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Introduction

Pressure injuries (PI) remain a persistent and serious challenge in aged care, impacting the health, dignity and quality of life of older adults.¹ In residential aged care facilities (RACF), where residents often experience limited mobility and complex comorbidities, nurses are at the forefront of prevention, early detection and effective management of pressure injuries.² Despite national guidelines and advancements in clinical practice, pressure injuries continue to occur, suggesting potential gaps in the knowledge and application of evidence-based care. Hence, to standardise assessment of nurses’ PI knowledge, the Pressure Ulcer Knowledge Assessment Tool (PUKAT) was developed and validated by Beeckman et al (2010). The PUKAT evaluates knowledge across six themes including aetiology, classification, risk assessment, nutrition and specific patient groups case studies. It has since been adapted internationally to benchmark nurses’ understanding. However, International research consistently demonstrates that nurses’ knowledge of PI prevention remains suboptimal across care settings. A study conducted in Belgium, reported a mean knowledge score of 50% among hospital nurses using the validated PUKAT instrument, with significant deficits in risk assessment and preventive measures.³ Similarly, Coventry et al⁴ found an average knowledge level of 54% among Australian acute care nurses, indicating that even in tertiary hospital environments knowledge gaps persist. Evidence-based interventions include regular repositioning, risk assessment using validated tools, use of pressure-relieving devices and appropriate skin care regimens.⁵ In addition, the knowledge gap contributes to weak adherence with preventive protocols, which has potentially significant clinical implications.

In the context of aged care, where residents often struggle with frailty, immobility and multiple comorbidities; delays in identifying or managing early-stage PIs can result in avoidable progression to more severe stages, often leading to intense pain, infection, sepsis and in some cases amputation or death. These are largely preventable injuries and when prevention fails, the consequences can be life-altering or fatal.^6,7 In addition to the clinical burden, such outcomes significantly diminish residents’ quality of life and can place a substantial emotional and financial strain on families and healthcare systems. Hence, these findings highlight the critical role that nurses’ clinical knowledge plays in timely and effective decision-making at the bedside. Additional studies reinforce this association. For example, Klaas & Serebro⁸ reported that low knowledge among nurses can lead to suboptimal prevention practices, such as failure to reposition residents regularly or assess risk systematically. 

Therefore, nurses’ knowledge is a key determinant of clinical decision-making and care quality in wound prevention and management. However, in aged care settings, there is limited recent data assessing how well equipped nurses are in recognising risk factors, staging pressure injuries and choosing appropriate wound care strategies.⁹ The current paucity of data frustrates efforts to draw meaningful conclusions or make informed decisions. A clearer understanding of current knowledge levels is necessary to inform future training and policy efforts aimed at improving resident outcomes and reducing avoidable harm. This review systematically identifies and describes literature reporting knowledge among enrolled and registered aged care nurses regarding the prevention, assessment and management of pressure injuries. This research further sought to describe knowledge gaps to inform educational needs and support the development of strategies to enhance clinical practice in aged care settings.

Methods

This unregistered review involved an initial literature search to explore aged care nurses’ knowledge of pressure injury. The databases searched included the Cochrane Library, MEDLINE, Scopus and the CINAHL. These databases were chosen due to their relevance to nursing disciplines.¹⁰ The search strategy was developed under the guidance of the research librarian and the final searches were completed on 15 April 2025. The review protocol is unpublished. Studies were included that were published within the past 25 years to ensure contemporary relevance and conducted exclusively in aged care or long-term care settings. Studies were required to focus on enrolled or registered nurses and assess knowledge of pressure injury prevention, assessment and/or management. Studies were excluded if they were conducted in acute care or hospital settings, involved nursing students or other healthcare professionals where nursing could not be described separately. Eligible study designs included cross-sectional studies, cohort studies, quasi-experimental designs and randomised controlled trials. Studies were restricted to humans and English texts only. Titles and abstracts and full texts were independently screened by researcher one, using Covidence, with 24% (n=448) double-screened independently by a researcher two to enhance reliability. This approach was selected for pragmatic reasons, given the time-bound nature of the project. Risk of bias assessment was undertaken by a single researcher, following screening, using the Critical Appraisal Skills Program (CASP) checklist. A PRISMA checklist is included as Appendix A.

Boolean operators were used to combine terms: synonyms were linked with ‘OR’ and the two main concepts were brought together using ‘AND’ to narrow the focus to relevant literature. Moreover, truncation was applied using the asterisk (*) symbol to capture multiple word variations from a single root. For example, the term, ‘nurs*,’ was used to retrieve results such as nurse, nurses and nursing. When designing the search strategy, Boolean operators and truncation were used to capture a broad but relevant range of studies. The Boolean operator “AND” was applied to combine key concepts, for example, pressure injury AND knowledge AND aged care, ensuring only articles addressing all areas of interest were retrieved. Moreover, “OR” was used to include synonyms and variations in terminology for instance, pressure injury OR pressure ulcer, which helped broaden the search and reduce the risk of missing relevant studies. Truncation symbols (“*”) were also applied to capture different word endings, such as nurs to retrieve nurse, nurses and nursing. This approach was critical for improving the sensitivity of the search, maximising the retrieval of relevant studies. The search was structured around three main concepts (Table 1). The first related to the profession itself, including terms such as aged care nurs* OR geriatric*. The second concept focused on knowledge. Finally, the third concept focused on pressure injury, incorporating terms such as “pressure injury” OR “pressure ulcer” OR “bedsore” along with synonyms and related terminology.

 

Table 1. Search strategy

 

Results

A total of 2536 records were retrieved across the four databases, CINAHL (n=1849), Scopus (n=687), MEDLINE (n=0) and Cochrane Library (n=0). Following the removal of 698 duplicates in Covidence, 1838 records remained for screening. Title and abstract review excluded 1814 records, leaving 24 articles for full-text assessment (Figure 1). All full texts were successfully retrieved. Of these, 23 were excluded for reasons such as wrong setting (n=11), abstract only (n=1), not in English (n=1), wrong comparator (n=3), wrong indication (n=1), wrong study design (n=1), nurses’ responses not reported separately (n=3), and aged care responses not reported separately (n=2). Following these exclusions, only one study met the inclusion criteria and was incorporated into the review (Figure 1 PRISMA). As this study was cross-sectional, risk of bias assessment employed the CASP Cross-Sectional Studies Checklist.

 

Figure 1. PRISMA Flow Chart

 

Study selection

Although several studies were identified that explored pressure injury prevention knowledge among healthcare workers in aged care settings, many of these included a mixed sample of nurses and other staff, such as care assistants or allied health professionals. Importantly, these studies did not report findings separately for registered nurses, making it difficult to extract nurse-specific data. As a result, they were excluded from this review to maintain a focused analysis on nurses’ knowledge specifically.

Study characteristics

In Belgium, Demarré et al.¹¹ conducted a cross-sectional survey among nurses and nursing assistants in nursing homes to assess knowledge and attitudes regarding pressure ulcer prevention. The study utilised the Pressure Ulcer Knowledge Assessment Tool (PUKAT), a validated instrument used to measure healthcare professionals’ knowledge of pressure injury prevention. It has 25 questions covering six themes such as aetiology, classifications, observation, risk assessment, nutrition and prevention.¹⁰

The study had a total of 145 participants, including 54 nurses and 91 nursing assistants, who completed instruments measuring both knowledge and attitudes toward pressure injury prevention. Risk of bias for this study was low, informed by the CASP Cross-Sectional Studies Checklist. While the inclusion of nursing homes in single care region in Belgium limits generalisability to other care settings, the use of validated PUKAT and Attitude Towards Pressure Ulcers instrument (APuP) tools reduced the risk of bias.

Study’s findings

The overall mean knowledge score was low at 29%, with the weakest results observed in nutrition (4%). Aetiology and development had a score of 24%; the classification and observation score was reported to be 27%; and reduction of pressure and shear score was 30%. The highest knowledge score was for the theme risk assessment (64%). When comparing both the study groups, knowledge levels did not differ significantly between nurses (29.3%) and nursing assistants (28.7%). In contrast, total mean attitude scores between both the groups were higher at 74.5%, with the greatest strength in prioritising pressure ulcer care (81.7%) and the lowest in recognising the patient impact (68%). Nurses demonstrated more positive attitudes (78.3%) compared with nursing assistants (72.3%). Importantly, logistic regression revealed that knowledge was not a significant independent predictor of guideline compliant prevention practices, whereas attitudes were found to be a significant predictor (Table 2).

 

Table 2. Study characteristics

 

Discussion

This review aimed to explore the current knowledge of aged care nurses in the prevention, assessment and management of pressure injuries within residential aged care settings. Despite a comprehensive search across multiple databases, only one study conducted in aged care by Demarre et al¹¹ met the inclusion criteria. Therefore, we have drawn comparisons here to studies conducted in other settings, mostly, hospital and community settings. While studies conducted in hospital environments were excluded from this systematic review, they are referenced to provide context and demonstrate that similar knowledge gaps exist globally. This limited finding is itself important, highlighting a substantial gap in the literature specifically focused on aged care nurses’ pressure injury knowledge. The included study was cross-sectional, conducted in a single area in Belgium. While the number of participants was sufficient, multi-center studies involving wider care settings would improve the generalisability of research findings. The scarcity of targeted research suggests a need for greater attention to this workforce and their specific educational and clinical support needs. The 2012 study by Demarré¹¹ and colleagues offers meaningful insight into the knowledge and attitudes of nursing staff regarding PI prevention in Belgian nursing homes.

Notably, while participants generally displayed positive attitudes toward prevention, their knowledge scores were low (29.3%). This finding underscores a critical gap between attitudinal support and practical competence, suggesting that favorable perceptions alone are insufficient to ensure adherence to evidence-based prevention strategies in aged care settings. The PUKAT tool used in the study revealed a substantial overall knowledge deficit, which aligns with similar findings in other healthcare settings. For example, findings from both Beeckman et al³ and Al Gharash et al¹² further highlight the concerning issue of low knowledge levels among nursing staff regarding pressure injury prevention.

In their multicentre study across 14 Belgian hospitals, Beeckman and colleagues³ reported a low mean knowledge score of 49.7% among nurses and only 13.9% of at-risk patients (Braden score <17) received adequate PI preventive strategies. Braden is a standardised tool, which evaluates mobility, sensory perception, moisture, activity, nutrition and friction/shear, key domains associated with pressure injury risk.¹³ Similarly, Al Gharash et al¹² conducting research across multiple regions in Saudi Arabia, found inadequate knowledge among nursing interns, with a mean score of 48.1%, and ‘unsatisfactory attitudes’ (61.3%). This score was much lower than the satisfactory benchmark of 75% or more. This shows that most interns did not have a very positive attitude toward pressure injury prevention. It suggests that even though participants may understand some parts of prevention, their overall attitude is not strong enough to make sure best practices are followed consistently.¹² This cross-sectional study also found that gender and internship duration significantly influenced knowledge levels. Female participants demonstrated higher knowledge and more positive attitudes toward pressure injury prevention than their male counterparts (p=0.008; p<0.001, respectively). Additionally, students who had completed longer internships scored significantly better on knowledge assessments (p=0.007), suggesting that extended clinical exposure may contribute to improved understanding.

Together, these findings underscore the need for educational programs that not only build knowledge but also foster positive attitudes and provide consistent, practical learning support to translate knowledge into effective pressure injury prevention in both hospital and aged care settings. A further international study by Strand and Lindgren¹⁴ examined the topic in intensive and critical care context in Sweden and similarly found that, despite staff expressing positive attitudes towards PI prevention, many lacked foundational knowledge and failed to implement prevention consistently. This finding reinforces the idea that motivation alone is insufficient; consistent application of best practices requires both education and an enabling workplace culture.^15,16

It should be noted, however, that in the above studies, knowledge levels were particularly low in the nursing home setting, with Demarré et al¹¹ reporting a mean score of just 29.3%. This contrasts with findings from hospital-based studies, where Beeckman et al³ reported a mean knowledge score of 49.7% in Belgian hospitals and Al Gharash et al¹² found a score of 48.2% among nursing interns in Saudi Arabia. These comparisons suggest that nurses working in residential aged care settings may have even lower levels of pressure injury knowledge than their hospital-based counterparts, highlighting a critical gap in preparedness within this sector.

While several studies indicate a relationship between nursing knowledge and the effectiveness of pressure injury prevention, the strength and consistency of this association remain an area for further investigation, especially in residential aged care. Wu et al⁷ conducted a systematic review and meta-analysis to estimate the pooled score of nurses’ knowledge about pressure ulcer prevention using PUKAT. The review found a pooled knowledge score of 51.5%, indicating that nurses’ knowledge of pressure injury prevention remains suboptimal across settings. These findings suggest a continuing need for targeted education to drive consistent best-practice implementation to improve pressure injury outcomes. Furthermore, a recent multiregional study by Al Gharash et al¹² found that inadequate knowledge among nursing interns was a strong predictor of poor confidence in executing evidence-based interventions, signaling potential risks even before nurses enter the workforce.

These findings point to an urgent need for targeted strategies to strengthen both knowledge and attitudes at the student level, ensuring that future nurses are adequately prepared to deliver safe, evidence-based care. This could be achieved by reviewing and strengthening education and training programs focused on pressure injury prevention. The term education refers to the formal instruction provided in nursing programs, where students gain foundational knowledge of clinical concepts, including wound prevention and management.Training, on the other hand, is typically more hands-on and practice-oriented, taking place in clinical settings or through professional development activities.¹⁷ Together, they form a continuum of learning, with continuing professional development (CPD) ensuring that nurses maintain and enhance their skills in PI prevention, early detection and evidence-based care delivery throughout their careers. In aged care settings, where residents are particularly vulnerable and clinical oversight may at times be limited, robust CPD is especially valuable. However, the effectiveness of CPD can depend on factors such as content quality, delivery method and organisational support.⁶ Recent evidence also suggests that formal postgraduate education in wound care can significantly enhance clinicians’ confidence, decision-making and ability to deliver evidence-based care, highlighting the value of structured education beyond routine CPD.¹⁸⁾

In the study by Demarré et al¹¹ 70.4% of registered nurses in Belgian nursing homes reported having received in-service training on PI prevention. However, despite this relatively high level of reported training, the mean knowledge score for nurses remained low at just 29.3%. Although, the study did not provide details about the content, duration or delivery format of the training, making it difficult to assess its quality or effectiveness. This lack of reporting and disparity raises questions about the effectiveness, depth and delivery methods of existing educational programs. It suggests that while training may be available, it may not be sufficiently comprehensive or aligned with clinical realities in aged care environments.

Aged care presents unique challenges, such as managing residents with multiple comorbidities, advanced frailty and cognitive impairment which may not be fully addressed in generic pressure injury prevention programs. At present, there is limited evidence of bespoke training programs specifically designed for residential aged care settings. For example, most existing frameworks, such as those used in acute care, may not adequately reflect the resource constraints or staffing models typical in long-term care. This highlights the potential value of developing and mandating aged care-specific training modules, tailored to the skill mix and care context of this sector.¹⁹

This issue is not unique to one country, as international research also points to persistent gaps in pressure injury knowledge despite exposure to training. For instance, Lee et al²⁰ found that nurses in South Korean nursing homes demonstrated significant knowledge gaps in pressure injury management, even when training had been provided. Their findings emphasised the need for structured, competency-based education tailored specifically to the nursing home context. Similarly, Al Gharash et al¹² reported that nursing interns who had received limited education lacked confidence and preparedness in PI prevention. These consistent findings across countries suggest that traditional CPD models, often lecture-based or compliance-driven, may not be sufficient to equip nurses with the nuanced skills required for prevention in complex care environments.

This is particularly concerning because registered nurses not only provide direct care but are also responsible for educating and delegating to care assistants. When nurses themselves have limited knowledge of pressure injury prevention, it compromises the entire care team’s ability to deliver evidence-based care.^{21, 22} The lack of confidence or capacity among nurses to guide others effectively underscores the urgent need for structured, high-quality training and supportive systems to ensure best practices are both understood and consistently applied.

Practical, embedded learning formats have been associated with more effective outcomes in PI education and training. Waird and Monaro²³ demonstrated that targeted education combined with audit-feedback and clinical support significantly reduced the incidence of pressure injuries (from 64% to 33% and elimination of suspected deep tissues injuries) in an Australian aged care facility. In addition, patient education also has a key role to play, because, Deakin et al²⁴ highlight the importance of patient involvement, showing that an education-based care bundle can also enhance patient knowledge, promoting shared responsibility in prevention efforts. Moreover, CPD is most impactful when it is ongoing, case-based and closely aligned with the everyday realities of clinical care in aged care settings.²⁵⁾

However, to truly bridge the gap between knowledge and practice, CPD should also incorporate structured reflection on audit findings and critical incidents.²⁶ These approaches help ground education in real-world events, allowing nurses to identify missed opportunities, examine outcomes, and apply learning in a way that is both meaningful and practical. Evidence supports this approach; for example, the Australian Commission on Safety and Quality in Health Care² and the Agency for Clinical Innovation²⁷ both highlight the value of audit-driven learning to improve pressure injury prevention. A recent study by Singh et al⁵ found that integrating audit-informed prevention bundles into practice to a sustained reduction in pressure injury rates over four years. These findings suggest that when education is connected to actual clinical data and reflective processes, it has a greater potential to drive lasting improvement in care.

Consistent with the aim of this review, the synthesis highlights the limited evidence exploring aged care nurses’ knowledge of pressure injury prevention, assessment and management. The review found only one eligible study specifically examined this topic within residential aged care settings, revealing substantial knowledge deficits, particularly concerning prevention and nutrition. These findings confirm a critical gap in the literature and reinforce the need for further research focused specifically on the aged care workforce to inform education, policy and best practice guidelines.

Limitations

This review has several limitations that should be acknowledged. Firstly, studies published only in English were included, which may have excluded relevant research published in other languages, particularly from non-English-speaking countries. The search strategy, while comprehensive, may have missed eligible studies due to differences in indexing or terminology. Furthermore, only one study met the final inclusion criteria, limiting the breadth of analysis and making it difficult to draw generalisable conclusions. Although a second reviewer independently screened a portion of the studies to enhance reliability, full double-screening was not performed. Lastly, variation in study design, setting and outcome measures across the broader literature makes comparison and synthesis challenging, underscoring the need for more high-quality, aged-care-specific research on nurses’ knowledge of pressure injury prevention and management.

Conclusions

This review provides an overview of the limited evidence available on aged care nurses’ knowledge of pressure injury prevention, assessment and management. Only one eligible study was identified, indicating a very small and geographically narrow evidence base. While the included study suggests that knowledge levels among aged care nurses may be low, particularly in prevention and nutrition domains, these findings cannot be generalised across all aged care settings. Nevertheless, the review highlights an important gap in the literature and underscores the need for further research using validated tools such as the PUKAT within the aged care contexts.

Acknowledgements

I appreciate the support of the university librarian for their assistance with research database searches and resource access.

Conflict of interest

The authors declare no financial or commercial conflicts of interest. This review was undertaken in partial fulfilment of a Master’s degree in Wound Care at Monash University.

Ethics statement

Ethical approval was not required for this study as it is a literature review and did not involve the collection of primary data from human participants.

Funding

This research received no external funding and was undertaken as part of a Master’s degree at the University.

Author contribution

Harpinder Jammu: conception, data screening, extraction, analysis, drafting and review of manuscript. Peta Tehan: conception, supervision, data screening and review of manuscript. Ben Bullen: conception, supervision, review of manuscript.

Author(s)

Harpinder Jammu*¹, Peta Tehan¹, Benjamin Bullen^1
1Monash University, Melbourne, Australia

*Corresponding author email harpinderjammu@gmail.com

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