Maylor and Torrance (1999) emphasize the importance ofa lack of individual motivation as a barrier for effectiveprevention. According to Moore and Price (2004), nursesdemonstrated an overall positive attitude toward pressure

ulcer prevention. Attitudes seem to be negatively affectedby lack of time (Moore & Price 2004), lack of nursing staff(Hill 1992; Moore & Price 2004), lack of knowledge (Hill1992), and insufficient equipment (Hill 1992).

Literature on knowledge about pressure ulcer preven-tion is often contradictory. Some researchers concludethat overall knowledge is appropriate (Bostrom & Ken-neth 1992; Hill 1992; Wilkes et al. 1996; Provo et al.1997; Maylor & Torrance 1999; Pancorbo-Hidalgo et al.2007; Kallman & Suserud 2009). Others conclude thatnurses knowledge about pressure ulcer prevention is inad-equate (Halfens & Eggink 1995; Pieper & Mattern 1997;

Caliri et al. 2003). Russell (1996) and Panagiotopoulouand Kerr (2002) identified lack of knowledge in specifictopics including etiology, pressure ulcer classification, andpreventive methods. Hulsenboom et al. (2007) state thatknowledge about pressure ulcer prevention in Dutchnurses barely improved in the previous decade. Evidenceabout the correlation between knowledge and the applica-tion of adequate prevention is lacking.

AIMS AND OBJECTIVES

This study aims to: (1) study the knowledge and attitudesof nurses about pressure ulcer prevention in Belgian hospi-tals and (2) to explore the correlation between knowledge,attitudes, and the application of fully adequate prevention.

METHODS

Study DesignA cross-sectional multicenter study was performed. Thestudy included a survey of pressure ulcer prevalence and

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adequacy of pressure ulcer prevention, and an assessmentof the knowledge and attitudes of nurses about pressureulcer prevention. The study was approved by the ethicsreview committee of Ghent University Hospital. Data werecollected in April 2008.

Study PopulationAdequacy of pressure ulcer prevention and pressure

ulcer prevalence. The adequacy of preventive care andpressure ulcer prevalence was studied in all hospitalizedpatients in a random selection of 94 nursing wards in 14Belgian hospitals. Patients under the age of 18 were ex-cluded. All patients or their relatives were asked for theirconsent to participate in the study. Patients in pediatriccare, day care, mother/child care, and mental health carewards were excluded from this study.

Knowledge and attitudes of nurses toward pressure ul-

cer prevention. Based on a baseline of 10% of patientsat risk receiving fully adequate prevention (Vanderweeet al. 2007) and an expected detectable difference of 20% ormore of fully adequate prevention between: (1) wards withsatisfactory knowledge (60%) and/or attitudes (75%)and (2) wards with insufficient knowledge (

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individual, anonymous, instruments on various aspects ofknowledge and attitudes about pressure ulcer preventionwere used.

Knowledge

The Pressure Ulcer Knowledge Assessment Tool was usedto assess the knowledge of the participating nurses aboutpressure ulcer prevention. The instrument includes 26multiple choice questions with 3 answer options and re-flects 6 domains expressing the most relevant aspects ofpressure ulcer prevention: (1) etiology and development;(2) classification and observation;(3) nutrition; (4) risk as-sessment; (5) reduction of the magnitude of pressure andshearing; and (6) reduction of the duration of pressure andshearing. The maximum score on the instrument was 26and a mean knowledge score of60% was considered to besatisfactory in this study. The instrument was extensively

validated in terms of item difficulty, discriminating index,and quality of the response alternatives (Beeckman et al.2010b). The internal consistency reliability (Cronbachs)was 0.77 and the 1-week test-retest intraclass correlationcoefficient (stability) was 0.88 (Beeckman et al. 2010b).

AttitudeThe validated Attitude toward Pressure Ulcer tool (APuP)was used to study the attitudes of the nurses toward pres-sure ulcer prevention (Beeckman et al. 2010a). The instru-ment includes 13 items and reflects five subscale domains:(1) personal competency to prevent pressure ulcers, (2)priority of pressure ulcer prevention, (3) impact of pres-sure ulcers, (4) responsibility in pressure ulcer prevention,and (5) confidence in the effectiveness of prevention. A 4-point Likert-type scale was designed to collect the data (1= strongly disagree, 2 = disagree, 3 = agree, 4 = stronglyagree). Sum scores were calculated to obtain the total at-titude score. Scores on the negatively worded items werereversed to obtain a total score. Higher scores indicatedmore positive attitudes. A mean attitude score of 75%was considered to be satisfactory in this study. Previousvalidation research indicated that the Content Validity In-dex of the items in the APuP was between 0.87 and 1.00and Cronbachs ranged from 0.76 to 0.81. The instru-

ment, as well as each of the five domain subscales, canbe considered a brief, conceptually sound, rigorously de-veloped instrument with strong evidence supporting thepsychometric properties (Beeckman et al. 2010b).

ProcedureAdequacy of pressure ulcer prevention and pressure

ulcer prevalence. In each hospital, a supervisor was ap-

pointed who was responsible for the local organization ofthe study. Prior to the study, all supervisors attended atraining session. This consisted of: (1) a theoretical train-ing (pathology, classification, risk assessment using theBraden Scale, and prevention); (2) an introduction to thestudy aims and protocol; and (3) the use of the data col-lection instrument. The purpose of this training was toensure the correctness and uniformity of completing thedata collection instrument. The supervisor created teamsof nurses who collected the data on the wards. Each teamconsisted of two nurses: a nurse from the staff of the wardbeing surveyed and a nurse from a different ward. Thefirst nurse was able to provide relevant background in-formation about individual patients. Accordingly, all pa-tients were observed by two nurses. Both nurses had toagree on the classification of the pressure ulcer. If theydisagreed, the opinion of the nonward nurse was takeninto account. The supervisors instructed the teams about

the study procedure. For that purpose, the supervisors re-ceiveda Powerpoint presentation and an information guideon the study procedure to increase the reliability of the datacollection.

Knowledge and attitudes of nurses toward pressure ul-cer prevention. The participating nurses were fully in-formed by the researcher about the purpose of the studyand were asked to complete the instruments individu-ally. In the instrument, the purpose, procedure, assuredanonymity, and confidentiality were fully explained. Thereturn of a completed instrument was considered as con-sent to participate. While completing the instruments, the

participants were not allowed to use other resources andwere supervised by the researcher. The time to completeboth instruments was 30 minutes.

Data AnalysisStatistical analyses were performed using SPSS 15.0 (SPSSInc., Chicago, IL, USA). Descriptive data are presentedin frequencies (percentages) and means ( standard de-viation). One-way analyses of variance and independentsample t-tests were performed to test for differences inscores among groups. Binary logistic regression modeling(Method Enter) was performed to assess the correlationbetween the application of fully adequate prevention in30% of the patients at risk (yes/no) and: (1) knowledge,(2) attitude, (3) additional pressure ulcer education onward level, and (4) the presence of a pressure ulcer nurseon ward level. A correlation analysis was performed to testfor multicollinearity between the independent variables.Spearmans needed to be less than 0.80 to be included inthe model. Results were considered to be significant if thetwo-tailed p-value was

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TABLE 1

Patient characteristics by ward type

SURGICAL MEDICALSURGICAL

MEDICAL GERIATRICINTENSIVE

CARE OTHER TOTAL

n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Agea

1939 years 38 (5.6) 33 (5.0) 11 (9.6) 0 (0.0) 2 (2.6) 7 (5.6) 91 (4.3)

4059 years 155 (23.0) 123 (18.7) 24 (20.9) 4 (0.9) 8 (10.4) 22 (17.6) 336 (16.0)

6069 years 127 (18.8) 108 (16.4) 18 (15.7) 18 (3.9) 18 (23.4) 22 (17.6) 311 (14.8)

7079 years 194 (28.8) 200 (30.4) 31 (27) 109 (23.9) 29 (37.7) 31 (24.8) 594 (28.2)

8089 years 139 (20.6) 169 (25.7) 26 (22.6) 271 (59.3) 19 (24.7) 41 (32.8) 665 (31.6)

>89 years 20 (3.0) 24 (3.7) 4 (3.5) 55 (12.0) 1 (1.3) 2 (1.6) 106 (5.0)

Genderb

Female 386 (57.3) 325 (49.5) 59 (51.3) 299 (65.4) 27 (35.1) 69 (55.2) 940 (44.7)

Male 288 (42.7) 332 (50.2) 56 (48.7) 158 (34.6) 50 (64.9) 56 (44.8) 1165 (55.3)

Incontinence

Urinary 94 (13.9) 149 (22.7) 22 (19.1) 219 (47.9) 4 (5.2) 38 (30.4) 526 (25.0)

Fecal 69 (10.2) 111 (16.9) 23 (20.0) 211 (46.2) 28 (36.4) 33 (26.4) 475 (22.6)

RiskBraden

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TABLE 3

Prevention in patients at risk (Braden

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TABLE 4

Demographic data of the participating nurses

NURSES (n= 553)% (n)

Gender

Male 10.3 (57)Female 89.7 (496)

Education

Certificate nursea 47.7 (264)

Bachelor degree 48.3 (267)

MScN degreeb 4.0 (22)

Age category

50 years 11.4 (63)

Work experience

20 years 28.4 (157)

Function

Staff nurse 86.1 (476)

Senior nurse 4.5 (25)

Tissue viability nurse 9.4 (52)

Ward

Surgical 29.7 (164)

Medical 26.6 (147)

Surgical/Medical 4.3 (24)

Geriatric 19.2 (106)

Intensive care 12.3 (68)

Other 8.0 (44)

aThecertificatenurseundertakespracticalnursetraining inthe fourth gradeof secondary school after completingsecondary school studies.The trainingis largely based on practice and apprenticeship.bMaster of Science in Nursing (advanced-level quaternary education de-gree for nurses having a Bachelor degree).

The results of the logistic regression analysis are shown inTable 6.

DISCUSSION

This study aims to investigate the knowledge and attitudes

of nurses about pressure ulcer prevention in Belgian hos-pitals and to explore the correlation between knowledge,attitudes, and the application of fully adequate prevention.The results showed that the knowledge of nurses aboutpressure ulcer prevention in Belgian hospitals was poor.Moreover, only half of the nurses showed attitude scoresof equal to or greater than 75%. The application of fully ad-equate prevention was statistically significantly correlatedwith the attitudes of nurses.

This study indicates that pressure ulcer prevalence andthe application of fully adequate prevention in patients atrisk has not improved over the last few years (Vanderweeet al. 2007). Similar to Vanderwee et al.s (2007) study,approximately 30% of the patients were at risk, and in thisgroup pressure ulcer prevention was found to be mainly in-adequate. Only 13.9% of all patients in need of prevention(either in bed or when seated) received fully adequate pre-vention. Prevention when seated and heel damage preven-tion were most problematic. Moreover, this study showedthat a significant amount of patients not at risk (71.5%)received some kind of prevention, which is unnecessaryand inefficient.

Knowledge and Attitudes of Nurses toward PressureUlcer Prevention

Knowledge. Adequate knowledge about pressure ul-cer prevention is important to decide: (1) which patients

should receive prevention, (2) which prevention shouldbe applied, and (3) how prevention should be applied.This study highlights concerns about nurses knowledgeof pressure ulcer prevention. Knowledge on none of theitems was satisfactory. Knowledge about: (1) risk assess-ment, (2) measures to reduce the magnitude of pressureand shearing, (3) observation/classification, and (4) etiol-ogy was insufficient. In less than a quarter of the nurses, adesirable level of knowledge was observed.

Knowledge was not significantly correlated with the ap-plication of fully adequate prevention. Wards with overallhigher knowledge scores did not show higher figures on

the application of pressure ulcer preventive measures. Thismay indicate that nurses with more adequate knowledgedo not perceive a need to act more adequately in practice.However, the application of prevention as observed in thisstudy might also be influenced by some other barriers.Several researchers explored barriers to guidelines use inclinical practice (Hutchinson & Johnston 2004). The ma-

jor barriers to the use of guidelines in practice include thatguidelines are not available, there is no access to research,poor facilities for implementation, lack of competent col-leagues, lack of time for reading and implementation, thecharacteristics of the nurses, the nurses lack of author-ity in the organization, the process of utilization, and the

organization (Hunt 1997; Nilsson Kajermo et al. 1998;Hutchinson & Johnston 2004). According to Kajermoet al. (2008), senior nurses and nurse managers shouldcreate clear/realistic goals and strategies to support nursesprofessional development and possibilities to implementresearch findings in clinical practice.

Although no significant correlation was found betweenknowledge and the application of adequate prevention, itis reasonable to suppose that insufficient knowledge does

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TABLE 5

Knowledge and attitudes of the participating nurses

KNOWLEDGE n/26 (%) DIFFERENCE ATTITUDE n/52 (%) DIFFERENCE

Overall 12.9/26 (49.6) NA 37.1/52 (71.3) NA

Gender t= 1.47, p= .14 t = 0.69, p= .49

Male 13.6/26 (52.3) 37.9/52 (72.9)Female 12.8/26 (49.2) 37.0/52 (71.2)

Education F= 4.88, p= .008 F = 2.62, p= .07

Certificate nursea 12.4/26 (47.7) 36.3/52 (69.8)

Bachelor degree 13.4/26 (51.5) 37.7/52 (72.5)

MScN degreeb 13.8/26 (53.1) 39.4/52 (75.8)

Age category F= 1.84, p= .14 F = 0.59, p= .63

50 years 12.3/26 (47.3) 36.7/52 (70.6)

Work experience F= 4.47, p= .004 F = 0.41, p= .75

20 years 12.4/26 (47.7) 37.6/52 (72.3)

Function F= 11.28,p< 0.001 F = 5.51, p= .004

Staff nurse 12.6/26 (48.5) 36.6/52 (70.4)

Senior nurse 14.1/26 (54.2) 40.5/52 (77.9)

Tissue viability nurse 15.1/26 (58.0) 39.9/52 (76.7)

Ward F= 2.28, p= .046 F = 0.72, p= .61

Surgical 12.4/26 (47.5) 36.5/52 (70.2)

Medical 13.5/26 (51.8) 36.8/52 (70.8)

Surgical/Medical 12.6/26 (48.5) 38.1/52 (73.3)

Geriatric 13.6/26 (52.2) 37.6/52 (72.3)

Intensive care 12.5/26 (48.2) 36.8/52 (70.8)

Other 12.4/26 (47.6) 39.0/52 (75.0)

Additional training t= 3.17, p= .002 t = 1.67, p= .10Yes 13.4/26 (51.5) 37.7/52 (72.5)

No 12.4/26 (47.7) 36.4/52 (70.0)

NA= not applicable.aThe certificate nurse undertakes practical nurse training in the fourth grade of secondary school after completing secondary school studies. The training islargely based on practice and apprenticeship.bMaster of Science in Nursing (advanced-level quaternary education degree for nurses having a Bachelor degree).

TABLE 6

Binary logistic regression modeling to assess the relationship between the adequacy of pressure ulcer prevention provided and: (1)

knowledge, (2) attitude, (3)% of patients at risk, (4) additional training, and (5) the presence of a pressure ulcer nurse on ward level

Bd (SE)e WALD 2 P OR (95% CI)

Application of fully adequate prevention in30% of the patients at risk

Knowledgea 0.284 (0.775) 0.134 0.714 0.753 (0.1653.442)

Attitudeb 1.122 (0.565) 3.944 0.047 3.071 (1.0159.295)

% Patients at riskc 0.597 (0.578) 1.066 0.302 1.816 (0.5855.637)

Additional training provided 0.076 (0.609) 0.16 0.901 1.079 (0.3273.559)

Presence of a pressure ulcer nurse 1.013 (0.603) 2.825 0.093 2.753 (0.8458.969)

aReference category: knowledge score

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lead to misconceptions about pressure ulcer preventionand subsequently to suboptimal care. Education is nec-essary to improve knowledge. However, McCluskey andLovarini (2005) found that continuing professional edu-cation can improve knowledge but also found that thesubsequent impact on behavior was limited. They statethat the ongoing challenge for educators, researchers, andmanagers is how to support health care workers to es-tablish new routines and priorities around evidence-basedpractice. This behavior change may probably require a lotof time. In a study by Caliri et al. (2003), nursing studentsknowledge scores were higher if they had participated inpractical training about pressure ulcers or used a Web siteabout pressure ulcers. It is therefore recommended thateducators consider different educational methods, struc-tures, or ways of presenting information on pressure ulcerprevention.

More highly educated nurses scored significantly higher

in knowledge scores than did those with lower levels ofeducation. These findings are comparable to Pancorbo-Hidalgo et al. (2007) who found that nurses holding a uni-versity degree obtained higher scores for knowledge andclinical performance. In contrast, other researchers did notfind any correlation between educational background andscores for knowledge (Pieper & Mott 1995; Pieper & Mat-tern 1997). In this study, attending additional training waspositively correlated with higher knowledge scores. Pieperand Mott (1995) also found that nurses knowledge wassignificantly higher when the nurses recently had heard alecture or read an article about pressure ulcers. In contrast,

Pieper and Mattern (1997) found that knowledge was nothigher if nurses recently read an article about pressureulcers.

Attitude. A significant correlation was found betweenknowledge and attitude. This finding indicates the sizeablecorrelation between what individuals know and how theyfeel about pressure ulcer prevention. Attitudes were signifi-cantly correlated with the application of fully adequate pre-vention. Wards with overall higher attitude scores showedhigher figures on the application of fully adequate preven-tion. According to Petty and Cacioppo (1996), attitudesare considered important because they give an indication

of what to expect from individuals. As stated by Ajzen andFishbein (2005), a positive attitude toward an issue is animportant influencing factor that determines an individ-uals likelihood of carrying out a positive behavior. Thisstatement is supported by Champion and Leach (1989)and Hicks (1996) who showed the positive impact of morepositive attitudes on the quality of nursing practice.

In this study, the attitudes of the nurses differed accord-ing to their professional role in clinical practice. Tissue

viability nurses showed significantly higher attitudes thanstaff nurses. This finding highlights the importance of thepresence of a tissue viability nurse on a ward or unit. Betterattitude scores in tissue viability nurses may be correlatedwith higher motivation, and more interest in pressure ul-cer prevention. Whether nurses had received any formaltraining in pressure ulcer prevention did not make a signif-icant difference. This finding is comparable to Moore andPrice (2004) who found that attitudes were not influencedby any formal training in pressure ulcer prevention andmanagement. The fact that formal training did not influ-ence the attitude of nurses requires some reflection. Mostof the interventions to improve patient care are focused onin-service training and refresher courses, using traditionallectures. The effectiveness of these educational methods toimprove attitudes should be questioned. Research in otherdomains indicate that interventions proposed to improveattitudes and practice should include interactive compo-

nents and constructive feedback (Pittet et al. 2000; Jenkins& Fallowfield 2002). Interventions to improve attitudesshould be focused on novice nurses as well as on seniorstaff, as the influence of senior staff may be substantial.In this study, the attitude toward the priority of pressureulcer prevention in care was positively correlated with theknowledge of the nurses and the application of fully ade-quate preventive care, which is comparable to the findingsof Bostrom and Kenneth (1992).

In this study, rigorously constructed and psychometri-cally evaluated instruments were used, increasing reliabil-ity of the study results (Vanderwee et al. 2007; Beeckman

et al. 2010a, 2010b). Evaluation of knowledge, attitudes,prevalence, and adequacy of prevention should be orga-nized on a frequent basis. In research by Lahmann et al.(2010), repeated participation in pressure ulcer surveys ledto: (1) lower pressure ulcer prevalence rates, (2) increaseduse of all guidelines/risk assessment scales, and (3) in-creased use of most preventive measures and devices. Incontrast, Hulsenboom et al. (2007) found that being em-ployed in an institution that monitors pressure ulcer carehardly affects the knowledge level.

Limitations

There are several limitations that should be considered.First, randomly selected participants may have been lessmotivated to complete the knowledge questionnaire, andthe results might be too negative. However, care was takenduring recruitment to minimize recruitment bias and ob-tain a representative sample. Second, participants couldhave given socially desirable answers during the attitudeassessment, despite the anonymous character of the instru-ment. Possibly, the attitude results may be too positive.


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CONCLUSIONS

The overall adequacy of pressure ulcer prevention in Bel-gian hospitals was poor and knowledge in nurses was in-adequate. Apart from that, only half of the nurses showedattitudesscores of equal to or greater than 75%. Attitudesof

nurses toward pressure ulcers were significantly correlatedwith the application of fully adequate prevention. Knowl-edge was not significantly correlated with the applicationof fully adequate prevention. Educators, both involved inbasic nursing education and in in-service training, havean important role in developing methods to improve bothknowledge and attitudes toward pressure ulcer preven-tion.

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