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Measuring Clinical Preparedness for Pressure Ulcer Prevention: Validation of the Pressure Ulcer Knowledge Assessment
*Corresponding author: Dr. Rozaine Osman, Faculty of Nursing, University College MAIWP International, Jalan Tangsi- 50480 Kuala Lumpur, Malaysia. rozaine@ucmi.edu.my
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Received: ,
Accepted: ,
How to cite this article: Hassan NS, Osman R, Ahmad Sabri AS, Yusop N, Kamarudin AS, Hussein Z. Measuring Clinical Preparedness for Pressure Ulcer Prevention: Validation of the Pressure Ulcer Knowledge Assessment. J Health Allied Sci NU. 2026;16:227-33. doi: 10.25259/JHASNU_131_2025
Abstract
Objectives
A good and reliable instrument enables clinical nurses to effectively evaluate pressure injuries in patients, which is vital in preventing early mortality and morbidity. This study aimed to evaluate the psychometric properties and practical usability of the pressure ulcer knowledge assessment tool (PUKAT) among clinical nurses in a public hospital.
Material and Methods
A cross-sectional survey was conducted among 20 clinical nurses in a Malaysian public hospital. Internal consistency was assessed using Cronbach’s alpha, and item analysis included item-rest correlations and mean scores across the knowledge, attitude, and practice subscales. The JAMOVI (ver. 2.6.44) for Windows software was used to analyse the data.
Results
The results demonstrated good to excellent internal consistency for the knowledge (α = 0.882), attitude (α = 0.804), and practice (α = 0.889) subscales. High item-rest correlations (r > 0.74) were found for the knowledge (items 3, 5, 13, and 17) and practice (items 1, 9, 12, and 16) items. Items that exhibited poor or negative correlations indicated the need for refinement.
Conclusion
The pressure ulcer knowledge assessment tool demonstrated strong reliability in assessing nurses’ competencies. Further refinement of low-performing items can enhance their usability in preventing clinical pressure injuries.
Keywords
Clinical nurse
Psychometric evaluation
Pressure ulcer
Pressure ulcer knowledge
PUKAT
INTRODUCTION
Pressure injuries persist as a common yet preventable challenge in healthcare. This injury significantly worsens patient outcomes and exerts pressure on healthcare resources. To mitigate the issue, previous researchers from the critical care unit analysed ventilator-associated pneumonia, catheter-related bloodstream infection, and postoperative complications to assess nurses’ perceptions of evidence-based recommendations to reduce complications. Their impact is especially critical in acute care, where nurses are central to prevention. Studies have revealed a substantial discrepancy between the guideline recommendations and clinical practices.[1] For instance, a recent study found that only 65% of intensive care nurses in Jordan adhered to established prevention protocols, with adherence often limited by institutional barriers such as inadequate accreditation and lack of standardised policies.[2] Similarly, widespread deficits in nursing compliance with pressure ulcer prevention (PUP) guidelines have been documented across countries, underscoring the urgent need for comprehensive assessments and educational improvement efforts.[2,3]
One key challenge lies in the disconnect between nurses’ knowledge, attitudes, and practices regarding PUP. Studies from China have shown considerable variation in nurses’ knowledge levels, ranging from minimal to expert, indicating an uneven understanding across the nursing workforce.[4,5] Despite positive attitudes, many Chinese nurses lacked core knowledge of pressure ulcer staging and pathophysiology.[6] Similarly, Australian nurses value PUP but often demonstrate insufficient clinical understanding, particularly in wound classification.[6-9] This mismatch between positive attitudes and limited competencies restricts the effective implementation of evidence-based wound care.[7-9]
Beyond individual factors, systemic and organisational issues also contribute to poor compliance with pressure injury prevention guidelines. A lack of structured training programs, low clinical prioritisation, inadequate staffing, and heavy workloads have all been identified as contributing factors, particularly in high-intensity settings such as intensive care units.[10-12] These factors critically undermine the preventive efforts. Moreover, recent studies emphasised the importance of engaging patients and caregivers in developing contextually relevant prevention strategies, highlighting the need for a holistic, stakeholder-inclusive approach.[13,14]
Several tools have been developed to assess nurses’ competencies in pressure injury prevention, including the Pressure Ulcer Knowledge Assessment Tool (PUKAT) and the Comprehension Attitude Practice of Pressure Ulcer Prevention Tool. However, their ability to detect specific knowledge gaps and drive behavioural changes remains uncertain.[15-17] The complex interrelationship between knowledge, attitudes, and practice underscores the need for tools that can inform targeted training interventions.[18,19] For instance, nurses in Jordan and Turkey continued to show major knowledge gaps due to curricular shortcomings.[20] Furthermore, improved patient outcomes do not always reflect upgraded nursing knowledge, suggesting that training alone may be insufficient.[21]
Despite progress in training and assessment, existing tools often lack cultural adaptability and fail to reflect the local clinical context. For example, pressure ulcer education frequently overlooks skin tone diversity, which can impede accurate wound assessment in multi-ethnic populations.[22,23] Moreover, commonly used risk stratification tools, such as the Waterlow scale, do not assess nurses’ knowledge or decision-making capacity.
In response to these gaps, this study evaluated the psychometric properties of the PUKAT among Malaysian clinical nurses. The findings aim to inform culturally responsive, evidence-based strategies to enhance pressure injury prevention in local health care settings.
MATERIAL AND METHODS
Participants and study design
This study employed a cross-quantitative design to evaluate the psychometric properties and practical usability of the PUKAT among clinical nurses working in a public hospital in Kedah, Malaysia. A cross-sectional approach enables rapid data collection and analysis, making it suitable for evaluating measurement tools in a specific context.[24] This non-probability technique was deemed appropriate because it enabled the selection of participants who met specific inclusion criteria and could provide informed feedback on the assessment tool used. The inclusion criteria were active involvement in direct patient care, at least 6 months of clinical experience, employment in an intensive care unit or medical and surgical ward, and willingness to participate and provide informed consent. Nurses were recruited from various shifts and clinical wards to ensure heterogeneity in responses and minimise the potential for unit-specific bias.
Sampling techniques
A sample size of 20 participants was determined a priori, in alignment with recommendations for pilot-scale psychometric evaluations. According to Consensus-based Standards for the selection of Health Measurement Instrument (COSMIN) guidelines, a minimum of 4-10 participants per item is deal for is considered acceptable for assessing internal consistency and item clarity.[25]
Instrument tools
This study utilised the PUKAT, developed by Beeckman et al. (2010), to measure nurses’ knowledge, attitudes, and practices related to pressure injury prevention.[26] The original PUKAT has demonstrated sound psychometric performance, with reported internal consistency ranging from Cronbach’s α = 0.77 to 0.82, and has been widely used in clinical contexts.[10] Prior to its use in this study, formal permission to adapt the PUKAT was obtained from the original author. Since the tool was administered in English, the official language used in the study hospital, translation and back-translation were not required. However, minor linguistic adjustments were made to ensure terminological clarity and relevance. The adapted tool comprised four parts: Part A collected demographic data; Part B included 20 true/false items on knowledge; Part C had 11 Likert-scale items assessing attitudes; and Part D included 17 items measuring practice frequency on a three-point scale. Part B responses were scored dichotomously (1 = correct, 0 = incorrect), and a score of ≥60% was set as the threshold for adequate knowledge.[26,27] Given the dichotomous scoring format of the knowledge items, the observed Cronbach’s α of 0.882 approximates the Kuder-Richardson Formula 20 (KR-20), thereby affirming the subscale’s internal consistency. In this cohort, 18/20 nurses (90%) achieved a knowledge score of 60% or higher, demonstrating that the majority possessed at least a baseline level of competence in PUP.
Data collection procedures
Data were collected between January and February 2024. The research team first identified clinical nurses who met the eligibility criteria and provided each with a participant information sheet. After obtaining written informed consent, the participants were given a questionnaire booklet to complete. Upon completion, the responses were placed in sealed envelopes to maintain confidentiality before being collected for analysis.
Data analysis
All statistical analyses were conducted using JAMOVI (ver. 2.6.44) for Windows. Descriptive statistics were used to summarise the demographic characteristics and item responses. The internal consistency of the knowledge, attitude, and practice subscales was assessed using Cronbach’s alpha, with a threshold of α ≥ 0.70 considered acceptable for reliability. The analysis demonstrated good internal consistency across all three subscales, with Cronbach’s alpha values exceeding the recommended cut-off.[28] Given that the focus of this study was on reliability assessment, no inferential statistical tests were conducted.
Ethics, consent, and permission
The ethical principles of autonomy, beneficence, confidentiality, and anonymity were upheld to safeguard the rights of individuals. Participation was voluntary, and the participants were informed of their right to withdraw at any time without consequence. Written consent was obtained following a full explanation of the study’s purpose and procedures. The University Research Ethics Committee approved this study, and all procedures were conducted in accordance with the ethical standards of the Helsinki Declaration and institutional guidelines.
RESULTS
Participant demographics
This study included 20 clinical nurses with varying demographic and professional backgrounds. Most respondents were aged 40-49 years, female (n = 9, 45.0%), and possessed a diploma as their highest academic qualification (n = 17, 85.0%). Approximately half of them had 11-15 years of clinical experience (n = 9, 45%). Of 20 participants, exactly half reported post-basic speciality training (n = 10, 50%), most commonly in palliative care (n = 6, 30%).
Reliability and mean scores of knowledge, attitude, and practice subscales
As shown in Table 1, the PUKAT demonstrated strong internal consistency across all three subscales in this study. The knowledge scale yielded a Cronbach’s alpha of 0.882 (mean = 0.797, SD = 0.212), the attitude scale reported α = 0.804 (mean = 1.93, SD = 0.493), and the practice scale achieved α = 0.889 (mean = 2.23, SD = 0.565). These reliability coefficients indicate satisfactory internal consistency for the pilot study. Although the sample size (n = 20) was modest, it aligned with methodological recommendations for early-stage psychometric testing, providing preliminary but meaningful evidence of the tool’s measurement stability.
| Scales | Mean | SD | Cronbach’s α | Mean % correct* | Mean item-total r* | α if deleted* |
|---|---|---|---|---|---|---|
| Knowledge scale | 0.797 | 0.212 | 0.882 | 79.7% | 0.54 | 0.892 |
| Attitude scale | 1.93 | 0.493 | 0.804 | - | 0.45 | 0.817 |
| Practice scale | 2.23 | 0.565 | 0.889 | - | 0.51 | 0.897 |
Mean % correct*: Percentage of respondents who answered the item correctly, representing the proportion of correct responses per item in the subscale; Mean item-total r*: Average correlation between each item and the total score of the subscale, indicating how well the items measure the same construct; α if deleted*: Cronbach’s alpha value if the item were removed from the scale; used to assess the impact of each item on the internal consistency of the subscale. PUKAT: Pressure Ulcer Knowledge Assessment Tool, SD: Standard deviation.
The knowledge subscale’s mean % correct was 79.9%, with an average item-total correlation of 0.54, and deletion of its lowest-performing item (item 1) would increase α to 0.892. The attitude and practice subscales showed mean item-total correlations of 0.45 and 0.51, respectively, and α-if-deleted values of 0.817 and 0.897.
The practice subscale, consisting of 17 items rated on a three-point Likert scale (“always,” “sometimes,” “never”), also showed strong reliability, with a Cronbach’s alpha of 0.889. The mean practice score was 2.23 (SD = 0.565), indicating a relatively consistent implementation of preventive measures by the participants.
Item analysis of the PUKAT knowledge subscale
The item-level performance of the 20-item knowledge subscale has been summarised in [Supplementary Table S1]. In this study, item-level discrimination was assessed via item-rest correlations, with several items (items 3, 5, 13, and 17) demonstrating high discriminative power (r > 0.77). Items 3, 5, 13, and 17 demonstrated strong discriminative ability (r = 0.81, 0.59, 0.81, and 0.81), all of which also achieved mean correct response rates ≥ 95.0%, indicating clear differentiation between higher and lower knowledge respondents. This suggests that these items effectively differentiate between individuals with higher and lower knowledge levels. However, item 1 (“Pressure ulcers are sterile wounds”) showed a negative item-rest correlation (r = 0.0122) and a 50.0% correct rate; deleting this item would raise Cronbach’s α from 0.882 to 0.892, underscoring its misalignment with the overall construct. Deletion of this item would increase the overall Cronbach’s α from 0.882 to 0.892, underscoring its negative impact on internal consistency and signalling the need for rewording or replacement. Item 7 showed moderate discrimination (r = 0.452), a 45.0% correct rate, and deletion would increase α to 0.888, suggesting either conceptual confusion or knowledge gaps. Overall, the subscale demonstrated robust internal reliability (α = 0.882) and a strong mean item-total correlation (mean r = 0.54).
Item analysis of the attitude subscale
In this study, item-level statistics for the 11-item PUKAT attitude subscale, including agreement and α if deleted, have been presented in [Supplementary Table S2]. Analyses revealed that item-rest correlations ranged from –0.1383 to 0.9278, indicating differences in the alignment between the individual items and the overall construct. Items 9 (“Pressure ulcers are a painful condition among people who are elderly or physically impaired,” r = 0.9278, %Agreement = 92.5% α if deleted = 0.780) and 0.10 (“Do you believe pressure ulcers are very costly to treat?” r = 0.8077, %Agreement = 90.0%, α if deleted = 0.788) and 7 (“Bony prominences should not have contact with one another,” r = 0.7583, %Agreement = 70.0%, α if deleted = 0.785) showed strong correlations with the total scale, reflecting good construct alignment. In contrast, Item 2 (“Obese patients are rarely malnourished and therefore at lower risk of developing pressure ulcers,” r = 0.1383, %agreement = 10.0%, α if deleted = 0.818) displayed a negative correlation, suggesting misinterpretation or unclear wording.
Similarly, Item 5 (“Do you believe a blister on a patient’s heel is not of concern?” r = 0.0362, %agreement = 15.0%, α if deleted = 0.802), indicated poor discrimination. Mean scores also varied, with the highest attitudinal agreement observed for Item 9 (M = 2.45, SD = 0.759), highlighting a strong awareness of pressure ulcer-related pain. Lower mean scores (e.g., Item 2, M = 0.60; Item 5, M = 0.65) may reflect either knowledge gaps or confusion due to the item wording.
Practice subscale analysis
In this study, the practice subscale demonstrated strong internal consistency, with a Cronbach’s alpha of 0.889, as shown in [Supplementary Table S3]. Item-rest correlations ranged from –0.0380 to 0.7677, indicating variable alignment with the overall construct. Items 1, 9, 12, and 16 showed strong correlations (r > 0.74), suggesting that they are reliable indicators of standard preventive practices. Conversely, Items 7 (“Avoid massage over bony prominences”) and 10 (“Repositioning must be done at least every 15 min”) showed weak or negative correlations (r = 0.1444 and –0.0380, respectively), indicating conceptual misalignment or impracticality in real-world practice.
The mean scores used to assess the endorsement of practices, with high values (≥ 2.45) for items 1, 6, 9, 11, and 12, indicate strong integration of these evidence-based practices in routine care. However, low means for Items 7 (1.50) and 10 (1.10) indicate areas of low adherence, possibly due to unclear guidelines or workload constraints.
DISCUSSION
This study confirms the reliability of the PUKAT in assessing nurses’ competencies in PUP. The knowledge subscale showed high internal consistency, which is consistent with findings from the original validation.[26] Similarly, a study in Kuwait reported a median knowledge score of 73.2%, but positive attitudes did not improve compliance or reduce hospital-acquired pressure ulcers.[29] This is in line with previous surveys that found pressure ulcers to be more prevalent among older adults, reinforcing the need to evaluate the general competencies of clinical nurses in prevention practices across mixed-age adult wards.[28,30] This consistency suggests the tool remains robust across cultural settings.
This finding also aligns with the results of global meta-analyses, which reported mean knowledge scores ranging from 51.5% to 73%, indicating persistent systemic gaps in foundational understanding, even when individual items demonstrated high discriminative power.[30-32] These benchmarks contextualise the present results, suggesting that while certain items effectively differentiate proficiency levels, the overall knowledge base remains insufficient and highlights the need for targeted educational interventions in the field.
In addition, the study’s findings agree with previous research demonstrating that specific PUKAT items are consistently capable of distinguishing between varying levels of knowledge.[33] This further reinforces their validity and generalisability, indicating that these items successfully measure well-integrated and widely accepted clinical concepts. Conversely, Item one in the knowledge scales demonstrated a near-zero item-rest correlation, suggesting conceptual ambiguity or misinterpretation. This is similar to issues reported in a 2020 adaptation of the PUP Knowledge Assessment Instrument.[34] Additionally, low mean scores for certain items were flagged for revision because of low construct alignment. Low mean scores on certain items, flagged for revision due to poor construct alignment, may reflect cognitive or conceptual gaps. Likewise, a 2021 study reported persistent foundational knowledge deficiencies in pressure ulcer care.[35] Overall, the results highlight the need to revise poorly performing items to improve their clarity, alignment with evidence-based practices, and diagnostic values.
This study reported that the attitude subscale demonstrated good reliability (α = 0.804). This result is consistent with previous studies showing that nurses generally hold moderate to high positive attitudes toward PUP. A recent systematic review reported mean attitude scores of 69% ± 14%, with European nurses averaging 79%, and Middle Eastern cohorts averaging 55%.[36] These findings highlight regional differences in perceptions of PUP. Overall, the results affirm that the attitude subscale is a valid and reliable tool for evaluating PUP attitudes, mirroring the results reported for related instruments such as the attitude toward PUP scale.[26]
Several items in the attitude subscale showed high item-total correlations, indicating strong alignment with the construct of interest and reaffirming findings from previous studies.[26,33,37] However, a subset of items showed weak or negative correlations, which may reflect ambiguous phrasing or contextual misfit rather than genuine ambivalence. These underperforming items also yielded lower mean scores (≤ 2.5 on the 5-point scale), suggesting potential misunderstandings or gaps in awareness. Similar psychometric issues have been observed in earlier studies.[34,38] Lower mean scores on these items may reflect misunderstandings or limited awareness rather than attitudinal indifference. Rewording these items may enhance their clarity, cultural relevance, and applicability to real-world settings.
The practice subscale also demonstrated strong internal consistency (Cronbach’s α = 0.889), consistent with previous validation studies.[39] Most items showed moderate to strong item-rest correlations, reflecting adherence to standard preventive practices, such as routine skin assessment, repositioning, and use of pressure-relieving devices, all of which are core components of evidence-based protocols, particularly in intensive care settings.[10,40,41]
However, the items on avoiding massage over bony prominences and repositioning every 15 minutes demonstrated weak or negative correlations. This indicates limited alignment with the overall construct. Meanwhile, repositioning every 15 minutes is often unrealistic in high-acuity settings due to staffing limitations.[42] Similarly, the recommendation to avoid massage over bony prominences may stem from outdated or poorly understood practices.[43] Likewise, the recommendation to avoid massaging bony prominences may stem from outdated practices or limited awareness among nurses.[43,44] Overall, these findings suggest the need to revise such items to enhance their clarity and clinical relevance.
This study has several limitations. First, the sample was limited to nurses from a single hospital, restricting generalisability. Second, the cross-sectional design precludes causal inference and provides only a snapshot of knowledge, attitudes, and practices; longitudinal or intervention studies are needed to assess changes over time. Third, while the PUKAT showed acceptable internal consistency, advanced psychometric testing was not conducted to confirm its dimensionality and cross-cultural validity.
CONCLUSION
This study showed that the PUKAT is a reliable and practical tool for assessing nurses’ knowledge, attitudes, and practices in PUP. While the subscales demonstrated strong internal consistency, some items need refinement for clarity and contextual relevance. Broader validation with larger, more diverse samples and advanced psychometric testing will strengthen its reliability, cultural adaptability, and contribution to evidence-based prevention.
Acknowledgment
The author expresses sincere gratitude for the institutional support provided throughout the completion of this work and extends appreciation to the faculty members involved for their valuable contributions.
Ethical approval
The research/study approved by the Institutional Review Board at University College MAIWP International, Malaysia, with number Project Code FF-2025-11, dated 10th January 2025.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for clinical information to be reported in the journal. The patient understand that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
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