Knowledge and Practices of Intensive Care Unit Nurses on the Prevention of Nosocomial Pressure Ulcers Using a Bundle Protocol: An Educational Intervention Study in Uganda

Knowledge and Practices of Intensive Care Unit Nurses on the Prevention of Nosocomial Pressure Ulcers Using a Bundle Protocol: An Educational Intervention Study in Uganda | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Knowledge and Practices of Intensive Care Unit Nurses on the Prevention of Nosocomial Pressure Ulcers Using a Bundle Protocol: An Educational Intervention Study in Uganda Kalanzi Phiona Katasi, Nyakuri Emma, Imujasi Martha, Ssemogerere Lameck, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6666554/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Aug, 2025 Read the published version in BMC Nursing → Version 1 posted 4 You are reading this latest preprint version Abstract Introduction Nosocomial pressure ulcers are wounds acquired within the hospital setting, pausing a burden to the patient families and the care teams due to patient discomfort and increased costs to treat and hospital resources. Globally, patients in intensive care units (ICUs) are most impacted, and the incidents go up to 33%, while a study done in Mbarara Regional Referral Hospital stated it at 19.3%. These incidents are preventable with the use of pressure ulcer prevention guidelines. This study aimed to investigate the effect of an educational intervention with a care bundle protocol on the knowledge and practices of intensive care unit nurses of Mulago Hospital in the prevention of nosocomial pressure ulcers. Methods This was a single-group quasi-experimental pre-test and post-test study that purposively selected 26 ICU nurses of Mulago National Referral Hospital. Their baseline knowledge and practice were assessed with an observation checklist and a knowledge assessment questionnaire, respectively. The nurses were then trained on the pressure ulcer prevention bundle protocol, and the training lasted two weeks. ICU nurses’ knowledge and practices were assessed two weeks after the training. Data was collected between May and July 2024 and was analyzed using STATA version 17. Independent sample t-test, Wilcoxon-rank sum test, ANOVA and Mann- Whitney U-test were used to compare variables. Results The critical care nurses’ knowledge of pressure ulcer prevention increased, however, on a moderate level, i.e., mean (SD) 63.2% (11.8) from (SD) 40.5 (10.6), yet practice increased from 37.6–62.6%, with a P value of 0.001. Conclusion Using pressure ulcer prevention guidelines significantly improved participants’ knowledge and practice. More in-service training on pressure ulcer prevention protocols and their availability to staff are recommended. Nosocomial pressure ulcers prevention A care bundle protocol Nurses’ knowledge and practice Introduction Nosocomial pressure ulcers are wounds acquired with in the hospital setting. They result from tissue damage and necrosis due to decreased blood supply to the affected area ( 1 ). These pressure ulcers commonly occur due to pressure, moisture, shearing and frictional forces ( 2 ). Other risk factors may be intrinsic like age, chronic conditions like vascular diseases and diabetes, smoking, malnutrition, immunosuppression, or extrinsic like long stay in ICU, poorly fitting prosthetic devices, lying on hard surfaces, poor hygiene and patient restraints ( 2 ). In high risk patients, nosocomial pressure ulcers have been witnessed to develop as quickly as within two hours after admission around the shoulder blades, knees, heels, on the occiput, sacrum etc ( 2 , 3 ) Even with the most up-to-date nursing interventions, nosocomial pressure ulcers are still an ongoing global issue among the critically ill ( 4 , 5 ). They have been noted to impose a huge burden to patients’ families and the managing teams due to patient discomfort, increased costs and hospital resources ( 6 , 7 ). The incidence of nosocomial pressure ulcers varies greatly. One recent large study on the incidence of Hospital acquired pressure ulcers (HAPU) globally demonstrated that they varied from 2.7–29%. In his research, Chou reports that the prevalence of hospital acquired ulcers in European hospitals ranges from 1 to 11% in medical wards and 4.7 to 66% in surgical wards ( 8 , 9 ). Importantly, patients in intensive care units (ICUs) are the most impacted by these incidents and the proportion of patients experiencing this outcome goes up to 33% in these settings ( 10 ). The World Stop Pressure Ulcer Day report of 2014 stated that nearly 700,000 patients were affected by pressure ulcers each year. According to the Coloplast summit report of 2013, 60,000 people die each year worldwide due to pressure ulcer related causes ( 9 , 11 ). Ideally, skin care for the critically ill is best done with the use of pressure ulcer prevention protocols ( 12 ). A pressure ulcer prevention bundle protocol is a set of eight evidence-based interventions. These are believed to improve outcomes if performed collectively and implemented consistently ( 13 ). These evidence based interventions include; education and training, risk assessment with a validated tool e.g. Braden scale, skin assessment (and those found to be at risk are given additional measures), Repositioning patients, skin care, managing incontinence of stool and urine, improving nutrition and hydration, using pressure relieving devices to reduce friction and sheer, and the outcomes to be documented and reviewed oftenly ( 14 , 15 ). A study at the University of Turkey, developed and validated a (Pressure ulcer) PU prevention bundle protocol following the European Pressure Ulcer Advisory Panel (EPUAP) guidelines. This protocol was developed mainly for critical care unit usage and results from its validation showed a content validity index of 0.99 rating it generally valid ( 16 ). In terms of effectiveness, it decreased pressure ulcer incidences from 22.1 to 13.0 per 100 patient-day ( 17 ). With these positive patient outcomes, nurses’ knowledge and practice were also seen to have improved greatly basing on interventional studies conducted in different countries i.e in Egypt, there was increment of knowledge and practice from 47–90% and 20–57% respectively ( 18 ), In Brazil knowledge increment was from 78.8–89.7% with satisfactory practice and in India nurses’ knowledge increased from 54.6 to 86.2% ( 19 ) rating these protocols highly essential in clinical practice. Besides the educational interventions, other organizational strategies like enforcing policies, performance evaluation of critical care staff, patient and care taker participation with the provision of pressure ulcer prevention pamphlets and visual tools are some of the interventions used in the nosocomial pressure ulcer prevention ( 20 , 21 ). These have complimented the educational interventions, hence improving health care, patient-related outcomes, and staff growth in this regard ( 22 ). Therefore, this study aimed to t investigate the effect of an educational intervention on the knowledge of critical care nurses and their practices in the prevention of nosocomial pressure ulcers with the use of a prevention bundle protocol at Mulago National Referral Hospital. Methods Design. This study used a descriptive quantitative quasi-experimental design. It was a single-group study with a pre/post-test approach. The research assistant observing the participants’ practice filled out an observation practice checklist two weeks before the training intervention to assess the participants' baseline practice. After baseline practice assessment, the nurses’ baseline knowledge was assessed with a pressure ulcer knowledge assessment questionnaire. Later, participants underwent a PU prevention training program using a bundle protocol. After two weeks, they were subjected to a post-test, and an observation checklist was completed. Relationships between and among selected dependent and independent variables were then determined. Setting. The study was conducted in the ICU of Mulago National Referral Hospital (MNRH). MNRH is located in the central region of Uganda, in the capital (Kampala), and has an 1800–2000 bed capacity. This is a specialized teaching hospital and Uganda’s largest public hospital (referral). The ICU has 27 beds and about 35 nursing staff, making it the largest ICU in the country. This study site was selected following evidence of increasing PUs in the critical care unit observed by Mwebaza in his study “Nurses’ Knowledge, Practices and Barriers in the Care of Patients with Pressure Ulcers in a Ugandan Teaching Hospital.” His emphasis was on training nurses on PU prevention guidelines( 23 ). Characteristics of participants. The target population was all nursing staff caring for critically ill patients in Mulago National Referral Hospital ICU. This population was targeted because these nurses spend most of their time with ICU patients, and pressure ulcer prevention in these patients is part of their responsibility. Data collection process. The data collection process was a three-phase process, i.e. pre-intervention, Intervention and Post-intervention. This lasted 12 weeks, and it took place within the intensive care unit of Mulago National Referral Hospital. The study’s research assistants (RA) were critical care nurses who once volunteered in the ICU of MNRH (RA1 and RA2). RA2 was in charge of knowledge assessment, while RA1 was in charge of observation for practice. These were excluded from the main study, and they underwent training on the study’s objectives and data collection process. Research assistants and the principal investigator (PI) sought permission to volunteer in the ICU of MHRH for one month before the data collection process, to reduce the Hawthorne effect. Pre-intervention phase. Objective one. Before filling out the baseline knowledge assessment questionnaires, it was necessary to first assess participants for the baseline practice. This was to ensure that the baseline knowledge assessment data collected wouldn’t cause any changes in the participants’ practice before the intervention. Once the waiver of informed consent was obtained from REC, The RA1 observed the study participants on duty for their practice in pressure ulcer prevention following the duty Rota with the use of an observation checklist, one at a time without their knowledge. This process lasted about two weeks. Objective two. Given that the study was conducted in the intensive care unit, it was important not to interrupt the staff’s work schedules. Therefore, the research assistant (RA2) engaged the staff during their afternoon break sessions to seek consent and administer the pressure ulcer knowledge assessment questionnaires to those cleared for baseline practice observation. This process lasted 45 minutes to 1 hour and continued for two weeks. Intervention phase. Immediately after completing the baseline data collection for all the study participants, the PI trained study participants on duty on the pressure ulcer prevention bundle protocol. The content was obtained from a study conducted in China about implementing a pressure injury care bundle in a Chinese ICU ( 24 ) and another study conducted in Turkey about the validating a pressure injury prevention care bundle ( 16 ). The training sessions were theory, demonstrations and return demonstrations. These took place in the Mulago National Referral Hospital ICU. Given that the sample size was small (26 participants), each study participant got a chance to have their training session lasting about one and a half hours. A total of 2 training sessions were conducted per day. This also continued for two weeks. The training was best done in the afternoon to avoid interrupting the morning unit activities like ward rounds, patient reviews, nursing care plans and priority interventions. Post intervention phase. Objective 3. After two weeks of training, RA2 administered the pressure ulcer knowledge assessment questionnaires to the study participants, i.e., those who were on the ward for their day duty and night shifts and those who could report from home while on their off duty. This activity lasted about 45 minutes and extended for two weeks until post-test knowledge assessment data was collected for all the study participants. After two weeks of training, using observation checklists, the RA1 observed the critical care nurses for their practice in hospital-acquired pressure ulcer prevention. Participants were observed on both shifts, day and night, without their knowledge, and the process lasted for two weeks. The data collected in this phase fulfilled the third objective of the research study. All the study participants were compensated for their time and transport. Data Analysis. Operational definitions. Knowledge The knowledge of pressure ulcers was assessed using a set of 30 multiple-choice questions, for which the correct answer was weighted “1” and all other wrong answers were weighted “0.” The percentage score was computed by summating all the weights, then divided by 30 (the highest possible score) and multiplied by 100. The higher score was indicative of adequate knowledge of the prevention of pressure ulcers. The practice Pressure ulcer prevention was assessed by observing all the participants for one moment while conducting procedures to prevent pressure ulcers. An observation checklist with 34 steps guided the RAs on the care given while preventing pressure ulcers among the critically ill with a care bundle protocol. Each step was assessed using a hierarchical 3-level scale where those who missed a step were given a score of “0”, those who performed the step partially were given a score of “1”, and those who performed the procedure correctly were given a score of “2”. The weights were then summated, and the total score was converted to a percentage by dividing the total score by 68 and multiplying by 100 to get each participant’s percentage of practice score. The data obtained was checked for completeness and correctness and cleaned before being exported into STATA. The data was exported to STATA version 17.0. Descriptive statistics were used to summarize the data. Continuous variables were summarized using the mean and standard deviation (SD) or the median and interquartile range (IQR). Categorical variables were summarized using frequencies and percentages. For objective 1, the practice score’s mean and SD were computed. The difference in the mean practice score between males and females was assessed using the independent sample t-test. The difference in median practice score between those who had ever received refresher training on the prevention of pressure ulcers was evaluated using the Wilcoxon-rank sum test. The two-sided P values were presented, and the significance level was 0.05. The difference in the mean practice score among the levels of education was assessed using one-way ANOVA. For objective 2, the knowledge score’s mean and SD were computed. The sex and previous training on pressure ulcer differences in median knowledge scores were assessed using the Wilcoxon-rank sum test. The difference in the mean knowledge score among the levels of education was evaluated using one-way ANOVA For objective 3, the mean difference in knowledge and practice scores before and after the educational intervention was assessed using a paired t-test. Results Demographic characteristics of the study participants. The study participants’ median (IQR) age was 37.5% (32, 49). Most of the participants were females (18/26). Nearly half of the participants had a Bachelor’s degree (10/26). Most participants had practiced critical care for over three years, yet only a few (9/26) had ever received training on preventing pressure ulcers. The participants reported caring for about 3 ( 2 , 4 ) pressure ulcers per week. (Table 1 ) Table 1 Demographic characteristics of 26 critical care nurses at MNRH who participated in the study. Variable Categories Frequencies and Percentages (%) Age (completed years) Median (IQR) 37.5 (32, 49) Sex Male 8 (30.8) Female 18 (69.2) Education level Certificate 2 (7.7) Diploma 10 (38.5) Bachelor’s degree 10 (38.5) Post-graduate degree 4 (15.3) Practice experience 2 years and less 3 (11.5) 3–5 years 10 (38.5) 6–10 years 8 (30.8) > 10 years 5 (19.2) Ever received training in pressure ulcer prevention and care Yes 9 (34.6) No 17 (65.4) Number of pressure ulcer patients seen weekly Median (IQR) 3 ( 2 , 4 ) Objective 1. Baseline practice of critical care nurses in preventing nosocomial pressure ulcers with a bundle protocol. The mean (SD) practice score was 37.6% (10.3). The difference in practice score between males and females was not statistically significant. Similarly, there was no difference in the median (IQR) practice score of those with previous training in preventing pressure ulcers and those without training. There was no statistical significance among participants’ practice in pressure ulcer prevention and their levels of education. (Table 2 ) Table 2 Distribution of baseline practice score of pressure ulcer prevention among critical care nurses at MNRH across independent variables. Variable Categories Median (IQR) P value Sex* Male 33.8 (11.5) 0.222 @ Female 39.2 (9.6) Ever received training in pressure ulcer prevention and care Yes 36.8 (33.8, 38.2) 0.608 No 35.3 (29.4, 45.6) Education level Certificate 34.6 (25.0, 44.1) 0.603 # Diploma 38.2 (29.4, 45.6) Bachelor’s degree 36.8 (32.0, 48.5) Post-graduate degree 34.6 (30.0, 36.1) *Mean (SD) presented Independent sample t-test P-value ANOVA P value Objective 2. Baseline knowledge of Critical care nurses in preventing nosocomial PUs with a bundle protocol. The overall mean (SD) knowledge score was 40.5% (10.6). The median (IQR) knowledge score was not statistically different between males and females. There was no difference in the median (IQR) knowledge score between those who had previous training in the prevention of pressure ulcers and those who didn’t have any training. The level of education did not impact the baseline knowledge in preventing pressure ulcers. (Table 3 ) Table 3 Distribution of baseline knowledge score about pressure ulcer prevention among critical care nurses at MNRH across independent variables. Variable Categories Median (IQR) P value Sex Male 43.3 (28.3, 53.4) 0.675 Female 40.0 (33.3, 46.7) Ever received training in pressure ulcer prevention and care Yes 43.3 (33.3, 50.0) 0.766 No 40.0 (33.3, 43.3) Education level Certificate 36.7 (4.7) 0.902 # Diploma 41.0 (12.3) Bachelor’s degree 39.7 (10.4) Post-graduate degree 43.3 (11.9) *Mean (SD) presented ANOVA P value Objective 3. The mean knowledge and practice scores were significantly and statistically high after the educational intervention. (Table 4 ) Table 4 Change in knowledge and practice of pressure ulcer prevention pre and post-intervention. Mean (SD) before intervention Mean (SD) after the intervention P value (Paired t-test) Knowledge 40.5 (10.6) 63.2 (11.8) < 0.001 Practice 37.6 (10.3) 62.6 (7.3) < 0.001 Discussion The baseline knowledge and practice of pressure ulcer prevention were found significantly lacking, just like in the studies conducted by Mohammed in Iran and Salwa in Egypt ( 18 , 25 ). The lack of an active protocol on pressure ulcer prevention in the study ICU may have contributed to this finding. Also, there was no significant difference in the baseline knowledge and practice among participants who had prior training on pressure prevention versus those with no prior training. The participants’ expression of the need for updated protocols on pressure ulcer prevention could support this finding. Some studies have shown that pressure ulcer prevention protocols are lacking in ICU environments and those with these protocols, nurses are found not to comply to them ( 26 , 27 ). The post-intervention knowledge and practice review revealed significant improvement in the study participants’ knowledge and practices on pressure ulcer prevention ( 9 , 28 ). Staff training on the pressure ulcer prevention protocol as an intervention yielded these expected results like in some studies done in Finland by Marki and Saleh in Egypt which showed an improvement in knowledge, practices, attitudes and intentions, hence an education intervention being a powerful tool for nurses in the pressure ulcer prevention ( 29 , 30 ). Baseline Practice of Critical Care Nurses in the prevention of hospital acquired pressure ulcers. The mean baseline practice score among critical care nurses before the intervention was 37.6% with a SD 10.3. given that the level of practice was below 75%, this concluded unsatisfactory level of practice as far as pressure ulcer prevention practice among the critical care nurses is concerned. The level of practice was not affected by the participants’ sex and level of education. Generally, the baseline participants’ practice scores were not to the satisfactory level and these findings are comparable to those in a study by Saad from Egypt, and that by Nuru from Ethiopia, as well as a study by Saleh where the practice scores were found to be 22%, 48.4% and 49% respectively ( 1 , 30 , 31 ). Baseline Knowledge of Critical Care Nurses in regards to hospital acquired pressure ulcers and their prevention. The overall mean (SD) knowledge score of critical care nurses in the prevention of hospital acquired pressure ulcers before the intervention was 40.5% (10.6). This indicated a poor level of knowledge agreeing with most studies conducted on the nurses’ knowledge and practice in the pressure ulcer prevention ( 32 – 34 ). This finding was because most nurses had never had any prior training on pressure ulcer prevention, while those who had training, it was not on this specific pressure ulcer prevention guideline ( 35 – 37 ). The change in knowledge and practice of the critical care nurses in the prevention of hospital acquired pressure ulcers after the intervention. This study revealed that an educational intervention with a power point material and demonstration with a pressure ulcer prevention bundle protocol had a positive effect on the critical care nurses’ knowledge and their practice in the prevention of hospital acquired pressure ulcers. The knowledge of the critical care nurses in regards to the pressure ulcer prevention increased however on a moderate level i.e mean (SD) 63.2% (11.8), yet practice increased from 37.6–62.6%, with a P value of < 0.001, hence a statistical significance. But since the study’s cutoff on practice was more than 75%, this finding left us at unsatisfactory. This moderate level of knowledge and practice is attributed to the training sessions which were limited to only one session in participants who barely had any training in PU prevention. Studies showed that training nurses more than once with multiple intervention programs improved their knowledge to over 80% ( 18 , 29 , 38 , 39 ). Also, it was noted that the nurses had been working to prevent pressure ulcers however they were not following any guidelines. Most of their knowledge and practice was developed from experience over the years. So compliance to this introduced guideline was not easy. Incompliance to new guidelines has been reported in most studies as a hindrance to quality care given to many patients within the critical care environment ( 31 , 40 , 41 ). In the subgroups, participants who had less years of experience showed poor level of knowledge as compared to the rest of the subgroups and because P value is more than 0.05, this might have been because they are still new to the critical care environment, not yet involved in knowledge development and research, and mostly needing support from their superiors, as well as more educational programs on pressure ulcer prevention ( 30 , 42 ). Therefore, more trainings on pressure ulcer prevention guidelines should be encouraged and scheduled within the intensive care units, the pressure ulcer prevention protocols should be availed to the staff and the nursing managers should supervise their utilization. Strengths and Limitations of the study. The study required less resources hence it was less costly. It also had a higher external validity because of the educational intervention used. This allowed the researchers to control for the confounding variables. One of the limitations was a possibility of observation bias (hawthorn effect). This was overcome by using a research assistant who once worked within the ICU of MNRH to do both pre and post intervention observation for the participants’ practice. This research assistant requested to volunteer again and was not disclosed to the study participants. Secondly, the study was conducted in one center, hence this might not be generalized for all the critical care nurses elsewhere. Last but not least, the number of intervention sessions was limited to one. Given that more participants had never trained in pressure ulcer prevention. Implications and recommendations of the study. The study findings implied that critical care nurses’ knowledge and skills in pressure ulcer prevention with the use of the bundle protocols were enhanced to an unsatisfactory level as per the cut off points. The researchers therefore recommend the Nursing management to enforce trainings for critical care staff in regards to pressure ulcer prevention with the use of bundle protocols to continue enhancing their knowledge and practices with use of these bundle protocols. To the ward in-charge, the researchers recommend that they organize continuous medical education sessions in relation to pressure ulcers, prevention and management with bundle protocols to boost the nurses’ knowledge and practice. Policy makers should ensure that Guidelines on pressure ulcer prevention are formulated and made easily accessible country-wide to increase awareness of these bundle protocols to the critical care staff and finally, the effect of the bundle protocols to be assessed by nursing staff as a multi-center study. Conclusion The intervention brought about an increase in knowledge of pressure ulcers and their prevention with the use of a bundle protocol as well as an improvement in nurses’ practice to ensure these pressure ulcers are eradicated from the critical care unit. Abbreviations MNRH Mulago National Referral Hospital ICU Intensive Care Unit HAPU Hospital Acquired Pressure Ulcers AHRQ Acquired Health Research Quality RA1 Research assistant one RA2 Research assistant two PI Principal investigator EPUAP European Pressure Ulcer Advisory Panel Declarations Ethical Approval and consent of participants. Ethical approval was obtained from the Mbarara University of Science and Technology (MUST), Faculty Research and Ethics Committee (FREC) and Institutional Review Committee (MUST-REC, MUST- 2023-1153). A waiver of consent for observation of study participants for practice in pressure ulcer prevention and permission to conduct the study were sought from the REC Mulago National referral hospital. Participants’ informed consents were sought for objective 2 and 3 and their confidentiality was observed strictly by awarding them codes for each questionnaire answered instead of personal identifiers, and their signatures validated the comments and rating awarded. All the collected data was stored carefully under lock and key drawers to ensure only authorized persons could access it. And in case of any highly sensitive information, guidance and permission was sought and granted by REC before public consumption. Availability of data and material. The data that supported the findings of this study are available from the first and corresponding author, Kalanzi Phiona Katasi but restrictions apply under license for the current study. Competing interests. The authors declare no competing interest. Funding. Funding for this study came from the Massachusetts General Hospital Center for Global Health’s project entitled ‘First Mile: Powering the Academic Medical Center to Delivery Healthcare in the Community in Uganda’ supporting through the Wyss Medical Foundation. Authors’ contributions. KPK conceived and designed the study. KPK, NE and IM implemented the study and conducted data analysis. AC supervised the study. KPK, SL, AC interpreted study results. KPK wrote the first draft of the manuscript. AC and SL reviewed and corrected the draft manuscript. All authors read and approved the final manuscript. Acknowledgement. The funders for this study, The Massachusetts General Hospital, Center for Global Health’s project entitled ‘First Mile: Powering the Academic Medical Center to Delivery Healthcare in the Community in Uganda’ supporting through the Wyss Medical Foundation. We appreciate all the participants in this study i.e Critical care nurses of Mulago National Referral Hospital Intensive Care Unit. References Saad E, Ragheb M, Sheta H, Hamed M. Effect of an Educational Program on Nurses’ Performance Regarding Reducing Pressure Ulcer and Safety of Immobilized Patients. Benha J Appl Sci (BJAS). 2022. Zuo X-L, Meng F-J. A care bundle for pressure ulcer treatment in intensive care units. Int J Nurs Sci. 2015;2(4):340–7. Anders J, Heinemann A, Leffmann C, Leutenegger M, Pröfener F, von Renteln-Kruse W. Decubitus ulcers: pathophysiology and primary prevention. Deutsches Ärzteblatt international. 2010;107(21):371. Kalowes P, Messina V, Li M. 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Nursing Students’ Knowledge on Pressure Injuries Following a Blended-Learning Unit: A Quasi-experimental Study. Adv Skin Wound Care. 2023;36(12):636–41. Dilie A, Mengistu D. Assessment of nurses’ knowledge, attitude, and perceived barriers to expressed pressure ulcer prevention practice in Addis Ababa government hospitals, Addis Ababa, Ethiopia, 2015. Adv Nurs. 2015;2015(1):796927. Malinga S, Dlungwane T. Nurses' Knowledge, Attitudes and Practices regarding Pressure Ulcer Prevention in the Umgungundlovu District, South Africa. Afr J Nurs Midwifery. 2020;22(2). Sardari M, Esmaeili R, Ravesh NN, Nasiri M. The impact of pressure ulcer training program on nurses’ performance. J Adv Pharm Educ &. 2019;3. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 Aug, 2025 Read the published version in BMC Nursing → Version 1 posted Editorial decision: Revision requested 16 May, 2025 Editor assigned by journal 15 May, 2025 Submission checks completed at journal 15 May, 2025 First submitted to journal 14 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6666554","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":457596633,"identity":"06a31795-7c1d-40d0-a0a7-4b09cee9bd89","order_by":0,"name":"Kalanzi Phiona Katasi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYBAC9mbGBwcbgAz74yDSwIKwFp7DzAZALQYMDGcOgLRIEKHlALMBI1jLjQQQnxgt7MyMB2fU/LFnnPn86oYfBRIM/O3dCfi1MDMzHNxwzCCxWTqn7GYP0GESZ85uwKvFnpn/wMEHbAYJbNI5aTd4gFoMJHLxawHb8uCfgT2P5Jm0m3+I1rKxzYBxhgT7sdvE2zKzzzhxA08O220ZAwkegn7h4T/M/LHnm5y9AfvxZzff/LGR42/vxa8FWbcBmCRWOQiwPyBF9SgYBaNgFIwgAAB8MEWjVvIl6wAAAABJRU5ErkJggg==","orcid":"","institution":"Mbarara University of Sciences and Technology","correspondingAuthor":true,"prefix":"","firstName":"Kalanzi","middleName":"Phiona","lastName":"Katasi","suffix":""},{"id":457596639,"identity":"040dd1f4-0292-4078-be9d-fa1d9944867c","order_by":1,"name":"Nyakuri Emma","email":"","orcid":"","institution":"Mulago National Referral Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nyakuri","middleName":"","lastName":"Emma","suffix":""},{"id":457596640,"identity":"0d781ba7-bc19-44f9-8a1e-7df3a6d336e1","order_by":2,"name":"Imujasi Martha","email":"","orcid":"","institution":"Mulago National Referral Hospital","correspondingAuthor":false,"prefix":"","firstName":"Imujasi","middleName":"","lastName":"Martha","suffix":""},{"id":457596641,"identity":"344a69bd-f253-4828-9389-12d65199581e","order_by":3,"name":"Ssemogerere Lameck","email":"","orcid":"","institution":"Makerere University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Ssemogerere","middleName":"","lastName":"Lameck","suffix":""},{"id":457596642,"identity":"ba6ae453-bc1f-42b6-a91b-5c745a659a2b","order_by":4,"name":"Atuhaire Catherine","email":"","orcid":"","institution":"Mbarara University of Sciences and Technology","correspondingAuthor":false,"prefix":"","firstName":"Atuhaire","middleName":"","lastName":"Catherine","suffix":""}],"badges":[],"createdAt":"2025-05-14 18:08:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6666554/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6666554/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12912-025-03731-4","type":"published","date":"2025-08-11T15:57:49+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":89310557,"identity":"b83c31ce-9517-4a5d-8cbd-67d3c03faaf7","added_by":"auto","created_at":"2025-08-18 16:07:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1064753,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6666554/v1/4508fe11-b5a0-4184-8c64-88aeb91b5024.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eKnowledge and Practices of Intensive Care Unit Nurses on the Prevention of Nosocomial Pressure Ulcers Using a Bundle Protocol: An Educational Intervention Study in Uganda\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNosocomial pressure ulcers are wounds acquired with in the hospital setting. They result from tissue damage and necrosis due to decreased blood supply to the affected area (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). These pressure ulcers commonly occur due to pressure, moisture, shearing and frictional forces (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Other risk factors may be intrinsic like age, chronic conditions like vascular diseases and diabetes, smoking, malnutrition, immunosuppression, or extrinsic like long stay in ICU, poorly fitting prosthetic devices, lying on hard surfaces, poor hygiene and patient restraints (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In high risk patients, nosocomial pressure ulcers have been witnessed to develop as quickly as within two hours after admission around the shoulder blades, knees, heels, on the occiput, sacrum etc (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eEven with the most up-to-date nursing interventions, nosocomial pressure ulcers are still an ongoing global issue among the critically ill (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). They have been noted to impose a huge burden to patients\u0026rsquo; families and the managing teams due to patient discomfort, increased costs and hospital resources (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe incidence of nosocomial pressure ulcers varies greatly. One recent large study on the incidence of Hospital acquired pressure ulcers (HAPU) globally demonstrated that they varied from 2.7\u0026ndash;29%. In his research, Chou reports that the prevalence of hospital acquired ulcers in European hospitals ranges from 1 to 11% in medical wards and 4.7 to 66% in surgical wards (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Importantly, patients in intensive care units (ICUs) are the most impacted by these incidents and the proportion of patients experiencing this outcome goes up to 33% in these settings (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The World Stop Pressure Ulcer Day report of 2014 stated that nearly 700,000 patients were affected by pressure ulcers each year. According to the Coloplast summit report of 2013, 60,000 people die each year worldwide due to pressure ulcer related causes (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIdeally, skin care for the critically ill is best done with the use of pressure ulcer prevention protocols (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). A pressure ulcer prevention bundle protocol is a set of eight evidence-based interventions. These are believed to improve outcomes if performed collectively and implemented consistently (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). These evidence based interventions include; education and training, risk assessment with a validated tool e.g. Braden scale, skin assessment (and those found to be at risk are given additional measures), Repositioning patients, skin care, managing incontinence of stool and urine, improving nutrition and hydration, using pressure relieving devices to reduce friction and sheer, and the outcomes to be documented and reviewed oftenly (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e A study at the University of Turkey, developed and validated a (Pressure ulcer) PU prevention bundle protocol following the European Pressure Ulcer Advisory Panel (EPUAP) guidelines. This protocol was developed mainly for critical care unit usage and results from its validation showed a content validity index of 0.99 rating it generally valid (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In terms of effectiveness, it decreased pressure ulcer incidences from 22.1 to 13.0 per 100 patient-day (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWith these positive patient outcomes, nurses\u0026rsquo; knowledge and practice were also seen to have improved greatly basing on interventional studies conducted in different countries i.e in Egypt, there was increment of knowledge and practice from 47\u0026ndash;90% and 20\u0026ndash;57% respectively (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), In Brazil knowledge increment was from 78.8\u0026ndash;89.7% with satisfactory practice and in India nurses\u0026rsquo; knowledge increased from 54.6 to 86.2% (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) rating these protocols highly essential in clinical practice.\u003c/p\u003e \u003cp\u003eBesides the educational interventions, other organizational strategies like enforcing policies, performance evaluation of critical care staff, patient and care taker participation with the provision of pressure ulcer prevention pamphlets and visual tools are some of the interventions used in the nosocomial pressure ulcer prevention (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). These have complimented the educational interventions, hence improving health care, patient-related outcomes, and staff growth in this regard (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTherefore, this study aimed to t investigate the effect of an educational intervention on the knowledge of critical care nurses and their practices in the prevention of nosocomial pressure ulcers with the use of a prevention bundle protocol at Mulago National Referral Hospital.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003e \u003cb\u003eDesign.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study used a descriptive quantitative quasi-experimental design. It was a single-group study with a pre/post-test approach.\u003c/p\u003e \u003cp\u003e The research assistant observing the participants\u0026rsquo; practice filled out an observation practice checklist two weeks before the training intervention to assess the participants' baseline practice.\u003c/p\u003e \u003cp\u003eAfter baseline practice assessment, the nurses\u0026rsquo; baseline knowledge was assessed with a pressure ulcer knowledge assessment questionnaire. Later, participants underwent a PU prevention training program using a bundle protocol. After two weeks, they were subjected to a post-test, and an observation checklist was completed.\u003c/p\u003e \u003cp\u003eRelationships between and among selected dependent and independent variables were then determined.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSetting.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe study was conducted in the ICU of Mulago National Referral Hospital (MNRH). MNRH is located in the central region of Uganda, in the capital (Kampala), and has an 1800\u0026ndash;2000 bed capacity. This is a specialized teaching hospital and Uganda\u0026rsquo;s largest public hospital (referral). The ICU has 27 beds and about 35 nursing staff, making it the largest ICU in the country.\u003c/p\u003e \u003cp\u003eThis study site was selected following evidence of increasing PUs in the critical care unit observed by Mwebaza in his study \u0026ldquo;Nurses\u0026rsquo; Knowledge, Practices and Barriers in the Care of Patients with Pressure Ulcers in a Ugandan Teaching Hospital.\u0026rdquo; His emphasis was on training nurses on PU prevention guidelines(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eCharacteristics of participants.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe target population was all nursing staff caring for critically ill patients in Mulago National Referral Hospital ICU. This population was targeted because these nurses spend most of their time with ICU patients, and pressure ulcer prevention in these patients is part of their responsibility.\u003c/p\u003e \u003cp\u003e \u003cb\u003eData collection process.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe data collection process was a three-phase process, i.e. pre-intervention, Intervention and Post-intervention. This lasted 12 weeks, and it took place within the intensive care unit of Mulago National Referral Hospital. The study\u0026rsquo;s research assistants (RA) were critical care nurses who once volunteered in the ICU of MNRH (RA1 and RA2). RA2 was in charge of knowledge assessment, while RA1 was in charge of observation for practice. These were excluded from the main study, and they underwent training on the study\u0026rsquo;s objectives and data collection process. Research assistants and the principal investigator (PI) sought permission to volunteer in the ICU of MHRH for one month before the data collection process, to reduce the Hawthorne effect.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePre-intervention phase.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eObjective one.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eBefore filling out the baseline knowledge assessment questionnaires, it was necessary to first assess participants for the baseline practice. This was to ensure that the baseline knowledge assessment data collected wouldn\u0026rsquo;t cause any changes in the participants\u0026rsquo; practice before the intervention.\u003c/p\u003e \u003cp\u003e Once the waiver of informed consent was obtained from REC, The RA1 observed the study participants on duty for their practice in pressure ulcer prevention following the duty Rota with the use of an observation checklist, one at a time without their knowledge. This process lasted about two weeks.\u003c/p\u003e \u003cp\u003e \u003cb\u003eObjective two.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eGiven that the study was conducted in the intensive care unit, it was important not to interrupt the staff\u0026rsquo;s work schedules. Therefore, the research assistant (RA2) engaged the staff during their afternoon break sessions to seek consent and administer the pressure ulcer knowledge assessment questionnaires to those cleared for baseline practice observation. This process lasted 45 minutes to 1 hour and continued for two weeks.\u003c/p\u003e \u003cp\u003e \u003cb\u003eIntervention phase.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e Immediately after completing the baseline data collection for all the study participants, the PI trained study participants on duty on the pressure ulcer prevention bundle protocol. The content was obtained from a study conducted in China about implementing a pressure injury care bundle in a Chinese ICU (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) and another study conducted in Turkey about the validating a pressure injury prevention care bundle (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe training sessions were theory, demonstrations and return demonstrations. These took place in the Mulago National Referral Hospital ICU. Given that the sample size was small (26 participants), each study participant got a chance to have their training session lasting about one and a half hours. A total of 2 training sessions were conducted per day. This also continued for two weeks. The training was best done in the afternoon to avoid interrupting the morning unit activities like ward rounds, patient reviews, nursing care plans and priority interventions.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePost intervention phase.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eObjective 3.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAfter two weeks of training, RA2 administered the pressure ulcer knowledge assessment questionnaires to the study participants, i.e., those who were on the ward for their day duty and night shifts and those who could report from home while on their off duty. This activity lasted about 45 minutes and extended for two weeks until post-test knowledge assessment data was collected for all the study participants.\u003c/p\u003e \u003cp\u003e After two weeks of training, using observation checklists, the RA1 observed the critical care nurses for their practice in hospital-acquired pressure ulcer prevention. Participants were observed on both shifts, day and night, without their knowledge, and the process lasted for two weeks. The data collected in this phase fulfilled the third objective of the research study. All the study participants were compensated for their time and transport.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis.\u003c/h2\u003e \u003cp\u003e \u003cb\u003eOperational definitions.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eKnowledge\u003c/strong\u003e \u003cp\u003eThe knowledge of pressure ulcers was assessed using a set of 30 multiple-choice questions, for which the correct answer was weighted \u0026ldquo;1\u0026rdquo; and all other wrong answers were weighted \u0026ldquo;0.\u0026rdquo; The percentage score was computed by summating all the weights, then divided by 30 (the highest possible score) and multiplied by 100. The higher score was indicative of adequate knowledge of the prevention of pressure ulcers.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eThe practice\u003c/strong\u003e \u003cp\u003e Pressure ulcer prevention was assessed by observing all the participants for one moment while conducting procedures to prevent pressure ulcers. An observation checklist with 34 steps guided the RAs on the care given while preventing pressure ulcers among the critically ill with a care bundle protocol. Each step was assessed using a hierarchical 3-level scale where those who missed a step were given a score of \u0026ldquo;0\u0026rdquo;, those who performed the step partially were given a score of \u0026ldquo;1\u0026rdquo;, and those who performed the procedure correctly were given a score of \u0026ldquo;2\u0026rdquo;. The weights were then summated, and the total score was converted to a percentage by dividing the total score by 68 and multiplying by 100 to get each participant\u0026rsquo;s percentage of practice score.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe data obtained was checked for completeness and correctness and cleaned before being exported into STATA.\u003c/p\u003e \u003cp\u003eThe data was exported to STATA version 17.0. Descriptive statistics were used to summarize the data. Continuous variables were summarized using the mean and standard deviation (SD) or the median and interquartile range (IQR). Categorical variables were summarized using frequencies and percentages.\u003c/p\u003e \u003cp\u003eFor objective 1, the practice score\u0026rsquo;s mean and SD were computed. The difference in the mean practice score between males and females was assessed using the independent sample t-test. The difference in median practice score between those who had ever received refresher training on the prevention of pressure ulcers was evaluated using the Wilcoxon-rank sum test. The two-sided P values were presented, and the significance level was 0.05. The difference in the mean practice score among the levels of education was assessed using one-way ANOVA.\u003c/p\u003e \u003cp\u003eFor objective 2, the knowledge score\u0026rsquo;s mean and SD were computed. The sex and previous training on pressure ulcer differences in median knowledge scores were assessed using the Wilcoxon-rank sum test. The difference in the mean knowledge score among the levels of education was evaluated using one-way ANOVA\u003c/p\u003e \u003cp\u003eFor objective 3, the mean difference in knowledge and practice scores before and after the educational intervention was assessed using a paired t-test.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cb\u003eDemographic characteristics of the study participants.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe study participants\u0026rsquo; median (IQR) age was 37.5% (32, 49). Most of the participants were females (18/26). Nearly half of the participants had a Bachelor\u0026rsquo;s degree (10/26). Most participants had practiced critical care for over three years, yet only a few (9/26) had ever received training on preventing pressure ulcers. The participants reported caring for about 3 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) pressure ulcers per week. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics of 26 critical care nurses at MNRH who participated in the study.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequencies and Percentages (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (completed years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.5 (32, 49)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u0026nbsp;\u0026nbsp;\u0026nbsp; (30.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u0026nbsp; (69.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCertificate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u0026nbsp;\u0026nbsp;\u0026nbsp; (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u0026nbsp; (38.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u0026nbsp; (38.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost-graduate degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u0026nbsp;\u0026nbsp; (15.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePractice experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 years and less\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u0026nbsp;\u0026nbsp; (11.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026ndash;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (38.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u0026nbsp; (30.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u0026nbsp; (19.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEver received training in pressure ulcer prevention and care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u0026nbsp; (34.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u0026nbsp; (65.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of pressure ulcer patients seen weekly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u0026nbsp; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eObjective 1.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eBaseline practice of critical care nurses in preventing nosocomial pressure ulcers with a bundle protocol.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe mean (SD) practice score was 37.6% (10.3). The difference in practice score between males and females was not statistically significant. Similarly, there was no difference in the median (IQR) practice score of those with previous training in preventing pressure ulcers and those without training. There was no statistical significance among participants\u0026rsquo; practice in pressure ulcer prevention and their levels of education. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of baseline practice score of pressure ulcer prevention among critical care nurses at MNRH across independent variables.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33.8 (11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.222\u003csup\u003e@\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.2 (9.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEver received training in pressure ulcer prevention and care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.8 (33.8, 38.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.608\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35.3 (29.4, 45.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCertificate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34.6 (25.0, 44.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.603\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.2 (29.4, 45.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.8 (32.0, 48.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost-graduate degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34.6 (30.0, 36.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e*Mean (SD) presented Independent sample t-test P-value ANOVA P value\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eObjective 2.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eBaseline knowledge of Critical care nurses in preventing nosocomial PUs with a bundle protocol.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe overall mean (SD) knowledge score was 40.5% (10.6). The median (IQR) knowledge score was not statistically different between males and females. There was no difference in the median (IQR) knowledge score between those who had previous training in the prevention of pressure ulcers and those who didn\u0026rsquo;t have any training. The level of education did not impact the baseline knowledge in preventing pressure ulcers. (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of baseline knowledge score about pressure ulcer prevention among critical care nurses at MNRH across independent variables.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43.3 (28.3, 53.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.675\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.0 (33.3, 46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEver received training in pressure ulcer prevention and care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43.3 (33.3, 50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.766\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.0 (33.3, 43.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCertificate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.7 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.902\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41.0 (12.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.7 (10.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost-graduate degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43.3 (11.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e*Mean (SD) presented ANOVA P value\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eObjective 3.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe mean knowledge and practice scores were significantly and statistically high after the educational intervention. (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChange in knowledge and practice of pressure ulcer prevention pre and post-intervention.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (SD) before intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean (SD) after the intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value (Paired t-test)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40.5 (10.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63.2 (11.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePractice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37.6 (10.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62.6 (7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe baseline knowledge and practice of pressure ulcer prevention were found significantly lacking, just like in the studies conducted by Mohammed in Iran and Salwa in Egypt (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The lack of an active protocol on pressure ulcer prevention in the study ICU may have contributed to this finding. Also, there was no significant difference in the baseline knowledge and practice among participants who had prior training on pressure prevention versus those with no prior training. The participants\u0026rsquo; expression of the need for updated protocols on pressure ulcer prevention could support this finding. Some studies have shown that pressure ulcer prevention protocols are lacking in ICU environments and those with these protocols, nurses are found not to comply to them (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The post-intervention knowledge and practice review revealed significant improvement in the study participants\u0026rsquo; knowledge and practices on pressure ulcer prevention (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Staff training on the pressure ulcer prevention protocol as an intervention yielded these expected results like in some studies done in Finland by Marki and Saleh in Egypt which showed an improvement in knowledge, practices, attitudes and intentions, hence an education intervention being a powerful tool for nurses in the pressure ulcer prevention (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eBaseline Practice of Critical Care Nurses in the prevention of hospital acquired pressure ulcers.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe mean baseline practice score among critical care nurses before the intervention was 37.6% with a SD 10.3. given that the level of practice was below 75%, this concluded unsatisfactory level of practice as far as pressure ulcer prevention practice among the critical care nurses is concerned.\u003c/p\u003e \u003cp\u003eThe level of practice was not affected by the participants\u0026rsquo; sex and level of education. Generally, the baseline participants\u0026rsquo; practice scores were not to the satisfactory level and these findings are comparable to those in a study by Saad from Egypt, and that by Nuru from Ethiopia, as well as a study by Saleh where the practice scores were found to be 22%, 48.4% and 49% respectively (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eBaseline Knowledge of Critical Care Nurses in regards to hospital acquired pressure ulcers and their prevention.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe overall mean (SD) knowledge score of critical care nurses in the prevention of hospital acquired pressure ulcers before the intervention was 40.5% (10.6). This indicated a poor level of knowledge agreeing with most studies conducted on the nurses\u0026rsquo; knowledge and practice in the pressure ulcer prevention (\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). This finding was because most nurses had never had any prior training on pressure ulcer prevention, while those who had training, it was not on this specific pressure ulcer prevention guideline (\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe change in knowledge and practice of the critical care nurses in the prevention of hospital acquired pressure ulcers after the intervention.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e This study revealed that an educational intervention with a power point material and demonstration with a pressure ulcer prevention bundle protocol had a positive effect on the critical care nurses\u0026rsquo; knowledge and their practice in the prevention of hospital acquired pressure ulcers.\u003c/p\u003e \u003cp\u003eThe knowledge of the critical care nurses in regards to the pressure ulcer prevention increased however on a moderate level i.e mean (SD) 63.2% (11.8), yet practice increased from 37.6\u0026ndash;62.6%, with a P value of \u0026lt;\u0026thinsp;0.001, hence a statistical significance. But since the study\u0026rsquo;s cutoff on practice was more than 75%, this finding left us at unsatisfactory. This moderate level of knowledge and practice is attributed to the training sessions which were limited to only one session in participants who barely had any training in PU prevention. Studies showed that training nurses more than once with multiple intervention programs improved their knowledge to over 80% (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Also, it was noted that the nurses had been working to prevent pressure ulcers however they were not following any guidelines. Most of their knowledge and practice was developed from experience over the years. So compliance to this introduced guideline was not easy. Incompliance to new guidelines has been reported in most studies as a hindrance to quality care given to many patients within the critical care environment (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the subgroups, participants who had less years of experience showed poor level of knowledge as compared to the rest of the subgroups and because P value is more than 0.05, this might have been because they are still new to the critical care environment, not yet involved in knowledge development and research, and mostly needing support from their superiors, as well as more educational programs on pressure ulcer prevention (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e Therefore, more trainings on pressure ulcer prevention guidelines should be encouraged and scheduled within the intensive care units, the pressure ulcer prevention protocols should be availed to the staff and the nursing managers should supervise their utilization.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStrengths and Limitations of the study.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe study required less resources hence it was less costly.\u003c/p\u003e \u003cp\u003eIt also had a higher external validity because of the educational intervention used. This allowed the researchers to control for the confounding variables.\u003c/p\u003e \u003cp\u003eOne of the limitations was a possibility of observation bias (hawthorn effect). This was overcome by using a research assistant who once worked within the ICU of MNRH to do both pre and post intervention observation for the participants\u0026rsquo; practice. This research assistant requested to volunteer again and was not disclosed to the study participants.\u003c/p\u003e \u003cp\u003eSecondly, the study was conducted in one center, hence this might not be generalized for all the critical care nurses elsewhere.\u003c/p\u003e \u003cp\u003eLast but not least, the number of intervention sessions was limited to one. Given that more participants had never trained in pressure ulcer prevention.\u003c/p\u003e \u003cp\u003e \u003cb\u003eImplications and recommendations of the study.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e The study findings implied that critical care nurses\u0026rsquo; knowledge and skills in pressure ulcer prevention with the use of the bundle protocols were enhanced to an unsatisfactory level as per the cut off points.\u003c/p\u003e \u003cp\u003eThe researchers therefore recommend the Nursing management to enforce trainings for critical care staff in regards to pressure ulcer prevention with the use of bundle protocols to continue enhancing their knowledge and practices with use of these bundle protocols.\u003c/p\u003e \u003cp\u003eTo the ward in-charge, the researchers recommend that they organize continuous medical education sessions in relation to pressure ulcers, prevention and management with bundle protocols to boost the nurses\u0026rsquo; knowledge and practice.\u003c/p\u003e \u003cp\u003e Policy makers should ensure that Guidelines on pressure ulcer prevention are formulated and made easily accessible country-wide to increase awareness of these bundle protocols to the critical care staff and finally, the effect of the bundle protocols to be assessed by nursing staff as a multi-center study.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e The intervention brought about an increase in knowledge of pressure ulcers and their prevention with the use of a bundle protocol as well as an improvement in nurses\u0026rsquo; practice to ensure these pressure ulcers are eradicated from the critical care unit.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMNRH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMulago National Referral Hospital\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntensive Care Unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHAPU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHospital Acquired Pressure Ulcers\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAHRQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAcquired Health Research Quality\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRA1\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eResearch assistant one\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRA2\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eResearch assistant two\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrincipal investigator\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEPUAP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEuropean Pressure Ulcer Advisory Panel\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and consent of participants.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Mbarara University of Science and Technology (MUST), Faculty Research and Ethics Committee (FREC) and Institutional Review Committee (MUST-REC, MUST- 2023-1153).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eA waiver of consent for observation of study participants for practice in pressure ulcer prevention and permission to conduct the study were sought from the REC Mulago National referral hospital.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants\u0026rsquo; informed consents were sought for objective 2 and 3 and their confidentiality was observed strictly by awarding them codes for each questionnaire answered instead of personal identifiers, and their signatures validated the comments and rating awarded.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll the collected data was stored carefully under lock and key drawers to ensure only authorized persons could access it. And in case of any highly sensitive information, guidance and permission was sought and granted by REC before public consumption.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that supported the findings of this study are available from the first and corresponding author, Kalanzi Phiona Katasi but restrictions apply under license for the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding for this study came from the Massachusetts General Hospital Center for Global Health\u0026rsquo;s project entitled \u0026lsquo;First Mile: Powering the Academic Medical Center to Delivery Healthcare in the Community in Uganda\u0026rsquo; supporting through the Wyss Medical Foundation. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKPK\u0026nbsp;conceived and designed the study. KPK, NE and IM implemented the study and conducted data analysis. AC supervised the study. KPK, SL, AC interpreted study results. KPK wrote the first draft of the manuscript. AC and SL reviewed and corrected the draft manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement.\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe funders for this study, The Massachusetts General Hospital, Center for Global Health\u0026rsquo;s project entitled \u0026lsquo;First Mile: Powering the Academic Medical Center to Delivery Healthcare in the Community in Uganda\u0026rsquo; supporting through the Wyss Medical Foundation.\u003c/p\u003e\n\u003cp\u003eWe appreciate all the participants in this study i.e Critical care nurses of Mulago National Referral Hospital Intensive Care Unit. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSaad E, Ragheb M, Sheta H, Hamed M. Effect of an Educational Program on Nurses\u0026rsquo; Performance Regarding Reducing Pressure Ulcer and Safety of Immobilized Patients. Benha J Appl Sci (BJAS). 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZuo X-L, Meng F-J. A care bundle for pressure ulcer treatment in intensive care units. Int J Nurs Sci. 2015;2(4):340\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnders J, Heinemann A, Leffmann C, Leutenegger M, Pr\u0026ouml;fener F, von Renteln-Kruse W. Decubitus ulcers: pathophysiology and primary prevention. Deutsches \u0026Auml;rzteblatt international. 2010;107(21):371.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKalowes P, Messina V, Li M. Five-layered soft silicone foam dressing to prevent pressure ulcers in the intensive care unit. Am J Crit Care. 2016;25(6):e108\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChapman K. Hospital Acquired Pressure Ulcer Prevention Using Mentoring Program. 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorghardt AT, Prado TNd, Bicudo SDS, Castro, DSd, Bringuente MEdO. Pressure ulcers in critically ill patients: incidence and associated factors. Revista brasileira de enfermagem. 2016;69:460\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMallah Z, Nassar N, Badr LK. The effectiveness of a pressure ulcer intervention program on the prevalence of hospital acquired pressure ulcers: controlled before and after study. Appl Nurs Res. 2015;28(2):106\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChou R, Dana T, Bougatsos C, Blazina I, Starmer AJ, Reitel K, et al. Pressure ulcer risk assessment and prevention: a systematic comparative effectiveness review. Ann Intern Med. 2013;159(1):28\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNasreen S, Afzal M, Sarwar H. Nurses knowledge and practices toward pressure ulcer prevention in general hospital Lahore. Age. 2017;87(166):344.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Medeiros Dantas AL, Ferreira PC, Valen\u0026ccedil;a CN, Diniz KD, de Paiva Nunes J, Germano RM. Complications of pressure ulcers in severely ill patients: a descriptive-exploratory study. Online Brazilian J Nurs. 2013;12(2):319\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBereded DT, Salih MH, Abebe AE. Prevalence and risk factors of pressure ulcer in hospitalized adult patients; a single center study from Ethiopia. BMC Res Notes. 2018;11:1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAntony L, Thelly AS, Mathew JM. Evidence-based Clinical Practice Guidelines for Caregivers of Palliative Care Patients on the Prevention of Pressure Ulcer. Indian J Palliat Care. 2023;29(1):75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMao X, Zhu L. Effects of care bundles for patients with pressure ulcers and the impact on self-care efficacy. Am J Translational Res. 2021;13(3):1799.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePadula WV, Black JM. The standardized pressure injury prevention protocol for improving nursing compliance with best practice guidelines. Wiley Online Library; 2019. pp. 367\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchubert A, Stanley C, Didier S, Bolton D, Clesi T, Fleming B. Severe Hospital-Acquired Pressure Injury (AHRQ Patient Safety Indicator 3). Optimizing Widely Reported Hospital Quality and Safety Grades: An Ochsner Quality and Value Playbook. Springer; 2022. pp. 127\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTilmazer T, Tuzer H. Pressure ulcer prevention care bundle: A Cross-sectional, Content Validation Study. Wound Manage Prev. 2019;65(5):33\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYilmazer T, Tuzer H. The effect of a pressure ulcer prevention care bundle on nursing workload costs. J tissue viability. 2022;31(3):459\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohamed SA, Weheida SM. Effects of implementing educational program about pressure ulcer control on nurses' knowledge and safety of immobilized patients. J Nurs Educ Pract. 2015;5(3):12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSardari M, Esmaeili R, Ravesh NN, Nasiri M. The impact of pressure ulcer training program on Nurses\u0026rsquo; performance over the pressure ulcer prevention at intensive care unit. J Adv Pharm Educ Res. 2019;9(3\u0026ndash;2019):145\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoban LM, Kim L, Yuan AH, Miltner RS. Organisational strategies to implement hospital pressure ulcer prevention programmes: findings from a national survey. J Nurs Adm Manag. 2017;25(6):457\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchoeps LN, Tallberg AB, Gunningberg L. Patients' knowledge of and participation in preventing pressure ulcers\u0026ndash;an intervention study. Int Wound J. 2017;14(2):344\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuva G, Sharma T, Campbell KE, Sibbald RG, An D, Woo K. Strategies to support pressure injury best practices by the inter-professional team: A systematic review. Int Wound J. 2018;15(4):580\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMwebaza I, Katende G, Groves S, Nankumbi J. Nurses\u0026rsquo; knowledge, practices, and barriers in care of patients with pressure ulcers in a Ugandan teaching hospital. Nursing research and practice. 2014;2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang X, Wu Z, Zhao B, Zhang Q, Li Z. Implementing a pressure injury care bundle in Chinese intensive care units. Risk Manage Healthc Policy. 2021:2435\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarimian M, Khalighi E, Salimi E, Borji M, Tarjoman A, Mahmoudi Y. The effect of educational intervention on the knowledge and attitude of intensive care nurses in the prevention of pressure ulcers. Int J risk Saf Med. 2020;31(2):89\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKang MJ, Kim MS. Correlations among attitude toward pressure ulcer prevention, knowledge and non-compliance risk for pressure ulcer prevention practice and degree of nursing performance. J Korea Academia-Industrial cooperation Soc. 2018;19(9):408\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahmoud Belal RE, Ali JS. The Effect of Nurses\u0026rsquo; Compliance to Evidence Based Guidelines on Pressure Ulcers Prevention for Critical Patients. Minia Sci Nurs J. 2023;14(1):73\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaad Soliman E, Mostafa Ragheb M, Sheta AE-S, Hamed Mohamed S. Effect of an Educational Program on Nurses\u0026rsquo; Performance regarding Reducing Pressure Ulcer and Safety of Immobilized Patients. J Nurs Sci Benha Univ. 2022;3(2):856\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM\u0026auml;ki-Turja‐Rostedt S, Leino‐Kilpi H, Koivunen M, Vahlberg T, Haavisto E. Consistent pressure ulcer prevention practice: The effect on PU prevalence and PU stages, and impact on PU prevention\u0026mdash;A quasi‐experimental intervention study. Int Wound J. 2023;20(6):2037\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaleh MY, Al-Hussami M, Anthony D. Pressure ulcer prevention and treatment knowledge of Jordanian nurses. J tissue viability. 2013;22(1):1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNuru N, Zewdu F, Amsalu S, Mehretie Y. Knowledge and practice of nurses towards prevention of pressure ulcer and associated factors in Gondar University Hospital, Northwest Ethiopia. BMC Nurs. 2015;14(1):1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAwali ZM, Nagshabandi E, Elgmail A. The effect of implementing pressure ulcer prevention educational protocol on nurses\u0026rsquo; knowledge, attitude and practices. Nurs Prim Care. 2018;2(4):1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarimian M, Khalighi E, Salimi E, Borji M, Tarjoman A, Mahmoudi Y. The effect of educational intervention on the knowledge and attitude of intensive care nurses in the prevention of pressure ulcers. Int J Risk Saf Med. 2020;31(2):89\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJeengar M. The effectiveness of Structured Teaching Programme regarding knowledge on prevention of pressure sores among Staff Nurses: A Pre-Experimental Study. Asian J Nurs Educ Res. 2018;8(4):467\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQaddumi J, Khawaldeh A. Pressure ulcer prevention knowledge among Jordanian nurses: a cross-sectional study. BMC Nurs. 2014;13(1):1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiller DM, Neelon L, Kish-Smith K, Whitney L, Burant CJ. Pressure injury knowledge in critical care nurses. J Wound Ostomy Cont Nurs. 2017;44(5):455\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTallier PC, Reineke PR, Asadoorian K, Choonoo JG, Campo M, Malmgreen-Wallen C. Perioperative registered nurses knowledge, attitudes, behaviors, and barriers regarding pressure ulcer prevention in perioperative patients. Appl Nurs Res. 2017;36:106\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGaspar S, Peralta M, Marques A, Budri A, Gaspar de Matos M. Effectiveness on hospital-acquired pressure ulcers prevention: a systematic review. Int Wound J. 2019;16(5):1087\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBobbink P, Gschwind G, Charbonneau L, Guex C, Chabal L, Probst S. Nursing Students\u0026rsquo; Knowledge on Pressure Injuries Following a Blended-Learning Unit: A Quasi-experimental Study. Adv Skin Wound Care. 2023;36(12):636\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDilie A, Mengistu D. Assessment of nurses\u0026rsquo; knowledge, attitude, and perceived barriers to expressed pressure ulcer prevention practice in Addis Ababa government hospitals, Addis Ababa, Ethiopia, 2015. Adv Nurs. 2015;2015(1):796927.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMalinga S, Dlungwane T. Nurses' Knowledge, Attitudes and Practices regarding Pressure Ulcer Prevention in the Umgungundlovu District, South Africa. Afr J Nurs Midwifery. 2020;22(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSardari M, Esmaeili R, Ravesh NN, Nasiri M. The impact of pressure ulcer training program on nurses\u0026rsquo; performance. J Adv Pharm Educ \u0026amp;. 2019;3.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Nosocomial pressure ulcers, prevention, A care bundle protocol, Nurses’ knowledge and practice","lastPublishedDoi":"10.21203/rs.3.rs-6666554/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6666554/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNosocomial pressure ulcers are wounds acquired within the hospital setting, pausing a burden to the patient families and the care teams due to patient discomfort and increased costs to treat and hospital resources. Globally, patients in intensive care units (ICUs) are most impacted, and the incidents go up to 33%, while a study done in Mbarara Regional Referral Hospital stated it at 19.3%. These incidents are preventable with the use of pressure ulcer prevention guidelines. This study aimed to investigate the effect of an educational intervention with a care bundle protocol on the knowledge and practices of intensive care unit nurses of Mulago Hospital in the prevention of nosocomial pressure ulcers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a single-group quasi-experimental pre-test and post-test study that purposively selected 26 ICU nurses of Mulago National Referral Hospital. Their baseline knowledge and practice were assessed with an observation checklist and a knowledge assessment questionnaire, respectively. The nurses were then trained on the pressure ulcer prevention bundle protocol, and the training lasted two weeks. ICU nurses’ knowledge and practices were assessed two weeks after the training. Data was collected between May and July 2024 and was analyzed using STATA version 17. Independent sample t-test, Wilcoxon-rank sum test, ANOVA and Mann- Whitney U-test were used to compare variables.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe critical care nurses’ knowledge of pressure ulcer prevention increased, however, on a moderate level, i.e., mean (SD) 63.2% (11.8) from (SD) 40.5 (10.6), yet practice increased from 37.6–62.6%, with a P value of 0.001.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing pressure ulcer prevention guidelines significantly improved participants’ knowledge and practice. More in-service training on pressure ulcer prevention protocols and their availability to staff are recommended.\u003c/p\u003e","manuscriptTitle":"Knowledge and Practices of Intensive Care Unit Nurses on the Prevention of Nosocomial Pressure Ulcers Using a Bundle Protocol: An Educational Intervention Study in Uganda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-23 06:01:12","doi":"10.21203/rs.3.rs-6666554/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-16T11:31:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-15T09:52:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-15T09:47:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-05-14T17:55:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a3fbc454-31c9-4a73-9519-6648cb151fc1","owner":[],"postedDate":"May 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-18T16:02:32+00:00","versionOfRecord":{"articleIdentity":"rs-6666554","link":"https://doi.org/10.1186/s12912-025-03731-4","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2025-08-11 15:57:49","publishedOnDateReadable":"August 11th, 2025"},"versionCreatedAt":"2025-05-23 06:01:12","video":"","vorDoi":"10.1186/s12912-025-03731-4","vorDoiUrl":"https://doi.org/10.1186/s12912-025-03731-4","workflowStages":[]},"version":"v1","identity":"rs-6666554","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6666554","identity":"rs-6666554","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}