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Introduction

Pressure injuries (PIs), also known as pressure ulcers (PUs) and bedsores, are defined as damage to the skin or underlying tissue caused by prolonged pressure with or without shear forces.¹ Considered a quality of healthcare indicator, PIs are largely preventable.² A 2020 meta-analysis found the global pooled hospital-acquired pressure injury (PI) incidence rate was 5.4 per 10,000 patient days, with most developing on the sacrum and heels.³ Nurses strive to deliver safe, evidence-based, PI prevention care^4,5 which may include repositioning and prophylactic sacral dressings.^1,6 Nurses’ clinical decision-making is informed by clinical practice guidelines,¹ practice standards,⁷ hospital policy and procedures,⁴ and individual-level factors,^8,9 such as knowledge, perceptions, priorities and attitudes toward care.

The psychological construct of ‘attitude’ is defined as “an individual’s predisposition towards people, events, objects or activities.”^{10 (p.549)} An individual’s attitude, beliefs and values are also associated with organisational and workplace culture.¹¹ Yet, the influence of nurses’ attitudes on PI prevention care is poorly understood, with conflicting findings reported¹⁰ thus, more research is needed.¹² Studies have measured nurses’ attitude toward PI prevention using different instruments, with 94% (n=33)¹⁰ using either the Moore and Price Attitude scale (n=17; 48.5%)¹³ or the Attitude toward Pressure Ulcer Prevention (APuP) instrument (n=16; 45.7%).¹⁴ However, in the Australian context, the APuP instrument was the predominant survey tool used.^12,15,16 The APuP instrument measures 13-items across five subscales with participants self-reporting their personal competency, prioritisation, impact, responsibility for PI prevention and confidence in prevention effectiveness.¹⁴ The instrument developer specifies that nurses recording ≥75% of the maximum total score across the 13-items was deemed to have a positive attitude toward PI prevention.¹⁴

Nurses’ APuP scores have been measured in Australia,^12,15 China,¹⁷ Europe,^18-22 Iran,^23,24 and Turkey.²⁵ Geographical differences in APuP scores are reported with lower scores reported in the Middle East and higher scores in Europe and Australia.^10,12,15 A 2022 systematic review and meta-analysis found the overall APuP score across a sample of 7824 nurses was 70.8% (95% CI: 66.34–75.35), or a moderate attitude toward PI prevention.²⁶ Three previous Australian studies found the attitudes of registered nurses^12,15 and student nurses¹⁶ towards PI prevention were positive. However, the registered nurse surveys were conducted a decade ago (2016–2017) in Sydney¹² and Western Australia.¹⁵ Since then, substantial advancements in clinical practice and technology have reshaped how care is delivered. Yet the absence of Queensland-specific data means we still lack contemporary, contextually relevant evidence to benchmark performance, identify gaps, and inform policy, education, and practice.

A handful of international studies have examined the relationship between nurses’ APuP scores and their age, gender, qualification, training or years of clinical experience.²⁶ Some studies report a positive correlation between nurses’ APuP scores and their years of clinical experience and prevention training,^13,17,27 while others found no relationship between nurses’ APuP scores and their age, gender and qualifications.^25,28 Yet, only one Australian study, conducted in 2016 across one local health district in Sydney, has investigated these relationships.¹² These inconsistent findings and the absence of local data confirm the need for further exploration in the Australian context. This is important because there are state-based variations in healthcare funding, training and delivery models,²⁹ so gaining a better understanding of Australian nurses’ PI prevention attitudes could be used to inform nurses’ education, training and practice. This current study was conducted alongside a larger randomised controlled trial (RCT) testing the effectiveness of a prophylactic sacral dressing for PI prevention (registration number ACTRESN12619000763145p)³⁰ however, the results are not intended to be used in the interpretation of the trial findings. The current study aimed to describe Queensland nurses’ attitudes toward PI prevention in medical and surgical units, and to explore if there were differences in scores based on demographic characteristics.

Methods

This multi-site descriptive study collected on-line APuP survey data from medical and surgical nurses working in the parent trial wards at three Queensland hospitals. These hospitals provide a large range of clinical services across medicine, surgery, emergency and critical care. Each site has strong nursing leadership in PI prevention with Clinical Nurse Consultants who oversee the organisation’s reporting of hospital-acquired PI incidence rates and oversee the availability of prevention resources. The international PI prevention and treatment international clinical practice guidelines³¹ and the Australian National Safety and Quality Health Service Standards⁷ inform the organisations PI prevention policies and procedures. The reporting of this study was guided by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.³²

The research questions were:

1. What are medical and surgical nurses’ APuP scores at three Queensland hospitals?
2. What are the differences in medical and surgical nurses’ APuP scores based on age group, gender, hospital site, job title and highest professional qualification?

This study was conducted between April and July 2023. Using convenience and snowball sampling, we planned for a pragmatic sample size of 100 consenting medical and surgical registered nurses, endorsed enrolled nurses, and assistants in nursing working in the parent trial wards. In Australia, registered nurses and endorsed enrolled nurses are regulated health professionals who need to be registered with AHPRA, the national regulatory body, to practice clinically.³³ Assistants in nursing are unregulated health workers who work under the direction and supervision of a registered nurse.³³ With prior consent from the ward managers, the RCT Research Nurse at each hospital site conducted information sessions with the nurses and addressed their questions.

To reduce potential response bias, nurse recruitment was undertaken by a trained Research Assistant not engaged with the parent trial. A multifaceted recruitment and sampling approach was employed. First, following each information session, the nurse manager or delegate distributed the on-line APuP survey link to all staff via email, with a follow-up email sent four weeks later. Second, during site visits the Research Assistant undertook opportunistic snowball sampling, with recruited participants accessing the on-line APuP survey via a study Quick Response (QR) code. Finally, study posters with a survey QR code were displayed in nursing handover spaces during the data collection period.

The on-line survey landing page contained the study information, which participants needed to agree to enable survey access. At the commencement of the survey, participants generated their own unique study identification (initials/year of birth) to prevent multiple completions from the same participant and as a quick identifier in the event of withdrawal. Launching the on-line APuP survey implied participant consent. Participants were advised that their study participation was voluntary, anonymous and their data would be de-identified. They could withdraw their consent at any time, resulting in the destruction of their data.

With prior permission from the author, the APuP survey instrument, which is psychometrically sound,¹⁴ was built on the Research Electronic Data Capture (REDCap^®) platform hosted at Griffith University.³⁴ Participants directly entered their survey responses into REDCap^® via their mobile phone or desktop computer. The APuP instrument has 13-items grouped into five subscales: (i) personal competency to prevent pressure ulcers (3-items), (ii) priority of pressure ulcer prevention (3-items), (iii) impact of pressure ulcers (3-items), (iv) responsibility in pressure ulcer prevention (2-items), and (v) confidence in the effectiveness of prevention (2-items).¹⁴ The items are either positively or negatively worded and rated using a 4-point Likert scale (1=strongly disagree; 2=disagree; 3=agree; 4=strongly agree). For each question, only one response could be selected. The total instrument score range is 13 (minimum) to 52 (maximum). In our study, a “positive attitude toward PI prevention” was defined as a total APuP survey score ≥75% of the maximum total score (such as ≥39/52).¹⁴ This study-specific cut-off score, based on the recommendation by the instrument developer¹⁴ and used in previous research,³⁵ is not a clinically validated threshold and should be interpreted within the context of the study. At the end of the survey, demographic data were captured on nurses’ age (whole years), gender, highest education qualification, job title and number of years in their current role, hospital site, and number of years employed at the site. The on-line survey remained open for eight consecutive weeks at each hospital site. Ethics approval was gained for the parent RCT from the Gold Coast Hospital and Health Services (HREC/2019/QGC/51088) and Griffith University Human Research Ethics Committees (GU Ref No: 2019/685).

The survey data were exported from REDCap^® into the Statistical Package for the Social Sciences (SPSS) version 30.0 (IBM, Chicago, IL, USA). Data were cleaned and accuracy checks were performed by examining ranges, frequencies, and plausibility of values to ensure data quality. Descriptive statistics were used to summarise the sample. Continuous variables were reported as mean and standard deviation (SD) or median and interquartile range (IQR 25%–75%), depending on their data distribution. Categorical variables were presented as frequencies and percentages. Following the instrument developers’ instructions, negatively worded APuP items (3, 4, 5, 7, 8, 10, and 13) were reverse-scored prior to analysis.¹⁴ Only surveys in which all items of the APuP instrument were completed were included in the analysis. The total APuP summed score was not normally distributed, as indicated by visual inspection of the histogram and the mean (SD) relationship. Therefore, the median and inter-quartile range (IQR) were calculated for the five subscales and the total APuP score. The total APuP score was subsequently categorised as either ‘positive attitude toward pressure ulcer prevention’ (scores of ≥75% correct or a raw score ≥39/52) or a ‘not positive attitude toward pressure ulcer prevention’ (scores of <75% correct or a raw score ≤38/52). Prior to analysis, the continuous variable of age (years) was dichotomised based on the median value. Inferential statistics were performed to identify any differences in APuP scores based on nurses’ demographic characteristics. Due to insufficient cases and a lack of variability in the gender categories of “non-binary” (n=1) and “prefer not to say” (n=1), these cases were excluded from the inferential analysis. The Mann-Whitney U and Kruskal-Wallis tests were used due to the non-normal distribution of the outcome variable, with a p<0.05 considered statistically significant.

Results

We recruited 79 nurses, and all completed the online APuP survey with no missing data. The sample was mostly female (n=63; 79.7%) and the median age was 37 years (IQR, 29 to 48), ranging from 18 to 66 years (Table 1). Prior to formal analysis, participants’ median age, was divided into two meaningful groups: ≤35 years and ≥36 years. Most participants (n=68; 86.1%) were registered nurses with a median of 5.5 years (IQR, 2 to 10) experience in their current role. Almost half (n=38; 48.1%) of participants were recruited from Site A.

 

Table 1. Nurses’ demographic data and attitude to pressure ulcer prevention (n=79)

 

Most nurses (n=73; 92.4%) achieved a total APuP score ≥75% (≥39/52), indicating a positive attitude toward PI prevention (Table 2). The median total APuP score was 43.(IQR, 42–46) or 82.7%, further suggesting a positive attitude toward PI prevention among nurses. The median (IQR) APuP scores for the five subscales were all ≥75%, ranging from 75% to 91.7%. The highest median subscale was noted for ‘Priority of pressure ulcer prevention’ (median 11; IQR, 10–12) while the lowest was for ‘Impact of pressure ulcers’ (median 9; IQR, 9–10), which nonetheless met the positive attitude threshold of 75%. The Cronbach’s alpha for the original APuP instrument was 0.79¹⁴ while for this study it was 0.61.

 

Table 2. Nurses’ Attitudes towards Pressure ulcer Prevention (APuP) sub-scale score n=79

 

There were no statistically significant differences in the median total APuP scores based on age, gender, hospital site, job title or highest qualification (Table 3).

 

Table 3. Differences in nurses’ APuP scores n=79

 

Discussion

This study is the first to evaluate Queensland nurses’ attitudes towards PI prevention across three acute hospitals. Evidence suggests nurses’ attitude toward PI prevention can be a barrier to implementing prevention strategies recommended in the clinical practice guidelines.^8,15,36,37 Over ninety percent (n=73) of nurses in our study reported a positive attitude toward PI prevention, exceeding the results of previous Australian^12,15 and international studies.^10,26,38 In our study, a “positive attitude toward PI prevention” is based on the ≥75% study-specific cut-off of the total APuP score recommended by the instrument developer,¹⁴ a threshold also used in previous research on this topic. Avsar et al conducted two systematic reviews and found a 10.7% lower mean APuP score between their 2019 (Mean 69%; SD14%)³⁸ and 2023 reviews (Mean 62%; SD18%).¹⁰ Individual-level factors, such as attitude, are complex constructs that are influenced by individual belief systems and values^8,9 and an organisation.¹¹ Several factors might explain our findings. The data for previous studies were gathered between 2004–2018,^{10,12,15,16,26,38} while our 2023 results provide a contemporary healthcare lens. In the past decade, there have been significant innovations and technological-driven PI prevention strategies available at the bedside, such as wearable devices that prompt repositioning, motorised tilting hospital beds and alternating pressure reliving mattresses.¹ While it is unknown if these technologies influence nurses’ attitudes toward PI prevention or the quality of care, evidence suggests nurses respond positively when appropriate clinical resources are available for patient care delivery.^37,39 At each study site, the international PI prevention and treatment guidelines³¹ and national healthcare standards⁷ inform the development of local PI prevention policy and procedures. Likewise, the sites conduct monthly benchmarking of hospital-acquired PI incidence rates across the hospital and within individual wards. This data is then disseminated to nurses, managers and leaders to raise awareness of these adverse events.⁴⁰ These factors may have contributed to raising the profile and priority of PI prevention in each setting⁴¹ and may have influenced nurses’ attitudes. The psychological construct of attitude is complex, and global research indicates that this alone does not influence PI prevention practice.¹⁰ Rigorous research is therefore needed to better understand the influence of nurses’ attitudes and knowledge of PI prevention practices.^12,35

Competing clinical priorities and heavy workloads are known barriers to PI prevention implementation.^36,37,42 In our study, nurses assigned the highest sub-scale score to ‘Priority of PI prevention’ (91.7%), indicating this as their clinical priority and confirming previous Australian research.^12,15 In many countries, including Australia, nurses lead the planning and implementation of PI prevention care,^35-37 which might in part explain our findings. Yet, some qualitative studies report that nurses assign a lower priority to PI prevention.^43,44 For example, Sving et al’s⁴³ study found Swedish registered nurses’ perceived PI prevention as basic care, which was either under-delivered or delegated to assistant nurses. Barakat-Johnson et al⁴⁴ also found Australian nurses experiencing heavy workloads or a lack of access to resources then assigned a lower priority to PI prevention care. Prioritising care is part of normal practice,⁴² however, factors such as heavy workloads can force nurses to choose which care to deliver or omit, which can impact patient outcomes.^4,45 As a result, organisations have a responsibility to ensure nurses have access to the necessary resources to prioritise the safe delivery of quality PI prevention care.

We found no differences in nurses’ APuP scores based on age group, gender, hospital site, job title or highest professional qualification. This finding demonstrates a consistent attitude across the nursing workforce at our three hospitals and may suggest a focus on system-level, rather than individual-level, interventions, such as resources is warranted.¹¹ However, we urge caution when interpreting these findings because our sample size was small and there was a strong ceiling effect in attitude scores. Several studies have examined the relationship or predictors between nurses’ APuP scores and factors including age, education level and years of clinical experience, with conflicting results reported.^12,35,46 For example, Asiri et al’s³⁵ meta-analysis of 10 studies published between 2019–2025 with a sample of almost 2500 nurses, found a statistically significant correlation between nurses’ PI prevention knowledge and attitudes (fixed-effects model: correlation value=0.389; CI=0.354–0.422; p<0.001). Highlighting the complex nature of PI prevention, individual-level factors such as level of experience and knowledge, as well as variations in healthcare funding, organisational (such as policies) and contextual (such as resources) factors are acknowledged to impact this practice area.⁸ This confirms the need for more research to explore their collective influence.^44,47 Variations in the nursing workforce, such as older and younger aged nurses, number of years of clinical experience (novice compared to experienced nurses),⁴⁸ heavy workloads and burnout⁴⁹ are acknowledged to impact care delivery and quality. Having a national and standardised approach to hospital-acquired PI incidence rate reporting and PI prevention care resourcing is important because it has the possibility of improving the quality of PI prevention care patients receive.²⁹

This study has notable strengths as well as some limitations. The APuP instrument, which has undergone psychometric testing¹⁴ to establish its validity and reliability, is a commonly used tool for measuring nurses’ attitudes toward PI prevention.^26,35 However, its internal consistency reliability, evidenced by the Cronbach’s alpha (0.61) in our sample, was low. While our findings of high APuP scores are encouraging, they should be interpreted with caution. We acknowledge dichotomising the continuous APuP score variable (<75%; ≥75%) reduces analytical sensitivity, however as suggested by the instrument developer, we employed this approach to increase data comparison and benchmarking of our findings to previous research. Our data was gathered alongside a parent RCT, which may have resulted in response bias that inflated our results. We employed strategies to reduce this risk, such as employing Research Assistants not engaged with the parent RCT to recruit nurses, and the use of QR codes, which were anticipated to be launched on participants’ mobile phones or computers either at home or away from the hospital setting. The ceiling effect in our participant responses may indicate social desirability response bias or that the scale was not sensitive enough to detect differences between our high-scoring participants. Our sample did not reach our target sample of 100, which may have precluded the identification of differences in total APuP scores based on the demographic data. So, these findings may not be representative of the larger nursing population at the three sites. A large volume of clinical research is undertaken at the three hospital sites, which might have resulted in participant fatigue. Further, recruiting nurses from multiple Queensland hospital sites is a major strength, which enabled us to examine attitudes across a range of clinical settings and provides novel baseline data in this local context.

Conclusions

This study showed Australian nurses at our hospital sites had a positive attitude toward PI prevention with no differences in the median attitude scores based on participant age, gender, hospital site, job title or highest qualification. Nurses also rated PI prevention as a priority care area. However, attitude is a complex psychological construct and its influence on PI prevention is not fully understood. More research is needed to better understand nurses’ attitudes and how this might translate into the implementation of PI prevention strategies and reductions in PI incidence.

Acknowledgements

We wish to acknowledge and sincerely thank the study participants, research assistants, nurses, and managers at each study site for their time and support.

Conflict of interest

The authors declare no conflicts of interest.

Ethics statement

Ethics approval was gained for the EEPOC trial from the Gold Coast Hospital and Health Services (HREC/2019/QGC/51088) and Griffith University Human Research Ethics Committees (GU Ref No: 2019/685). Due to Human Research Ethics Committee conditions, the data gathered in this article cannot be publicly shared.

Funding

The EEPOC trial was supported by a grant from the National Health and Medical Research Council of Australia [APP11583879]. The funding body was not involved in any aspect of the study including the design, its execution, analyses, data interpretation or manuscript writing.

Author contribution

Sharon Latimer: data curation; formal analysis; writing (original draft); supervision. Rachel Walker: conceptualisation; data curation; project administration; writing (review & editing); investigation. Wendy Chaboyer and Marie Cooke: conceptualisation; writing (review & editing). Lukman Thalib: formal analysis; writing (review & editing). Brigid Gillespie: conceptualisation; project administration; data curation; writing (review & editing); investigation; supervision.

Author(s)

Sharon Latimer*¹, Rachel M Walker^2,3, Wendy Chaboyer¹, Marie Cooke⁴, Lukman Thalib⁵, Brigid M Gillespie^1,6
1NHMRC Centre of Research Excellence in Wiser Wound Care, School of Nursing and Midwifery, Griffith University, Brisbane Australia
²College of Healthcare Sciences Academy, James Cook University, Townsville, Australia
³Townsville Institute of Health Research & Innovation, Townsville University Hospital, Townsville, Australia
⁴School of Nursing and Midwifery, Griffith University, Brisbane, Australia
⁵Department of Biomedical Engineering, Yildiz Technical University, Istanbul, Türkiye
⁶Nursing and Midwifery Education and Research Unit, Gold Coast Hospital and Health Service, Brisbane, Australia

*Corresponding author email s.latimer@griffith.edu.au

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Supplementary information

STROBE Statement—checklist of items that should be included in reports of observational studies