This study is the first to examine the effects of a multifaceted intervention on peri-operative nurses’ knowledge and practice with regard to pressure injury risk assessment and pressure injury prevention strategies. There were mixed results in regard to the impact of our intervention on aspects of self-reported knowledge and practice, with improvements not occurring in the desired direction. These results have implications for patient care and safety in the peri-operative setting. Similar findings have also been reported in similar studies that have targeted nurses in other settings [21, 49].
There were significant improvements post-intervention in participants’ ability to correctly describe pressure injury stages. There were also improvements in relation to knowledge of the correct management of patients, with significantly more nurses reporting they would re-assess risk assessment score for a patient with a new pressure injury stage 1 on the heel (recommended practice). In addition, significantly fewer nurses reported post-intervention they would use the non-recommended action of rubbing or massaging the affected area for a patient with a new pressure injury. There were, however, no improvements in knowledge regarding notification of the nurse at handover of new pressure injuries (stage 1 or 2); completion of an incident report and repositioning the patient onto their side (recommended practice). It is of concern from a patient safety perspective that a multifaceted and comprehensive evidence-based intervention, specifically targeted at nurses who are involved at all stages of the patient peri-operative journey, did not increase their knowledge on these factors.
Encouragingly, two measures of nurses’ reported practice showed improvement following the intervention. Significantly more nurses post-intervention reported using a tool in combination with clinical judgement in line with best practice . This is noteworthy because while clinical judgement is recognised as an important component of risk assessment, research has shown that clinical judgement in isolation is not an adequate or reliable predictor of pressure injury risk [50, 51]. Judgement of a patient’s risk status is an important basis for deciding to implement preventive measures . Reasons for this favourable change occurring, might be because risk assessment documentation is included within a patient’s medical notes. Thus, once the intervention raised awareness about the importance of risk assessment, the risk assessment form provided an ongoing and salient reminder of need to complete an assessment.
There were no changes in relation to knowledge or practice of use of non-recommended pressure prevention devices. Ongoing use of non-recommended actions for pressure injuries such as the use of donut air-pillows, which have been long discredited, has also been reported by other researchers [23, 26, 52]. The persistence of these practices are thought to have their source in education from past decades, when these devices were more commonly advocated as part of nursing care and pressure prevention . Considering that most of our sample reported obtaining their first nursing qualifications after 1986, meaning they had undergone university undergraduate nursing education it could be expected that they would have more current knowledge of the evidence. Yet, 59% of our sample reported that they could not recall when they had last read anything on pressure injury risks and management prior to our intervention. This indicates that recency of education through the tertiary system is insufficient for overcoming non-recommended practices and that pressure injury education needs to be ongoing within facilities. Another issue that may have impacted on our results, is one that is now commonly reported in respect of patient safety issues. That is that there are now many competing campaigns to improve patient safety and quality of care within facilities and this may lead to messages being diluted or health care professionals’ experiencing message fatigue . The other possibility is that the continued availability of non-recommended devices within practice settings contribute to their continued use, years after such devices have been discredited and are no longer recommended [49, 55]. Furthermore, implementation science research suggests that not only is it difficult to implement new practices, it can be equally challenging to undo practices that have been in place for some time .
In addition, there was no reported increase in terms of perioperative nurses use of recommended pressure-relieving devices. However, for some recommended devices use was high at both time points (90% for one recommended device and nearly 80% for another). It is likely too that surgeons’ and anaesthetists’ preferences for particular pressure-relieving devices may be an influential factor in use of particular devices. This suggests that future interventions focused on disseminating evidence-based recommendations should target the entire peri-operative team.
Our results indicated that there are reported practices and areas of knowledge that are harder to shift in the desired direction in line with the evidence, a situation that has been reported in nursing implementation research . Studies have found nurses’ improved knowledge does not necessarily lead to improved practice or changed behaviours [23, 57], and other educational interventions targeting pressure injury prevention have found similar results among other groups of nurses [39, 58]. Educational strategies that are combined with either audit and feedback [31, 59]; the introduction of recommended pressure relieving devices ; and simultaneous introduction of guidelines  may increase the effectiveness of educational interventions. A top-down push by nursing leadership to support changes in nurses’ practice can also be effective .
Deficiencies in knowledge and practice of aspects of pressure injury prevention in the peri-operative setting despite a multi-faceted intervention is concerning because surgical patients are at high risk of postoperative pressure injuries. Further research is therefore warranted to investigate the factors that influence peri-operative nurses and other peri-operative team members decision-making in respect of evidence-based care, in order to better inform the development of future targeted interventions.
Strengths and limitations
The strengths of this study include the survey size, which was multi-site, with peri-operative nurses participating from two large metropolitan hospitals, and the good response rate of 62% pre-intervention and 63% post-intervention which is comparable with other surveys of hospital clinicians . We calculated a post-hoc power calculation based on the results for change of difference in reported practice relating to undertaking risk assessment. This calculation found that a sample size of 70 has 95% power to detect a difference between means of 0.5 at the 0.05 level (2-tailed). We concluded that this was reasonable power to detect this difference in mean score. However, this was a convenience sample and the main objective of the study was to evaluate the impact of an intervention on reported rather than actual knowledge and practice. The intervention was multifaceted, in line with current evidence , and was developed by peri-operative nurse educators and based on evidence-based guidelines. The post-intervention survey was performed between one and three months after the intervention, so we cannot report on the nurses’ long-term knowledge retention or the sustainability of the nurses’ reported practice change beyond that period. We sampled and targeted only peri-operative nurses because generally they are present at all stages of the patient journey in the peri-operative setting. However, our results, particularly those relating to use of recommended and non-recommended pressure-relieving devices, suggests that the whole peri-operative team should be exposed to educational interventions. This should include surgeons and anaesthetists.