Swedish translation, cultural adaptation and psychometric evaluation of the pressure ulcer knowledge assessment tool for use in the operating room

Abstract

The aim of this study was to psychometrically evaluate the Swedish operating room version of PUKAT 2.0. In total, 284 Swedish operating room nurses completed the survey of whom 50 completed the retest. The item difficulty P-value of 14 items ranged between 0.38 and 0.96 (median 0.65). Three items were found to be too easy (0.90-0.96). The D-value of 14 items ranged between 0.00 and 0.42 (median 0.46). Three items had a D-value lower than 0.20 (0.11-0.16) and eight items scored higher than 0.40 (0.45-0.61). The quality of the response alternatives (a-value) ranged between 0.00 and 0.42. This showed that nurses with a master's degree had a higher knowledge than nurses with a professional degree (respectively 9.4/14 versus 8.6/14; t = -2.4, df = 199, P = 0.02). The ICC was 0.65 (95% CI 0.45-0.78). The ICCs for the domains varied from 0.12 (95% CI = -0.16-0.39) to 0.59 (95% CI = 0.38-0.75). Results indicated that 11 of the original items contributed to the overall validity. However, the low participation in the test-retest made the reliability of the instrument low. An extended evaluation with a larger sample should be considered in order to confirm aspects of the psychometric properties of this instrument.

Full text

ORIGINAL ARTICLE
Swedish translation, cultural adaptation and psychometric
evaluation of the pressure ulcer knowledge assessment tool
for use in the operating room
Karin Falk-Brynhildsen
1
| Charlotte Raepsaet
2
| Camilla Wistrand
3
|
Carina Bååth
4,5
| Christine Leo Swenne
6
| Mervyn Gifford
1
|
Lena Gunningberg
6
| Ann-Christin von Vogelsang
7,8
| Catrine Björn
9
|
Dimitri Beeckman
1,2
1
Faculty of Medicine and Health, School
of Health Sciences, Nursing Science Unit,
Swedish Centre for Skin and Wound
Research, Örebro University, Sweden
2
Skin Integrity Research Group (SKINT),
University Centre for Nursing and
Midwifery, Department of Public Health
and Primary Care, Ghent University,
Belgium
3
University Health Care Research Centre,
Faculty of Medicine and Health, Örebro
University, Sweden
4
Department of Health Sciences, Faculty
of Health, Science and Technology,
Karlstad University, Karlstad, Sweden
5
Faculty of Health, Welfare and
Organisation, Östfold University College,
Fredrikstad, Norway
6
Department of Public Health and Caring
Sciences, Uppsala University, Sweden
7
Department of Neurosurgery, Karolinska
University Hospital, Stockholm, Sweden
8
Department of Clinical Neuroscience,
Karolinska Institute, Stockholm, Sweden
9
Centre for Research & Development,
Uppsala University/Region Gävleborg,
Sweden
Correspondence
Karin Falk-Brynhildsen, Faculty of
Medicine and Health, School of Health
Sciences, Örebro University, SE-70182
Örebro, Sweden.
Email: karin.falk-brynhildsen@oru.se
Abstract
The aim of this study was to psychometrically evaluate the Swedish operating
room version of PUKAT 2.0. In total, 284 Swedish operating room nurses
completed the survey of whom 50 completed the retest. The item difficulty
P-value of 14 items ranged between 0.38 and 0.96 (median 0.65). Three items
were found to be too easy (0.90–0.96). The D-value of 14 items ranged
between 0.00 and 0.42 (median 0.46). Three items had a D-value lower than
0.20 (0.11–0.16) and eight items scored higher than 0.40 (0.45–0.61). The
quality of the response alternatives (a-value) ranged between 0.00 and 0.42.
This showed that nurses with a master's degree had a higher knowledge than
nurses with a professional degree (respectively 9.4/14 versus 8.6/14; t=2.4,
df =199, P=0.02). The ICC was 0.65 (95% CI 0.45–0.78). The ICCs for the
domains varied from 0.12 (95% CI =0.16–0.39) to 0.59 (95% CI =0.38–
0.75). Results indicated that 11 of the original items contributed to the overall
validity. However, the low participation in the test-retest made the reliability
of the instrument low. An extended evaluation with a larger sample should
be considered in order to confirm aspects of the psychometric properties of
this instrument.
KEYWORDS
knowledge, operating room nurse, pressure ulcer, psychometric evaluation, PUKAT2.0
Key Messages
•a Swedish version of the pressure ulcer assessment instrument for use in an
operating room (PUKAT OR) was developed and psychometrically validated
•PUKAT OR showed satisfactory psychometric properties, but further studies
with a larger sample are needed to confirm the results
Received: 14 April 2022 Revised: 11 October 2022 Accepted: 20 October 2022
DOI: 10.1111/iwj.14008
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any
medium, provided the original work is properly cited and is not used for commercial purposes.
© 2022 The Authors. International Wound Journal published by Medicalhelplines.com Inc (3M) and John Wiley & Sons Ltd.
1534 Int Wound J. 2023;20:1534–1543.
wileyonlinelibrary.com/journal/iwj

•the initial results suggest that continuing education in this area is needed
and would be appreciated by OR nurses to provide safe patient care
•future research should include mixed methods to gain a deeper understand-
ing of the knowledge and skills of OR nurses to prevent pressure ulcers
1|INTRODUCTION
Pressure ulcers (PUs) are a global problem in healthcare.
A recent review identified an overall prevalence of 12.8%
in hospital settings.
1
In Sweden, nationwide PU preva-
lence surveys began in 2011 and the prevalence of PUs
has varied over the years, from 17% in 2011 to 11.4% in
2020.
2
The European Pressure Ulcer Advisory Panel
(EPUAP) reports that surgery-related PUs occur in rela-
tion to 4%–45% of surgical procedures.
3
PUs can occur
between 48 and 72 h postoperatively
4
due to prolonged
pressure. Moreover, all medical devices in contact with
the patient increase the risk of PUs to both skin and
mucosa.
3
Therefore, knowledge of the prevention of PUs
is crucial.
The prevention of PUs in patients undergoing surgical
procedures must take into account complex risk factors
and doing so is paramount for ensuring safe patient care
in the operating room (OR). In addition to patient-related
factors, risk factors within the OR include surgical
position,
5
intraoperative medical devices/positioning
devices,
6
time on the OR table,
7
anaesthesia and low arte-
rial blood pressure.
8
Moreover, a recent study
9
identified
high fasting blood glucose levels before surgery, emer-
gency surgery, some types of vasoactive drugs, and longer
surgery duration as predisposing factors for the occur-
rence of PUs. Longer surgery duration means that
patients remain immobile for longer periods which
increases the risk for PUs,
10
therefore, deep and multi-
disciplinary etiological understanding is required for
effective prevention of intraoperatively acquired tissue
damage.
11
The OR team members have a key role in protecting
the patient using their knowledge of PU prevention and
management. There is, however, a lack of awareness of
OR-related PUs among OR team members as a possible
adverse event. Although the attitudes of OR nurses may
be acceptable, their knowledge of PU prevention and
management remains inadequate.
12
In addition, nurses
ought to understand their role in skin protection and
they should perform skin assessments in order to estab-
lish a preoperative baseline so that the patient's postoper-
ative skin status may be compared.
7
A recent study
13
found that OR nurses need to improve the prevention
and management of OR-related PUs.
A systematic review with a meta-analysis based
on the Pressure Ulcer Knowledge Assessment Tool
(PUKAT) regarding PU prevention
14
showed that suffi-
cient knowledge regarding PU prevention in emergency
departments was dependent on nurses' PU identification
and classification skills after training and workshops
15
Another study showed that teaching and scenario simula-
tions were also important factors in optimising the educa-
tion of OR nurses.
16
The role of scientific evidence in
influencing behaviour continues to be debated. The the-
ory of planned behaviour
17
suggests that behaviour is
influenced more by attitudes, subjective norms and per-
ceived behavioural control than by knowledge. However,
there is ample evidence that more knowledge about PUs
leads to safer behaviours.
18
In order to be able to map OR team knowledge of
PUs in Sweden, the Pressure Ulcer Knowledge Assess-
ment Tool (PUKAT 2.0) was developed to measure con-
textual knowledge about PUs in Swedish. This tool could
enable the identification of areas that need strengthening,
to ensure patient safety and evidence-based care during
surgery in relation to PUs.
The aim of this study was to psychometrically evalu-
ate the Swedish OR version of the PUKAT 2.0.
2|MATERIAL AND METHODS
2.1 |Study design
A prospective psychometric instrument validation study
was designed to translate and validate PUKAT 2.0. The
present version consists of 14 items developed specifically
for the OR context. The elements included are listed in
Table 1.
2.1.1 | Sample and data collection
In order to evaluate the Swedish version of the PUKAT
2.0 OR questionnaire, the Swedish county councils
(n=21) were invited to participate by providing the
work email addresses of clinically active OR nurses. All
clinical OR nurses working in OR departments in
Sweden and OR nurses with a managerial role were
included in the study. The questionnaire was distributed
FALK-BRYNHILDSEN ET AL.1535

by email together with information about the voluntary
nature of the study to 2247 of the estimated 4000 OR
nurses in Sweden for whom we got contact information.
Of the email addresses provided, 343 were non-func-
tional, leaving 1904 participants eligible for the study.
The data was collected between August and September,
2020. The questionnaire was sent to the collected work
email addresses with a reminder 1 week later. One week
after the reminder, the re-test (the same questionnaire)
was sent to all OR nurses who answered the first time. A
reminder was also sent out for the re-test at this time.
The purpose of the re-test was to investigate test–retest
reliability.
2.2 |Ethical considerations
The study was approved by the Ethics Review Board in
Linköping, Sweden Dnr 2020-01212. The participant
information sheet and a link to the survey were sent as
an email. Informed consent was taken from the partici-
pants when returning the questionnaire. The anonymity
of the participants was guaranteed, and the data were
kept confidential in data files on the servers of Ghent
University, protected by firewalls, in accordance with
Swedish Law of Personal Data Protection (GDPR).
2.2.1 | Instrument development
ThePressureUlcerKnowledgeAssessmentTool(PUKAT),
an instrument to assess clinical nurses' knowledge of
PUs, was developed in 2010 at Ghent University,
Belgium. The original instrument has good overall inter-
nal consistency (Cronbach's alpha value =0.77) and a
test–retest correlation coefficient within class =0.88.
This 26-item knowledge instrument was designed to
reflect six themes reflecting the most important aspects
of PU prevention.
19
A revised 25-item version of the PUKAT tool (PUKAT
2.0) also showed good psychometric properties for asses-
sing PU prevention knowledge.
20,21
This instrument con-
tains 25 multiple-choice items, each consisting of five
response alternatives, including an “I don't know the
answer”option. The items were designed to address six
themes: Aetiology (6 items), Classification and Observa-
tion (4 items), Risk Assessment (2 items), Nutrition
(3 items), Pressure Ulcer Prevention (8 items) and Spe-
cific Patient Groups (2 items). Responses to the questions
were recoded into a dichotomous variable (correct/not
correct).
The knowledge instruments have been evaluated in
different cultural contexts.
21,22
The original version of the
PUKAT was translated from English into Swedish,
23
but
TABLE 1 PUKAT 2.0 OR - Domains and items
Domains Items
Aetiology 1 What is the cause of pressure ulcers?
2 A patient undergoes surgery in a semi-upright position (e.g. the head of the operating table at a 60angle).
What happens on sacrum and ischial tuberosities if the patient slides down?
3 Moist skin (due to e.g., incontinence, wound exudate, irrigation fluid or skin disinfection) and increased
body temperature are associated with pressure ulcer development. This statement is…….
4 Where in the tissue do deep tissue injuries develop during surgery
5 What type of patients (in terms of body weight) have an increased risk for developing pressure ulcers?
Classification and
observation
6 You observe a blister on both heels of a patient following a 3-hour surgical procedure. Which statement is
correct?
7 Which of these pictures is a pressure ulcer category I?
Prevention 8 CASE: A patient is positioned pre-operatively in a Semi-Fowler position (position in which the individual is
supine and the head of the operating table is elevated). Which statement is correct?
9 A patient undergoes surgery in a side-lying position (e.g., hip surgery, lung surgery). Which positioning
angle during surgery is associated with the highest risk for developing a pressure ulcer at the trochanter
major?
10 How should surgical linen be used to prevent pressure ulcers?
11 CASE: Your patient is lying on a pressure redistributing OR mattress. Do you take other measures to prevent
pressure ulcers on the heels?
12 Why is repositioning necessary to prevent pressure ulcers?
13 Which statement is correct?
14 Indicate the location on the body where babies have the highest risk of developing a pressure ulcer?
1536 FALK-BRYNHILDSEN ET AL.

the PUKAT 2.0 version of the instrument has not yet
been validated in a Swedish context with OR nurses.
2.3 |The validation process
The validation process consisted of two stages.
The first phase of validation was the translation and
cultural adaptation of the instrument after approval by
the original author of PUKAT. Guidelines comprising
10 steps described by the International Society for Phar-
macoeconomics and Outcomes Research (ISPOR) Task
Force were followed for the translation and cultural
adaptation process.
24
Based on feedback from the OR expert group (AvV,
BÅ, CLS, CW and KFB) on cultural relevance, the topics
in the new PUKAT 2.0 OR were divided into three cate-
gories: Aetiology (5 items), Classification and Observa-
tion (2 items) and Prevention (7 items). Consistent with
the original PUKAT 2.0, it consists of five response alter-
natives, including an “I do not know the answer”option.
An overview of the translation and adaptation processes
is given in Table 2.
In the second stage a psychometric instrument
validation was conducted. Construct validity, stability,
reliability and validity of the multiple-choice test items
were evaluated.
3|STATISTICS
Statistical analyses were performed using the software
package IBM SPSS v24.0 (SPSS Inc., Chicago, IL, USA).
Components of the knowledge assessment instrument
PUKAT 2.0 OR were analysed. Participants' descriptive
data are presented in percentages and numbers. A signifi-
cance level of 0.05 was applied to all statistical tests.
3.1 |Analysis of PUKAT 2.0 OR
3.1.1 | Analysis of the knowledge assessment
instrument
Responses to the knowledge assessment instrument were
recoded as dichotomous variables (not correct-correct). The
option “Idonotknowtheanswer”was interpreted as “not
correct. The total score on the instrument was calculated as
the sum of correct responses (maximum score =14).
3.1.2 | Validity of the multiple-choice test
items
The item difficulty (P-value), discrimination index
(D-value) and the quality of a response alternative
TABLE 2 Overview of the translation and adaptation process
1. Preparation The research group KFB, CW, CLS, and DB prepared and planned the upcoming process
2. Forward translation CB, LG, and CB, three bilingual nurse researchers and experts in PU prevention, translated
each item independently in the original version of PUKAT 2.0 from English into Swedish in
collaboration with the research group. Translation was performed by members of the
research group, who were all knowledgeable about English-speaking culture but had
Swedish as their primary language. This process was carried out until consensus was
reached.
3. Reconciliation KFB compared and merged three forward translations into a single forward translation until
consensus was reached.
4. Back translation This was carried out by MG, a professional translator, fluent in Swedish and a certified teacher
and native speaker of English. The translation was then compared with the original versions
by DB.
5. Back translation Review KFB, the project manager, identified items which had been found to be conceptually
problematic and shared translation solutions. The OR expert researcher group, (AvV, BÅ,
CLS, CW and KFB) commented independently on the items regarding cultural relevance
and suggested which items needed to be clarified or were not relevant in the OR context.
6. Harmonisation The English and Swedish versions were discussed in the research group in order to reach a
consensus on meaning, intelligibility, and relevance for the OR. 13 items were judged to be
irrelevant and one item was added, which resulted in a 14-item PUKAT in the Swedish OR
version.
7. Cognitive debriefing The Swedish version was tested with five clinically active OR nurses for face validity,
comprehensibility and relevance.
8. Review of Cognitive Debriefing
Results and Finalisation
Small adjustments of the instrument were made, based on cognitive debriefings in the
research group
FALK-BRYNHILDSEN ET AL.1537

(a-value) were used to assess the validity of the
multiple-choice test items.
The proportion of respondents who answered the
item correctly is defined as the difficulty of an item
(P-value).
25,26
For items with five response options, an
item difficulty of P=.70 is ideal
27,28
whilst a value of
0.10 was considered too difficult.
20
The discriminant index (D-value) of the items was
calculated by dividing the respondents into two
extreme groups: the 27% of respondents with the
best performance and the 27% of respondents with the
worst performance (high total score versus low total
score).
20,25,28
The percentage of correct responses in the
27% worst group was subtracted from the percentage of
correct responses in the 27% best group for each item.
The D value ranges from +1to1. D values in the
range between 0.20 and 0.40 are recommended as
minimal.
26,27
The quality of a response alternative (a-value) was
assessed by calculating the proportion of respondents
who chose the alternative. The optimal a-value for an
item with five response options is 0.10. For each item, the
a-values must be less than the P-value. Equal a-values
indicate that all response alternatives function as equal
distractors.
20,27
3.1.3 | Construct validity
Discriminatory power was assessed using the known-
groups technique to assess the ability of the
instrument to discriminate between groups with theo-
retically expected different levels of knowledge
regarding PUs.
20,30,31
It was hypothesised that groups
would differ in knowledge levels based on role,
education level, work experience, expertise and
preference for receiving pressure ulcer training. The
independent samples t-test was used to detect differ-
ences between the knowledge scores of the predefined
groups.
20,31
3.1.4 | Stability reliability (intraclass
correlation)
To evaluate the reliability of the instrument, a test–
retest procedure was used. Two random single factorial
intraclass correlation coefficients (ICC) were calculated
for the overall instrument and for each domain. Reli-
ability coefficients ≥0.70wouldbeconsideredsatisfac-
tory and coefficients ≥0.80 would be considered
preferable.
31
TABLE 3 Demographics of the participants
Total (n=284)
n%
Gender
Female 264 93.0
Male 20 7.0
Role in the operating room
OR nurse 267 94.0
OR nurse with a leading function 11 4.0
Other 5 1.8
No data available 1 0.2
Education
Professional degree 96 33.8
Bachelor's degree 75 26.4
Master's degree 105 37.0
Doctoral degree 2 0.7
Other 6 2.1
Surgical specialities
Acute/trauma surgery 8 2.8
General or mixed surgery 117 41.2
Cardiothorac surgery 30 10.6
Gynaecological surgery 13 4.6
Neurosurgery 11 3.9
Orthopaedic (bone and joint) surgery 45 15.9
Otolaryngological and eye surgery 14 4.8
Paediatric (children's) surgery 12 4.1
Plastic and reconstructive surgery 9 3.2
Outpatient surgery 13 4.6
Urological surgery 7 2.5
Other 5 1.8
Work experience in healthcare
< 5 years 33 11.6
5–10 years 71 25.0
11–20 years 73 25.7
> 20 years 107 37.7
Expertise in pressure ulcers
a
Novice 2 0.7
Competent 108 38.0
Proficient 142 50.0
Expert 32 11.3
Would pressure ulcer training be useful?
Yes 247 87.0
No 37 13.0
a
Self-estimated expertise in relation to the assessment and management of pressure
ulcers (basedon the levels of proficiency defined by Patricia Benner (1982)).
1538 FALK-BRYNHILDSEN ET AL.

3.1.5 | Internal consistency
The internal consistency was calculated by inter-item
correlations of Cronbach's α. Results were interpreted
using the criteria for Cronbach's αas defined by
32
(0.70 < Cronbach's α<0.90).
4|RESULTS
4.1 |Demographic characteristics of the
participants
A total of 284 participants (93.0% female, age [mean
± SD] 48.2 ± 9.4 years) completed the first survey (test),
of whom 50 (17.61%) also completed the second survey
(retest). Most of the participants were OR non-
managerial nurses (94.0%) and 63.4% had more than
10 years of professional experience. More than half of the
participants (64.1%) had a bachelor's degree or higher
and estimated their expertise in PUs as being good or bet-
ter (61.3%). Of all respondents, 247 (87.0%) indicated that
they would find pressure ulcer education useful. A sum-
mary of the sample demographics is presented in Table 3.
5|PSYCHOMETRIC EVALUATION
OF THE KNOWLEDGE TOOL
5.1 |Validity of the multiple-choice test
items
5.1.1 | Item difficulty
The item difficulty (P-value) of 14 items ranged between
.38 and .96, with a median value of 0.65. Three items
were found to be too easy (0.90–0.96). None of the items
had a difficulty index lower than 0.10 (see Table 4).
5.1.2 | Discriminating index
The discriminating index (D-value) of 14 items ranged
between 0.11 and 0.61, with a median value of 0.46. Three
TABLE 4 Validity of the multiple-choice test items and stability reliability knowledge tool
Proportion of respondents choosing each response option
a
Response options
Domains Items a b c d
Do not
know
c
D-value
d
ICC (95% CI)
e
Cronbach's
αICC (95% CI)
e
Aetiology 1 0.03 0.00 0.04 0.96
c
0.00 0.11 0.39 (0.13–0.60) 0.56 0.65 (0.45–0.78)
2 0.05 0.01 0.94
b
0.00 0.00 0.16
3 0.12 0.74
c
0.02 0.03 0.08 0.45
4 0.00 0.38
b
0.10 0.43 0.09 0.40
5 0.00 0.00 0.90
b
0.07 0.01 0.16
Classification
and
observation
6 0.00 0.41
b
0.12 0.16 0.31 0.61 0.12 (0.16–0.39) 0.22
7 0.10 0.63
b
0.06 0.01 0.20 0.51
Prevention 8 0.04 0.03 0.51
b
NA
f
0.42 0.57 0.59 (0.38–0.75) 0.74
9 0.04 0.06 0.07 0.52
b
0.31 0.50
10 0.57
b
0.03 0.18 0.02 0.20 0.53
11 0.05 0.22 0.41
b
0.28 0.04 0.53
12 0.03 0.28 0.66
b
0.01 0.03 0.30
13 0.00 0.01 0.68
b
0.24 0.08 0.34
14 0.72
b
0.03 0.01 0.03 0.22 0.47
a
Based on the proportion of respondents who did NOT choose the “I do not know the answer”option (=a-value for incorrect response alternatives).
b
Intraclass correlation coefficient (95% confidence interval).
c
Correct answer (=P-value).
d
Not applicable.
e
Proportion of respondents who choose the ‘I do not know the answer’option.
f
Discriminating index.
FALK-BRYNHILDSEN ET AL.1539

items had a D-value lower than 0.20 (0.11–0.16) and eight
items scored higher than 0.40 (0.45–0.61). None of the items
had a negative discriminating index (see Table 4).
5.1.3 | Quality of the response alternatives
The quality of the response alternatives (a-value) ranged
between 0.00 and 0.42, with a median value of 0.035. None
of the a-values were higher than the P-value (see Table 4).
6|CONSTRUCT VALIDITY
6.1 |Discriminating power
For one group, the scores of participants with a theoreti-
cally expected higher level of knowledge were statistically
significantly higher than those of the group with a theo-
retically expected lower level of knowledge. It was found
that nurses with a master's degree had a higher level of
knowledge than nurses with a professional degree
(respectively, 9.4/14 versus 8.6/14; t=2.4, df =199,
P=.02). No significant differences were found between
OR nurses with or without a leadership role, or between
nurses with a professional degree with or without a bach-
elor's degree; between nurses with fewer or more than
10 years of professional experience; between experts and
non-experts, or between nurses who would or would not
find further education useful (see Table 5).
6.2 |Stability reliability (intraclass
correlation)
A total of 50 nurses completed the instrument twice, with a
1-week interval between administrations. The overall intra-
class correlation coefficient (ICC) was 0.65 (95% CI =(0.45–
0.78)). The ICCs for the domains varied from 0.12 (95%
CI =0.16–0.39) to 0.59 (95% CI =0.38–0.75) (see Table 4).
7|DISCUSSION
The purpose of the study was to assess the psychometric
properties of the Swedish version of the PUKAT 2.0 OR
TABLE 5 Known-groups technique knowledge tool
Groups n
Mean score (SD)
(max =14) t
a
df
b
P
c
OR nurse
d
(A) 267 9 (2.2) 0.40 10.75 .80
versus OR nurse with leading function
(B)
11 9.3 (2.3)
Professional degree (A) 96 8.6 (2.1) 0.90 169 .40
versus Bachelor's degree (B) 75 8.9 (2.1)
Bachelor's degree (A) 75 8.9 (2.1) 1.30 161.6 .20
versus Master's degree (B) 105 9.4 (2.1)
Professional degree (A) 96 8.6 (2.1) 2.40 199 .02
versus Master's degree (B) 105 9.4 (2.1)
≤10 years' work experience (A) 104 9.5 (2.0) 1.60 175 .11
versus > 10 years' work experience (B) 73 9.0 (2.4)
Non-expert (novice and competent)
e
(A) 110 8.9 (2.9) 0.65 282 .52
versus Expert (proficient and expert)
e
(B) 174 9.1 (2.1)
Pressure ulcer training could be useful
(B)
147 9.0 (2.2) 0.39 282 .90
versus Not useful (A) 37 9.0 (1.8)
Note: (A): Group with theoretically expected lower level of knowledge (B): Group with theoretically expected higher level of knowledge.
a
Independent sample t-test.
b
Degrees of freedom.
c
P-value.
d
Operating room.
e
Self-estimated expertise in relation to the assessment and management of pressure ulcers (based on the levels of proficiency defined by Patricia
Benner (1982)).
1540 FALK-BRYNHILDSEN ET AL.

for measuring OR nurses' knowledge of pressure ulcer
prevention with reference to three specific themes. The
first step in the study was to conduct a translation and
adaptation process to attempt to ensure that the Swedish
version was linguistically and semantically equivalent to
the original version of the instrument. The various stages
of this process, detailed in Table 1, led to the retention of
14 items from the original instrument of 28 items, with
14 other items having been rejected as irrelevant to the
final Swedish PUKAT 2.0 OR version.
In relation to the psychometric evaluation of the
available data and the validity of the multiple choice test
items, three items were found to be too easy. These were
items related to the reasons for PUs developing, the effect
of the position of the patients on the operating table on
the development of PUs, and the characteristics of
patients who are at increased risk for developing PUs. In
general, tests to identify item difficulty (the P-value) are
judged to be more reliable if the P-values are spread
across a range of 0.0–1.0. This was the case in this study
(Table 4).
The same three items also showed low ability to dis-
criminate (D-value) between the groups with theoreti-
cally different levels of knowledge. In considering these
results, it is gratifying to note that all categories of OR
nurses had acceptable knowledge of these specific factors,
even if the analysis of these factors does not contribute to
the instrument's overall ability to identify areas where
there is potential to increase OR nurses' level of knowl-
edge. Therefore, analysis of the instruments indicates that
11 of the original items contributed to the overall validity
of the instrument.
In evaluating the quality of the response alternatives,
the distribution of the incorrect answers over the
response alternatives was measured. None of the a-values
were higher than the P-value. This indicates that each of
the alternative answers served equally well as distractors.
It was possible to discriminate between groups with
theoretically lower or higher levels of knowledge by using
the instrument, that is, nurses with master's degrees had
higher levels of knowledge than those with professional
degrees. It was not possible to discriminate between
nurses with professional degrees or bachelor's degrees,
nurses with differing work experience, expert and non-
expert nurses, or nurses who either did or did not express
a desire for further education. It may be important to be
able to discriminate between levels of knowledge in order
to enhance patient safety. A study by Aiken et al. showed
that the level of education was important with regard to
patient outcome after surgery. The study showed that
having nurses with higher education and working in
wards was associated with a reduced risk of patient mor-
tality within 30 days of admission.
33
It was difficult to make feasible judgements about the
reliability of the instrument since only 2.6% of the sample
completed the instrument twice. It is worth noting that
the data collection took place during the 2020 COVID-19
pandemic. During this period, Swedish healthcare was
under severe pressure because of the high prevalence and
incidence of COVID-19 infections. It may be that there
were many absences from work because of illness or
because staff were required to work in other departments
to cover for ill colleagues and therefore did not have the
time or possibility to fill in the questionnaire
34
Low
response rates can affect the external validity
35
and, in
general, digital questionnaires have a lower response rate
than paper versions.
36
The overall intraclass correlation was 0.65, but the
ICCs for the domains were low, ranging from 0.12 to
0.59. In the absence of more reliable data, it is not feasi-
ble to speculate about these low values. We can only
speculate about the reasons for the low participation in
the retest. An extended evaluation of this Swedish ver-
sion of the PUKAT 2.0 OR instrument is warranted in
order to confirm its psychometric properties and, accord-
ingly, its possible utility with Swedish OR nurses.
We suggest further validation of the PUKAT 2.0
instrument, with a particular focus on the research
methodology, in order to acquire as much valid and reli-
able data as possible. The limitations imposed by the
COVID-19 pandemic must be addressed. The response
rate may have been higher if we had used different sur-
vey modalities, such as written reminders being sent to
participants instead of email. In addition, if the
reminder mode were to be changed from postal to per-
sonal contact, perhaps through the head nurses who
have knowledge of all the OR nurses working in their
departments, there might have been a higher participant
response rate.
37
There were likely elements of sampling and selection
bias in the survey, given the low response rates. Partici-
pants of web surveys decide whether or not to participate
in filling in questionnaires, and as such, the researcher
does not have full control of the selection process.
38
In a
Cochrane review, it is suggested that in order to increase
response rates, questionnaires, letters and emails could
be made more personal and preferably kept short.
39
Analysis of the Swedish OR version of the PUKAT 2.0
gave some tantalising information about how this type of
quantitative methodology can contribute to our under-
standing of OR nurses' knowledge and application of
knowledge in the area of PU nursing. Since OR nurses
stated that they would like more education in pressure
ulcer nursing, it would be valuable to identify areas in
which more education is needed and to devise relevant
educational strategies for the OR nurses.
FALK-BRYNHILDSEN ET AL.1541

Extending future research to include qualitative and
quantitative mixed research methods could enable the
acquisition of additional valuable data to complement and
enhance existing quantitative data.
40
This could help to
increase our understanding of how PUs may be prevented.
The desirability of having a reliable and valid Swedish
version of the PUKAT 2.0 OR instrument is clear. Its use
could enable the identification of areas of knowledge that
would benefit from additional pedagogical support. This
could support the ultimate goal of improving patient care
and patient safety.
8|CONCLUSION
There is some evidence that the development of a Swed-
ish OR version of the PUKAT 2.0 questionnaire was suc-
cessful. Operational difficulties during the research
process because of the COVID-19 pandemic led to subop-
timal response rates of the survey participants in both the
test and retest phases of the study. Accordingly, the psy-
chometric properties of the Swedish PUKAT 2.0 OR ques-
tionnaire found in this study should be confirmed.
ACKNOWLEDGEMENTS
The authors thank all the OR nurses in Sweden who par-
ticipated in the study for sharing their experiences.
FUNDING INFORMATION
This research did not receive any specific grant from
funding agencies in the public, commercial, or not-for-
profit-sectors.
CONFLICT OF INTEREST
The authors declare no potential conflict of interest.
DATA AVAILABILITY STATEMENT
Data sharing is not applicable to this article as no new
data were created or analyzed in this study.
ORCID
Charlotte Raepsaet https://orcid.org/0000-0002-3517-
5711
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How to cite this article: Falk-Brynhildsen K,
Raepsaet C, Wistrand C, et al. Swedish translation,
cultural adaptation and psychometric evaluation of
the pressure ulcer knowledge assessment tool for
use in the operating room. Int Wound J. 2023;20(5):
1534‐1543. doi:10.1111/iwj.14008
FALK-BRYNHILDSEN ET AL.1543