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Nursing competencies in the prevention of pressure ulcers


How to cite this article:
Duque-Ruelas P, Romero-Quechol G, Martínez-Olivares M. Competencias de enfermería para prevenir úlceras por presión. Rev Enferm Inst Mex Seguro Soc. 2015;23(3):163-9.

Nursing competencies in the prevention of pressure ulcers

Paula Duque-Ruelas,1 Guillermina Romero-Quechol,2 Marilin Martínez-Olivares2

1Hospital de Cardiología, Centro Médico Nacional Siglo XXI; 2Unidad de Investigación Epidemiológica y Servicios de Salud, Coordinación de Investigación en Salud. Instituto Mexicano del Seguro Social, Distrito Federal, México

Correspondence: Paula Duque-Ruelas

Email: paula_duque_75@hotmail.com

Received: June 30th 2014

Judged: August 20th 2014

Accepted: November 19th 2014


Introduction: Competencies allow nurses to develop their ability to act correctly in critical areas, where the patient is totally dependent on nursing care in order to prevent pressure ulcers.

Objective: To determine the level of competency of nursing staff for pressure ulcer prevention in tertiary care.

Methodology: A cross-sectional study from February to June 2014, in critical areas of Hospital de Cardiología del Centro Médico Nacional. An instrument with 52 items was designed, divided into two sections: the first with demographic, employment, and training data (12 items), the second with structured clinical cases (40 items), which assesses the stages of knowledge, skills and attitudes, evaluating competencies according to Patricia Benner’s model of 5 levels: novice (< 8), advanced beginner (9-16), competent (17-24), efficient (25-32) and expert (33-40). Content and construct were validated in 3 expert rounds out of 3. Descriptive and nonparametric statistics, Kruskal-Wallis and chi-square tests were used.

Results: 75 nurses were interviewed, 31 % in the 37-41 age range, 61 % female, post-technical education in 60 %, and according to the skill phases: knowledge 62 %, skills 47 %, and attitudes 50 %.

Conclusions: There is a need for educational activities that will be reflected in the quality of care provided by nurses to patients in critical areas.

Keywords: Competencies; Nursing; Pressure ulcers


The Comisión Permanente de Enfermería defines pressure ulcers (PU) as localized lesions of ischemic origin, a consequence of tissue crushing caused by prolonged pressure, rubbing, friction, or shearing of the tissue between two planes that can develop into necrosis.

According to the World Health Organization (WHO), the prevalence of PU ranges between 5 and 12%, in Latin America 7%, and in Mexico between 4.5 and 13%.1

PU epidemiological data show a significant increase in this problem, 95% of which may be preventable.2

In Mexico an investigation took place in 2013 to determine the prevalence of this health problem, with results crude prevalence of 12.93% and average prevalence of 20.07% with a standard deviation of +/- 15.79%.3

These figures are present in critical areas, so nursing should be at the forefront in pressure ulcer prevention in response to this health problem.

In the Instituto Mexicano del Seguro Social, nursing education based on competencies is integrated, since in critical areas patients are exposed to risk factors for PU, such as sedation, invasive devices, mechanical ventilatory support, etc. For these reasons, patients depend totally on nursing attention for their physical mobility, skin lubrication, some key aspects of pressure ulcer prevention, as these have an impact on the health of patients and on the days of hospital stay.

McClelland (cited by Rodriguez) conceptualized competencies as a combination of knowledge, skills, and attitudes that people bring into play in various real work situations according to their own standards of satisfactory performance in each professional area.4

Patricia Benner noted that the acquisition of skills based on experience (Dreyfus model) is safer and faster when produced from a solid educational foundation. Qualified skill and practice consist in implementing nursing interventions and clinical decision skills in real situations.

Benner proposes the following levels:


  • Novice: They have no previous experience of the situation they must face. This level corresponds to nursing students, but Benner suggested it could also be applied to expert nurses in a given area who must face a situation or an area not known to them.
  • Advanced beginner: the person has the experience needed to master some aspects of the situation. Nurses at this stage follow rules and are guided by the tasks to be performed. They have trouble mastering the current situation of the patient from a broader perspective.
  • Competent: this is characterized by considerable conscious and deliberate planning that determines which aspects of current and future situations are important and which are not.
  • Efficient: the nurse perceives the situation as a whole. The performance is guided by rule, guideline, and maxim; the person is able to recognize the main aspects and has an intuitive control of the situation from the previous information that they know.
  • Expert: they have an intuitive control of the situation and are able to identify the source of the problem without wasting time on alternative solutions and diagnostics.5


Competencies integrate knowledge, skills, and attitudes, elements that nurses need to develop their capacity in daily work experience.

Assessment through clinical simulation requires defining specific and comprehensive scenarios that correspond with the skills to improve the decision-making process, team communication, optimization of resources, and the possibility of error.

Innovation in the nursing area facilitates reflection and learning from experience, providing a new model of learning and training in which knowledge, skills, and attitudes interweave.6

The estimation of clinical competency can be assessed using objective structured clinical examination (OSCE), an instrument that describes the relationship between competencies and characteristics of health professionals and evaluates both theoretical and practical aspects. Its reliability and validity construct and content have been proven, since one can evaluate a large sample of skills, abilities and attitudes, as well as control for variables by placing examiners in real clinical settings.7

In critical areas, care by nursing competency ensures the efficiency and quality of care to patients for the prevention, management and treatment of pressure ulcers.

Competency development is not limited to a single perspective; these are built over a career from experience and practice with people who form the teams, or the circle of patients and family. These skills are not acquired in the specific description of a job, they are defined through the rationale of this science that is care.

The importance of this to develop this research is that the level of competency of the nurse is unknown and is this a way to identify it.

The results allowed us to describe the sociodemographic characteristics and data to identify the level that the nurse was at in tertiary care.

Competency-based training responds to the current challenges of the profession and is the best way to evaluate nursing professionals because it allows information to identify learning needs, techniques, and procedures to promote better personal and work relationships.

Nurses need competencies that integrate methodologies for interventions they provide, and to include quality criteria in the care they provide for the scope of the planned objectives.


A cross-sectional study was performed from February to June 2014, in the highly specialized medical unit Hospital de Cardiología del Centro Médico Nacional Siglo XXI. It included the nursing staff from critical areas: Post-surgical therapy, Intermediate Care Unit, Coronary Care Unit, from the staff listing, with a total of 219 nurses.

To calculate the sample size, the finite population formula was used with n = 63; to identify a proportion, the selection was made by simple random sampling.

An instrument entitled "Competencies of the nursing professional in pressure ulcer prevention in third-level care" was designed. It was made in two sections: the first included sociodemographic variables and the second was structured based on the method of objective structured clinical examination (OSCE), as well as clinical simulation. Its content and construct were validated by an expert panel 3/3.

The instrument consists of 52 items; it is divided into two sections: the first contains sociodemographic data (questions 1 through 4), about work (5-9) and about training (10-12), with a total of 12 items.

The second section was to solve a clinical case. Elements were integrated that interacted and simulated reality to evaluate the clinical performance of competencies with a total of 40 items. Stages of knowledge (questions 13-25), skills (26-36) and attitudes (37-52) were also assessed. The competency level is determined according to Patricia Benner’s model with its 5 levels: novice (< 8), advanced beginner (9-16), competent (17-24), efficient (25-32) and expert (33-40).

The instrument was self-administered in the critical areas with an estimated 20-35 minutes of reply time. It was conducted from Monday to Friday in the morning, evening, and night shifts.

Nursing professionals were invited to participate in research according to the inclusion criteria. The researcher provided an instrument and included the informed consent form for signature, allowing us authorization for this research and the use of the information and personal data content for statistical purposes. We ensured the confidentiality of the data with respect and discretion for their contents. Their decision was accepted if they left the investigation and they could do so at any time they wished without repercussions to themselves or their working rights.

This research was determined as minimal risk, as it consisted of answering an instrument.

The intention was for the criterion of respect for human dignity and the protection of the rights and welfare of participants to prevail, in accordance with the practice in health research material, as established by the Ley General de Salud,8 the Reglamento de la Ley General de Salud en Materia de Investigación para la Salud,9 and ethical principles such as the Declaration of Helsinki of the World Medical Association.10 Data were analyzed in the program Microsoft Excel Professional 2013 and descriptive statistics were used. Measures of average and median central tendency (frequencies and percentages) were obtained, and nonparametric measures for the analysis of variables of age, educational level, years of service, service, and shift. We used the Kruskal-Wallis test and chi squared for the variable of training.


We interviewed 75 nurses from the critical areas of Hospital de Cardiología del Centro Médico Nacional Siglo XXI. 31% were in the age range of 37-41 years, 61% were female, 48% were married, 60% had an academic level of post-technical. Regarding the shift, 40% belonged to the morning, 35% to the afternoon, and 25% to the night. Regarding institutional years of service, 29% were in the range of 6-10 years, and the length of service in the range more than two years accounted for 30% (Table I).

Table I. Socio-demographic data of nurses (n = 75)
  Frequency %
24-30 12 16
31-36 19 25
37-41 23 31
42-46 14 19
47 and older 7 9
Male 14 19
Female 61 81
Academic degree
Post-technical 45 60
Bachelor's degree 28 37
Master's 2 3
Marital status
Bachelor 27 36
Married 36 48
Divorced 5 7
Cohabitating 7 9
Source: instrument "Competencies of the nursing professional in pressure ulcer prevention in third-level care"

According to the phases of the skills, knowledge corresponded to 62%, skills to 47%, and attitudes to 50% (Figure 1). In overall competency, the nurses stood at the competent level, with 75% (Figure 2).

Figure 1. Phases of the competencies of nursing professionals for pressure ulcer prevention. Source: "Competencies of the nursing professional in pressure ulcer prevention in third-level care" instrument

Figure 2. Level of competency of nursing professionals for pressure ulcer prevention. Source: "Competencies of the nursing professional in pressure ulcer prevention in third-level care" instrument

The association of the levels with training showed that for the beginner level none received training, in the competent level one-third of them had it in some form, and in efficiency level over 50% were trained.

The academic degrees that related with competent and efficient level were an academic preparation of post-technical, bachelor's and master’s. For the competent level over 50% have post-technical education, 35% have bachelor's and 5% a master's. For the efficient level, 45% had post-technical or bachelor’s, and only 8% a master's degree.

As for the correlation of competencies with shift, 60% of the advanced beginner level were in the night shift, 41% of competent personnel were in the morning, and 43% of the efficient were at night.

As for the comparison of level of competency with years of service in the institution, in the range of 6-10 years over 40% were found in the competent level, and in the range of 11-15 years, 60% were found in advanced beginner.

Kruskal-Wallis statistical test was used for crossing variables of academic degree (0.299), years of service in the institution (0.78) and shift (0.1). No statistically significant differences were seen in relation to levels of competency; p <0.05 was found for this.

The correlation of training with competency levels was 0.000, which showed that there must be continual training to reach the level of competency and improve service processes aimed at implementing specific interventions in patients in the critical areas (Table II).

Table II. Competencies of nurses by having received training or not  
Level of competency Training
Yes No
n (20) % n (55) %
Advanced beginner - 5 9
Competent 14 70 42 76
Efficient 6 30 8 15
p* 0.000
* Chi-square was used
Source: instrument ""Competencies of the nursing professional in pressure ulcer prevention in third-level care"

According to Patricia Benner’s theory, in the data analysis three of the five levels were found, which were advanced beginner, competent, and efficient.


In research conducted by Juvé et al.,11 "Expertise threshold required for nursing competency performance", the authors obtained an average age of this group of 43.7 years, and gender distribution of 86% women and 14% men. There is no significant difference in the age range (5 years), and sex is still predominantly female because nursing remains a profession that from its origin is carried out by women.

The study also states that the threshold of expertise identifies the minimum level of necessary interaction of knowledge, skills, and attitudes for decision-making in clinical practice. The elements identified with a higher threshold of skill correspond to competency contents that require a developed ability of clinical judgment, strong analytical skills, extensive knowledge of the discipline, and a formidable capacity for intuitive judgment.

Although some scientific disciplines traditionally have ascribed much more value to analytical principles and methods, disdaining intuition and seeing it as the basis of irrational actions, unfounded knowledge and even supernatural inspiration, intuition, understood as the ability to understand things instantly and the ability to concretely foresee a certainty that has not yet made itself clear, is not an accidental human capacity.

Making staff competent allows us to identify areas of opportunity to propose strategies to achieve the level of expertise; in the words of Benner, "intuitive judgment is what distinguishes the highest levels of expertise".11

In addition, the six key principles of intuitive judgment described by Dreyfus include pattern recognition, analysis of similarities, integration of common sense, highly skilled know-how, the ability to discriminate and prioritize (sense of salience) and deliberative reasoning. In real life and in practice, these properties act synergistically to set the highest levels of expertise. 

The data of this research placed the specialist staff at the competent level; however, Carrillo described in his research "Patricia Benner’s philosophy in clinical practice," that the profile required in these areas requires attributes that classify them as experts.5

Of all individuals surveyed in relation to levels of competency and training, in the advanced beginner level none had received training in any form; for the competent level, a third of the staff had a significant difference, pointing to responsibility and interest in acquiring new knowledge for improved care; at the efficient level over 50% had it.
In integrated nursing training, improvement will continuously be reflected in daily activity, both in processes involving specific management, and in interventions administered for pressure ulcer prevention, health problems that delay a state of wellness in the patients in critical areas.

This approach works as an answer to the current challenges of the profession because of its utility in modifying and improving prior and future training for professionals, for certification or whatever professional system.

Angera et al.12 also report in their investigation "Education as a key piece in the prevention and good course of pressure ulcers" that the training of professionals in the application of standardized preventive measures decreases the incidence of pressure ulcers.

Designing an educational intervention will allow us to increase the area of ​​opportunity identified during the skill phase. About this, Romero de San Pio,13 in her article entitled "Decreased incidence of pressure ulcers in Intensive care: a program goal of improving care" shows results of significantly lower incidence rates at four months after introducing standardized measures of prevention and care improvement.

According to the publication of Roca et al,14 with the research entitled "Pressure ulcers in the critically ill patient: detection of risk factors" in its conclusions, body mass index ≥ 30, an EMINA score and noradrenaline are established as risk factors for pressure ulcers. Days of sedation, dynamic surfaces, high-protein diet, postural changes and polyurethane nasogastric tube were established as protective factors.

The specialist nurse faces these working conditions daily, which are common characteristics of the patient in critical condition. The implementation of practices based on clinical practice guidelines (CPG), prevention and treatment of pressure ulcers (PU) in hospitals, findings and recommendations, and the clinical practice guides master catalog IMSS-105-08,15 may facilitate planning interventions aimed at the reduction of pressure ulcers in patients in critical areas.

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