Nurses’ Perceived Barriers to The Prevention of Pressure Injury and Related Factors in Indonesia

Background : Incidence of pressure injury (PI) in Indonesia is high. Therefore, Indonesian nurses should take measures to prevent PI from developing. Considering the high incidence of PI in Indonesia, there could be some barriers faced by Indonesian nurses in performing prevention of PI. However, to date, no study has assessed the perceived barriers and factors associated with perceived barrier of prevention of PI in Indonesian nurses. Objective : This study aimed to assess perceived barriers to prevention of PI and associated factors in Indonesian nurses. Method: A total of 521 nurses participated in the study. A pressure injury prevention barriers questionnaire was used to assess perceived barriers of prevention of PI. A multivariate logistic regression model was used to analyse factors associated with the perceived barriers. Results : The two most perceived barriers in nurses were lack of preventive devices such as special mattresses, cushions, and skin care products, and a lack of training courses related to prevention of PI. Associated factors emerging from the results were working experience (AOR =1.74) and working unit (AOR =2.73). Conclusion : Nurses perceived behaviors control over nursing care documentation were slighty over the mediocre values, Nurses tend to have positive perception on their control over documenting nursing care.


INTRODUCTION
Pressure injury (PI) is injury to the skin and soft tissue that usually occurs over a bony prominence and may be associated with medical devices (European Pressure Ulcer Advisory Panel and Alliance, 2014;Edsberg et al., 2016). It is a serious problem in various clinical settings (Hahnel et al., 2017;Tubaishat et al., 2018;Li et al., 2020), and its significance in Indonesia is indicated by high incidences of PI (28.4%) and high incidences of severe PI (42.3%) in the country (Suriadi et al., 2008). Preventive measures should be conducted by Indonesian nurses since patients with PI commonly suffer from physiological, physical and economic problems, frequently leading to diminished quality of life and even death (Allman, 1997;Spilsbury et al., 2007;Padula and Delarmente, 2019;Song et al., 2019).
Pressure injury is considered as being primarily preventable (Black et al., 2010;Barker et al., 2013;Amir et al., 2017;Schmitt et al., 2017). Therefore, nurses should take measures to prevent PI from developing or deteriorating. Considering the high PI incidence in Indonesia, barriers to prevention of PI might be faced by Indonesian nurses. It is important to determine what the perceived barriers faced by Indonesian nurses are, so that appropriate programs to reduce these barriers can be conducted. A previous study in the US showed that the barriers faced by nurses in the US are lack of staff and lack of time (Moore and Price, 2004). There is an urgent need for a greater understanding of it, and therefore, the first aim of this study was to investigate Indonesian nurses' perceived barriers to prevention of PI.
To reduce the barriers of prevention of PI, it is needed to investigate the factors associated with perceived barriers of prevention of PI in Indonesia.
Therefore, the second aim of our study was to investigate the factors related with Indonesian nurses' perceived barriers to prevention of PI in hospital settings. Determining the factors related to Indonesian nurses' perceived barriers to prevention of PI is crucial since it can guide nurse administrators to develop specific programs to reduce those barriers.

Population and Sample
A cross-sectional study was carried out to assess Indonesian nurses' perceived barriers to PI prevention and related factors. The study was conducted in public hospitals in Central Java Province, Indonesia via convenience sampling. The sample calculation was obtained using the following formula: n=Z 2 P(1−P)/d 2 (n = sample size, Z = 1.96, P = 0.5, and d = 0.05) (Pourhoseingholi, Vahedi and Rahimzadeh, 2013 being given for each "frequently" or "always", and no points being given for each "never" or "sometimes".
Those scoring less than or equal to the mean value were categorized as perceiving low barriers, while those scoring greater than the mean value were categorized as perceiving high barriers. The questionnaire has a satisfactory Cronbach alpha of 0.90, and the Cronbach alpha of this study was 0.92.
The translation process followed that of a previous study (Brislin, 1970

Results
A total of 521 nurses participated in this study.
The socio demographic characteristics of the participants can be seen in Table 1.  We found that one of factors related with barriers of PI prevention is the working experience.
Surprisingly, nurses with five or more years of clinical experience perceived almost two times more barriers than those with less experience. This might be because those with more working experience have more awareness than those with less working experience about best practice or standard practice in the prevention of PI and are therefore more likely to understand that prevention of PI in their workplace is still far from standard practice. The higher awareness in those nurses with more working clinical experience might be due to them having significantly higher knowledge regarding prevention of PI than those with less clinical experience, as suggested in the previous studies (Pancorbo-Hidalgo et al., 2007;Aydin and Karadağ, 2010;Ebi, Hirko and Mijena, 2019 et al., 2010;Zuo and Meng, 2015;He et al., 2016;Coyer and Tayyib, 2017;Coyer et al., 2017;de Azevedo Macena et al., 2017;Masyitha et al., 2020;de Assis et al., 2021;Jacq et al., 2021;Labeau et al., 2021