A review of selected studies assessing nurses’ knowledge of pressure injury prevention

Introduction

Evidence-based medicine (EBM) is defined as the integration of scientific facts with clinical knowledge [1]. The practice of EBM is linked to a process of lifelong learning, where the treatment and care of individuals in health and illness create a demand for acquiring and processing essential information related to clinical and holistic paradigms of health [2]. Viewing the patient as an individual and making decisions in the therapeutic process based on their condition and preferences provides a broad spectrum of actionable possibilities grounded in scientific findings and recommendations.
A nurse, as a healthcare professional, undertakes numerous actions, ranging from professional care, elements of treatment and rehabilitation, to management of the healthcare team; they are required to make therapeutic and nursing decisions [3]. Additionally, increasing demands on the nursing profession, arising from the expansion of competencies, necessitate the continuous broadening and deepening of knowledge within a given specialization. Individual professional development aims to ensure professional and effective care, as well as meet the expectations of patients and their families [4]. As a result of these demands, the introduction of evidence-based nursing practice (EBNP) has emerged, which refers to the application of scientific evidence in nursing practice. EBNP can be described as making clinical decisions that take into account the latest research findings and making therapeutic decisions based on the patient’s condition [5].
An analysis of global literature shows an increasing involvement of nurses in the process of wound prevention and treatment. Wounds of various etiologies affect approximately 10.5 million patients in the USA and 2.2 million people in the UK. Based on epidemiological data from other countries, it is estimated that in Poland, the number of individuals with difficult-to-heal wounds may range from 650,000 to 1.2 million [6]. The incidence of difficult-to-heal and chronic wounds varies and depends on numerous factors influencing the condition of the observed group, such as age, self-care capabilities, and clinical status. These are primarily wounds resulting from diabetes – “diabetic foot disease”, trophic ulcers of the lower leg related to peripheral circulatory insufficiency (venous, arterial, and mixed ulcers), and pressure injuries. A specific group that often does not respond to causal treatment is the group of wounds at “the end of life”, where pressure injuries and metastatic (cancerous) skin and subcutaneous tissue damage predominate [7].
The scope of nursing competencies in selecting methods and measures for the treatment of difficult-to-heal wounds is broad and uncontroversial within the medical community. To effectively and safely care for patients with wounds, nursing staff should possess high qualifications, extensive knowledge, and undeniable social competencies [8, 9]. The specific nature of the profession offers significant opportunities for the prevention and local treatment of wounds in individuals with self-care deficits who are at risk of developing pressure injuries. Professional prevention is a well-thought-out, learned, guideline-based, and broadly holistic professional activity. Early implementation of preventive actions and the use of effective measures can delay the onset of pressure injuries and allow for early-stage treatment. Identifying individuals at risk of developing pressure injuries is the beginning of the preventive process [10]. Procedures implemented within the framework of prevention should consider the quality of nursing care as well as recommendations and research findings. A patient at risk for pressure injuries should be continuously assessed by an interdisciplinary team, where each member’s actions are directed, with specific roles and tasks assigned. The actions taken should be based on recommendations from scientific societies and global guidelines [11, 12].
Considering the conditions of the healthcare system in the area of prevention, a literature review was conducted on selected variables in the field of pressure injury prevention.
The objective of the article is to analyze the literature on pressure injury prevention among nurses.

Material and methods

In the course of the research, a literature analysis method was employed. A review of available literature from 2015 to 2025 was conducted, searching using the keywords: knowledge, prevention, pressure injury. The following databases were used: PubMed, EBSCO, as well as the national databases Termedia and Eve­reth. Studies with randomization, cross-sectional studies, and meta-analyses were included. The collected material was categorized into the following themes: (a) nurses’ knowledge and education in pressure injury prevention, (b) evidence-based prevention, and (c) the role of the clinical leader (mentor) in pressure injury prevention. The preparation of the paper focused on analyzing 22 studies, with the remaining cited manuscripts providing background for the discussion of the issue. The process of duplicate search is presented in Figure 1.

Knowledge and education of nurses in pressure injury prevention

Pressure injuries represent a significant health, social, and economic issue. On a global scale, it is believed that most pressure injuries can be avoided by implementing basic preventive measures [13]. In the community environment, behaviors related to self-care are key to preventing them. However, adherence to guidelines for preventing pressure injuries remains low, and much evidence points to improper collaboration between patients and nurses regarding pressure injury prevention. Heywood-Everett et al. conducted a review of thirty studies, indicating that a positive relationship was facilitated by knowledge, motivation to work with patients and their priorities, and interpersonal skills to build rapport and trust. Barriers included the lack of healthcare professionals’ skills in addressing delicate issues, paternalistic views on patient adherence to recommendations, and organizational processes that affect building rapport. The authors pointed to psychosocial factors that may influence the ability to achieve compliance between patients, caregivers, and healthcare professionals implementing pressure injury prevention guidelines. Insufficient knowledge about pressure injuries (PI) can adversely affect preventive care strategies. Individuals with limited mobility, poor health due to age, and chronic diseases are at risk [14]. Latimer et al. identified a high risk of skin damage from pressure injuries within the first 36 hours of hospital admission. In a study sample of 1047 participants, pressure injuries were confirmed in 10.8% of the individuals. The researchers observed that older people, those with multiple comorbidities, and those living in nursing homes more frequently presented to the hospital with existing pressure injuries or developed them shortly after admission [15]. The steadily increasing number of patients with chronic wounds, especially, determines the development of nurses’ competencies and qualifications. Ensuring professional care and implementing therapeutic procedures requires in-depth knowledge, competencies, and practical skills. Procedures implemented within the framework of prevention should therefore be tailored to specific and defined risk factors. They will differ in the operating room, intensive care unit, and pediatric wards. A patient at risk of developing pressure injuries should be continuously assessed by an interdisciplinary team, where the scope of actions for each team member is clearly defined.
Qaddumi et al. in their research highlight that limited use of knowledge is a common problem in clinical practice. The nurses studied were not fully aware of current care protocols and lacked sufficient knowledge about current evidence-based practices, indicating that their actions were not based on knowledge but rather on intuition, experience, or habit [16]. Interesting observations were presented by Fukada, who drew attention to the assessment of nursing competencies using the Clinical Nursing Competency Self-Assessment Scale (CNCSS) by Nakayama. The questionnaire consists of four concepts and 13 competencies. The tool measures the following four competency concepts: basic nursing skills (basic duties, ethical practice, and supportive relationships); the ability to provide care tailored to individual needs (clinical assessment, planned nursing implementation, care evaluation, health promotion); the ability to modify the care environment and systems of collaboration (risk management, care coordination, and nursing care management – execution of duties); and the ability to dedicate time to professional development in nursing practice (increased professionalism, improved quality of nursing, continuous education) [17].
Research conducted in Poland [10, 18–21] indicates that the issue of prevention and treatment of pressure injuries (and other chronic wounds) is well known, and the level of knowledge is satisfactory. The data are presented in Table 1. However, a detailed analysis of the studies illustrating the level of knowledge in the discussed area reveals the methodological preparation of the research, which is primarily based on proprietary tools that have not been incorporated into the scientific taxonomy process. Considering the efforts made by the authors, some of the cited studies shed light on the area of wound prevention and treatment, which remains a focus of interest for the profession. The most recent study presented by Przybek-Mita et al. [22] was prepared and conducted using the validated Polish version of the PZ-PUKT tool. In 2024, in collaboration with experts from the Polish Society of Angiological Nurses (Polskie Towarzystwo Pielęgniarek Angiologicznych – PTPA), a multicenter study was launched aiming to conduct psychometric evaluation of the second standardized PUKAT tool and assess nurses’ knowledge according to PZ-PUKT after completing a wound care module in master’s degree studies. The results obtained are expected to provide a reliable assessment of knowledge and create opportunities for evaluation in the area of wound prevention and treatment. Based on a meta-analysis conducted by Kielo et al., the mentioned tools are most commonly used in the process of assessing nursing staff knowledge, and the number of validations in different countries indicates their measurement reliability [23]. The tools are presented in Table 2.

Evidence-based prevention

The successful implementation of preventive actions requires recognizing the environment in which they will be carried out (home environment, hospital ward) followed by a clinical assessment of the patient’s condition. Both global and national guidelines also indicate highly specific situations, such as operating room conditions, patient transportation, prostheses, and medical equipment [44, 45]. The assessment of the environment, individual (personal) risk, as well as the availability of healthcare professionals, knowledge level, and skills, the possibility of using pressure-relieving equipment, and medical products for preventive purposes create a unified, coherent concept of pressure injury prevention. A reliable risk assessment for pressure injuries is based on physical examination using questionnaire instruments. In today’s times, relying solely on questionnaires is insufficient and carries a high risk of error. Considering that it is within the nurse’s competence to assess health status and conduct a physical examination, every patient should be examined according to the recommended algorithm, with the evaluation being concluded by the selected (recommended) instrument. Most risk assessment instruments cover many risk factors (e.g., activity, mobility, nutrition, moisture, sensory perception, friction and shear, and general health). Recent studies have expanded knowledge about important risk factors in the development of pressure injuries. Many risk assessment instruments do not incorporate these advances in knowledge. Moore and Patton [46] conducted a systematic review to determine whether the use of risk assessment instruments reduces the incidence of pressure injuries. The authors identified only two studies that met the criteria [47, 48]. The low or very low certainty of the available evidence from the included studies is insufficiently reliable to definitively recommend the use of standardized risk assessment instruments for pressure injuries. Other studies also indicate a link between the development of pressure injuries and a shortage of healthcare professionals as well as underutilization of their qualifications and competencies in pressure injury prevention and treatment [49–51]. Providing education on pressure injury prevention and treatment at the undergraduate level forms the foundation for improving care quality and reducing the incidence of pressure injuries. In several studies, an educational initiative was included in the quality improvement program, resulting in a decrease in the incidence of pressure injuries. Educational initiatives included didactic presentations, bedside practical teaching, and e-learning. The programs included a variety of educational methods, thus increasing the accessibility of new information for healthcare professionals with different learning preferences. Educating healthcare professionals is considered an integral part of pressure injury prevention. Educational programs aim to have a positive impact on changing healthcare workers’ behavior, encouraging them to implement preventive practices to reduce the incidence of pressure injuries. Some of the conducted studies have shown that competency-based education programs with mandatory attendance predispose to behavioral changes and foster a greater sense of responsibility in the area of prevention [52, 53]. In the learning process, medical simulation, low-, intermediate-, and high-fidelity programs, and the use of so-called simulated patients are gaining increasing importance, enhancing the possibilities of learning and applying acquired knowledge and skills in clinical practice [54]. The results of studies conducted by Silva et al. show that simulation enables the acquisition of practical skills for wound assessment and treatment [55]. The obtained results clearly indicate that clinical simulation can be an effective strategy for improving clinical outcomes but has a lesser impact on acquiring theoretical knowledge compared to other educational methods [56]. The authors suggest that learning outcomes may include perceived or explicitly measured knowledge gains as a result of simulation interventions [57, 58].
The increasing number of epidemiological studies in this field allows for a better understanding and correct interpretation of the risk factors leading to the development of pressure injuries. Over 90 years ago, Landis (1930) pointed out that pressure is the primary predictor of impaired tissue perfusion. As a result of repeated pressure, inflammatory states, necrosis, and subsequent pressure injury develop in sequence. Continuous pressure lasting more than 2-3 hours results in irreversible morphological changes in tissues. Crenshaw (1989) emphasized that the skin has greater tolerance to hypoxia than deeper tissues; according to the author, skin necrosis is the “tip of the iceberg” of a pressure injury, observable in cases of deep subcutaneous pressure injuries caused by high sustained pressure.
Pressure redistribution is an important strategy in the prevention and management of pressure injuries, involving the use of support surfaces and posture management. According to the literature, nursing staff have standardized comprehensive care practices for posture control; however, adequate attention is still lacking in the utilization of support surfaces. Support surfaces include specially designed beds, mattresses, mattress overlays, and cushions, which are intended to protect vulnerable body areas and distribute surface pressure more evenly. Research on pressure injury prevention shows that more than 60% of patients at risk for pressure injuries use pressure redistribution materials, primarily including alternating pressure electric and static mattresses designed for individuals in a horizontal position. For active individuals with motoneuron dysfunction, gel, silicone, and foam products are recommended to redistribute pressure and reduce shear. The effectiveness of alternating pressure mattresses compared to other mattresses in treating pre-existing pressure injuries is controversial in current studies and available scientific evidence [59, 60].
Nevertheless, the use of pressure redistribution as a preventive measure is not controversial and is considered a fundamental and recommended action in this area.
Nursing actions are conditioned both by the knowledge possessed and the available equipment that a particular facility has for pressure injury prevention. The authors point out that the knowledge of nurses and staff providing care for dependent patients regarding the rational use of support surfaces should be reinforced by presenting research findings and the potential for using pressure redistribution materials in daily practice [60].
The literature also reports barriers related to the use of pressure relief, with data primarily coming from the African continent. Survey studies conducted among healthcare professionals have shown that improper equipment, or a lack of it, was a barrier to implementing best practices [61–63].
In professional nursing care, standards and tools/protocols are also essential to support decision-making, helping the staff to choose the appropriate care strategies, use the proper equipment, and effectively treat the resulting pressure injuries.

The role of the clinical leader (mentor) and the issue of pressure injury prevention

The mentoring program is an effective form of education and development for young nursing professionals. Mentorship-based nursing practice prepares individuals for future work in a more professional manner, while also teaching independence and decisiveness. The mentorship program allows for the selection of leaders in a given field, raising the status of the profession and improving the quality of care provided [64]. The establishment and implementation of clinical leader support programs should be a priority at this stage of advancing clinical nursing practice. A substantial amount of evidence supports the implementation of actions to support nurses in the development of clinical practice. In two studies, the role of a “mentor” in the field of pressure injury prevention and treatment was designated as part of a successful multi-faceted quality improvement program [65]. In another study, a clinical leader was identified, in this case, a nurse with an academic title working at a given institution [66]. Other studies also delegated clinical leadership to a clinical nurse or a nurse trained in elderly care, as well as specialized staff from related fields or a wound care team [67]. Studies conducted in intensive care units, geriatric wards, home care, and pediatric care show that appointing a clinical leader to a quality improvement program was associated with a reduction in the occurrence of pressure injuries in many clinical settings. The initiatives for creating clinical leaders helped improve quality programs and facilitated the identification and delegation of staff – mostly nurses – with specialized knowledge and skills in pressure injury prevention and treatment. These individuals were referred to as leaders, mentors, or clinical specialists and played an educational, caregiving, preventive role, and – most importantly – they guided and led the treatment of pressure injuries that developed [68].

Implications for practice

Prevention should be based on the strength of scientific evidence. The effectiveness of the implementation and application of clinical guidelines is achievable through well-designed studies and quality improvement initiatives for current practices. Clinical decision-making should be based on up-to-date scientific evidence and present a range of options to aid in decision-making between healthcare professionals, patients or their caregivers, and the entire interdisciplinary team in pressure injury prevention. It seems highly reasonable to establish the role of a clinical leader in the prevention and treatment of wounds. The leader could be a nurse specialist, also working as a researcher/scientist, to guide the integration of professional experience with scientific evidence. This role would not only enhance the quality of care but also ensure that clinical decisions are rooted in evidence-based practice, fostering improved outcomes in pressure injury prevention and management.

Conclusions

Pressure injuries lead to irreversible complications for the patient and their family, increase treatment costs, and may result in death. Effective prevention relies on training and improving the working conditions of healthcare professionals. Preventive actions should be based on physical assessment using questionnaire instruments and the implementation of pressure redistribution surfaces. Prevention, along with regular staff training, should be prioritized in the healthcare sector. Clinical decision-making should be based on current scientific evidence and present a range of options to aid in decision-making among healthcare professionals, the patient or their caregiver, and the entire interdisciplinary team.

Disclosures

1. Institutional review board statement: Not applicable.
2. Assistance with the article: None.
3. Financial support and sponsorship: None.
4. Conflicts of interest: None.

References