NURSING TEAM KNOWLEDGE ABOUT PRESSURE INJURIES

Objective: to assess the level of knowledge of the nursing staff of the medical clinic of a university hospital about pressure injuries. Method: descriptive-exploratory study, approved by the Research Ethics Committee. Data were collected through a validated questionnaire. Fifty individuals participated, 35 nursing technicians and 15 nurses. Results: nursing technicians had an average of 83.5% and nurses had an average of 89.9%. A regression model was carried out to verify variables that influence the level of knowledge, and it was identified that having more than 5 years in the profession increases 1.61 times the chance that the professional has adequate knowledge. Conclusion: a weakness in knowledge about pressure injuries was identified. In view of the costs involved in the treatment and complications arising from these injuries, health institutions must implement educational actions about this condition.


INTRODUCTION
In recent years, hospital care has become more complex due to growing technological innovation, the countless activities performed by professionals, in addition to the presence of interruptions in patient care. From this perspective, unsafe care results in preventable morbidity and mortality, with individuals more vulnerable to complications such as pressure injury (PI) 1,2 .
PI is evaluated as a negative indicator of the quality of health care, being defined as localized damage to the skin and/ or underlying soft tissue over a bony prominence. PI may also be related to the use of a medical device or other artifact.
It is understood as an adverse event and represents an important care challenge, as it generates physical and psychological suffering for patients and families, in addition to high financial costs for institutions 3,4 .
A study conducted in a university hospital in Minas Gerais identified a frequency of PI of 29% in the medical clinic unit, 16% in the surgical clinic and 53.8% in the observation of the emergency room. In the international scenario, a research aimed at analyzing the prevalence and characteristics of PI related to the use of medical devices in patients from Canadian and North American institutions identified that the overall prevalence was 7.2%, and the prevalence acquired in institutions was 3.1% 5,6 .
The recommendations for the prevention and treatment of chronic wounds involve the systematic assessment of the patient and his wound, the control of causal and associated factors and the preparation of the wound bed, elements that require constant updating by nurses 7 .
In this context, researchers developed international guidelines related to the prevention and treatment of PI, considering, among the guidelines and conducts on this injury, recommendations for the implementation of public policies, education of professionals and research on the subject. However, despite these guidelines, studies point to deficiencies in the knowledge of professionals, in addition to high rates of incidence and prevalence of PI in health services and households 8-10 .
Among the various professionals that make up the multidisciplinary team, the nursing team remains in contact with patients in health institutions for a longer time. In clinical settings, they play a fundamental role in taking preventive actions. Hence the importance of maintaining adequate levels of knowledge and assertive attitudes on the part of these professionals. The use of care practices based on evidence-based nursing favors the reduction of hospital stay and the reduction of adverse events 11,12 . Given the above and considering the constant need to diagnose the level of knowledge of health professionals about PI, as well as the scarcity of publications on this topic in the Midwest region of Brazil, the objective of the present article is justified: to evaluate the level of knowledge about PI, of the nursing staff of the medical clinic of a university hospital. All participants signed the Informed Consent Form and kept a copy in their possession.
The total staff of nursing professionals in the unit was 57 nursing technicians and 15 nurses (n=72). All professionals present during the data collection period were invited to participate. A non-probabilistic convenience sample was chosen due to the characteristics of the sector in which PI is prevalent. The inclusion criteria were: to work directly in the care of patients at the unit and to voluntarily accept to participate in the study. Exclusion criteria were: absence of the server due to vacation, sick leave or time off.
For the collection of information, first, an instrument developed by the authors of this study was used, in order to collect the sociodemographic data of the professionals. As for data collection regarding the level of knowledge, the Pieper For the present research, the questionnaire underwent adaptations due to the updating of the literature on the subject, which will be described below: change from the term pressure ulcer to pressure injury; modification in item 8, removing the indication for use of cornstarch and adding the polyurethane foam cover to prevent friction, and change in item 26, in which the term Intensive Care Unit was modified for the sector, since the application of the instrument took place in a medical clinic unit 8 . The changes did not go through a validation process, however, the use of the instrument and the modifications were authorized by the author.
The instrument was applied individually, during the work shift, and returned in an envelope to the researcher, without identification, in order to ensure the anonymity of the participants.
Data was entered and double-entered. Subsequently, statistical analysis was performed using the Statistical Package for Social Science (SPSS) program, version 22.0. Descriptive statistical analysis and statistical tests were performed to compare possible variables. To verify possible differences between the correct answers scores between the professional categories, the Student t test and the Mann-Whitney test were applied. When considering the adequate knowledge represented by the percentage of correct answers of 90% of the items, the level of knowledge of professionals was dichotomized into adequate (average greater than or equal to 36.9) and not adequate (average less than 36.9) 14 .
A binary logistic regression (enter method) was performed to identify whether the variables working time (greater than or equal to 5 years), having previous training on PI and Incontinence Associated Dermatitis (IAD) (yes or no) and position (nurse or technical) would be predictors for the outcome of adequate knowledge. A significance level of 5% was adopted.

RESULTS
The study consisted of 50 nursing professionals. Of these, 35 were nursing technicians and 15 nurses. The sample was characterized by predominant age ranging from 30 to 39 years old (46%), followed by 20 to 29 years old (22%); female (56%) and professional experience between 5 and 9 years and 15 and 19 years (both 26%). Regarding the level of education of professionals, (62%) had an undergraduate degree and (46%) had a specialization.
Considering the average of overall correct answers for the 41 questions, the nursing technicians had an average of (83.5%) and the nurses had an average of (89.9%). Items about the PI evaluation and classification are described in Table 1. The highest rate of correct answers in the PI assessment and classification category was obtained by nurses in items 6, 9, 32 and 33, with 100% accuracy. The same professionals had a lower rate of correct answers in item 20. In relation to technicians, they achieved a high rate of correct answers in items 1, 9 and 33; they also had a lower mean in item 20.
Considering the total number of respondents, there was a weakness in knowledge about classification of stage II PI (item 20) and in the question regarding the presence of pain in stage II PI (item 38). Items related to PI prevention are described in Table 2.    Regarding the comparison in the performance of respondents, the Mann-Whitney statistical test and the t test for independent samples were performed for this purpose. These data are presented in Table 3.  When verifying whether the levels of knowledge could be influenced by the factors of working time, the existence of previous training on PI and IAD and the position held, the model described below in Table 4 was obtained. The model was not statistically significant [ 2 (4) = ,712 p = 0,607; Nagelkerke R 2 = 0,095], in which only working time greater than 5 years was significant for adequate knowledge (Exp(b) 1,612 [95% IC: 1,143-18,117]), demonstrating that the chance of those with more than 5 years of experience presenting an adequate level of knowledge is 1.61 times greater than the chance of those with less than 5 years of experience presenting an adequate level of knowledge.

DISCUSSION
Considering the overall results of this study, there were significantly higher averages of correct answers among nurses, both for the PI prevention category and for the PI assessment and classification category.
Less satisfactory results were obtained in similar studies with the application of the same knowledge test. In a research carried out with the nursing staff of the Intensive Care Unit, there was a lower total average of correct answers among nurses (51.4%) than among nursing technicians and assistants (63,4%) 9 .
A similar study carried out in Brazil, with the same instrument, found that only 2 nurses (5.2%) answered 90% or more of the questions correctly. Most nurses got between 70% and 89% of the instrument right 15 .
It is known that it is the nurse's responsibility to privately assess the patients' injuries and the risk of developing wounds, as well as this professional's responsibility to prescribe measures for the prevention, treatment and management of skin lesions, through institutional protocols. Thus, it is expected that nurses have clinical reasoning and adopt assertive behaviors regarding skin lesions and their prevention 16 .
Regarding PI prevention measures, there were scores below 90% for both nurses and nursing technicians. This finding is in line with other Brazilian studies, in which knowledge considered inadequate regarding the prevention of PI was identified.
This data is worrisome, since this is a preventable injury in most cases, and can be prevented with the implementation of adequate care, based on scientific evidence, which emphasizes the importance of implementing permanent education about this condition 8, 16,17 .
In Turkey, researchers used the same Pieper knowledge test to assess nurses' knowledge about PI. Only 8 participants (2.6%) scored above 80% and none of the items were answered correctly by all professionals. The investigation highlights that the scores were statistically higher among nurses who read articles, participate in courses related to the topic, care for patients at risk of developing or who have PI 18 .
In the present study, it was found that the participants had a high rate of correct answers, in both professional groups, in 25 questions (61.0%). Comparatively, another Brazilian study carried out only with nurses, with the same instrument, showed that only 20 items were answered with a rate of correct answers above the desirable 15 .
A success rate of less than 50% was found in both professional categories participating in this study in 5 questions (12.2%). These questions refer to the thickness of the stage 2 PI, the use of water gloves for pressure relief, the use of devices with a central orifice to prevent PI, the appropriate degree of elevation of the head of the bed and the frequency of repositioning the patient while sitting in a wheelchair. Other researches identified a low rate of correct answers in the item referring to the use of pillows with central holes to prevent PI 9,15 .
In some questions in this study, success rates were identified well below the expected in both professional categories.
One of these items is related to the application of massage in areas of bony prominences. In similar studies, it was found a rate of correct answers well below the adequate of the participants in the same item 9,10 .
It is known that two decades ago, in the United States of America, a guideline was published that contraindicated the use of water gloves, saline bags and/or pillows with central holes for the prevention of PI. In this document, it was emphasized that massage in bone prominences should not be performed due to the risk of this procedure worsening local congestion, thus increasing the risk of developing an PI. These guidelines are disclosed in more recent documents, including those translated into Portuguese 8 .
In this context, the important role of continuing education within health institutions as an agent of changes in care practices is highlighted. Continuing education is carried out in the service and for the service, that is, it is aimed at answering the servants' doubts regarding the pathologies found in their daily work in the field of health.
This education should be seen as a priority within institutions, with the aim of promoting improvements in the care provided to the client [19][20][21][22] .
In Brazil, measures related to prevention and treatment protocols with regard to educational activities are recent and have started to be instituted due to institutional accreditations for quality and safety of the patient 2,9 .
The present research has some limitations, among them is the small sample size. In addition, the multidisciplinary team was not included and the degree of knowledge of respondents was not compared before and after carrying out an educational intervention activity. Due to the period of data collection, another limitation is related to the instrument used, since in Brazil there is already a more recent and validated instrument for the same purpose 4 . It is recommended to carry out similar, multicenter studies, in order to investigate the national scenario on the knowledge of nursing professionals about the prevention, evaluation and classification of PI.

CONCLUSION
In this study, it was possible to identify knowledge gaps among 50 nursing professionals from a medical clinic unit of a university hospital, considering that the average of correct answers regarding the 41 questions was less than 90%.
In order to improve knowledge on this subject, health care institutions must implement permanent education actions about this problem, considering the costs they entail and their complications. These educational processes must be based on dialogue to encourage the exchange of experiences and increase the feeling of belonging to those involved. The use of