ArticlePDF Available

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



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.
Swedish translation, cultural adaptation and psychometric
evaluation of the pressure ulcer knowledge assessment tool
for use in the operating room
Karin Falk-Brynhildsen
| Charlotte Raepsaet
| Camilla Wistrand
Carina Bååth
| Christine Leo Swenne
| Mervyn Gifford
Lena Gunningberg
| Ann-Christin von Vogelsang
| Catrine Björn
Dimitri Beeckman
Faculty of Medicine and Health, School
of Health Sciences, Nursing Science Unit,
Swedish Centre for Skin and Wound
Research, Örebro University, Sweden
Skin Integrity Research Group (SKINT),
University Centre for Nursing and
Midwifery, Department of Public Health
and Primary Care, Ghent University,
University Health Care Research Centre,
Faculty of Medicine and Health, Örebro
University, Sweden
Department of Health Sciences, Faculty
of Health, Science and Technology,
Karlstad University, Karlstad, Sweden
Faculty of Health, Welfare and
Organisation, Östfold University College,
Fredrikstad, Norway
Department of Public Health and Caring
Sciences, Uppsala University, Sweden
Department of Neurosurgery, Karolinska
University Hospital, Stockholm, Sweden
Department of Clinical Neuroscience,
Karolinska Institute, Stockholm, Sweden
Centre for Research & Development,
Uppsala University/Region Gävleborg,
Karin Falk-Brynhildsen, Faculty of
Medicine and Health, School of Health
Sciences, Örebro University, SE-70182
Örebro, Sweden.
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 (0.900.96). 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 (0.110.16) and eight items scored higher than 0.40 (0.450.61). 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 0.450.78). The ICCs for the
domains varied from 0.12 (95% CI =0.160.39) 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.
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 Inc (3M) and John Wiley & Sons Ltd.
1534 Int Wound J. 2023;20:15341543.
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
Pressure ulcers (PUs) are a global problem in healthcare.
A recent review identified an overall prevalence of 12.8%
in hospital settings.
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
The European Pressure Ulcer Advisory Panel
(EPUAP) reports that surgery-related PUs occur in rela-
tion to 4%45% of surgical procedures.
PUs can occur
between 48 and 72 h postoperatively
due to prolonged
pressure. Moreover, all medical devices in contact with
the patient increase the risk of PUs to both skin and
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
intraoperative medical devices/positioning
time on the OR table,
anaesthesia and low arte-
rial blood pressure.
Moreover, a recent study
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,
therefore, deep and multi-
disciplinary etiological understanding is required for
effective prevention of intraoperatively acquired tissue
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.
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.
A recent study
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
showed that suffi-
cient knowledge regarding PU prevention in emergency
departments was dependent on nurses' PU identification
and classification skills after training and workshops
Another study showed that teaching and scenario simula-
tions were also important factors in optimising the educa-
tion of OR nurses.
The role of scientific evidence in
influencing behaviour continues to be debated. The the-
ory of planned behaviour
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.
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.
2.1 |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
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 testretest
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
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
testretest 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.
A revised 25-item version of the PUKAT tool (PUKAT
2.0) also showed good psychometric properties for asses-
sing PU prevention knowledge.
This instrument con-
tains 25 multiple-choice items, each consisting of five
response alternatives, including an I don't know the
answeroption. 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
The knowledge instruments have been evaluated in
different cultural contexts.
The original version of the
PUKAT was translated from English into Swedish,
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 60angle).
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
6 You observe a blister on both heels of a patient following a 3-hour surgical procedure. Which statement is
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
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?
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.
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 answeroption.
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.
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
Responses to the knowledge assessment instrument were
recoded as dichotomous variables (not correct-correct). The
option Idonotknowtheanswerwas 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
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
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
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
(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
For items with five response options, an
item difficulty of P=.70 is ideal
whilst a value of
0.10 was considered too difficult.
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
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 +1to1. D values in the
range between 0.20 and 0.40 are recommended as
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
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.
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
3.1.4 | Stability reliability (intraclass
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
TABLE 3 Demographics of the participants
Total (n=284)
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
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
510 years 71 25.0
1120 years 73 25.7
> 20 years 107 37.7
Expertise in pressure ulcers
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
Self-estimated expertise in relation to the assessment and management of pressure
ulcers (basedon the levels of proficiency defined by Patricia Benner (1982)).
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
(0.70 < Cronbach's α<0.90).
4.1 |Demographic characteristics of the
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.
5.1 |Validity of the multiple-choice test
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 (0.900.96). 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
Response options
Domains Items a b c d
Do not
ICC (95% CI)
αICC (95% CI)
Aetiology 1 0.03 0.00 0.04 0.96
0.00 0.11 0.39 (0.130.60) 0.56 0.65 (0.450.78)
2 0.05 0.01 0.94
0.00 0.00 0.16
3 0.12 0.74
0.02 0.03 0.08 0.45
4 0.00 0.38
0.10 0.43 0.09 0.40
5 0.00 0.00 0.90
0.07 0.01 0.16
6 0.00 0.41
0.12 0.16 0.31 0.61 0.12 (0.160.39) 0.22
7 0.10 0.63
0.06 0.01 0.20 0.51
Prevention 8 0.04 0.03 0.51
0.42 0.57 0.59 (0.380.75) 0.74
9 0.04 0.06 0.07 0.52
0.31 0.50
10 0.57
0.03 0.18 0.02 0.20 0.53
11 0.05 0.22 0.41
0.28 0.04 0.53
12 0.03 0.28 0.66
0.01 0.03 0.30
13 0.00 0.01 0.68
0.24 0.08 0.34
14 0.72
0.03 0.01 0.03 0.22 0.47
Based on the proportion of respondents who did NOT choose the I do not know the answeroption (=a-value for incorrect response alternatives).
Intraclass correlation coefficient (95% confidence interval).
Correct answer (=P-value).
Not applicable.
Proportion of respondents who choose the I do not know the answeroption.
Discriminating index.
items had a D-value lower than 0.20 (0.110.16) and eight
items scored higher than 0.40 (0.450.61). 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).
6.1 |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
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 =0.160.39) to 0.59 (95% CI =0.380.75) (see Table 4).
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
OR nurse
(A) 267 9 (2.2) 0.40 10.75 .80
versus OR nurse with leading function
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)
(A) 110 8.9 (2.9) 0.65 282 .52
versus Expert (proficient and expert)
(B) 174 9.1 (2.1)
Pressure ulcer training could be useful
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.
Independent sample t-test.
Degrees of freedom.
Operating room.
Self-estimated expertise in relation to the assessment and management of pressure ulcers (based on the levels of proficiency defined by Patricia
Benner (1982)).
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 0.01.0. 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.
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
response rates can affect the external validity
and, in
general, digital questionnaires have a lower response rate
than paper versions.
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.
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.
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.
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.
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.
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.
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.
The authors thank all the OR nurses in Sweden who par-
ticipated in the study for sharing their experiences.
This research did not receive any specific grant from
funding agencies in the public, commercial, or not-for-
The authors declare no potential conflict of interest.
Data sharing is not applicable to this article as no new
data were created or analyzed in this study.
Charlotte Raepsaet
1. Li Z, Lin F, Thalib L, Chaboyer W. Global prevalence and inci-
dence of pressure injuries in hospitalised adult patients: a sys-
tematic review and meta-analysis. Int J Nurs Stud. 2020;105:
2. Källman U, Hommel A, Borgstedt Risberg M, Gunningberg L,
Sving E, Bååth C. Pressure ulcer prevalence and prevention
interventionsa ten-year nationwide survey in Sweden. Int
Wound J. 2022;112.
3. European Pressure Ulcer Advisory Panel (EPUAP) NPIAPN,
Pan Pacific Pressure Injury Alliance (PPIA). Prevention and
Treatment of Pressure Ulcers/Injuries: Clinical Practice Guide-
line. European pressure ulcer advisory panel (EPUAP),
National Pressure Injury Advisory Panel (NPIAP), Pan Pacific
Pressure Injury Alliance (PPIA); 2019.
4. Scott EM, Buckland R. Pressure ulcer risk in the peri-operative
environment. Nurs Stand. 2005;20(7):74-81.
5. Burlingame BL. Guideline implementation: positioning the
patient. AORN J. 2017;106(3):227-237.
6. Jackson D, Sarki AM, Betteridge R, Brooke J. Medical device-
related pressure ulcers: a systematic review and meta-analysis.
Int J Nurs Stud. 2019;92:109-120.
7. Engels D, Austin M, McNichol L, Fencl J, Gupta S, Kazi H.
Pressure ulcers: factors contributing to their development in
the OR. AORN J. 2016;103(3):271-281.
8. Spruce L. Back to basics: preventing perioperative pressure
injuries. AORN J. 2017;105(1):92-99.
9. Tang Z, Li N, Xu J. Construction of a risk prediction model for
intraoperative pressure injuries: a prospective, observational
study. J Perianesth Nurs. 2021;36(5):473-479.
10. Sving E, Bååth C, Gunningberg L, Björn C. The experiences of
operating room teams working with real-time feedback of
interface pressure to prevent pressure injuriesa feasibility
study. Perioper Care Oper Room Manag. 2020;20:100096.
11. Gefen A, Creehan S, Black J. Critical biomechanical and clini-
cal insights concerning tissue protection when positioning
patients in the operating room: a scoping review. Int Wound J.
12. Khong BPC, Goh BC, Phang LY, David T. Operating room
nurses' self-reported knowledge and attitude on perioperative
pressure injury. Int Wound J. 2020;17(2):455-465.
13. Cebeci F, Çelik SS¸. Knowledge and practices of operating room
nurses in the prevention of pressure injuries. J Tissue Viability.
14. Dalvand S, Ebadi A, Gheshlagh RG. Nurses' knowledge on
pressure injury prevention: a systematic review and meta-
analysis based on the pressure ulcer knowledge assessment
tool. Clin Cosmet Investig Dermatol. 2018;11:613-620.
15. Ham WH, Schoonhoven L, Schuurmans MJ, Veugelers R,
Leenen LP. Pressure ulcer education improves interrater
reliability, identification, and classification skills by emer-
gency nurses and physicians. J Emerg Nurs. 2015;41(1):
16. Zhang M, Fan L, Zhou Y. Practical value of hierarchical teach-
ing combined with simulation scenario training for operating-
room nurses. Am J Transl Res. 2021;13(3):1833-1839.
17. Ajzen I. The theory of planned behaviour: reactions and reflec-
tions. Psychol Health. 2011;26(9):1113-1127.
18. Beeckman D, Defloor T, Schoonhoven L, Vanderwee K.
Knowledge and attitudes of nurses on pressure ulcer preven-
tion: a cross-sectional multicenter study in Belgian hospitals.
Worldviews Evid-Based Nurs. 2011;8(3):166-176.
19. Beeckman D, Vanderwee K, Demarré L, Paquay L, Van
Hecke A, Defloor T. Pressure ulcer prevention: development
and psychometric validation of a knowledge assessment instru-
ment. Int J Nurs Stud. 2010;47(4):399-410.
20. Manderlier B, Van Damme N, Vanderwee K, Verhaeghe S, Van
Hecke A, Beeckman D. Development and psychometric
validation of PUKAT 2 0, a knowledge assessment tool for pres-
sure ulcer prevention. Int Wound J. 2017;14(6):1041-1051.
21. Dalli ÖE, Yildirim Y, Çalis¸kan G, Girgin NK. Reliability and
validity of the Turkish version of pressure ulcer knowledge
assessment tool-updated version (PUKAT 2.0). J Tissue Viabil-
ity. 2022;31(1):52-57.
22. Hu L, Sae-Sia W, Kitrungrote L. Intensive care Nurses' knowl-
edge, attitude, and practice of pressure injury prevention in
China: a cross-sectional study. Risk Manag Healthc Policy.
23. Gunningberg L, Mårtensson G, Mamhidir AG, Florin J,
Muntlin Athlin Å, Bååth C. Pressure ulcer knowledge of regis-
tered nurses, assistant nurses and student nurses: a descriptive,
comparative multicentre study in Sweden. Int Wound J. 2015;
24. Wild D, Grove A, Martin M, et al. Principles of good practice
for the translation and cultural adaptation process for patient-
reported outcomes (PRO) measures: report of the ISPOR task
force for translation and cultural adaptation. Value Health.
25. Haladyna TM. Developing and Validating Multiple-Choice Test
Items. 3rd ed. Mahwah, NJ, US: Lawrence Erlbaum Associates
Publishers; 2004.
26. McAlpine M. A Summary of Methods of Item Analysis. Luton:
Luton: CAA Centre, University of Luton; 2002.
27. Sabbe E, Van de Poele L, De Cock K. Multiple choice: een han-
dleiding bij de ontwikkeling en kwaliteitscontrole van meerkeuze
examens in het universitair onderwijs. (Unpublished master's
thesis). Ghent, Belgium: Ghent University; 2007.
28. Lord F. A theory of test scores. Psychomet Monogr. 1952;7:x, 84-x:84.
29. Kline T. Psychological Testing: A Practical Approach to Design
and Evaluation. California: Sage Publications; 2005.
30. DeVon HA, Block ME, Moyle-Wright P, et al. A psychometric
toolbox for testing validity and reliability. J Nurs Scholarsh.
31. Polit DF, Beck CT. Nursing Research: Generating and Assessing Evi-
dence for Nursing Practice. Philadelphia: Lippincott Williams &
Wilkins; 2008.
32. Streiner DL, Norman GR, Cairney J. Health Measurement
Scales: a Practical Guide to their Development and Use. USA:
Oxford University Press; 2015.
33. Aiken LH, Sloane DM, Bruyneel L, et al. Nurse staffing and
education and hospital mortality in nine European countries: a
retrospective observational study. Lancet. 2014;383(9931):1824-
34. Ebert JF, Huibers L, Christensen B, Christensen MB. Or web-
based questionnaire invitations as a method for data collection:
cross-sectional comparative study of differences in response
rate, completeness of data, and financial cost. J Med Internet
Res. 2018;20(1):e8353.
35. Murad MH, Katabi A, Benkhadra R, Montori VM. External
validity, generalisability, applicability and directness: a brief
primer. BMJ Evidence-Based Med. 2018;23(1):17-19.
36. Shih T-H, Fan X. Comparing response rates in e-mail and
paper surveys: a meta-analysis. Educ Res Rev. 2009;4(1):26-40.
37. Phillips AW, Reddy S, Durning SJ. Improving response rates
and evaluating nonresponse bias in surveys: AMEE guide
No. 102. Med Teach. 2016;38(3):217-228.
38. Bethlehem J. Selection bias in web surveys. Int Stat Rev. 2010;
39. Edwards PJ, Roberts I, Clarke MJ, et al. Methods to increase
response to postal and electronic questionnaires. Cochrane
Database Syst Rev. 2009;3.
40. Kumar R. Research Methodology: A Step-by-Step Guide for
Beginners. 3rd ed. London, England: Sage; 2011.
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):
15341543. doi:10.1111/iwj.14008
ResearchGate has not been able to resolve any citations for this publication.
Full-text available
The aim of this study was to describe pressure ulcer prevalence and prevention interventions in hospital care in Sweden based on nationwide surveys conducted over a 10‐year period. All Swedish hospitals were invited to participate in annual pressure ulcer prevalence surveys during the period 2011–2020. The data collection protocols included gender, age, skin assessment, risk assessment, and preventive interventions. In total, more than 130,000 patients were included in the ten prevalence surveys. The prevalence of pressure ulcers in Swedish hospital patients decreased significantly from 17.0 %to 11.4% between 2011 and 2020 and hospital‐acquired pressure ulcers decreased from 8.1% to 6.4% between 2018 and 2020. There was no significant decline in medicaldevice‐related pressure ulcers during the same period. The proportion of patients who were risk and skin assessed increased, as did the use of pressure‐reducing mattresses, sliding sheets, heel protection, and nrepositioning plans. This study shows that the implementation of a national patient safety program has had an impact on the nationwide prevalence of pressure ulcers in hospital care and the occurrence of prevention strategies. However, one in ten patients in Swedish hospitals still suffers from pressure ulcers. Further improvements can be made.
Full-text available
Background: Pressure injury (PI) remains a critical health issue worldwide. The global incidence of hospital-acquired PI is 8.4%, and among intensive-care unit (ICU) patients, it is even higher, ranging from 6.60% to 36.80%. It is important to investigate ICU nurses' PI prevention knowledge, attitudes, and practices (KAP). Aim: The aim of this study was to describe the level of Chinese ICU nurses' knowledge, attitudes, and self-reported practices of PI prevention. Materials and methods: From March 31 to April 30, 2019, we recruited a total of 510 ICU nurses into the current study using convenience sampling. The Modified Pressure Ulcer Knowledge Assessment Tool version 2.0, Attitudes toward Pressure Ulcer Prevention instrument, and Questionnaire to evaluate nurses' Adherence to Recommendations for Preventing Pressure Ulcers were used for data collection. We used one-way analysis of variance, Student's t-test, and the Mann-Whitney U-test to assess differences in knowledge, attitudes, and self-reported practices of PI prevention among ICU nurses, whom we categorized by their demographic characteristics. Results: Mean scores of participants' knowledge, attitude, and their self-report practice were 65.82 ± 9.29, 76.65 ± 8.62, and 83.35 ± 13.55, respectively. Participants with bachelor's degrees or higher, who worked in tertiary hospitals, and who had received training on PI prevention over the last year had higher scored on PI prevention knowledge (all P < 0.05). Participants who had received training on PI prevention over the last year scored higher on attitude than those who had not received such training over the last year (P = 0.001). Conclusion: ICU nurses surveyed in this study did not demonstrate an acceptable level of knowledge about PI prevention, while their attitudes and self-reported practices were acceptable. Continuing education or in-service training should be provided to enhance ICU nurses' knowledge of PI prevention.
Objective This study aimed to determine the reliability and validity of the Turkish version of the measurement tool developed and updated by Manderlier et al. to evaluate the nurses’ evidence-based knowledge about pressure ulcers. Materials and methods A methodological study design was used. The instrument was translated to Turkish and back-translated to English. A group of faculty members, including physicians and nurses who are experts in the subject area, evaluated the content validity of the tool with the Lawshe technique. A group of 240 nurses who met the inclusion criteria were reached, and then a pilot study was conducted with 35 nurses by using the test-retest method to determine the invariance of the tool over time. The nurses in the pilot study were excluded from the overall sample, and the evaluations were performed with 205 nurses. Item difficulty index and discrimination index were used for the validity of the items since they were multiple-choice items; Kuder-Richardson 20 analysis was used to determine the internal consistency. Results The translated and modified instrument demonstrated acceptable psychometric properties as follows: 1) overall content validity index was 0.90, 2) overall test-retest reliability was 0.83 (0.70–0.92 for the sub-themes), 3) item difficulty indexes were 35–75%, 4) discrimination indexes were 0.44–0.92, and 5) overall Cronbach's alfa for the internal consistency was 0.72. Conclusions Similar to the earlier version, the Turkish version of PUKAT 2.0 was demonstrated to be a valid and reliable tool to evaluate the nurses’ knowledge of evidence-based current information about pressure ulcers.
Purpose To explore the incidence and risk factors of intraoperatively acquired pressure injuries (IAPIs) in patients transferred to the intensive care unit (ICU) after surgery and establish a risk factor prediction model for IAPIs for guiding clinical intervention. Design A prospective, observational study was conducted. Methods This study was conducted in the West China Hospital of Sichuan University. A total of 648 patients who were transferred to the ICU after surgery were recruited from May 1, 2019, to October 30, 2020. Data were collected preoperatively, intraoperatively, and postoperatively (3 days after transfer to the ICU). The enrolled patients underwent well-developed preventive measures to prevent IAPIs in the operating room and ICU. A sociodemographic and clinical characteristic questionnaire, the Braden pressure injuries risk assessment scale, the activity of daily living scale, and the Nutrition Risk Screening-2002 were used. Descriptive, bivariate, and logistic regression analyses were conducted. Findings The incidence rate of IAPIs within 3 days was 18.67%. The Braden pressure injuries score, preoperative fasting blood glucose level, emergency surgery, and types of vasoactive drugs in the ICU were significant factors for increased risk. The risk factor prediction model was established using the perioperative Braden pressure injuries score (P = 0.027, odds ratio [OR] = 0.901), preoperative fasting blood glucose level (P = 0.027, OR = 1.111), emergency surgery (P < 0.01, OR = 5.054), types of vasoactive drugs in the ICU (P = 0.038, OR = 1.668), and surgery time (P = 0.021, OR = 2.434). The area under the receiver operating characteristic curve was 0.74; 95% confidence interval was 0.671 to 0.810; sensitivity was 0.635; specificity was 0.860; and the Youden index was 0.495. Conclusions In patients transferred to the ICU after surgery, high fasting blood glucose level before surgery, emergency surgery, types of vasoactive drugs, and surgery time should be treated as predisposing factors in the prevention and control of IAPIs. However, the predictive effect of the perioperative Braden pressure injuries risk assessment scale on the risk of IAPIs needs to be further verified.
Background Operating room (OR) nurses play an important role in preventing the pressure injuries (PIs) that may develop during the perioperative process. This study was conducted to determine OR nurses’ level of knowledge about PIs, and how they manage them. Methods This is a cross-sectional, quantitative and descriptive study. The sample of the study consisted of 234 OR nurses working in eight different public hospitals in Ankara. The questionnaire applied in this study was prepared in accordance with the guidelines. This questionnaire consisted of three sections: demographic profiling, common preventive practices, and the knowledge of OR nurses about intraoperative PI prevention. Findings 66.7% of the participants had received education about PIs during their basic nursing training, and 41.5% had received education after graduation. 97.4% of OR nurses did not follow international guidelines about PIs. The mean total score of the OR nurses for the questions about PIs was 52.0±13.7 out of a possible score of 100. The lowest mean score was obtained for the topic of ‘staging pressure injuries', and the highest score was obtained from 'interventions to prevent pressure injuries'. In addition, 81.5% of the OR nurses stated that they were not given information about patients with a high PI risk by clinical nurses. 97.9% of the OR nurses did not use a scale to assess intraoperative PI risks. Fewer than half of the nurses said that they assessed the risk of PIs during surgery. 90.8% the nurses did not record risk assessment and interventions to prevent PIs. Conclusion There is a need to incorporate basic operating room PI (ORPI) training into both the basic nursing and in-service training to improve the knowledge of OR nurses about how to prevent and manage ORPIs. In addition, measures to assess PI risk and prevent ORPI should be included in institutional policies and procedures.
Objective: This study explored the application value of combined training by hierarchical teaching with situational simulations for operating-room (OR) nurses. Methods: A total of 41 nurses that received pre-job training for the operating room from January 2018 to December 2019 were selected as the research subjects and randomly divided into a control group and a study group. The control group was given the hierarchical nurse-teaching method, while the study group was given combined training with the hierarchical teaching and scenario simulations. In this study, the operating room capability, clinical work ability, results of theoretical assessment and specialized operation, and nurses' satisfaction with the teaching patterns were compared between the two groups. Results: After training, the scores of the operating-room operations in the study group, such as laying of aseptic towels, surgical hand washing, wearing of surgical gowns and gloves, and the setting up of the operating table, were higher than that in the control group (P<0.05). The scores of clinical work abilities in the study group, such as emergency handling ability, standardized operation ability, mastery of professional knowledge, observation and evaluation ability of disease, and clinical thinking ability, were higher than those in the control group (P<0.05). The theoretical examination scores and specialized operation scores of nurses in the study group were higher than those in the control group (P<0.05). The satisfaction with the degree of teaching methods in the study group was higher than that in the control group (P<0.05). Conclusion: The application of the combined training methods of hierarchical teaching with situational simulations for OR nurses can effectively improve their operational and clinical work ability, deepen their mastery of theoretical knowledge, and enable junior nurses to master the professional skills required in the operating room in a faster way, which is worthy of clinical teaching application.
An optimal position of the patient during operation may require a compromise between the best position for surgical access and the position a patient and his or her tissues can tolerate without sustaining injury. This scoping review analysed the existing, contemporary evidence regarding surgical positioning‐related tissue damage risks, from both biomechanical and clinical perspectives, focusing on the challenges in preventing tissue damage in the constraining operating room environment, which does not allow repositioning and limits the use of dynamic or thick and soft support surfaces. Deep and multidisciplinary aetiological understanding is required for effective prevention of intraoperatively acquired tissue damage, primarily including pressure ulcers (injuries) and neural injuries. Lack of such understanding typically leads to misconceptions and increased risk to patients. This article therefore provides a comprehensive aetiological description concerning the types of potential tissue damage, vulnerable anatomical locations, the risk factors specific to the operative setting (eg, the effects of anaesthetics and instruments), the complex interactions between the tissue damage risk and the pathophysiology of the surgery itself (eg, the inflammatory response to the surgical incisions), risk assessments for surgical patients and their limitations, and available (including emerging) technologies for positioning. The present multidisciplinary and integrated approach, which holistically joins the bioengineering and clinical perspectives, is unique to this work and has not been taken before. Close collaboration between bioengineers and clinicians, such as demonstrated here, is required to revisit the design of operating tables, support surfaces for surgery, surgical instruments for patient stabilisation, and for surgical access. Each type of equipment and its combined use should be evaluated and improved where needed with regard to the two major threats to tissue health in the operative setting: pressure ulcers and neural damage.
Background Surgical patients have an increased risk of sustaining a pressure induced injury. Novel technology has made it possible to objectively measure and visualize the interface pressure between the patient's tissue and the support surface in real time. The aim of this study was to describe operating room team members’ experiences of working with a pressure mapping system as a means to prevent intraoperative and postoperative recovery unit pressure injuries, and to describe the interface pressures and the incidence of observed pressure injuries. Methods We used a descriptive design with a qualitative approach to investigate the operating room team members’ experiences of working with real-time feedback of interface pressure, and a quantitative approach to investigate the interface pressures and the incidence of observed pressure injuries. The technology was used during 49 surgeries. Results The system increased clinician awareness and was considered beneficial in pressure injury prevention activities. There were wide variations in the interface pressures that measured from < 50 to 255 mmHg. Eight patients developed blanchable erythema during surgery and five other patients developed category 1 pressure injuries two hours postoperatively. Conclusions This study shows that the new technology could play an important role in preventing pressure injuries during surgery in the future.