Operating Room Nurses Confident but Undertrained on Pressure Ulcer Prevention, Swedish Survey Finds

Every surgical patient is, to some degree, a patient at risk. Lying motionless on an operating table under anaesthesia, deprived of the instinctive micro-movements that protect healthy tissue, the body is exposed to sustained mechanical forces that deform cells and compress capillaries. The consequences can appear within 48 to 72 hours after surgery as pressure ulcers, also known as pressure injuries, which are among the most stubborn and costly complications in modern healthcare. A new national survey from Sweden, published in the open-access journal Nursing Open, has now measured how well the professionals who spend the most time at the operating table, the operating room nurses, actually understand this threat, and the results reveal a striking mismatch between attitude and knowledge.

The study, conducted by Karin Falk-Brynhildsen, Carina Bååth, Dimitri Beeckman, Christine Leo Swenne, Charlotte Raepsaet and Camilla Wistrand, set out to describe Swedish operating room nurses’ self-estimated knowledge and attitudes regarding the prevention of intraoperative pressure ulcers. Using a cross-sectional design reported according to the STROBE guidelines for observational studies, the team distributed an online questionnaire by email to operating room nurses across all 21 of Sweden’s healthcare regions. Of the 2247 addresses contacted, 343 proved non-functional, leaving 1904 eligible recipients. After two reminders, 284 nurses completed the survey, a response rate of 15 percent. Data collection took place in August and September 2020 as part of a larger project developing two validated instruments tailored to the operating room: the Pressure Ulcer Knowledge Assessment Tool for the operating room, known as PUKAT 2.0 OR, and the Attitudes toward Pressure Ulcer Prevention instrument adapted for the same setting, the APuP-OR.

The scale of the clinical problem provides the context for why this matters. According to the European Pressure Ulcer Advisory Panel guidelines, surgery-related pressure ulcers occur in approximately 4 to 45 percent of surgical procedures. Recent studies have documented intraoperative incidence rates ranging from 6.2 to 16.2 percent, and one study of patients aged 65 and older reported an incidence of 18.8 percent, with operative times of 180 minutes or longer strongly associated with increased risk. Medical devices compound the danger: blood pressure cuffs, adhesive tapes, endotracheal tubes and spectral index monitors can all damage skin and mucosal surfaces, and device-related pressure ulcers have been estimated at a prevalence of around 11.8 percent, while positioning-related ulcers may reach 23.5 percent. The operating room is therefore recognised as a high-risk environment where every member of the surgical team shares responsibility for tissue protection.

The 284 respondents were an experienced and highly educated group. Their mean age was 42.8 years, 93 percent were women, and 37 percent held a master’s degree while another 33.8 percent held a professional operating room nursing degree. More than 63 percent had over 11 years of experience in healthcare, and 37.7 percent had more than 20 years. When asked to rate their own expertise using Benner’s classic proficiency levels, half identified as proficient and 38 percent as competent, with 11.3 percent claiming expert status and only two nurses describing themselves as novices. Crucially, 87 percent said that further education in pressure ulcer prevention would be beneficial, an appetite for learning that the study’s findings suggest is well founded.

The knowledge assessment told a story of two halves. In the domain of aetiology, the nurses performed impressively. More than 95 percent correctly identified the causes of pressure ulcers and understood the biomechanical consequences of a patient sliding in a semi-upright position, and 90.1 percent recognised that body weight contributes to risk. These results align with previous research emphasising the role of knowledge in delivering evidence-based care. But when the questions turned to prevention, classification and observation, performance dropped sharply. Only 38 percent correctly identified where deep tissue injuries develop during surgery, and just 41.2 percent correctly classified blisters observed on both heels after a three-hour procedure. Nearly 60 percent answered incorrectly when asked about heel protection measures for a patient already lying on a pressure-redistributing mattress, and questions about patient positioning yielded correct response rates of only around 51 to 52 percent.

The researchers applied a demanding benchmark to these results, using a 90 percent threshold for correct answers, and only 3 of the 14 knowledge items met it. Even when the cut-off was lowered to 70 percent, the number of adequate responses remained limited. The authors deliberately retained the stricter threshold, reflecting on whether adjusting the standard of what counts as sufficient knowledge in pressure ulcer prevention is appropriate at all. The finding that positioning competencies are limited is consistent with earlier work by Sørensen and colleagues, who reported similar gaps among surgical teams, and it points to a specific, teachable weakness at the heart of intraoperative care: knowing how to position a patient safely is not the same as knowing why pressure damages tissue.

Attitudes, by contrast, were overwhelmingly positive. A remarkable 94.7 percent of respondents reported feeling confident in their ability to prevent pressure ulcers, and 98.6 percent agreed that prevention should be a priority and a personally important responsibility. Fully 94 percent acknowledged the financial burden that pressure ulcers place on society. The nurses firmly rejected dismissive statements: 93.7 percent disagreed that the impact of pressure ulcers on patients is exaggerated, 96.5 percent rejected the notion that too much attention is paid to prevention, and 96.1 percent refused the idea that they bear no responsibility if an ulcer develops in their patient. Attitude scores were higher than those reported in a previous study by Khong and colleagues, suggesting Swedish operating room nurses occupy an unusually favourable motivational position.

Experience shaped confidence in measurable ways. Pairwise comparisons revealed statistically significant differences across years of operating room experience in perceived training: nurses with more than 20 years of experience felt significantly better trained than those with 5 to 10 years, with a p-value of 0.049. A similar pattern emerged for perceived confidence, with significant differences between the most experienced nurses and those with 5 to 10 years of experience, and between the 11-to-20-year group and their less experienced colleagues. Yet the study’s central paradox remains: despite this confidence and experience, overall knowledge was insufficient, and positive attitudes did not translate into consistently correct answers about prevention strategies such as surgical linen use, positioning angles and heel offloading.

The authors are candid about the limitations of their work. Self-reported data are vulnerable to recall bias and social desirability bias, and some question wording may have confused participants. The 15 percent response rate restricts generalisability, and it is possible that respondents were more interested in pressure ulcer prevention than non-respondents, which could have inflated the apparent knowledge and attitude scores. The measurement instruments themselves, while validated, showed modest internal consistency on some subscales, and the authors note that PUKAT 2.0 OR requires further refinement to capture the complexity of pre-positioning across different surgical procedures while preserving operative exposure for the surgeon.

The implications reach beyond Sweden. Because most pressure ulcers are preventable, the authors argue, raising awareness and promoting evidence-based prevention strategies across the entire operating room team is imperative, including surgeons, anaesthesiologists and nurse anaesthetists, not nurses alone. They call for systematic, evidence-based educational interventions, structured training programmes, simulation-based learning and regular competency assessments integrated into continuing professional development, alongside mixed-methods research to clarify why positive attitudes fail to produce adequate knowledge or consistent preventive action. Structured risk assessment tools, which guidelines consider the gold standard, should complement rather than replace clinical judgement. For a complication that can begin forming the moment a patient is positioned on the table, the message of this survey is clear: the will to prevent pressure ulcers is present in the operating room, but the knowledge to do so reliably still needs to be built, one training programme at a time.

Subject of Research: Operating room nurses' knowledge and attitudes regarding intraoperative pressure ulcer prevention

Article Title: Preventing Pressure Ulcers in the Operating Room: A National Survey of Operating Room Nurses' Knowledge and Attitudes

Article References: Falk‐Brynhildsen, K., Bååth, C., Beeckman, D., Leo Swenne, C., Raepsaet, C., & Wistrand, C. (2026). Preventing Pressure Ulcers in the Operating Room: A National Survey of Operating Room Nurses' Knowledge and Attitudes. Nursing Open, 13(9), Article e70808. https://doi.org/10.1002/nop2.70808

Image Credits: AI Generated

DOI: 10.1002/nop2.70808

Keywords: pressure ulcers, operating room nurses, patient safety, intraoperative care, nursing knowledge, survey research, Sweden, patient positioning, surgical complications, nursing education, pressure injury prevention, cross-sectional study