An-Najah National University 

Faculty of Graduate Studies 

 
 

THE EFFECTIVENESS OF USING THE 

EDUCATION PROGRAM ON INTENSIVE 

CARE NURSES’ KNOWLEDGE TO PREVENT 

MEDICAL DEVICE-RELATED PRESSURE 

INJURIES (MDRPIS) 

 
 

 

By 

Suhaila Kharoosheh 

 

Supervisor 

Dr. Aidah Alkaissi 

 

 

 

 

This Thesis is submitted in Partial Fulfillment of the Requirements for the Master's 

Degree in Critical Care Nursing, Faculty of Graduate Studies, An-Najah National 

University, Nablus, Palestine. 
 

2025 



II 

 

 

 

 

 

 

 
 

 

 

 

 

 

THE EFFECTIVENESS OF USING THE 

EDUCATION PROGRAM ON INTENSIVE 

CARE NURSES’ KNOWLEDGE TO PREVENT 

MEDICAL DEVICE-RELATED PRESSURE 

INJURIES (MDRPIS) 

 
By 

Suhaila Kharoosheh 

 

This Thesis was Defended Successfully on 30/6/2025 and approved by 

Dr. Aidah Alkaissi 
Supervisor 

 

Signature 

Dr. Abdallah alwawi 

External Examiner 

 

Signature 

Dr. Nizar Said  

Internal Examiner 

 

Signature 



III 

 

Dedication 

I dedicate this work to those who have directly and visibly influenced my path. My 

achievement has been built on the foundation of my family‘s steadfast love and sacrifice; 

your support has always given me strength. Thank you for everything, parents whose 

sacrifice allowed me to bypass and achieve everything and whose faith in me never 

faltered. To my supervisor, whose practical mentoring and perceptive criticism have 

made my work easier and more real. To my instructors, whose commitment to 

instruction and direction has moulded my academic journey. Lastly, I would like to 

express my sincere gratitude to everyone who has aided my academic and personal 

development. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



IV 

 

Acknowledgement 

My sincere gratitude goes out to everyone who has helped me along the way in my 

academic career and helped me finish this task.  

First and foremost, I want to express my gratitude to my supervisor, Dr. Aidah Alkaissi, 

for her tremendous assistance, continual support and expert advice during this project. 

Her expertise and perceptions have greatly influenced the course of this study. 

My instructors and the academic staff at An-Najah National University have my sincere 

gratitude for their unwavering support and for creating a stimulating learning 

atmosphere that encouraged my intellectual development. 

Special thanks to my family, whose love, patience, and unwavering support have been 

the foundation of my success. To my parents, thank you for your endless sacrifices and 

belief in me, which has made all of this possible. 

I would like to thank all the nurses who agreed to participate in the study and the 

administrators of the institutions for permission to conduct the research. 

Finally, I would like to thank my friends and colleagues for their help, encouragement, 

and understanding during this journey. Your friendship and support have been 

invaluable to me. 

This work would not have been possible without all of your contributions. Thank you to 

everyone who played a role in this achievement. 

 

 

 

 

 

 

 



V 

 

Declaration 
 

I, the undersigned, declare that I submitted the thesis entitled: 

THE EFFECTIVENESS OF USING THE EDUCATION PROGRAM ON 

INTENSIVE CARE NURSES’ KNOWLEDGE TO PREVENT MEDICAL 

DEVICE-RELATED PRESSURE INJURIES (MDRPIS) 
 
 

I declare that the work provided in this thesis, unless otherwise referenced, is the 

researcher‘s own work, and has not been submitted elsewhere for any other degree or 

qualification. 

 

_____________________________________ Student's Name:  

_____________________________________ Signature: 

_____________________________________ Date: 

 

 

 

 

 

 

 

 

 

  



VI 

 

List of Contents 

 

Dedication ....................................................................................................................... III 

Acknowledgement .......................................................................................................... IV 

Declaration ....................................................................................................................... V 

List of Contents ............................................................................................................... VI 

List of Tables ............................................................................................................... VIII 

List of Figures ................................................................................................................. IX 

List of Appendices ........................................................................................................... X 

Abstract .......................................................................................................................... XII 

Chapter One: Introduction ................................................................................................ 1 

1.1 Background ................................................................................................................. 1 

1.2 Problem Statement ...................................................................................................... 4 

1.3 Significance of the study ............................................................................................. 4 

1.4 Statement of Purpose .................................................................................................. 5 

1.5 Objectives ................................................................................................................... 5 

1.6 Research Question ...................................................................................................... 6 

1.7 Hypotheses .................................................................................................................. 6 

1.8 Literature Review ....................................................................................................... 7 

1.8.1 Introduction of Literature Review ........................................................................... 7 

1.8.2 Review of relevant literature .................................................................................... 7 

1.8.3 Summary of the Literature Review ........................................................................ 16 

1.9 Conceptual definitions .............................................................................................. 16 

1.10 Operational definitions ........................................................................................... 16 

1.11 Framework .............................................................................................................. 16 

1.11.1 Theoretical Framework ........................................................................................ 16 

1.11.2 Structure ............................................................................................................... 17 

1.11.3 Process ................................................................................................................. 17 

1.11.4 Outcome ............................................................................................................... 17 

1.11.5 Conceptual framework ......................................................................................... 17 

Chapter Two: Method ..................................................................................................... 19 

2.1 Introduction ............................................................................................................... 19 

2.2 Description of research design: ................................................................................. 19 

2.3 Identification of the population and sample ............................................................. 20 

2.3.1 Population .............................................................................................................. 20 

2.3.2 Sample size ............................................................................................................ 20 



VII 

 

2.3.3 Sampling Criteria (Eligibility Criteria) .................................................................. 20 

2.3.4 Sampling method ................................................................................................... 21 

2.4 Setting ....................................................................................................................... 21 

2.5 Measurement Method ............................................................................................... 21 

2.6 Presentation of ethical consideration: ....................................................................... 27 

2.7 Data Collection ......................................................................................................... 27 

2.8 Data Analysis Plan: ................................................................................................... 32 

Chapter Three: Result ..................................................................................................... 34 

3.1 Introduction ............................................................................................................... 34 

3.2 Data Analysis ............................................................................................................ 34 

3.3 Statistical Methods .................................................................................................... 34 

3.4 Validity and Reliability of the Questionnaire ........................................................... 35 

3.5 Normality Test of the Study Variables ..................................................................... 35 

3.6 Population and Sample ............................................................................................. 36 

3.7 Research Questions: .................................................................................................. 42 

3.4 Study Hypotheses ..................................................................................................... 49 

3.5 Summary of the Results ............................................................................................ 53 

Chapter Four: Discussion and Conclusion ...................................................................... 58 

4.1 Introduction ............................................................................................................... 58 

4.2 Discussion ................................................................................................................. 58 

4.2.1 Sociodemographic Characteristics ......................................................................... 59 

4.2.2 Professional Qualifications and Training .............................................................. 60 

4.2.3 Knowledge regarding MDRPIs ............................................................................. 60 

4.3 Limitation .................................................................................................................. 62 

4.4 Conclusion ................................................................................................................ 62 

4.5 Recommendation ...................................................................................................... 63 

List of Abbreviations ...................................................................................................... 65 

References ....................................................................................................................... 67 

Appendices ...................................................................................................................... 73 

 ة‌ .............................................................................................................................. اٌٍّخص

 

 

 

  



VIII 

 

List of Tables 

 

Table 1: Frequencies and percentages of the nurses‘ answers regarding MDRPIs 

Knowledge items. ........................................................................................... 43 

Table 2: Frequencies and percentages of the nurses‘ answers toward Risk Factors items

 ........................................................................................................................ 44 

Table 3: Frequencies and percentages of the nurses‘ answers toward staging items ..... 45 

Table 4: Frequencies and percentages of the nurses‘ answers toward Prevention and 

Treatment items .............................................................................................. 47 

Table 5: Means and standard deviations of the total nurses‘ pre- and post-educational 

program knowledge ........................................................................................ 48 

Table 6: Means, standard deviations, and the results of paired samples T-test of the 

differences in the nurses‘ knowledge pre and post-educational program ...... 49 

Table 7: Means, standard deviations, and the results of paired samples T-test of the 

differences in the nurses‘ knowledge regarding risk factors pre- and post-

educational program ....................................................................................... 50 

Table 8: Means, standard deviations, and the results of paired samples T-test of the 

differences in the nurses‘ staging-related knowledge pre and post-educational 

program .......................................................................................................... 50 

Table 9: Means, standard deviations, and the results of paired samples T-test of the 

differences in the nurses‘ prevention and treatment knowledge pre and post-

educational program ....................................................................................... 51 

Table 10: Means, standard deviations, and the results of paired samples T-test of the 

differences in the total nurses‘ knowledge pre and post-educational program

 ........................................................................................................................ 52 

 

 

 

 

  



IX 

 

List of Figures 

 

Figure 1: Conceptual map ............................................................................................... 18 

Figure 2: Have you ever received training on medical device-related pressure     injuries?

 ........................................................................................................................ 38 

Figure 3: Information Sources about MDRPIs ............................................................... 38 

Figure 4: Was the training on MDRPIs helpful? ............................................................ 39 

Figure 5: Frequency of Encountering a Patient with MDRPIs ....................................... 39 

Figure 6: Information Sources about the Prevention/Treatment of MDRPIs ................. 40 

Figure 7: Do you think that prevention/treatment of MDRPIs should be assumed by 

nurses? ............................................................................................................ 40 

Figure 8: Is it possible to prevent MDRPIs with good nursing care? ............................. 41 

Figure 9: Are your nursing practices for the prevention/treatment of MDRPIs sufficient?

 ........................................................................................................................ 41 

Figure 10: Is a nursing care protocol necessary for the prevention of MDRPIs? ........... 42 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



X 

 

List of Appendices 

 

Appendix A:‌Tables of Study ......................................................................................... 73 

Table A1:‌Matrix Chart/Table‌for Studies Regarding MDRPIs ..................................... 73 

Table A2:‌Examples of Donabedian Model Components .............................................. 79 

Table A3:‌Symbolic Representation of Study Design .................................................... 79 

Table A4:‌MDRPI-KQ Dimensions and Item Distribution ............................................ 79 

Table A5:‌Scoring Assessment Levels Based on Correct Answer Percentages (Sönmez 

& Bahar, 2022) ............................................................................................. 79 

Table A6:‌Test of Normality and the Skewness coefficients .......................................... 80 

Table A7:‌Socio-demographic Characteristics (N=74) .................................................. 81 

Table A8:‌Professional Qualifications and Training (N=74) .......................................... 82 

Table A9:‌Means, standard deviations, and the results of T or ANOVA tests of the 

differences in the means of the total nurses‘ knowledge post-educational 

program according to the demographic variables ........................................ 83 

Table A10:‌Tukey Post-hoc Pairwise Comparisons ....................................................... 84 

Appendix B:‌Figures of Study ........................................................................................ 85 

Figure B1:‌Age Group Distribution via Pie Chart .......................................................... 85 

Figure B2: Gender Group Distribution via Pie Chart ..................................................... 85 

Figure B3: Martial status Distribution via Pie Chart ...................................................... 86 

Figure B4: Years of experience Distribution via Pie Chart ............................................ 86 

Figure B5: Graduated nursing program Distribution via Pie Chart ................................ 87 

Figure B6: Department Distribution via Pie Chart ......................................................... 87 

Figure B7: Position Distribution via Pie Chart ............................................................... 88 

Figure B8: Do you think you have sufficient information about MDRPIs? ................... 88 

Appendix C: Questionnaire ............................................................................................ 89 

Appendix D: Request for Permission to Use Questionnaire ........................................... 96 

Appendix E: Consent Form for Participation in Research ............................................. 97 

Appendix F: Education program ................................................................................... 101 

Appendix G: Concise Guidelines: MDRPI-Prevention ................................................ 102 

Appendix H: Poster Evidence-based practice MDRPIs prevention ............................. 103 

Appendix I: Thesis Title and Supervisor Approval Form ............................................ 104 

Appendix J: IRP Approval letter at An-Najah National University ............................. 105 



XI 

 

Appendix K: Official Cover letter from your Institution: (cover letter directed from your 

dean/head to the medical director of NNUH requesting permission to collect 

data ............................................................................................................. 106 

Appendix L: Approval to conduct a research project at An-Najah National University 

Hospital (NNUH) ....................................................................................... 107 

Appendix M: Educational Program Invitation Samples ............................................... 108 

Appendix N: QR code regarding to consent form ........................................................ 110 

Appendix O: Educational Program Participation Details and Participant Anonymization 

Process ....................................................................................................... 111 

Appendix P: The Questionnaire (pre-test) QR ............................................................. 112 

Appendix Q: The Questionnaire (post- test) QR .......................................................... 113 

 

 

 
  



XII 

 

 

THE EFFECTIVENESS OF USING THE EDUCATION PROGRAM ON 

INTENSIVE CARE NURSES’ KNOWLEDGE TO PREVENT MEDICAL 

DEVICE-RELATED PRESSURE INJURIES (MDRPIS). 
 

By 

Suhaila Kharoosheh 

Supervisor 

Dr. Aidah Alkaissi 

 

Abstract 

Background: Using devices intended for diagnostic or therapeutic purposes can lead to 

pressure injuries related to medical devices. In most cases, the pressure injury that 

results fits the device's shape or pattern.  

Aim: The purpose of the study is to assess how well the educational program has 

improved the knowledge of intensive care nurses about preventing medical device-

related pressure injuries (MDRPIs).  

Design: A quasi-experimental research design. 

Setting: The study was carried out in a number of An-Najah National University 

Hospital's (NNUH) intensive care units (ICUs) in Nablus, Palestine. 

Subjects: A total of 74 ICU nurses take part in the study.  

Instruments: Data were gathered using two main instruments: 1. The Nursing form 

was utilized to acquire professional and demographic data. A self-report survey called 

the Medical Device-Related Pressure Injures Knowledge Questionnaire (MDRPI-KQ) 

evaluated nurses‘ knowledge and comprehension of MDRPI and various common 

measures to prevent it from occurring.  

Results: The nurses‘ knowledge improved significantly from 68.2% pre-intervention to 

94.9% post-intervention across all subdomains (p < 0.05). Indicating a statistically 

significant improvement across all knowledge domains, which include knowledge, risk 

factors, staging, prevention, and treatment.  



XIII 

 

Conclusion: It was demonstrated that the MDRPI prevention and management training 

program was a successful instrument for raising nurses' awareness and knowledge of the 

problem while also equipping them with current, evidence-based techniques and 

expertise.  

Recommendation: Institutions should adopt ongoing educational programs, establish 

MDRPI-specific clinical protocols, and promote evidence-based training for ICU staff. 

Keywords: Education Program; Intensive Care Nurses‘ Knowledge; Medical Device-

Related Pressure Injuries (MDRPIs); Pressure Injury Prevention. 

 

 
 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



1 

 

Chapter One 

Introduction 

1.1 Background  

In intensive care units, medical devices are used to treat or diagnose patients who are 

very sick. These devices, however, have the potential to harm their users by exerting 

pressure on any part of the body for an extended period (Barakat-Johnson et al., 2019). 

Foley catheters, nasogastric tubes (NGT), endotracheal tubes (ETT), oxygen masks, and 

other medical devices are examples of devices that can result in pressure injuries 

(Sönmez & Bahar, 2022). Conventional pressure injuries, often caused by prolonged 

immobilization over bony prominences, differ significantly from medical device-related 

pressure injuries (MDRPIs), which result from localized pressure exerted by external 

medical equipment. MDRPIs are typically characterized by the distinct shape or pattern 

of the device, often occurring beneath or adjacent to the device itself, and may involve 

areas with little subcutaneous tissue or mucosal surfaces. It usually takes the shape 

of the medical equipment and appears beneath or around it, mirroring the shape of 

the device. The lack or decrease of adipose tissue in the ulceration sites can cause these 

pressure injuries to develop into full-thickness ulcers (Pittman & Gillespie, 2020).Based 

on the World Health Organization (WHO) estimation, a sizable percentage of avoidable 

injuries in hospitalized patients worldwide is caused by pressure injuries, including 

MDRPIs (Brophy et al., 2021). These injuries are common in intensive care units 

(ICUs). Studies show that 60–90% of patients rely on medical devices (Celik et al., 

2023). It places additional strain on already overburdened healthcare systems, 

compromising patient outcomes and increasing healthcare expenses by 20–25% (Gefen 

et al., 2020). 

The expenditure of treating a single pressure level injury is estimation to be around 

$75,000, which is a startling amount that highlights the significance of preventative 

measures (Dallı et al., 2022). Sadly, a recent report indicated that 74% of MDRPIs were 

not detected until they had advanced to Stage III, Stage IV, or were unstageable, even 

though they are preventable. This suggests that early identification and treatments were 

lacking (Gefen et al., 2020). Additionally, 63% of cases were not properly documented, 

indicating clinical practice gaps that impede efficient therapy and prevention (Sönmez 

& Bahar, 2022). 



2 

 

With significant incidence rates shown throughout the Middle East, MDRPIs are a 

growing regional concern. Medical equipment was implicated in 38.1% of pressure 

injuries in Jordan (Najjar et al., 2022). Endotracheal tubes and Foley catheters 

accounted for 37% of MDRPIs in Saudi Arabia, with traction equipment (1.6%), 

nasogastric tubes (9.4%), and neck collars (12.5%) following closely behind (Schroeder 

& Sitzer, 2019). In Egypt, the rate of MDRPIs linked to nasogastric tubes (NGT) was 

77.8%, while the rate linked to endotracheal tubes (ETT) was a startling 90% (Zakaria 

et al., 2018). 

Moreover, patients in critical condition are more vulnerable to experiencing MDRPI for 

a variety of reasons. Long-term use of devices such as nasogastric tubes, endotracheal 

tubes, and Foley catheters can put pressure on the skin and underlying tissues. It causes 

tissue ischemia and damage. Patient factors that increase risk include severe nerve 

damage, being unable to move, poor nutrition, critical illness, sedating medications, and 

reduced blood flow to tissues (Barakat-Johnson et al., 2019). 

Medical devices create pressure, heat, and moisture that can affect the skin around them. 

These devices often need tight attachment to work properly, which can put pressure on 

unexpected areas, including over bones. It can also be difficult to monitor under devices 

because of the straps or tape used to hold them in place. Certain device features increase 

the risk of medical device-related pressure injuries (MDRPIs), such as constant pressure 

from hard materials, skin changes from heat and moisture, and poor fit (Gefen et al., 

2020). MDRPIs can cause serious problems. These are known as tissue death, local 

infections, slow wound healing, and body-wide infections like sepsis. These 

complications make patients suffer more and increase medical costs by making hospital 

stays longer, increasing readmissions, and requiring more treatments. To address these 

problems, hospitals need a prevention-focused approach that emphasizes early action 

(Gefen et al., 2020). 

Preventing pressure injuries from medical devices is a unique challenge for ICU nurses. 

Nurses should be able to check the skin under and around medical devices, recognize 

the stages of pressure injury, and secure devices properly to prevent them from moving, 

and put on and remove devices according to the manufacturer's instructions             

(Galetto et al., 2021). 



3 

 

MDRPIs often receive insufficient clinical attention despite their serious impact. 

Research shows that healthcare providers have poor awareness and understanding of 

MDRPIs. Several factors cause this gap, including a lack of clear risk assessment and 

management guidelines, poor integration of prevention methods into nursing and 

medical education, and limited training on these strategies. The problem deteriorates 

because of inconsistent documentation practices and a lack of research on device-

specific risks (Erzincanlı et al., 2024; Kurtgöz et al., 2024; Najjar et al., 2022; Sönmez 

& Bahar, 2022). 

Complete educational programs are essential for giving nurses the knowledge to prevent 

MDRPIs. Focused training programs have been shown to greatly improve nurses' 

understanding of risk factors, early identification, and evidence-based prevention 

techniques. For example, practical workshops, simulation-based learning, and ongoing 

education on risk assessment tools have successfully reduced MDRPI rates. These 

programs also encourage following best practices, including regular skin checks, proper 

device selection, and repositioning procedures, which helps create a culture of patient 

safety (Çakar & Karadağ, 2024; Sayed et al., 2022; Sönmez & Bahar, 2022). 

Healthcare systems can reduce MDRPI rates and effects by focusing on complete 

educational programs, investing in advanced prevention methods, and encouraging 

cooperation between countries and regions. Collaborative work can ensure better patient 

care and outcomes, as well as greatly reduce the financial burden on healthcare systems 

worldwide. In addition to being a therapeutic necessity, addressing MDRPIs is also a 

moral and ethical obligation to protect each patient's well-being (Dallı & Girgin, 2024; 

Sayed et al., 2022).  

Finally, a variety of teaching and learning techniques are coordinated, and activities are 

meticulously designed in the educational program developed for this study.  The goal is 

to improve nurses' understanding of pressure injuries from medical devices by giving 

them complete knowledge and current information. Following these priorities, this 

study aims to find out how well an educational program works in improving ICU 

nurses' knowledge about preventing MDRPIs. 

 



4 

 

1.2 Problem Statement 

In modern healthcare, MDRPIs are a major global problem that is often overlooked, 

especially in intensive care units (ICUs), where patients depend heavily on life-saving 

medical equipment (Barakat-Johnson et al., 2019). These injuries happen from constant 

pressure from devices like Foley catheters, breathing tubes, and feeding tubes. They are 

complex and can cause serious problems if not managed properly. Starting as local skin 

injuries, these can get worse over time, causing pain, visible scarring, and infections like 

sepsis. They may also lead to reduced quality of life, changes in body image, and 

permanent hair loss. Also, MDRPIs are associated with prolonged hospitalization and 

increased healthcare utilization 

Higher use of resources, and major effects on the patient's body image and self-esteem, 

often requiring expensive cosmetic procedures (Barakat-Johnson et al., 2019; Gefen et 

al., 2020). MDRPIs also harm patient quality of life and stress healthcare systems by 

increasing readmission rates, making hospital stays longer, and raising healthcare costs 

(Gefen et al., 2020). Even though MDRPIs are common and serious, the topic remains 

underexplored in the current literature , especially in areas like Palestine (Omar et al., 

2024). Research shows that nurses do not understand these injuries well enough, leading 

to poor prevention actions and putting patients at risk for complications (Gefen et al., 

2020; Sönmez & Bahar, 2022). 

Globally, MDRPIs affect more than one-third of patients (Sönmez & Bahar, 2022). 

Research consistently shows information gaps, poor risk assessment practices, and a 

lack of standard prevention guidelines. Different documentation standards and a lack of 

research on device-specific risks make these problems worse. This knowledge gap 

prevents effective prevention and management of MDRPIs, especially in high-risk 

settings like intensive care units (ICUs), where 60–90% of patients use medical devices, 

making them very vulnerable (Celik et al., 2023). Regional studies, especially in the 

Middle East, show concerns about MDRPI rates with specific devices. This highlights 

the urgent need for prevention measures and focused educational programs (Najjar et al., 

2022; Schroeder & Sitzer, 2019; Zakaria et al., 2018). 

 



5 

 

ICU nurses are essential in solving this problem because they are at the forefront of 

patient care and device management. Improving their knowledge and skills through 

evidence-based educational programs is key to reducing MDRPI occurrence, 

minimizing complications, and improving patient outcomes (Çakar & Karadağ, 2024). 

This research aims to address these challenges by evaluating how well a complete 

educational program works to give ICU nurses the necessary skills to prevent MDRPIs. 

The research seeks to decrease MDRPI rates and effects and improve patient care. It 

also aims to reduce the financial burden on healthcare systems by raising awareness, 

encouraging best practices, and implementing focused training programs. 

1.3  Significance of the study 

Based on clinical observations at An-Najah University Hospital, pressure injuries 

caused by medical devices are a major problem for critically ill patients. MDRPIs 

remain insufficiently addressed in clinical practice, as highlighted by direct observations 

and reports from frontline practitioners. Pre-existing conditions connected to pressure 

injuries can exacerbate the patient‘s health and negatively impact their outcomes. 

According to a prior study, 70% of medical device-related pressure injuries in the 

intensive care unit were caused by medical equipment, and almost one-third of patients 

suffer from such injuries (Sönmez & Bahar, 2022). To reduce these problems, nurses' 

education programs on medical device preventative measures related to pressure injuries 

are crucial (Sönmez & Bahar, 2022).  

1.4 Statement of Purpose 

The purpose of this study is to evaluate the effectiveness of a structured educational 

program in enhancing intensive care nurses‘ knowledge related to the prevention and 

management of medical device-related pressure injuries (MDRPIs) in the Palestinian 

healthcare context. 

1.5 Objectives  

1. To evaluate ICU nurses‘ baseline knowledge of MDRPIs before and after the 

implementation of the educational program. 

2. To assess the impact of the educational program on nurses' knowledge about the 

prevention and management of MDRPIs. 



6 

 

3. To determine whether demographic variables (e.g., age, professional experience, 

educational level, and prior training) significantly influence post-intervention 

knowledge scores 

1.6 Research Question  

1. What are the levels of nurses‘ knowledge regarding MDRPIs pre- and post-

educational programs? 

2. What are the levels of nurses‘ knowledge domains about risk factors connected to 

MDRPIs pre- and post-educational program? 

3. What are the nurses‘ staging-related knowledge levels regarding MDRPIs pre- and 

post-educational programs? 

4. What are the levels of nurses‘ prevention and treatment knowledge about MDRPIs 

pre- and post-the educational program? 

5. What are the total nurses‘ knowledge levels regarding MDRPIs pre- and post-the 

educational program? 

1.7 Hypotheses 

Null hypothesis (H0):  

1. There is no statistically significant impact of the implementation of the educational 

program on improving nurses' knowledge regarding MDRPIs at the level of 

significance (α) ≤ 0.05. 

2. There is no statistically significant influence of the implementation of the 

educational program on improving nurses' knowledge about risk factors related to 

MDRPIs at the level of significance (α) ≤ 0.05. 

3. There is no statistically significant impact of the implementation of the educational 

program on improving nurses' staging-related knowledge about MDRPIs at the 

degree of significance (α) ≤ 0.05 



7 

 

4. There is no statistically significant impact of the implementation of the educational 

program on improving nurses' prevention and treatment knowledge regarding 

MDRPIs at the level of significance (α) ≤ 0.05 

5. There is no statistically significant impact of the implementation of the educational 

program on improving the total nurses' knowledge about MDRPIs at the level of 

significance (α) ≤ 0.05. 

6. There are no statistically significant differences at the 0.05 level in the total level of 

nurses' knowledge regarding MDRPIs in the educational program according to 

demographic characteristics (Gender, Marital Status, work experience, Graduation 

from a Nursing Program, Department, Position, and Training). 

1.8 Literature Review 

1.8.1 Introduction of Literature Review 

The knowledge, attitudes, and preventative strategies of intensive care unit (ICU) nurses 

about MDRPIs are examined in this review of the literature.  It examines the frequency, 

severity, and characteristics of MDRPIs in adult intensive care unit patients, as well as 

the variables influencing ICU nurses' awareness, perspectives, and actions regarding 

MDRPI prevention. Additionally, the review assesses the impact of implementing 

educational programs on preventive nursing measures for MDRPIs, focusing on their 

effects on nurses' performance. 

Search Engines: PubMed, Google Scholar, Cochrane, & Science Direct. 

Keywords: MDRPIs, Continuous Education Program (CEP), Nurses' Competencies, 

Nurses' Performance, Pressure Injury Prevention, Intensive Care Unit (ICU), Nursing 

Education, Knowledge Enhancement, Patient Outcomes & Healthcare Quality 

Improvement. 

Research method: A systematic approach was used to find relevant studies for this 

study. Keywords were used to search different academic databases for articles related to 

the research topic. Abstracts of the found articles were reviewed to check if they were 

relevant to the study. Relevant studies were saved or linked to a Word document for 

further review. Each selected article was carefully evaluated for how useful it could be 



8 

 

in addressing the research aims. After thorough reading and analysis, the insights and 

findings from these articles were included in the study framework as needed. 

1.8.2 Review of relevant literature 

 An Overview of Pressure Injuries (PIs) and MDRPIs: Definitions and Key 

Differences: 

Pressure injuries (PIs) occur when force is applied to the skin's surface over bony areas. 

The National Pressure Injury Advisory Panel states that pressure injuries can develop 

under medical devices anywhere on the body, and the damage can replicate the device's 

shape or pattern (Kottner et al., 2019). This force can include friction, shearing between 

the skin and another surface, or continuous pressure on the skin. MDRPIs are a type of 

pressure injury defined as localized damage to the skin and underlying tissue, including 

mucous membranes, caused by pressure from an external medical device at the injury 

site. MDRPIs replicate the device's shape (Edsberg et al., 2016;  2016; Pittman & 

Gillespie, 2020). Unlike regular pressure injuries, MDRPIs do not usually occur over 

bony areas. They commonly happen in places that are not easily visible or have little 

soft tissue, such as the bridge of the nose, ears, face, trunk, crotch, underarms, or wrists 

where medical equipment is used (Gefen et al., 2020). Medical devices that touch or go 

through a patient's skin can greatly increase MDRPI risk. Common devices linked to 

MDRPIs include respiratory equipment (oxygen tubing, nasal cannulas, face masks for 

non-invasive positive pressure ventilation), cervical collars, nasogastric tubes, 

endotracheal tubes with tube holders, vascular access devices for intravenous drug or 

fluid administration, splints, casts, and urinary catheters for bladder drainage (Duerst et 

al., 2022; Saleh & Ibrahim, 2023). 

 Statistics and Risk Factors of MDRPIs 

The substantial impact of MDRPIs on patient care is demonstrated by the fact that they 

make up almost one-third of every hospitalized pressure injury setting                    

(Gefen et al., 2020). 

 

 

 



9 

 

 Occurrence by Setting 

A recent systematic review of MDRPIs in intensive care units (ICU) showed incidence 

rates from 0.9% to 41.2% and prevalence rates from 1.4% to 121%. This compares to 

0.4% in general wards. The higher rates in ICUs are likely because more devices are 

used in ICU settings than in general wards. 

 Occurrence by Anatomical Location 

According to Gefen et al. (2020), the most common sites for MDRPIs are the face, ears, 

sacrum/coccyx, heels, and buttocks. This shows the importance of targeted prevention 

actions in these high-risk areas. 

 Occurrence by Type of Device 

Up to 68% of MDRPIs are related to respiratory equipment. Of these, 20% are linked to 

continuous positive airway pressure (CPAP) and bilevel positive airway pressure 

(BiPAP) devices. According to Gefen et al. (2020), these injuries often appear as ulcers 

on the nasolabial fold or nose bridge. 

 Neonates, Infants, and Pediatric Patients 

Neonates, babies, and pediatric patients are at particular risk due to their advanced 

metabolic rates and physiological swelling, which are common in critically ill children. 

MDRPI rates in pediatric populations may reach 28%. Non-invasive mechanical 

ventilation systems play a major role in causing injuries, with a relative risk ratio of 

12:24 (Gefen et al., 2020). 

 Cost of MDRPIs 

MDRPIs create huge financial problems that get worse as people age and more develop 

diabetes. In the US alone, pressure ulcers from hospitals cost $26.8 billion every year. 

England's NHS spent over £530 million on pressure ulcers in just one year (May 2012 

to April 2013) (Gefen et al., 2020). 

 Classification and Early Detection of MDRPIs 

MDRPIs can be categorized using the standard Pressure Injury (PI) system (Edsberg et 

al., 2016). These wounds often turn into deep ulcers, especially in areas with little fat 

tissue (Kayser et al., 2018). Most MDRPIs show up as Stage 1 injuries (54.1%) or Stage 

2 injuries (15.3%) (Dang et al., 2022). About 28% of patients develop MDRPIs within 3 



10 

 

to 5 days of using medical devices (Celik et al., 2023). This means nurses need to watch 

for these injuries early and prevent them. 

 Recent Studies and Findings on MDRPIs: Incidence, Risk Factors, Prevention, 

and Nursing Knowledge 

MDRPIs can be categorized using the established Pressure Injury (PI) stage method 

(Edsberg et al., 2016). These lesions often progress to full-thickness ulcers, especially in 

areas with little or no adipose tissue (Kayser et al., 2018). Dang et al. (2022) report that 

Stage 1 injuries (54.1%, 53/98) and Stage 2 injuries (15.3%, 15/98) are the most 

common manifestations of MDRPIs. Within three to five days of employing medical 

devices, MDRPIs are found in about 28% of patients (Celik et al., 2023). These results 

underscore the vital need for early detection and stringent preventive measures to halt 

the progression of these injuries. 

The purpose of this cross-sectional study was to determine the factors influencing 

critical care nurses' understanding of MDRPIs and to assess their level of familiarity 

with them. The study, which involved a convenience sample of 71 nurses who 

completed the MDRPIs Knowledge Questionnaire in 2024, was conducted at a large 

medical facility in Palestine. The findings highlight that inadequate knowledge of 

MDRPIs can negatively impact patient care. Therefore, developing targeted training 

programs and policies based on nurses' knowledge and practices is essential to 

effectively enhance prevention and administration strategies. 

A cross-sectional study conducted between October 2018 and March 2019 examined the 

prevalence of MDRPI and its risk factors among 694 patients in 66 adult intensive care 

units (ICUs) at 30 hospitals in China. The National Pressure Ulcer Advisory Panel's 

definitions were used to stage each MDRPI. The study followed STROBE guidelines. 

Results showed that the prevalence of MDRPI remained high. To reduce MDRPI rates, 

nurses should consider these risk factors when caring for ICU patients and implement 

appropriate prevention measures. A separate prospective observational study 

investigated the development, characteristics, and risk factors of MDRPIs in ICUs. 

MDRPI occurred in 27.2% of patients, with the majority developing in the mouth and 

nose areas, according to the survey, which comprised 302 individuals who were 

admitted to the hospital within a year. The STROBE Declaration was followed in the 



11 

 

reporting of the study. The majority of orthopedic devices, fasteners, and non-invasive 

ventilation and oxygen masks drove the development. Hospitalization days in the 

intensive care unit and the quantity of medical devices utilized were significant 

determining risk factors, accounting for 28.3% of the variance in MDRPI development 

overall. The quality of nursing care is at risk due to the high rate of MDRPI 

development. 

Researchers in Ankara, Turkey, studied 355 nurses from December 2020 to March 2021 

to see how much they knew about MDRPIs. They used a basic information form and a 

knowledge questionnaire to collect the data. According to the findings, just 23.1% of 

nurses are generally aware of these injuries. The study discovered that nurses' mean 

scores on the MDRPIs Knowledge Questionnaire varied significantly depending on 

their gender, experience working in an intensive care unit, and prior training. The study 

concludes that nurses lack sufficient knowledge about these injuries and recommends 

regular training sessions to reduce the rate of these injuries and deliver high-quality care.  

To evaluate nursing students' attitudes and understanding of MDRPIs and the factors 

influencing them in Turkey, a descriptive and cross-sectional study was conducted. 

Between January and May 2024, 581 nursing students participated in the study. The 

Medical Device-Related Pressure Injury Attitude Questionnaire (MDRPI-AQ), the 

Medical Device-Related Pressure Injury Knowledge Assessment Test (MDRPI-KAT), 

and the Student Information Form were used to gather data. According to the survey, 

Turkish nurses have a 75.0% positive attitude regarding MDRPI prevention and care; 

however, 54.7% of them lack the appropriate expertise. Preventive nursing interventions, 

classification, and patient groups at risk are the areas that require the most excellent 

attention. Knowledge can be enhanced by clinical experience and training in these fields. 

More positive views about care practices and preventive measures are correlated with 

higher levels of expertise.  Strengthening training curricula, providing clinical 

experience, and implementing continuing education programs can improve knowledge 

and attitudes towards MDRPI management. 

In 2023, a quantitative cross-sectional study was conducted to investigate the 

relationship between factors affecting ICU nurses' knowledge, attitudes, and practices 

regarding MDRPIs and the prevalence of these injuries in critically ill patients. The 

Clinical Nurses' Knowledge, Attitude, and Practice Questionnaire for the Prevention of 



12 

 

MDRPI in Critically Ill Patients was administered to 322 intensive care unit nurses from 

Chinese tertiary institutions between January 1, 2022, and June 31, 2022. A 72% 

passing rate was found in the findings. A variety of characteristics, including years of 

employment, professional title, training, and educational background, influenced 

MDRPI's knowledge, attitude, and practice.  Professional titles, years of job experience, 

training, and a high level of education were found to be overlaid and synergistic. To 

increase ICU nurses' understanding of MDRPI and lower patient occurrence, the study 

recommends creating efficient scheduling systems and MDRPI training courses. 

A quasi-experimental study was conducted at the Tanta University Emergency 

Hospital's Surgical Intensive Care Unit in 2022. The purpose of this study was to 

evaluate the impact of an educational program on clinical outcomes for patients and 

nurses, with a focus on MDRPIs. Three instruments for gathering data were used:  

 Tool (I) collected nurses' demographic characteristics and assessed their knowledge 

about MDRPIs. 

 Tool (II) was an observational checklist used to evaluate nurses' practices. 

 Tool (III) assessed patients' clinical outcomes. 

Seventy nurses participated in the trial, and sixty critically sick adults were purposefully 

sampled and split into two groups of thirty each. The overall mean ratings of nurses' 

knowledge and practices significantly improved as soon as the program was 

implemented, according to the data. Over time, though, this improvement waned.  

The purpose of a pre-posttest intervention study was to evaluate the impact of training 

on MDRPI prevention on the knowledge, preventive performance, and point prevalence 

of intensive care unit nurses. ICU nurses participated in the study in three stages from 

May to July 2023: pre-training (E0) (104 nurses, 116 patients), training implementation 

(E), and post-training (E1) (89 nurses, 120 patients). The study consisted of three stages: 

pre-training, implementation, and post-training. A variety of methods were employed to 

gather data, including MDRPI follow-up, performance observation checklists, 

knowledge evaluation questionnaires, Braden Pressure Ulcer Risk Assessment scales, 

pressure injury grading, patient and nurse characteristics, and feedback forms.The 



13 

 

MDRPI knowledge levels significantly increased, especially in the staging and 

prevention themes, according to the results. 

Additionally, MDRPI preventive performance improved dramatically. The study found 

that MDRPI training improved preventive performance and knowledge, but further 

research with larger sample sizes is required. To reduce MDRPIs in ICUs, nurses need 

to get medical device sizing right, secure devices properly, check skin regularly, and use 

good prevention methods. 

Researchers in Saudi Arabia tested whether a prevention program called SKINCARE 

could reduce MDRPIs in critical care patients. They worked with 400 nurses across 

three ICUs from January to April 2020. The SKINCARE program included hygiene 

practices, repositioning patients, regular skin checks, and specific treatments to prevent 

MDRPIs - which are injuries caused by pressure from medical devices. The program 

worked. It significantly cut down on new MDRPIs by improving how nurses care for 

patients' skin. 

A previous systematic review study aimed to compile research on pressure injury 

prevention strategies related to medical devices for critically ill patients. The pressure 

injury incidence dropped from 8.1-96.7% prior to intervention to 0.3-53.3% following 

intervention in the twelve articles. Nurse education, evaluation, documentation, and 

treatments such as repositioning, cleanliness, and emergency therapy are examples of 

strategies. Hydrocolloid foam dressings and transparent hydrocolloid formulations were 

among the pressure injury dressings that successfully decreased incidence rates. 

Specialized techniques for various medical devices and pressure injury locations should 

be the primary focus of future research.  

A significant amount of research is being conducted to prevent MDRPI, as it is a 

prevalent issue. Nevertheless, there aren't many systematic reviews of techniques and 

solutions available. Interventions include clothing, full-face masks, hyperoxygenated 

fatty acids, training, multidisciplinary education, and the use of specific securement 

devices, according to a systematic analysis of 24 peer-reviewed publications. Six 

databases were searched, without regard to the year of publication, including Medline, 

CINAHL, EMBASE, Cochrane Library, Web of Science, and ProQuest. According to 

the study's findings, considerable effort has been invested in developing MDRPI 



14 

 

prevention techniques. Although a variety of devices have been reported, it is clear that 

further research is needed.  

Investigating the efficacy of therapies to avoid pressure damage in adults admitted to 

critical care units was the goal of a systematic review and meta-analysis of randomized 

controlled trials. In mid-2019, a systematic review and meta-analysis of 26 studies were 

carried out using five databases (CINAHL, MEDLINE, Scopus, Web of Science, and 

Embase) with an emphasis on pressure injury prevention treatments in acute hospital 

settings. According to the findings, pressure damage in people in critical care units 

could only be successfully avoided using preventative sacrum and heel dressings. All 

intervention types require further intensive care-specific studies, and future research 

should be conducted and published by relevant standards and recommendations to 

minimize bias. To reduce bias, the study emphasizes the need for further studies tailored 

to critical care.  

To determine the prevalence and risk factors for MDRPI, a cross-sectional study was 

conducted among adult patients (aged 18 years or older) admitted to an intensive care 

unit (ICU) at a Brazilian referral hospital between December 2019 and February 2020. 

Patients who agreed to participate had their skin examined for the presence of an 

MDRPI, and all medical instruments were used. From the medical records, additional 

independent variables were extracted, including sociodemographic characteristics, 

medical history, risk factors for pressure injuries, prescription drugs, and duration of 

hospitalization. According to this study, pressure injuries from medical devices were 

common in individuals between the ages of 15 and 97. Since the majority of these 

accidents were stage 1, regular monitoring and, when practical, device relocation may 

help avoid more serious injuries. Further studies involving other Brazilian institutions 

are needed to better understand the risk factors and prevalence of MDRPIs in patients in 

intensive care units.   

Finding the traits of MDRPI in Jordanian adult intensive care patients was the goal of 

another study. Due to a lack of comprehensive clinical examination, the true scope of 

MDRPIs—which are serious health issues among hospitalized patients—is 

underestimated. A total of 329 adult patients from three sizable teaching and referral 

centers participated in the study, and a screening questionnaire was used to collect data. 

MDRPI, which is defined as a pressure injury on the skin or mucous membrane caused 



15 

 

by a medical device in use, was the main result. Only 177 preventative and treatment 

interventions were given to 15 patients during two weeks, according to the study. The 

report suggests more research to monitor MDRPI prevention and treatment practices 

among patients in intensive care units.  

As part of a doctoral dissertation in nursing practice from the University of the Incarnate 

Word, a Quality Improvement Project was carried out in the intensive care unit (ICU) of 

Hospital X in the United States in 2021. In comparison to the national standard, the 

medical-surgical intensive care unit had a high proportion of hospital-acquired pressure 

injuries, which the initiative sought to remedy. 

 The project's main goal was to prevent hospital-acquired pressure injuries by 

collaborating with interdisciplinary team members to develop an evidence-based 

instructional suite. A simultaneous integumentary examination using a standardized 

scale and visual documenting of high-risk anatomy followed the instructional 

session, which was held in a special classroom. 

 Forty-three (90%) of the forty-eight nurses came to the educational suite and 

completed the evaluation. The project demonstrated the dedication of the personnel 

to raising the standard of care for the integumentary system. It is viewed as the 

beginning of numerous ongoing improvement processes. 

 To investigate the knowledge, attitudes, and prevention performance of intensive 

care unit (ICU) nurses regarding multidrug-resistant pathogens (MDRPs), a cross-

sectional survey was conducted in 2022 by the STROBE Guidelines. 

The research was conducted utilizing the MDRPI Knowledge Assessment 

Questionnaire. The results showed that nurses had an average knowledge score of 68.4% 

on MDRPIs, with the highest percentage of accurate response in skin evaluation 

(83.6%). The total score did not significantly correlate with specializations, age, or job 

experience, according to the study. On the other hand, master's degree holders and 

women scored higher. The results have the potential to enhance nursing policies and 

practices in acute care environments.  

 



16 

 

1.8.3 Summary of the Literature Review 

In conclusion, the reviewed literature emphasizes the high prevalence and significant 

impact of MDRPIs in critical care settings. Device type, anatomical location, and 

patient demographics influence MDRPI risk. The effectiveness of preventive bundles, 

targeted treatments, and educational programs in reducing the incidence of MDRPI is 

supported by evidence. To improve these tactics, ensure durability, and refine therapies 

for various clinical conditions, further research is still required. However, no 

interventional studies to date have assessed the effect of educational programs on ICU 

nurses‘ knowledge of MDRPI prevention in the Palestinian context 

Matrix Chart/Table‌for Studies Regarding MDRPIs (See the table in appendix A1) 

1.9 Conceptual definitions 

 The use of gadgets intended for medicinal or diagnostic purposes leads to MDRPIs. 

According to Edsberg et al. (2016), these injuries typically follow the shape or 

pattern of the device. 

 A device-related pressure injury occurs when an external medical device is utilized 

at the ulcer site, causing localized harm to the skin and/or underlying tissue, 

including mucous membranes. The device's shape is reflected in the injury    

(Pittman & Gillespie, 2020). 

1.10 Operational definitions 

 The MDRPI-KQ is a specialized tool developed to evaluate the knowledge levels of 

healthcare professionals regarding medical device‐related pressure injuries   

(Sönmez & Bahar, 2022). 

1.11 Framework 

1.11.1 Theoretical Framework 

This study uses the Donabedian model. It studies three key areas: structure, process, and 

outcome. It's a well-known way to measure healthcare quality. The model fits perfectly 

with what we're trying to do - see if an educational program actually improves how ICU 

nurses prevent MDRPIs. The structure covers things like resources and training. The 

process looks at what nurses actually do. Outcome measures whether patients get better 



17 

 

care. These three areas connect to each other. Understanding how they work together 

helps improve healthcare (Ghofrani et al., 2024). So, if we train nurses better (structure), 

they should use better prevention methods (process), which should mean fewer pressure 

injuries (outcome). 

1.11.2 Structure 

Structure means having the right setup to run the educational program. This includes 

enough qualified nurses, hospital policies that support patient safety, and resources for 

continuing education; without a supportive hospital environment, even the best training 

will not work. Nurses need backup from their institution to actually use what they learn 

about preventing MDRPIs. 

1.11.3 Process 

The process domain focuses on what happens during the educational program. This 

covers training sessions, clinical guidelines, and getting evidence-based practices into 

everyday care. Basically, it is about how the program changes what ICU nurses know 

about preventing MDRPIs. 

1.11.4 Outcome 

The outcome domain studies whether the educational program actually worked and if 

ICU nurses learn more about preventing MDRPIs. It also studies using better prevention 

methods. These results show that the program did what it was supposed to do to 

improve patient care in intensive care units. (See the table in Appendix A2 for examples 

of the Donabedian Model components) 

1.11.5 Conceptual framework 

The conceptual framework shows how the educational program leads to better nurse 

knowledge, which improves clinical practice and patient outcomes. This study aligns 

with the Donabedian model's three components: structure (available resources), process 

(actual activities), and outcome (results achieved).  

 

 

 

 

 



18 

 

Figure 1 

Conceptual map 

 

 

 

 
 

 

 

  



19 

 

Chapter Two 

Method 

2.1 Introduction 

This chapter describes the research design, population selection, sample techniques, and 

data management procedures utilized to produce the study's findings.  

 

2.2 Description of research design: 

The effectiveness of an educational program provided to critical care nurses on care and 

prevention management for MDR-TB was assessed using a quasi-experimental pre-

posttest (before-after) quantitative study design. The objective of this design is to 

enhance nurses' understanding of how to prevent MDRPIs by evaluating their 

knowledge both before and after the program's implementation.  

 Symbolic representation:  

 One group pertest-posttest designs: 

O1 X O2 

1. O1: Pre-test (Baseline Measurement) 

This represents the initial assessment of nurses' knowledge regarding the care and 

prevention of MDRPIs prior to the educational program. It serves as a baseline to 

compare with post-test results. 

2. X: Intervention (Educational Program) 

It represents the implementation of the educational program provided to the participants.  

3. O2: Post-test (Follow-up Measurement) 

This evaluation assesses nurses' knowledge after the educational program has been 

implemented. The impact of the program will be shown by comparing O1 and O2.  

Symbolic Representation of Study Design (see the table in Appendix A3) 



20 

 

2.3 Identification of the population and sample 

2.3.1 Population 

A variety of intensive care units (ICUs) including the Medical Intensive Care Unit 

(MICU), Surgical Intensive Care Unit (SICU), Pediatric Intensive Care Unit (PICU), 

and Cardiac Care Unit (CCU) at An-Najah National University Hospital (NNUH), on 

the West Bank of the Palestinian Territories employ critical care nurses, who are the 

study's target demographic.  

2.3.2 Sample size 

The sample size for this study was determined using the ROASOFT sample size 

calculator, which had the following parameters: a population size of 75, a response 

distribution of 50%, a margin of error of 5%, and a 95% confidence level. This 

computation determined a minimal sample size of sixty-three participants. The adjusted 

sample size was expanded to 70 participants to account for an estimated 10% attrition 

rate. The suitability of the sample size was verified by speaking with a biostatistician. 

To assess the suitability of the data collection procedure and instruments, a pilot study 

was conducted with 15 nurses from the Post Cardiac Care Unit (PCCU). 

2.3.3 Sampling Criteria (Eligibility Criteria) 

A. Inclusion criteria: 

 Position: Registered nurses working in intensive care units (ICUs) at An-Najah 

National University Hospital (NNUH). 

 Experience: Nurses must have at least six months of experience in their respective 

ICU settings. 

 Department: Variety of intensive care units (ICUs) 

B. Exclusion Criteria: 

 Leave of Absence: Nurses who were on leave during the study period. 

 Declined Participation: Nurses who chose not to participate in the study. 

 Outpatient Services: Nurses working in units that provide outpatient services were 

excluded from the study. 



21 

 

 Open Ward Units: Nurses working in open ward units/general care units were 

excluded from the study. 

 ‌Participants who were part of the pilot study were excluded from the main analysis 

to avoid overlap and to maintain the integrity of the study sample, which was nurses' 

work in the Post Cardiac Care Unit (PCCU). 

2.3.4 Sampling method 

Participants were carefully selected from among those who met the participation criteria 

using a convenience sampling method. The selection was not random but rather subject 

to specific controls to ensure their suitability for the study objectives. 

2.4 Setting 

The location for the study, Nablus, Palestine, was deliberately selected based on its 

accessibility and the unique challenges posed by the ongoing Israeli-Palestinian conflict. 

An-Najah National University Hospital (NNUH), a private medical facility with 

specialized intensive care units, was chosen as the study site. Established in 2014 as the 

first medical teaching centre in the region, NNUH is a leading healthcare and academic 

institution in Palestine. The hospital aims to improve healthcare quality, support health 

education, and promote scientific research. Initially, it started with 100 beds, four 

operating rooms, and an emergency department, later expanding to 140 beds, five 

intensive care units (Medical intensive care units MICU, surgical intensive care unit 

SICU, pediatric intensive care unit PICU, cardiac care units CCU & Post Cardiac Care 

Unit PCCU) and a team of 80 nurses. The hospital operates the nation's first bone 

marrow transplant facility for adult leukemia patients and provides specialized services 

including organ transplants, advanced liver surgeries, open heart procedures, and 

pediatric blood disorder treatments. NNUH is also recognized for its expertise in 

women's health, vascular surgery, kidney medicine, and cancer treatment. 

To support its healthcare and education goals, NNUH established a Clinical Education 

and Training Center and a Clinical Research Center. These centers advance academic 

work and address health problems in Palestinian society. The hospital's Professional 

Development Program in Nursing, started in 2014, emphasizes ongoing education and 

independent learning to help nurses provide high-quality patient care. NNUH became 

the first Palestinian medical center accredited by the Joint Commission International 



22 

 

(JCI) for healthcare quality and safety and received a four-star rating from Statista and 

Newsweek, demonstrating its commitment to international standards and healthcare 

innovation. 

2.5 Measurement Method 

The Nurse Information Form and the MDRPI-KQ-Self-report- were used as data 

collection tools. An open-access version of the questionnaire was utilized, and 

permission to use it was obtained by sending an email to the author (see Appendix D). 

 Nurse Information Form and MDRPIs Knowledge Questionnaire (Sönmez & 

Bahar, 2022) 

1) Part A: study instrument 

Part A collects information about the participating nurses through 18 questions 

organized into two sections. The first section gathers socio-demographic data, including 

age, marital status, and educational level. The second section focuses on professional 

qualifications such as academic background, years of experience, and specialized 

training. This information supports the study objectives and ensures reliable results 

 Section 1: Sociodemographic Characteristics: 

A. This section aims to gather basic demographic and work-related information about 

the nurses to understand the context of their experiences and qualifications. 

B. Age: This item requests the nurse's age in years. It indicates the nurse's age group, 

which might influence their approach or experience in the field. 

C. Gender: Male/female: this item allows the classification of participants based on 

gender, offering insight into the gender distribution of the nursing workforce in the 

context of the study. 

D. Marital Status: Married/Single: information about the marital status of the nurse is 

collected here, which could be useful to understand personal circumstances that may 

influence their work-life balance. 



23 

 

E. Work Experience: This question categorizes the years of work experience, helping 

to classify nurses into experience brackets, which may reflect their level of expertise 

and knowledge regarding MDRPIs. 

F. Most Recently Graduated Nursing Program: Diploma, Bachelor‘s Degree or 

Postgraduate Degree: this question determines the nurse's highest level of completed 

education, which can impact their knowledge and approach to care, including 

MDRPIs. 

G. Department Currently Worked In: Internal Services‌Medical intensive care units 

(MICU), surgical intensive care unit (SICU), Pediatric intensive care unit (PICU) or 

Cardiac care units (CCU). Here, nurses are asked about the department they work in. 

The department type can affect the frequency of exposure to MDRPIs, with more 

specialized departments likely encountering them more often. 

H. Position in the Department: This item seeks to classify the nurse‘s position within 

the department. It helps identify their level of responsibility and leadership within 

the unit, which may influence their knowledge and approach to patient care, 

including prevention and management of MDRPIs. 

 Section 2: Professional Qualifications and Training 

This section collects information about the nurse's work background, previous training, 

and opinions on MDRPI treatment and prevention. Nurses answer based on their 

knowledge and views on these topics. 

A. Have you ever attended a course on pressure injuries caused by medical devices? In 

order to assess the nurse's readiness and capacity to prevent and treat these injuries, 

it is crucial to know if they have received formal training on MDRPIs. 

B. Information Sources about MDRPIs: This question enables the nurse to identify the 

formal training, courses, seminars, and other media that they have used to learn 

about MDRPIs. 

C. Was the MDRPI training beneficial? This item evaluates the nurse's perception of 

the training's efficacy and offers information on how much of an influence it had on 

their practice. 



24 

 

D. Frequency of Encountering a Patient with MDRPIs: This section assesses the 

nurse‘s exposure to patients with MDRPIs, which is important for understanding 

how familiar they are with the issue. 

E. Information Sources about the Prevention/Treatment of MDRPIs: This question 

identifies where nurses gain their knowledge about preventing and treating 

MDRPIs, helping to understand the influence of various learning sources on their 

practice. 

F. Do you think that prevention/treatment of MDRPIs should be assumed by nurses? 

This item explores the nurse‘s view on whether they believe the responsibility for 

preventing and treating MDRPIs falls within their scope of practice. 

G. Is it possible to prevent MDRPIs with good nursing care? This question assesses the 

nurse's belief in the effectiveness of proper nursing care as a preventive measure for 

MDRPIs. 

H. Are your nursing practices for the prevention/treatment of MDRPIs sufficient? This 

question assesses the nurse's self-perception of their adequacy in preventing and 

treating MDRPIs. 

I. Is a nursing care protocol necessary for the prevention of MDRPIs? This item asks 

whether the nurse believes formal protocols or guidelines are necessary to 

effectively prevent MDRPIs. 

J. Do you think you have sufficient information about MDRPIs? This item helps 

assess the nurse‘s perceived level of knowledge about MDRPIs, identifying possible 

knowledge gaps. 

K. Would you be willing to participate in training on MDRPIs? This final item tests the 

nurse‘s willingness to engage in further training, which can help tailor educational 

interventions to improve knowledge and practice around MDRPIs. 

 

 

 



25 

 

2) Part B: MDRPI-KQ 

 Development and Validation of the MDRPI-KQ: Expert Review and Content 

Validity 

The researchers reviewed existing literature and studies about MDRPIs in nursing 

practice. This ensured the research tool was based on solid scientific evidence (Sönmez 

& Bahar, 2022). The researchers also consulted with clinical nurses to gain practical 

insights about this topic. The MDRPI-KQ scale was then developed with 36 items 

covering different aspects of pressure injuries caused by medical devices, using 

established methods from the literature (Sönmez & Bahar, 2022). 

Later, it was sent to seven experts. These experts are nursing professors, ICU nurses 

with long experience, and wound care specialists. All these experts had knowledge 

about managing pressure injuries. The questionnaire was given to this panel to check if 

the questions were clear and related to the research goal. This also tested content 

validity to make sure the scale measured what it was supposed to measure (Sönmez & 

Bahar, 2022). 

Based on expert feedback, a content validity index (CVI) was calculated for each 

question in the scale. All values were above 0.80, showing high agreement that the 

items were suitable. The overall CVI for the entire scale was 0.99, which shows the 

measurement tool is very reliable (Sönmez & Bahar, 2022). Also, Kendall's W analysis 

was done to measure how much the experts agreed with each other. The W value was 

0.271; p = 0.041. Kendall's W ranges from 0 to 1, with zero representing a complete 

lack of agreement and one indicating complete agreement. The results of the analysis 

revealed a moderate level of agreement between the experts' ratings regarding the 

scale's content (Sönmez & Bahar, 2022). 

 Structure and Composition of the MDRPI-KQ: Dimensions and Item 

Breakdown 

The MDRPI-KQ is composed of 36 statements organized into four main dimensions: 

1. Description: 9 items 

2. Risk Factors: 8 items 



26 

 

3. Staging: 3 items 

4. Prevention and Treatment: 16 items 

MDRPI-KQ Dimensions and Item Distribution (See the table in appendix A4) 

 Scoring System and Interpretation of the MDRPI-KQ 

Among these statements, 20 are affirmative, while 16 are negative. Each statement is 

designed to assess nurses' knowledge regarding MDRPIs and can be answered as "true," 

"false," or "no idea (Sönmez & Bahar, 2022). 

One point was assigned for each correct answer within the questionnaire items. No 

points were awarded for answers that fell within the incorrect answer category or the 'I 

have no idea' option, both of which were scored zero. Accordingly, the total score a 

participant could obtain in this questionnaire ranged from a minimum of 0 to a 

maximum of 36 points, proportional to the total number of items included in the 

instrument. The higher overall average scores obtained by the nurses are a positive 

indicator reflecting their improved level of knowledge about the concept of medical 

device-related pressure injuries (MDRPIs) (Sönmez & Bahar, 2022). 

As for the method for calculating the percentage of correct answers, a simple equation 

was adopted. This equation consists of adding the total number of correct answers 

provided by the participant, dividing this result by the total number of questions 

included in the scale, and finally multiplying the result by 100 to convert it to a clear 

percentage value reflecting the level of knowledge acquired. A percentage of 70% 

(equivalent to 25.2 points out of 36) was set as the standard. To succeed in this test, the 

participant is considered to have achieved a passing score if he or she exceeds or 

reaches this threshold. In contrast, scores that fall below this level are an indication of 

the need for further cognitive enhancement(Sönmez & Bahar, 2022). 

 Scoring Assessment Levels Based on Correct Answer Percentages (Sönmez & 

Bahar, 2022) ( See the table in appendix A5) 

This combined approach enables a comprehensive evaluation of both the demographic 

and professional backgrounds of nurses, as well as their understanding and management 

of MDRPIs‌(See Appendix C). 



27 

 

2.6  Presentation of ethical consideration 

1. Ethical approval was obtained from the institution review board (IRB) (16th 

February 2025 & Fsg/Med.Feb.2025/53) at An-Najah National University, as well 

as permissions from the Medical Research and Ethics Committee of the Ministry of 

Health in Palestine and the managers of the hospitals included in this study, detailed 

supporting data and materials are included in Appendices (J-L) 

2. The confidentiality of all study participants was assured by ensuring that no form of 

identification was required from participants or any markers to identify participants 

on the questionnaires. 

3. Participation in the study was voluntary, with no coercion involved, and participants 

had the right to self-determination. 

4. No rewards were given to the participants. 

5. A written consent form was obtained from all participants, which is included in 

Appendix E. 

6. Participants' protection rights were assured, and participants were informed that no 

harm or risks would be encountered during their participation in the study. 

7. The identity of the participants was protected if the research was published. 

2.7 Data Collection 

The following steps were taken to complete the study: 

1. Administrative process: 

The Director of Nursing at An-Najah National University Hospital informed of the 

official approval of the study, which was obtained from the appropriate authorities at 

An-Najah National University's Faculty of Nursing. 

2. Informed Consent 

The nurses' informed written consent to participate in the study was obtained after the 

study's objective was explained and confidentiality was preserved. 

 



28 

 

3. Data Collection 

Data was gathered from February to April 2025 over two months. The researcher started 

each interview by introducing herself and explaining the purpose and nature of the study. 

The study was conducted in three phases. 

  Pre-Education Program Phase 

An initial invitation to attend the training course was emailed to all nurse staff members. 

Special invitation cards were also designed to emphasize attendance at the educational 

program. These cards were distributed to the heads of departments in various intensive 

care units, who placed them in visible locations within the units to publicize the 

invitation and share it with their departmental communication what‘s up groups. Photos 

of the invitation cards are attached in Appendix M. 

 Education program- implementation phase 

The educational training program was conducted over one full day, lasting 

approximately six hours. To accommodate nurses‘ varying schedules and shift duties in 

critical care units, the nursing staff was divided into three separate groups, each 

consisting of 25 nurses. This division was also intended to ensure a better understanding 

of the training content by all participants and to avoid exceeding the internationally 

recommended number of attendees per training session. This helps maintain an optimal 

learning environment and facilitates interactive engagement. As a result, the training 

program was repeated three times on different dates: February 26th, March 12th, and 

March 17th, 2025. 

At the beginning of each session, the researcher explained the purpose, goals, and what 

participants needed to do. This included signing an informed consent form through a 

QR code. Participants scanned the code with their phones and completed the digital 

consent form, which took about 10 minutes. During this introduction, participants could 

ask questions and many of them asked about the study's goals, how to participate, and 

ethical issues. The researcher answered these questions to make sure everyone 

understood and wanted to participate voluntarily. The QR code is in Appendix N. Each 

participant got a unique number from 1 to 74 to protect their privacy. No names or other 

personal information were collected because this numbering system kept participants 

anonymous. These numbers identified participants throughout the study. The numbers 



29 

 

had two main purposes: they kept each participant's identity private, and they helped 

match the before and after surveys to the same person so results could be compared 

accurately. This anonymization technique complied with ethical standards and 

safeguarded participant data, which is included in Appendix O while enabling privacy 

and tracking each participant's progress throughout the training program. 

After giving their consent, participants were asked to fill out a pre-test questionnaire to 

gauge their baseline understanding of MDRPIs. The questionnaire was also made 

available using a QR code for convenience the questionnaire, which is attached in 

Appendix P, took the nurses 15 to 20 minutes to complete. 

Each participant received paper sheets and pens. This ensured they had the supplies 

needed for the required tasks and surveys during the session. 

The educational program content then began. The first part was an interactive 

PowerPoint presentation based on international standards like the 

EPUAP/NPIAP/PPPIA Clinical Practice Guidelines and recent research (Dallı & Girgin, 

2024) about MDRPIs. The information was designed to fill knowledge gaps and 

matched the questionnaire topics. The session covered: 

 Definition and Differentiation: 

Define MDRPIs and explaine how they differ from pressure injuries. 

 Risk Factors: 

Identifying the risk factors that increase the likelihood of MDRPIs. 

 Staging of MDRPIs: 

Explain the staging of MDRPIs. 

 Evidence-Based Prevention and Management Strategies: 

Providing evidence-based strategies for preventing and managing MDRPIs, including 

proper use of medical devices, repositioning techniques, and skin care interventions. 

The presentation was designed to be engaging. The participants asked questions, made 

comments, and discussed cases. After the first part, there was a 30-minute breakfast 

break from 11:00 am to 11:30 am for relaxation and refreshments. The session 



30 

 

continued with the second part of the PowerPoint presentation. Then, participants 

reviewed a professional educational poster from an American journal. This poster 

showed different types of medical devices and how to prevent pressure injuries from 

each one. Copies of these posters were planned for each department to remind staff 

about prevention. The poster was based on "Evidence-based practice: Medical device-

related pressure injury prevention" (Camacho-Del Rio & MBA‐HM, 2018). A sample is 

in Appendix H. 

All participants received a summary brochure to help them remember what they learned. 

This brochure gives clear, practical instructions on preventing MDRPIs in hospitals. It 

was also based on the same research (Camacho-Del Rio & MBA‐HM, 2018) and is 

included in Appendix G. 

The session ended with a question-and-answer discussion. Nurses could ask questions, 

get clarification, and share their experiences with MDRPIs. This interactive part helped 

improve understanding and engagement. 

The Education Program: 

Program Overview: 

A. Purpose:  

This program aims to teach nursing staff how to recognize, avoid, and treat pressure 

injuries related to medical devices (MDRPIs). 

B. Objectives: 

 To explain the aim of the study and its significance in preventing MDRPIs. 

 To define MDRPIs and differentiate them from regular pressure injuries. 

 To identify and discuss the risk factors contributing to the development of pressure 

injuries. 

 To cover the principles of risk assessment related to pressure injuries. 

 To identify the signs and symptoms of pressure injuries. 

 To explain the pressure injury staging system and its clinical importance. 



31 

 

 To discuss the most common disorders and complications associated with pressure 

injuries. 

 To explain preventive measures for device-related pressure injuries. 

 To provide practical strategies for implementing prevention in clinical practice. 

 To distribute a knowledge booklet and printed materials with guidelines and case 

scenarios to reinforce learning 

In order to strengthen learning, a knowledge booklet and printed materials with 

instructions and case studies will be distributed. 

C. Timeline: 

 Program Duration: 8 hours in one day as a workshop. 

 Dates: February 26th, March 12th, and March 17th, 2025. 

 Location: 

 Venue: An-Najah National University Hospital (NNUH) - Student Training Center. 

D. Choose Delivery Methods and Resources: 

 Appendix F contains the interactive PowerPoint presentation that will be used to 

deliver the training sessions. Included in the presentation will be:  

 Visual Aids: Images and movies that highlight MDRPIs at various phases. 

 Interactive Elements: Many interactive activities were used to improve participant 

involvement, including case study discussions and question-and-answer sessions in 

which nurses were asked to evaluate and resolve actual MDRPI-related situations. 

Participants were able to evaluate their comprehension of the subject matter and 

apply what they had learned. 

 

 

 



32 

 

Additionally, as a supportive method:  

 Concise Guidelines: A set of concise guidelines based on the research "Evidence-

based practice: Medical device-related pressure injury prevention" will be 

distributed to each nurse(Camacho-Del Rio & MBA‐HM, 2018). The guidelines 

will also be included in the appendix G. 

 Posters: Posters on the topic will be placed in each department to raise awareness 

and provide continuous visual reminders. These posters will be based on the same 

article(Camacho-Del Rio & MBA‐HM, 2018) and included in Appendix H. 

 Post-education program phase: To measure the effectiveness of the program, 

participants completed a pre-program questionnaire before the workshop and a post-

program questionnaire after the workshop. The questionnaires assessed the nurses‘ 

knowledge of MDRPIs and their prevention strategies. To avoid data contamination, 

the post-test was administered only after the completion of the educational program 

for all participants, using the same methodologies, research team, and data 

collection tools—excluding the Nurse Characteristic Form. The post-test 

questionnaire was also provided electronically in the form of a QR code to facilitate 

easy access and completion, was attached in Appendix Q. 

2.8 Data Analysis Plan 

Quantitative data was analyzed using descriptive statistics in Statistical Package for 

Social Sciences (SPSS) version 22 to describe the distribution of variables used to 

summarize socio-demographic data, knowledge, and practice levels. The results are 

presented through pie charts, and tables. 

 Paired samples t-test compared participants' practice scores and perceived barriers 

before the educational program and three months after.  

 The one-way ANOVA examined differences in knowledge scores across 

demographic variables with three or more categories (age group, years of 

experience, clinical department, and job position).  

 

 



33 

 

 The independent samples t-test assessed knowledge score differences for 

demographic variables with two categories (gender, marital status, nursing 

education type, and prior training participation). This analysis approach helped 

identify significant patterns in the data and supported reliable interpretation of the 

study findings. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  



34 

 

Chapter Three 

Result 

3.1 Introduction 

This chapter is devoted to presenting the study results and analyzing the collected data 

systematically, in line with the research questions and hypotheses previously formulated 

to guide the study's progress and achieve its research objectives. A set of statistical 

methods appropriate to the nature of the data were adopted. Descriptive statistics were 

used as the special tool for data analysis, along with calculating arithmetic averages, 

with a focus on stating frequencies and percentages. It was done to provide a 

comprehensive and clear picture of the characteristics of the data extracted from the 

participants' answers. The number of individuals who participated in providing data was 

'seventy-four", which provided the researchers with a sufficient database to study 

general patterns and analyze trends related to the study topic in a precise and organized 

scientific way. 

3.2 Data Analysis 

The final sample consisted of 74 individuals. The correct answers in the knowledge 

scale were recoded to 1, and the incorrect answers to 0, and the total knowledge was 

computed for each respondent by summing the answers and then converting the total 

knowledge to percentages by dividing the sum by the total number of items, which is 36. 

The same procedures were used to compute the total scale of the sub-knowledge parts 

(Knowledge Items, Risk Factors, Staging, and Prevention and Treatment). 

3.3 Statistical Methods 

Data analysis in this study was conducted using the Statistical Package for Social 

Sciences (SPSS), Version 22. A range of descriptive statistical techniques was 

employed, including frequencies, percentages, means, and standard deviations, with the 

purpose of summarizing and presenting the socio-demographic and personal 

characteristics of the participants, as well as describing the levels of the study variables 

both before and after the implementation of the educational program. Additionally, 

Cronbach‘s alpha coefficients were calculated to assess the internal consistency and 

reliability of the items included in each of the employed measurement scales, ensuring 

that the instruments used provided consistent and dependable data for analysis. 



35 

 

To answer the research questions and test the study hypotheses, several statistical tests 

were used with a significance level of p ≤ 0.05. The paired samples t-test compared 

participants' practice scores and perceived barriers before the educational program and 

three months after. The one-way ANOVA examined differences in knowledge scores 

across demographic variables with three or more categories (age group, years of 

experience, clinical department, and job position). The independent samples t-test 

assessed knowledge score differences for demographic variables with two categories 

(gender, marital status, nursing education type, and prior training participation). This 

analysis approach helped identify significant patterns in the data and supported reliable 

interpretation of the study findings. 

3.4 Validity and Reliability of the Questionnaire 

The researcher sent the questionnaire to nursing and health education experts. These 

experts reviewed the content and provided feedback on question clarity, topic relevance, 

and research goal alignment. The researcher then revised the questionnaire based on this 

feedback. This made it a good tool for measuring how well the educational program 

improved ICU nurses' knowledge about preventing MDRPIs in Palestinian hospitals. 

To check the validity and accuracy of the tool, the researcher did a pilot study with 15 

participants who met the study requirements. The researcher used Cronbach's alpha to 

measure internal consistency. Txu‌ eeensyyy‌ uuyrnsy‌ yxsaut‌ sxes‌ sxu‌ luseresxsy‌ enaxe‌

ssuvvysyues‌vsu‌enn‌36‌ysu y‌aey‌0.76a‌e‌aenru‌sxes‌venny‌aysxye‌sxu‌ysyuesyvysenns‌essuase 

rnu‌ueewu.‌hs‌yetysesuy‌sxes‌sxu‌ ueyruu ues‌sssn‌ryut‌xey‌e‌xywx‌tuwuuu‌sv  uunyerynyss‌eet‌

yesuueen‌sseyyysuessa‌axysx‌uexeesuy‌sxu‌suutyrynyss‌sv‌sxu‌uuyrnsy‌sxes aynn‌ru‌srseyeut‌

vus ‌eaansyew‌sxu‌nruysyseeeyuu‌ye‌sxu‌auy eus‌ysrts. 

3.5 Normality Test of the Study Variables 

The normal distribution test was performed for the study variables in order to select 

between the parametric and the non-parametric methods for data analysis. The results of 

the tests of normality and the skewness coefficients are shown in test of Normality and 

the Skewness coefficients table in the appendix A6. 

The results of normality tests (Kolmogorov-Smirnov and Shapiro-Wilk) in Table A6 

show that most of the study variables are not normally distributed (P-values <0.05). On 

the other hand, most of the Skewness coefficients are less than 1, and since the sample 



36 

 

size is reasonable and large (more than 30), the researcher decided to use the parametric 

methods (ANOVA and T-test) in the study analysis. 

3.6  Sociodemographic Characteristics & Professional Qualifications and Training 

The study population included all nurses working in the various intensive care units of 

An-Najah National University Hospital, located in the West Bank, Palestine. These 

nurses were selected as the target group for this study because their experience and 

practice were directly related to the study topic of preventing medical device-related 

pressure injuries (MDRPIs). The actual study sample consisted of 74 nurses working in 

these units, 46 of whom were male and 28 female, reflecting a relative 

overrepresentation of males in this specialty within the study environment. Regarding 

marital status, approximately 55% of the sample were married, which may reflect the 

diverse living and social circumstances of the participants. 

Regarding the age profile of the participating nurses, the results revealed that the 26-30 

age group was the most represented within the sample, representing approximately 57%, 

indicating that the majority of the sample was young and still in the early to mid-career 

stages. The results also showed that 55.4% of the sample had between 3 and 5 years of 

nursing experience, reinforcing the hypothesis that they possess a good amount of 

practical experience related to practicing nursing in intensive care units. About 78% of 

the nurses had bachelor's degrees in nursing. This shows that the study participants had 

good education levels. So, the findings are more reliable. 

The nurses worked in different units at An-Najah National University Hospital. 28.4% 

worked in the Medical ICU, 27% in the Surgical ICU, 25.7% in the Cardiac Care Unit, 

and 18.9% in the Pediatric ICU. Having nurses from different speciality units made the 

study results more complete. 

Regarding job titles, it was found that more than half of the participants (52.7%) hold 

Registered Nurse (RN) positions, while 41.9% of them hold Senior RN positions, while 

a smaller percentage (5.4%) of the sample members hold Head Nurse positions. The 

attached table shows the detailed distribution of the study sample according to socio-

demographic and personal characteristics in detail, which provides a comprehensive 

background on the sample's characteristics and contributes to the accurate scientific 

interpretation and analysis of the study results (see the table A7 in appendix A) 



37 

 

Sociodemographic Characteristics Distribution via Pie Chart (see appendix B) 

The distribution of the study sample according to the professional qualifications and 

training (see The Table 8 in appendix A) 

The study sample consisted of 41 nurses who received training on MDRPIs (55.4%), 

and the majority of them answered that the training on MDRPIs was helpful, and most 

of these 41 nurses have information about MDRPIs from courses and conferences            

(29.3% and 39%). The nurses frequently or sometimes encounter patients with MDRPIs 

(86.4%). The information sources about the Prevention/Treatment of MDRPIs for the 

nurses are 20.3% from Journals/Books on the Subject, 18.9% from the knowledge 

acquired during Nursing Education, 10.8% from co-working with experienced nurses, 

only 4.1% and 1.4% from Internet, Newspapers, or TV and Suggestions/Guidance of the 

Physician, and mostly from the other sources (44.6%). Most nurses think that 

prevention/treatment of MDRPIs should be assumed by nurses (97.3%), and most 

believe it is possible to prevent MDRPIs with good nursing care (95.9%). In addition, 

most nurses believe that their nursing practices for the prevention/treatment of MDRPIs 

are sufficient (75.7%), and most nurses believe that nursing care protocol is necessary to 

prevent MDRPIs (97.3%). Finally, most nurses believe they have sufficient information 

about MDRPIs (62.2%), and all the nurses in the sample answered that they would be 

willing to participate in training on MDRPIs. 

 

  



38 

 

Figure 2 

Have you ever received training on medical device-related pressure injuries? 

 

Figure 3 

Information Sources about MDRPIs 

 



39 

 

Figure 4 

Was the training on MDRPIs helpful? 

 

Figure 5 

Frequency of Encountering a Patient with MDRPIs 

 



40 

 

Figure 6 

Information Sources about the Prevention/Treatment of MDRPIs 

 

Figure 7 

Do you think that prevention/treatment of MDRPIs should be assumed by nurses? 

 



41 

 

Figure 8 

Is it possible to prevent MDRPIs with good nursing care? 

 

Figure 9 

Are your nursing practices for the prevention/treatment of MDRPIs sufficient? 

 



42 

 

Figure 10 

Is a nursing care protocol necessary for the prevention of MDRPIs? 

 

Do you think you have sufficient information about MDRPIs? (Show it in Appendix B8) 

3.7 Research Questions 

In this section, the researcher introduces the analysis of the study questions based on the 

study sampling answers: 

3.7.1 Q1) what are the levels of nurses’ knowledge regarding MDRPIs pre and 

post-the educational program?  

To answer this question, the researcher computed frequencies and percentages of the 

correct answers of the nurses toward the items regarding MDRPIs pre and post-

educational program, and the following table nine shows the results: 

 

 

 



43 

 

Table 1 

Frequencies and percentages of the nurses’ answers regarding MDRPIs Knowledge items. 

Items Pre Post 

N % N % 

1. ‗MDRPIs are pressure injuries caused by medical 

devices and equipment.‘ 

74 100.0% 74 100.0% 

2. ―MDRPIs are caused by constant pressure or 

friction due to medical devices.‖ 

65 87.8% 74 100.0% 

3. ‗MDRPIs constitute approximately 1/3 of all 

pressure injuries that may occur in the hospital 

environment.‘ 

40 54.1% 71 95.9% 

4. ‗In MDRPIs, the tissue around or under the 

device and equipment takes the shape of the device.‘ 

60 81.1% 73 98.6% 

5. ―The source of pressure in MDRPIs is the 

medical device itself.‖ 

56 75.7% 70 94.6% 

6. ―MDRPIs usually occur in areas with bony 

prominences.‖  

29 39.2% 65 87.8% 

7. ―MDRPIs are simple wounds and do not cause 

serious complications.‖ 

46 62.2% 70 94.6% 

8. ‗MDRPIs are most common in the sacrum.‘ 40 54.1% 66 89.2% 

9. ―There are no differences in the appearance of 

general pressure injuries and MDRPIs.‖ 

44 59.5% 69 93.2% 

Total (Average) knowledge 68.2% 94.9% 

 

The results shown in Table (1) showed that nurses' level of knowledge regarding 

medical device-related pressure complications (MDRPIs) before the educational 

program was 68.2%. At the same time, this percentage increased significantly after the 

program, reaching 94.9%. These results reflect the significant positive impact of the 

educational program in enhancing the knowledge level of the nurses participating in the 

study, confirming the effectiveness of the educational intervention in achieving its 

desired objectives. 

Furthermore, the results showed a clear improvement in nurses' knowledge of all 

knowledge items related to the study topic after completing the educational program. 

For example, the percentage of nurses who correctly answered the statement "MDRPIs 

constitute approximately one-third of all pressure injuries that may occur in the hospita