Pressure ulcer leads to severe pain and annoyance situation for patients and also cause expand illness duration, delay restoration of health and physical activity, increase patient’s hospital stay, and may lead to inability and even death. The main objective of this study will be assessing the nurse’s knowledge towards bed sores prevention and barriers to implantation of preventive measures. To check the association between nurse’s job experience and their knowledge in addition to barriers to implementing prevention measures regarding bed sores prevention at Al-Makassed Islamic Charitable hospital. A cross-sectional study will be use that conducting at Al-Makassed Islamic Charitable hospital. The study participants will be selected by selection sampling technique.



















Background and Problem of the Study

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Prevention of bed sore is an essential aspect of nursing care and the knowledge, bed sores are universal matter in healthcare institution and produce a serious load on patient, family or relatives, and health care professional (Ayello & Meany, 2003) . On another hand, the patient suffers from pain and annoyance because bed sore extends illness for a long time, delay rehabilitation, increase patient hospital stay, and may lead to disability and even death (Fogerly et al., 2008; Sewehuk, Padula & Osborms, 2006). However, (Brain & Luder, 2004) they confirmed in their study that 60,000 death happened every year in United States of America (USA) related to bed sores complication. So, deficiency of nursing skill and knowledge in bed sores prevention participate significant to the development or deteriorate of a bed sore. Furthermore, nurses well knowledge about bed sore prevention not only can affect the quality of care that provides by nursing but also, in this way can minimize the patient period of hospital stay and reduce the number of patients who suffer from the painful situation that caused by bed sores (Aure-Grumbach, 2008). 

The occurrence of a problem such as bed sores is on a steady rise and is a major cause of severe pain and impaired physical mobility to the patients, not to admonish the high costs of its treatment and supplies requiring the valuable time, facilities, high advance technology, equipment and skill of the healthcare staff.  (Haalboom, 2007). These bed sores develop due to any disturbance in the circulation in the affected area of the patient due to external factors (Aure-Grumbach, 2008). Hence bed sores are preventable when correct and proper attention is paid to maintenance of the blood flow through the variety of equipment’s and techniques. Haalboom, also states that 45% of these bed sores are preventable. The key to these prevention techniques is to increase knowledge and decrease of barriers to implementation of preventive measures that facing nursing staff (Haalboom, 2007).


A pressure ulcer is increasing in incidence. A study was performed in Amsterdam at cardio surgery intensive care unit reported 15.4% incidence rate for stage 2 of pressure ulcer. Some causes for rising incidence of bed sores might be regarded to lack of nurse’s knowledge to risk assessment and prevention measures, and the study found gap between practice and theory in the treatment and prevention of bed sores (Langemo et al., 2008). Also, Gunningberg et al (2001) found that staff nurses in Sweden had inadequate knowledge and skill to perform documentation or record process of risk assessment, treatment, and prevention of bed sores in patients with hip fracture, this is a serious problem, that may be cost health institutions a lot of money. In this regard, health care institutions have some responsibility that affects nurse’s implementation of knowledge into practice through insufficient of education and training program, and shortage of nursing staff, which leads to the patient over-load decreases quality of care provided to the patient by nurses. Additionally to deficiencies in equipment and a mechanical devices that helps to reduce pressure ulcers exit (Ayello & Meany, 2003).


Significant of the Study

In AL-Makassed Islamic Charitable hospital, there is very limited data available about bed sore prevention, the measure that used by staff nursing. Actually, there is no evidence at an Al-Makassed hospital about nurse’s knowledge related to bed sores prevention and their barriers that prevent them to implement of bed sores prevention measures and this study will be the first of the kind in Al-Makassed hospital. However, bedsores incidence and prevalence not available. So, it is important to explore the nurse’s knowledge and barriers to implementation regarding bed sores prevention. Thereby, this study may be contributing to enhance staff nurse’s body knowledge through give recommendations to develop service training and educational programs.


Research Objective

The main aim of the research will be assessing nurse’s knowledge related to pressure ulcer prevention and barriers to implementations of the preventive measure at AL-Makassed Hospital. And sub-objective of the study will be as follows:

§  To determine the level of nurse’s knowledge toward d bed sores prevention.

§  To identify the difficulties of implementation of bed sores preventive measures among AL-Makassed hospital nurses. 

§  To explore nurses needs and problem toward bed sores prevention.













This section will describe literature review and research finding concern to Assess nurses’ knowledge related to bed sores prevention and the barriers to the implementation of bed sores measures at AL-Makassed Hospital. The review will be present as follows:

Concept of bed sores development

§  Definition of bed sores and pathophysiology.

§  Risk factors for bed sores development.


Bed sores prevention practice

§  Skin care.

§  Good nutrition to maintain healthy skin.

§  Management of mechanical loads.

§  Educational and training program for patient, family, and staff.



Barriers to implementing bed sore prevention among nurses. 

§  Shortage of nursing staff.

§  Reduction of training and education program about bed sores.

§  Insufficient of time for documentation.











A pressure ulcer is the serious problem and worrying negative event that can illustrate the failure of care that provides by staff nursing. Most of the pieces of literature define bed sore or pressure ulcer in various ways. Presently, “National Pressure Ulcer Advisory Penal NPUAP, 2007” defined bed sore as localized damage or injury to the skin and/or under the tissue usually occur over a bony protrusion, as a result of contentious pressure, or pressure associated on with shear. Zulkowski et al. (2007) provide another definition is pressure ulcer occur from lack of mobility that reduced blood circulation due to fixed pressure and finally causes cell death, skin collapse, and emergent of an open wound.

According to “Wound International Pressure ulcer prevention”, (2010), when applying heavy and strong pressure at intake skin. The skin appears pale and cyanosed, from reducing blood flow and inadequate oxygenation (ischemia), when removing the pressure the skin will return to normal states and becomes red due to physiology response. If ischemia maintained for short times, blood flow and skin will absolutely return to normal but, if maintained for a long time this will cause blood cells to aggregates and blocks capillaries, also this will lead to damage capillaries well, allowing red blood cells and fluid to leak into intestinal space, these consequences result in skin discoloration.

To improve quality of life and reduce pressure ulcer risk factors that contributes to developing the pressure ulcer should be identifying. Most studies classified risk factor in to tow major category, extrinsic and intrinsic factors. An extrinsic factor related to immobility especially when patients stay at long-term bedridden at the hospital that causes skin damage.  Less activity and skin moisture play role for developed pressure ulcer, the patient who admitted ICU unite will have the high risk to develop pressure ulcer-related to maceration from incontinence, leaking wound, or sweating (Keller et al.,2002).

Intrinsic factor including gender, age, malnutrition, poor blood circulation, vasoactive medication, sensory perception, bodybuilding.

Prevention of pressure ulcer is very important due to the serious complication, which occurs from lack of knowledge in pressure ulcer prevention between nurses, that effect on quality of life for the patient (Clark & Watts, 1994). Also, pressure ulcer considers burden in health care institutions and effect at all aspect of patient well-being such as (social, physical, financial, and psychological). Moreover, health institutions budget spends billions of dollars around the word on prevention and treatment of the patient who had bed sore. So, healthcare institutions should work at improving nursing knowledge and practice to prevent pressure ulcer from the root.

Lack of nursing knowledge about how should maintain skin integrity and identifying sign and symptoms of pressure ulcer, in addition to the inability of nursing to applicate suitable intervention contribute to bed sore development, it is major problem in a healthcare setting. However, Pieper & Mott (1995) found that bed sore development mostly related to a lack nursing knowledge and clinical skill, where nurses do not have the ability to distinguish between the patients who should place on bed sore prevention care plan. This is very serious finding, concluding we can improve nursing knowledge and practice by updating their information

Furthermore, (Hulsenboom, Halfens & Bous,2007) debated that the success beds sore prevention at any hospital depended on education of health care professional, especially nursing who are dealing with patient most of the time. Also, patient and their relative should include in education to make sufficient preventive measures to reduce pressure ulcer for the hospitalized patient.

Another important part of knowledge is who nurses dealing with patients have pressure ulcers, which method should be used to maintain skin integrity. In general, the nurses used frequent repositioning that reduced the period of pressure, in this way nurse’s elements bedsores formation. While Peiper (2007) recommended making the schedule for repositioning and recurrent turning at least once every 2hours. However, maintain good nutrition is one of most important factor neglected by nursing, if nurses provide good and benefit nutrition, will prevent hypoproteinemia that the risk of pressure ulcer development. According to (Gunnigberg et al, 2001) their chance to enhance nursing knowledge and practice to a higher level through apply correct feeding policies and continuing education program.

Skincare is very important; it is like a mirror that reflects health condition for the patient who stays long-term in hospital. According to (Nursing Clinical Practice Guideline, 2001) the nurses should inspect skin at least twice daily especially over bony prominences. The nurses should have enough knowledge about pressure ulcer prevention to provide instruction and educate patient about how should be maintained skin hygiene, by using warm water with antiseptic cleanser followed by lotion cream to maintain skin moisture to minimize skin dryness and irritation. Piper (2007) clarifies in his study that nursing knowledge can be influenced patient and their relative knowledge of bed sore management and prevention.

Improving knowledge in the nursing field is very necessary, to reduce the incidence of pressure ulcer for the hospitalized patient. (Langemo et al., 2008) study that focuses on education and how nursing should manage mechanical lodes by sharing knowledge and loads with patient and their family, in addition, to use all source in hospital that reduces mechanical load like wheelchair, dining room chairs, recliners, toilet, stretchers, etc. In this way, we can provide a comprehensive educational program that involved all health worker, patient, and their family. According to (Pieper & Mott, 2007) conduct that nurses who give lecture and shearing in educational programs or read scientific research about pressure ulcer prevention had the higher level of knowledge than who did not get the educational program. Even so, this not mean the nurses does not have any kind of information, maybe some obstacles in work prevent them to provide adequate care for the patient who has a pressure ulcer.

Some barriers that the healthcare setting faces, contribute in increasing cases of pressure ulcer prevention in hospital, such as inadequateness equipment and supplies for bed sore prevention and management and shortage of nursing staff, most of the time nurses have high ratio of patient, this lead to lack of care that provides to patient, also, in this case, nurses will not have enough time to document information about patient condition. Moreover, some health care institution to provide enough education program for nursing staff and keep them at the same level of information, which leads to wrong practice and bad skill when dealing with the patient has a pressure ulcer.

In summary, to prevent pressure ulcer in a successful way this requires that the nurses have sufficient knowledge and skill about good management and perfect ways when dealing with the critically ill patient had a pressure ulcer. Most of the literature reviewed highlighted the foundational requirement for bed sores prevention practice, should include: maintain skin care, good nutrition with high nutritional value to keep skin at the healthy condition, good shearing, and management of mechanical overloads, and provide sufficient education program and turning for nursing, patient and their relative.
















Research Methodology

Type of the Study

A quantitative cross-sectional study design will be used to assess nurse’s knowledge concern to bed sores prevention for the hospitalized patient in an Al-Makassed hospital. In addition, to investigate about barriers for implementing prevention measures of bed sores.



The study will carry in medical, orthopedic, surgical ward and intensive care units (adult intensive care unit, critical cardiac unit, adult open heart intensive care unit, and neurosurgical intensive care unit) at Al-Makassed Islamic Charitable hospital, the mountain an olive neighborhood, Jerusalem.



The selective sampling technique will be taken to choose a specific group of nurse’s who give care to the patient at risk of bed sores, the sample size will determine according to literature review will be at least 150 nurses who have following criteria:

Including criteria

·         Nurses should be work full time at an Al-Makassed hospital.

·         Nurses should be had experience on their units at least 6 months.

·         Nurse’s should be had at least bachelor’s degree in nursing.

Excluding criteria

Midwifery, student nurse’s, and nurses who will not participate in the study.



Tools and Operationalization of Concept

To meet the aim of this study, I will make combination between tow tools to develop instrument can be measure be assessing nurse’s knowledge related to pressure ulcer prevention and barriers to implementations of the preventive measure at AL-Makassed Hospital.

Tool 1:- is structured questionnaire; it was divided into 2 parts.  First part will contains demographic data for nurses who work at AL-Makassed Hospital, also will include gender, age, marital status, years of clinical experience in the hospital, last attendance at training or educational program on bed sores, and the present level of higher education. Second part was a list of 15 barriers confront nurse’s in the prevention of bed sores and nurses can be select one or more choice, developed and validated by “Price & Moore in 2004”, used to measure barriers regarding determining, documenting, and performing bed sores prevention practices.

 Tool 2:- is questionnaire was developed to determine the level of nurse’s knowledge related to bed sores prevention dependent on the first three level of cognitive scope of “Bloom’s Taxonomy”. Those three level contain on applying, understanding, remembering, that includes of 22 item of multiple choice questions that developed by “Maylor & Torrance (1999)”. However, after participant answer, the question will have used McDonald’s standard to categorize nurse’s level of knowledge related to bed sores prevention. This standard was developing in order to measure real performance of nursing.

“Level of Knowledge/Practice”

“Composite percent of scores”

“Very low”

“< 60%" "Low" "60% - 69.99%" "Moderate" "70% - 79.99%" "High" "80% - 89.99%" "Very high" "90% - 100%"     Data Analysis Every paper of data collection will manually score. The "Statistical Package for Social Science (SPSS version 19.0)" will use to examine after that will enter and analyze the collected data. Data were analyzed using descriptive statistics, which contain mean, frequency, standard deviation, and percentage. And will use Multivariate analysis (MVA) to detect association between dependent variables (gender, age, years of clinical experience, and marital status,) and independent variables (nurse's knowledge and barriers to implementations of the preventive measure).  .            Ethical Consideration First of all, the aim of study should be explained to the participant. After that take agreement with them to participate in this study. Before data collocation, the nurse will take oral consent from the participant. Participations will be anonymity and voluntary. However, clarify to the participant that has a chance to reject to participate and they can drop out at any phase of study. Also, nurses will give promise to the participant that the information will keep confidential and will just use for study purpose. On another hand, formal permeation will take from Al-Makassed hospital administration for data collocation.   Strength and Limitation of Study This investigation about nurse's knowledge and barriers to implementation regarding bed sores prevention will provide baseline information for more enhancement of nursing care in an Al-Makassed hospital. There will be few limitations to this study. The most important one, when using a self-report questionnaire to test nurse's knowledge. The response might not reflect real nursing knowledge. On another hand, cannot generalized the result of a study to other hospital or hospitals not follow the same protocols or standard to prevent bed sores.  


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