Prevention of Pressure Ulcers: Attitudes and Perceived Hindrances of Nurses - A Critique of Two Studies

This article critiques two studies on the attitudes and perceived hindrances of nurses towards the prevention of pressure ulcers. The studies used different research designs and data collection methods. The findings of both studies can be used to enhance care for pressure ulcer patients by addressing the work-related issues that contribute to the negative attitude of the nurses.

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Measurement and Evaluation for Healthcare Practices
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Introduction
The prevention of pressure ulcers (PU) is a very important indicator for acute care hospitals.
Pressure ulcers have commonly been perceived to be output measure of quality in nursing care
and in general health of patients. Pressure ulcers substantially restrict most of the elements of
one’s general health and well-being, and quality of life (Langemo, 2012). An attitude is cultured
and influenced by facts, purpose, and the extent of passion for or against a given matter. An
individual with a positive attitude towards something will have higher chances of undertaking a
helpful behaviour associated with the matter (Megens, and Weerman, 2012). For example,
nurses who have an optimistic attitude in the prevention of pressure ulcers do demonstrate better
practice in its prevention (Demarré et al., 2012). Gunningberg et al. (2015) observed a
worthwhile association between positive feeling to and the prevention of PU. The major
hindrances to evidence-based practices at one’s own level of healthcare include negative
feelings, lack of knowledge, and weak skills (Tacia et al., 2015). The increased PU prevalence in
hospitals has been given much attention (Sullivan, and Schoelles, 2013), in addition to the fact
that it comes with dire consequences, and very costly to treat. Therefore, it is critical that the
association between nurses’ attitude and the prevention of PU be examined comprehensively. In
order to achieve this objective two research papers with distinct designs on the same clinical
interest have been selected for critiquing. The quantitative and qualitative researches conducted
by Etafa et al. (2018) and Roberts et al. (2016) respectively will be critiqued.
Research Question
The research question for the qualitative study was “what are the perspectives of nurses about the
importance and effect of a pressure ulcer prevention care bundle (PUPCB) intervention on

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healthcare practice?” whereas that for the quantitative study was “what are the attitudes and
perceived hindrances of nurses on the prevention of PU?” the quantitative research question was
aimed at exploring the nurses’ attitude and their perceived hindrances to the its prevention at
public hospitals, whereas the qualitative research question was aimed at examining the
perceptions of nurses of the importance and effect of a PUPCB on healthcare.
Both research questions were basically aimed at achieving the same answer but with different
approaches due to the chosen research design.
Research Design and Underlying Philosophy
The quantitative research method used a multiple cross-sectional study design to gather data
from registered nurses from six different hospitals in Addis Ababa. A positivism approach
enables future predictions and is effective in generalization in different social contexts. However,
the approach prevents a researcher from detaching oneself from the hypothesis and it is possible
then he is being unjust to himself. A multiple cross-sectional study design is a type of
observational study that examines data collected from a population, a representative subset, at a
specific time. This type of approach was appropriate for the study because it is applicable when
examining different groups of people with different interests in the variable under study but who
share some common characteristics such as educational background or profession. Additionally,
cross-sectional designs are used to examine trends in the prevalence of a given disease or
severity for a given period of time (Sedgwick, 2014). The study by Etafa et al. (2018) examined
222 staff nurses assigned to six public hospitals in the month of April 2018. The objective was
to evaluate nurses’ attitudes in the prevention of PU and to find out their alleged hindrances to
the prevention of PU. This kind of objective and the nature of the study population justifies the

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use of the multiple cross-sectional study in answering the research question. However, the
research design cannot measure the change in variables over time and is not appropriate for
determining the existence or absence of causal relationships. Moreover, the researchers have
limited or no control over the environment implying that a weak implementation can ruin an
appropriate design and generate irrelevant data (Sedgwick, 2014).
On the other hand, the study by Roberts et al. (2016) used a qualitative descriptive design to
gather data from staff nurses of any designation and assigned to the wards in four Australian
hospitals in which the PUPCB intervention was executed. Constructivism approach allows
transferability and thus enabling other researchers to create organizing principles appropriate for
their settings. however, the approach lacks structure yet most of the researchers require a
structured environment for effective study and research. A qualitative descriptive research design
is an approach designed to collect data regarding the present situation. This approach involves a
collection of data so as to test the hypothesis or to search for answers on the current status of the
study participants (Maltby et al., 2014). A qualitative descriptive design was ideal for the study
because it is applicable when a researcher aims at describing the nature of a situation as it exists
during the time of the study in order to explore the causes of a specific phenomenon. It is also
important when exploring the association between two variables. The qualitative study examined
18 nurses distributed across four hospitals in Australia with an objective of determining their
attitudes and reflections regarding the prevention of PU. A cluster randomized trial testing
PUPCB intervention was used to observe the attitudes and perception of the nurses. The study
objective in addition to the nature of the study warrants the use of a qualitative descriptive design
to answer the research question. However, the design makes it impossible to separate variable
that will explain the causal relationship.

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There is the possibility of selection bias in the choice of the sampling frame in the qualitative
descriptive design as it is used in the study (Smith and Noble, 2014). This is because the decision
on who constitutes the sample is entirely dependent on the researcher who may be subjective or
judgmental based on preference. Alternatively, the study could have adopted random sampling as
a strategy to reduce or eliminate selection bias. Moreover, information bias is also likely to affect
the study. This might be due to measurement error obtained from the data collection instrument.
Type 2 error could be prevented from both studies by making the sample size large enough in
order to detect an actual difference between the hypothesis. This is to ensure that the hypothesis
test has sufficient power (Charan and Kantharia, 2013).
Hypothesis or Aim
The aim of the two studies was actually the same with variations existing in the research design.
The studies aimed at exploring whether the attitudes of nurses regarding pressure ulcers affected
their prevention. Etafa et al. (2018) also aimed at evaluating the nurses’ perceived barriers in
addition to the above-mentioned aim.
Approaches to Sampling
The qualitative study used purposive sampling technique to select four to five eligible subjects to
the four sites of study. Purposive sampling requires that the researcher be thoroughly aware of
the characteristics of the subjects under study, as a result, the pre-knowledge of the subjects of
the population, the chosen sample is more representative. A highly representative sample of the
target population eliminates sampling bias and thus increasing the reliability and validity of the
findings. Since the sample is only selected based on the purpose of the study, there is a high
probability that the objectives or the research questions of the study are met or answered

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respectively (Boddy, 2016). This sampling method is ideal when there is time constraint and the
target population need to be reached quickly. Additionally, purposive sampling is appropriate in
studies with multi-purpose objectives (Etikan, Musa, and Alkassim, 2016) such as the qualitative
study which aimed at evaluating the views of the nurses on the importance and impact of a
PUPCB intervention in healthcare. However, this approach only requires that the team of
researchers be well informed and knowledgeable regarding the population to be studied. This
may be thought of as an advantage and a disadvantage at the same time depending on the
perception. For instance, the use of only qualified and experienced authors in a study is likely to
increase the credibility of the study, and on the other hand, it is likely that the study might not be
carried out if there is a shortage of the experts. Purposive sampling is a non-probability sampling
technique that is more biased than others because the sample selection is solely dependent on the
judgement of the researcher (Boddy, 2016).
On the other hand, the quantitative study used the lottery method to select the six hospitals. A
population proportionate sampling was used to determine the number of respondents in each of
the hospitals under study. Then a random sampling approach was used to select the specific
participants to each of the six clusters. Simple random sampling was the most appropriate for the
study for multiple reasons. Simple random sampling is appropriate for a small population which
is homogenous and easily accessible. This is not the case with the study by Roberts et al. (2016)
which examined 252 nurses. This approach was very much appropriate in the qualitative study
which sampled 18 nurses only. These number of participants were so many as much as they were
homogeneous and therefore could have used stratified sampling technique in which the nurses
could have been grouped into different classes based on the status of employment. Simple
random sampling increases the representativeness of the target population because all subsets of

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the frame have an equal opportunity of being selected. This limits selection bias which also
affects the credibility of the findings.
Data Collection Methods
A semi-structured interview guide was used to gather information in the qualitative study. The
interview guide was revised accordingly after piloting and review. Semi-structured interviews
are very much appropriate for qualitative studies because they allow different modes of
interviews such as face to face or telephone based on the choice of the interviewee. This ensures
that the respondents are free to participate and provide accurate information. Additionally, semi-
structured interviews provide in-depth and valuable information that cannot be obtained through
other methods of data collection. This increases the validity of the study because the analysis is
based on concrete data. Interviews provide an encouraging and relaxed environment in which to
gather data because of the informal conversation as opposed to filling in questionnaires.
However, the infrequent use of spontaneous questions makes the responses problematic to
quantify and analyze. It is also prone to possible bias because the interviewer is likely to veer off
the interview guide and make suggestions or explanations that can influence the decision or
response of the interviewee. The digital recording of the transcriptions improves the results of
the analysis because they can be retrieved and played severally to accurately report the feedback
of the interviewee (Brinkmann, 2014).
On the other hand, the quantitative study used a questionnaire and a Standardized Pressure Ulcer
Attitude Test Tool to record the opinions of the nurses in a 5-point Likert scale. The standardized
tool limits any possible bias when analyzing data. The questionnaires are standardized thus
making it impossible for the researcher to interfere with the responses and thus limiting

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researcher bias. With such high reliability is attained. It is ideal for a large population because
data is simply collected by handing over the questionnaires and waiting for the responses. The
quantitative study examined 222 nurses, thus making the questionnaire method appropriate for
data collection. The questionnaires allow the participants to respond to the questions at their
own convenience as opposed interviews in which interviewees are expected to respond almost
immediately. This means that the feedbacks in the questionnaires are well thought out and
therefore more likely to be true, thus improving the credibility of the results. However, low rates
of response in questionnaires imply that the collected data and the analysis outcomes will not be
representative of the study population (Creswell and Clark, 2017).
Conclusion
Both studies found out that the attitude of nurses towards PU affected the prevention of the
disease. Moreover, the barriers to the prevention of PU were work-related and which further
affected their attitude. The findings of both studies can be used to enhance care for pressure ulcer
patients by addressing the work-related issues that contribute to the negative attitude of the
nurses. The PUPCB intervention was found to be effective in the prevention of PU and received
an overwhelmingly positive response from the nurses. Therefore, it can be used to improve care
to pressure ulcer patients. The research designs can also be replicated in other studies and also
form a basis for future research to further explore the phenomena under study to suggest other
alternatives for prevention of pressure ulcers.

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References
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