Iran Journal of Nursing

Introduction
Pressure ulcer is one of common issues in patients due to the prevailing conditions in clinical environments. It is one of the most important challenges in hospitals that endangers patient safety and puts a significant financial burden on the patient, families, and the health care system. It has a high negative impact on the quality of life in terms of physical, psychological and social aspects, and can lead to pain, increased length of hospitalization, and rehabilitation. Pressure ulcer prevention is still an important challenge for the intensive care unit (ICU) nurses. Pressure ulcers occur due to a combination of internal and external factors. One of the most important external factors is the insufficient knowledge and practice of health care professionals. Knowledge can be acquired through learning. This study aims to determine the effect of online pressure ulcer prevention training on the knowledge, attitude and practice of ICU nurses.

Methods
This is an assessment single-group study with a pre-test/post-test design. The sampling was done using a continuous sampling method from April 2022 to January 2023. The samples were selected from among the nurses working in the ICU of Firouzgar and Hazrat Rasool Akram teaching hospitals. The inclusion criteria were  a history of work in the ICU for at least 6 months, at least a bachelor’s degree in nursing, and the ability to use WhatsApp. The exclusion criteria were unwillingness to continue cooperation and leaving the study. Initially, 80 nurses were selected. Three were excluded due to not completing the questionnaires and 4 due to unwillingness to continue cooperation. Finally, 43 nurses from Firouzgar Hospital and 30 from Hazrat Rasul Akram hopsital participated (total= 73). The data collectioin tools included a demographic form, the Pieper pressure ulcer knowledge test (PPUKT), the attitude towards pressure ulcer prevention questionnaire (APuP), and the practice of pressure ulcer prevention questionnaire (PPU). They were completed by the researchers. 
All participants joined a WhatsApp group with an active WhatsApp user account and access to the Internet. Then, the educational materials were shared in the group for 4 weeks. In the first week, an introduction to pressure ulcer and skin anatomy was presented. In the second week, the information about the definition and classification of pressure ulcers the prone areas to pressure ulcer were provided. In the third and fourth weeks, there was training on predisposing factors and pressure ulcer prevention methods, focusing on ICUs. The educational content was presented in the form of short text, audio, animation, images and video. One month after the completion of the training, the knowledge, attitude and practice questionnaires were completed for the nurses again. 
To describe the collected data, descriptive statistics were used. Paired t-test was used to compare the knowledge, attitude and practice of nurses. SPSS software, Version 22 was used to analyze the data. The significance level was set at 0.05.

Results
The mean score of knowledge was 64.47±10.61 before the intervention and 70.47±10.48 after the intervention. Based on the results of paired t-test, this difference was significant (P<0.001). Before the intervention, 61.6% of the nurses had positive attitudes, while after the intervention, 56.2% of the nurses had a positive attitude. The results of paired t-test showed no statistically significant difference in the attitudes before and after the intervention (P=0.526). Before the intervention, the practice of 78.1% of the nurses was poor. After the intervention, 65.8% had poor practice and 34.2% had good practice. The results of paired t-test indicated no statistically significant difference before and after training (P=0.493). 

Conclusion
Online pressure ulcer prevention training can increase the knowledge of pressure ulcer prevention among ICU nurses. However, it causes no significant change in the attitude and practice of nurses towards the prevention of pressure ulcers. Therefore, it is recommended to use face-to-face training to improve the attitude and practice of ICU nurses towards pressure ulcer prevention. 

Ethical Considerations
Compliance with ethical guidelines
Ethical approval was obtained from the ethics committee of Iran University of Medical Sciences (Code: IR.IUMS.REC.1399.1421). Informed consent was obtained from all participants, after explaining the study objectives to them and protecting their confidentiality.

Funding
This article was extracted from the master’s thesis of Fezeh Khalili Bagheri, at the Faculty of Nursing & Midwifery, Iran University of Medical Sciences. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions
Conceptualization and supervision: Mehri Bozorgnejad; Methodology: Mehri Bozorgnejad and Tahera Najafi; Data analysis: Hamid Haghani and Fezeh Khalili Bagheri; Data collection: Fezeh Khalili Bagheri; Data analysis: Hamid Haghani ; Review, writing, and review and editing: All authors. 

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank the personnel of Hazrat-e Rasool Akram and Firouzgar Hospital. 

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