Yun Jin Lee; Seungmi Park; Jung Yoon Kim; Chul-Gyu Kim; Sun Kyung Cha

doi:10.4040/jkan.2013.43.4.526

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Original Article
Clinical Nurses’ Knowledge and Visual Differentiation Ability in Pressure Ulcer Classification System and Incontinence-associated Dermatitis: Yun Jin Lee¹, Seungmi Park², Jung Yoon Kim³, Chul-Gyu Kim⁴, Sun Kyung Cha⁴; Journal of Korean Academy of Nursing 2013;43(4):526-535.
DOI: https://doi.org/10.4040/jkan.2013.43.4.526
Published online: August 12, 2013

¹Department of Nursing, Severance Hospital, Seoul, Korea

²Department of Nursing, Hoseo University, Asan, Korea

³Department of Plastic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea

⁴Department of Nursing, Cheongju University, Cheongju, Korea

¹Department of Nursing, Severance Hospital, Seoul, Korea

²Department of Nursing, Hoseo University, Asan, Korea

³Department of Plastic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea

⁴Department of Nursing, Cheongju University, Cheongju, Korea

Address reprint requests to : Park, Seungmi Department of Nursing, Hoseo University, 79-20 Hoseo-ro, Sechul-ri, Baebang-eup, Asan 336-795, Korea Tel: +82-41-540-9533 Fax: +82-41-540-9558 E-mail: seungmipark@hoseo.edu

• Received: March 5, 2013 • Revised: March 15, 2013 • Accepted: June 27, 2013

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
REFERENCES

Abstract

Purpose
This study was done to compare clinical nurses’ knowledge and visual differentiation diagnostic ability for the pressure ulcer classification system (PUCS) and incontinence-associated dermatitis (IAD).
Methods
A convenience sample of 602 nurses took the pressure ulcer classification system and incontinence-associated dermatitis knowledge test (PUCS & IAD KT) and completed the visual differentiation tool (VDT), consisting of 21 photographs with clinical information.
Results
The overall mean score for correct answers was 14.5 (± 3.2) in PUCS & IAD KT and 11.15 (± 4.9) in PUCS & IAD VDT. Incorrect responses were most common for statements related to stage III, IAD for PUCS & IAD KT, and suspected deep tissue injury (SDTI), un-stageable, and stage III for PUCS & IAD VDT. Significant correlations were found between PUCS & IAD KT and VDT (r= .48, p< .001). Factors affecting scores for PUCS & IAD VDT were PUCS & IAD KT, frequency of pressure ulcer, IAD management and participation in wound care education programs.
Conclusion
Results indicate that nurses have an overall understanding of PUCS & IAD, but low visual differentiation ability regarding stage III, SDTI, and unstageable ulcers. Continuing education is needed to further improve knowledge and visual differentiation ability for PUCS & IAD.
Keywords: Pressure ulcer; Nurses; Knowledge; Dermatitis

Figure 1.

Answer rate on visual differentiation tool by the nurses (N=602).

Table 1.

Comparison of the Pressure Ulcer Classification System and Incontinence-associated Dermatitis Knowledge Test and Visual Differentiation Tool (N=602)

Characteristics	Categories	n (%) or M±SD	PUCS & IAD KT			PUCS & IAD VDT
Characteristics	Categories	n (%) or M±SD	M±SD	t or F	p	M±SD	t or F	p
Age (year)	<30	304 (50.5)	14.3±3.8	1.36	.257	11.6±4.7	0.46	.628
	30-39	199 (33.1)	14.5±3.6			11.6±5.3
	≥40	99 (16.4)	15.0±3.0			11.1±4.8
		31.6±7.0
Gender^*	Male	13 (2.2)	13.4±4.8	−0.87	.398	12.5±4.0	0.75	.453
	Female	572 (97.8)	14.6±3.1			11.5±5.0
Education^*	Diploma	181 (30.2)	14.7±3.0	0.85	.430	11.6±4.6	0.07	.933
	Bachelor	328 (54.9)	14.3±3.3			11.4±5.0
	≥Master	89 (14.9)	14.6±3.4			11.6±5.6
Position^*	Staff nurse	420 (70.8)	14.2±3.2^b	5.66	<.001	11.4±4.7^a	4.86	<.001
	Charge nurse	71 (12.0)	14.7±3.0^b			10.5±5.1^b
	Manager	33 (5.6)	14.6±2.8^b			12.2±4.3^b
	CNS	47 (7.9)	16.4±2.8^a			14.3±5.6^a
	Others	22 (3.7)	15.0±4.1^b			11.2±6.5^b
Career length (year)	<5	239 (39.7)	14.1±3.5	2.80	.061	11.6±4.5	2.23	.107
	5-9	160 (26.6)	14.8±2.7			12.1±5.2
	≥10	203 (33.7)	14.7±3.2			11.0±5.1
		8.1±6.6
Unit^*	Surgical ward	224 (37.7)	14.5±3.3	0.03	.991	11.1±5.3	1.34	.261
	Medical ward	130 (21.9)	14.5±2.8			11.8±4.6
	ICU	115 (19.4)	14.4±2.8			12.2±4.3
	Others	125 (21.0)	14.5±3.6			11.6±5.1
Number of beds^*	≥1,000	249 (43.0)	13.8±3.6^b	10.73	<.001	11.1±4.9	1.48	.228
	500-999	286 (49.4)	14.9±2.6^a			11.8±4.8
	<500	54 (7.6)	15.5±2.5^a			11.4±5.2
Frequency PU and	Never	83 (13.9)	12.4±4.0^c	17.30	<.001	8.0±4.3^c	26.51	<.001
IAD management^*	Sometimes	182 (30.5)	14.5±2.7^b			11.1±4.3^b
	Often	192 (32.2)	14.8±3.0^b			12.1±4.9^b
	Almost always	140 (23.4)	15.4±2.8^a			13.5±4.7^a
Participation of wound	Never	181 (30.5)	14.1±3.1^b	6.02	<.001	10.0±4.7^b	15.01	<.001
care education	1-2	347 (58.5)	14.4±3.3^b			11.8±4.7^b
program^*	3-4	52 (8.8)	16.1±2.4^a			14.6±4.9^a
	≥5	13 (2.2)	15.9±2.3^a			14.1±6.1^a
Provider of PU	Doctor	122 (21.9)	14.6±3.4	1.49	.217	10.6±4.8^b	3.62	.013
treatments^*	Staff nurse	168 (30.2)	14.1±3.1			11.5±4.7^b
	CNS	224 (40.2)	14.8±2.9			12.3±5.0^a
	Others	43 (7.7)	14.8±3.3			10.9±5.3^b

PUCS=Pressure ulcer classification system; IAD=Incontinence-associated dermatitis; KT=Knowledge test; VDT=Visual differentiation tool; CNS=Clinical nurse specialist; ICU=Intensive care unit; PU=Pressure ulcer; a, b, c=Duncan multiple range test grouping.

^*Except for non-response.

Table 2.

Pressure Ulcer Classification System and Incontinence-associated Dermatitis Knowledge Test (N=602)

Items	n (%) or M±SD
Stage I pressure ulcers are defined as intact skin with nonblanchable erythema on bony prominence.	525 (87.2)
If there is perineal skin injury with erythema due to incontinence and no pressure, it is a pressure ulcer^*.	436 (72.4)
It is not a pressure ulcer if there are skin injuries with blanching erythema.	356 (59.1)
Moisture associated skin damage such as urinary and fecal incontinence is related to the development of pressure ulcers.	567 (94.2)
Pressures and/or shearing force increase the risk for pressure ulcers.	581 (96.5)
Stage II pressure ulcers are intact skin with vesicles on pressure.	420 (69.8)
The nose, ear, occiput, and malleolus do not have subcutaneous tissue and these ulcers cannot become stage III^*.	541 (89.9)
There is no necrotic tissue on wound bed in patients with incontinence-associated dermatitis.	283 (47.0)
Stable eschar on the heels serves as the body’s biological cover and should not be removed.	302 (50.2)
Suspected deep tissue injury may further evolve and become covered by eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.	529 (87.9)
Unstageable pressure ulcers are wounds whose bases are covered by dead tissues composed of slough and/or eschar.	513 (85.2)
Secondary cutaneous infection such as fungal infection may easily develop in patients with incontinence-associated dermatitis.	582 (96.7)
Incidence of incontinence-associated dermatitis is higher in fecal incontinence than urinary incontinence.	498 (82.7)
Suspected deep tissue injury appears as an area of purple or maroon discoloration in intact skin or as a blood-filled blister.	540 (89.7)
It is stage II if there is no bony prominence but moisture associated skin damage with fecal incontinence^*.	389 (64.6)
A stage IV pressure ulcer is damage to muscle and bone.	575 (95.5)
Necrotic tissue, undermining, and tunneling may exist in Stage III and Stage IV.	566 (94.0)
A stage III pressure ulcer involves the fat tissue and fascia^*.	137 (22.8)
It is possible to label the ulcer as Stage II when Stage III is healing with granulation tissue^*.	386 (64.1)
Total number of correct answers	8726 (76.3)
Total	14.5±3.2

^*Opposite coding.

Table 3.

Correlations of Pressure Ulcer Classification System and Incontinence-associated Dermatitis Knowledge Test and Visual Differentiation Tool (N=602)

Variables	Pressure ulcer classification system and incontinence-associated dermatitis visual differentiation tool
Variables	r (p)
Pressure ulcer classification system and incontinence-associated dermatitis knowledge test	.48 (<.001)

Table 4.

Factors Influencing Pressure Ulcer Classification System and Incontinence-associated Dermatitis Visual Differentiation Tool (N=602)

Dependent variables	Independent variables	ß	SE	t or F	p	Partial R²	Model R²
PUCS, IAD, & VDT	Intercept	−1.04	0.79	−1.43	.154
	Knowledge of PUCS and IAD	0.54	0.04	13.76	<.001	.30	.30
	Frequency PU and IAD management	0.97	0.17	5.45	<.001	.04	.34
	Participation of wound care education program	1.19	0.28	4.33	<.001	.02	.36
	Model			108.31	<.001

PUCS=Pressure ulcer classification system; IAD=Incontinence-associated dermatitis; VDT=Visual differentiation tool; PU=Pressure ulcer.

REFERENCES

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Defloor T &, Schoonhoven L. 2004;Inter-rater reliability of the EPUAP pressure ulcer classification system using photographs. Journal of Clinical Nursing. 13(8):952–959. http://dx.doi.org/10.1111/j.1365-2702.2004.00974.xArticle PubMed
Defloor T, Schoonhoven L, Katrien V, Weststrate J &, Myny D. 2006;Reliability of the European Pressure Ulcer Advisory Panel classification system. Journal of Advanced Nursing. 54(2):189–198. http://dx.doi.org/10.1111/j.1365-2648.2006.03801.xArticle PubMed PDF
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Honaker J S, Forston M R, Davis E A, Wiesner M M &, Morgan J A. 2013;Effects of non contact low-frequency ultrasound on healing of suspected deep tissue injury: A retrospective analysis. International Wound Journal. 10(1):65–72. http://dx.doi.org/10.1111/j.1742-481X.201200944xArticle PubMed
Hopkins A, Dealey C, Bale S, Defloor T &, Worboys F. 2006;Patient stories of living with a pressure ulcer. Journal of Advanced Nursing. 56(4):345–353. http://dx.doi.org/10.1111/j.1365-2648.2006.04007.xArticle PubMed
Jin Y S. 2009;Knowledge, performance, and awareness of importance on pressure ulcer care among nurses at a general hospital. Unpublished master’s thesis, Yonsei University, Seoul.
Kelly J &, Isted M. 2011;Assessing nurses’ ability to classify pressure ulcers correctly. Nursing Standard. 26(7):62–64, 66 passim.Article
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Clinical Nurses’ Knowledge and Visual Differentiation Ability in Pressure Ulcer Classification System and Incontinence-associated Dermatitis

J Korean Acad Nurs. 2013;43(4):526-535. Published online August 12, 2013

DOI: https://doi.org/10.4040/jkan.2013.43.4.526

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Clinical Nurses’ Knowledge and Visual Differentiation Ability in Pressure Ulcer Classification System and Incontinence-associated Dermatitis

Figure 1. Answer rate on visual differentiation tool by the nurses (N=602).

Figure 1.

Clinical Nurses’ Knowledge and Visual Differentiation Ability in Pressure Ulcer Classification System and Incontinence-associated Dermatitis

Characteristics	Categories	n (%) or M±SD	PUCS & IAD KT			PUCS & IAD VDT
Characteristics	Categories	n (%) or M±SD	M±SD	t or F	p	M±SD	t or F	p
Age (year)	<30	304 (50.5)	14.3±3.8	1.36	.257	11.6±4.7	0.46	.628
	30-39	199 (33.1)	14.5±3.6			11.6±5.3
	≥40	99 (16.4)	15.0±3.0			11.1±4.8
		31.6±7.0
Gender^*	Male	13 (2.2)	13.4±4.8	−0.87	.398	12.5±4.0	0.75	.453
	Female	572 (97.8)	14.6±3.1			11.5±5.0
Education^*	Diploma	181 (30.2)	14.7±3.0	0.85	.430	11.6±4.6	0.07	.933
	Bachelor	328 (54.9)	14.3±3.3			11.4±5.0
	≥Master	89 (14.9)	14.6±3.4			11.6±5.6
Position^*	Staff nurse	420 (70.8)	14.2±3.2^b	5.66	<.001	11.4±4.7^a	4.86	<.001
	Charge nurse	71 (12.0)	14.7±3.0^b			10.5±5.1^b
	Manager	33 (5.6)	14.6±2.8^b			12.2±4.3^b
	CNS	47 (7.9)	16.4±2.8^a			14.3±5.6^a
	Others	22 (3.7)	15.0±4.1^b			11.2±6.5^b
Career length (year)	<5	239 (39.7)	14.1±3.5	2.80	.061	11.6±4.5	2.23	.107
	5-9	160 (26.6)	14.8±2.7			12.1±5.2
	≥10	203 (33.7)	14.7±3.2			11.0±5.1
		8.1±6.6
Unit^*	Surgical ward	224 (37.7)	14.5±3.3	0.03	.991	11.1±5.3	1.34	.261
	Medical ward	130 (21.9)	14.5±2.8			11.8±4.6
	ICU	115 (19.4)	14.4±2.8			12.2±4.3
	Others	125 (21.0)	14.5±3.6			11.6±5.1
Number of beds^*	≥1,000	249 (43.0)	13.8±3.6^b	10.73	<.001	11.1±4.9	1.48	.228
	500-999	286 (49.4)	14.9±2.6^a			11.8±4.8
	<500	54 (7.6)	15.5±2.5^a			11.4±5.2
Frequency PU and	Never	83 (13.9)	12.4±4.0^c	17.30	<.001	8.0±4.3^c	26.51	<.001
IAD management^*	Sometimes	182 (30.5)	14.5±2.7^b			11.1±4.3^b
	Often	192 (32.2)	14.8±3.0^b			12.1±4.9^b
	Almost always	140 (23.4)	15.4±2.8^a			13.5±4.7^a
Participation of wound	Never	181 (30.5)	14.1±3.1^b	6.02	<.001	10.0±4.7^b	15.01	<.001
care education	1-2	347 (58.5)	14.4±3.3^b			11.8±4.7^b
program^*	3-4	52 (8.8)	16.1±2.4^a			14.6±4.9^a
	≥5	13 (2.2)	15.9±2.3^a			14.1±6.1^a
Provider of PU	Doctor	122 (21.9)	14.6±3.4	1.49	.217	10.6±4.8^b	3.62	.013
treatments^*	Staff nurse	168 (30.2)	14.1±3.1			11.5±4.7^b
	CNS	224 (40.2)	14.8±2.9			12.3±5.0^a
	Others	43 (7.7)	14.8±3.3			10.9±5.3^b

Items	n (%) or M±SD
Stage I pressure ulcers are defined as intact skin with nonblanchable erythema on bony prominence.	525 (87.2)
If there is perineal skin injury with erythema due to incontinence and no pressure, it is a pressure ulcer^*.	436 (72.4)
It is not a pressure ulcer if there are skin injuries with blanching erythema.	356 (59.1)
Moisture associated skin damage such as urinary and fecal incontinence is related to the development of pressure ulcers.	567 (94.2)
Pressures and/or shearing force increase the risk for pressure ulcers.	581 (96.5)
Stage II pressure ulcers are intact skin with vesicles on pressure.	420 (69.8)
The nose, ear, occiput, and malleolus do not have subcutaneous tissue and these ulcers cannot become stage III^*.	541 (89.9)
There is no necrotic tissue on wound bed in patients with incontinence-associated dermatitis.	283 (47.0)
Stable eschar on the heels serves as the body’s biological cover and should not be removed.	302 (50.2)
Suspected deep tissue injury may further evolve and become covered by eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.	529 (87.9)
Unstageable pressure ulcers are wounds whose bases are covered by dead tissues composed of slough and/or eschar.	513 (85.2)
Secondary cutaneous infection such as fungal infection may easily develop in patients with incontinence-associated dermatitis.	582 (96.7)
Incidence of incontinence-associated dermatitis is higher in fecal incontinence than urinary incontinence.	498 (82.7)
Suspected deep tissue injury appears as an area of purple or maroon discoloration in intact skin or as a blood-filled blister.	540 (89.7)
It is stage II if there is no bony prominence but moisture associated skin damage with fecal incontinence^*.	389 (64.6)
A stage IV pressure ulcer is damage to muscle and bone.	575 (95.5)
Necrotic tissue, undermining, and tunneling may exist in Stage III and Stage IV.	566 (94.0)
A stage III pressure ulcer involves the fat tissue and fascia^*.	137 (22.8)
It is possible to label the ulcer as Stage II when Stage III is healing with granulation tissue^*.	386 (64.1)
Total number of correct answers	8726 (76.3)
Total	14.5±3.2

Variables	Pressure ulcer classification system and incontinence-associated dermatitis visual differentiation tool
Variables	r (p)
Pressure ulcer classification system and incontinence-associated dermatitis knowledge test	.48 (<.001)

Dependent variables	Independent variables	ß	SE	t or F	p	Partial R²	Model R²
PUCS, IAD, & VDT	Intercept	−1.04	0.79	−1.43	.154
	Knowledge of PUCS and IAD	0.54	0.04	13.76	<.001	.30	.30
	Frequency PU and IAD management	0.97	0.17	5.45	<.001	.04	.34
	Participation of wound care education program	1.19	0.28	4.33	<.001	.02	.36
	Model			108.31	<.001

Table 1. Comparison of the Pressure Ulcer Classification System and Incontinence-associated Dermatitis Knowledge Test and Visual Differentiation Tool (N=602)

Except for non-response.

Table 2. Pressure Ulcer Classification System and Incontinence-associated Dermatitis Knowledge Test (N=602)

Opposite coding.

Table 3. Correlations of Pressure Ulcer Classification System and Incontinence-associated Dermatitis Knowledge Test and Visual Differentiation Tool (N=602)

Table 4. Factors Influencing Pressure Ulcer Classification System and Incontinence-associated Dermatitis Visual Differentiation Tool (N=602)

PUCS=Pressure ulcer classification system; IAD=Incontinence-associated dermatitis; VDT=Visual differentiation tool; PU=Pressure ulcer.