1. Introduction
Medical device-related pressure ulcers (MDRPUs) are defined as localized damage to the skin and underlying tissues caused by the use of medical devices [
1]. The incidence rate of hospital-acquired pressure ulcers (PUs), including MDRPUs, is 41.2% [
2]. The MDRPUs most commonly encountered by nurses are endotracheal tube (ETT)-related PUs, which account for 27.6% of MDRPUs [
3]. Additionally, 45.0% of oral mucosa PUs are caused by fixation devices or the ETT itself [
4]. PUs in the lower lip have been reported at a higher frequency than those in the upper lip [
5]. Oral mucosa PUs can result in frequent pain and discomfort [
6], and have negative effects on health-related quality of life, as they can cause deterioration in the systemic infection related to ventilator-associated pneumonia [
7]. Therefore, this issue warrants greater attention, which must include frequent assessment, periodic relocation, and early removal of the ETT for the prevention, and early detection, of oral mucosa PUs [
8]. However, there seems to be a low interest in oral health among nurses. A study reported that only 44% of qualified oncology nurses documented oral an assessment merely once per day [
9]. Moreover, as the performance rate of general PU prevention is as low as 67.6% [
10], that of oral mucosa PUs would be even lower. Even though several strategies, including clinician self-report, patient-report, and medical record review are recommended for checking preventive care performance, their evidence-based effectiveness remains limited [
11].
Identifying a person’s intention is an effective way to predict their actual behavior [
12]. Performance intention represents one’s self-awareness of one’s plan to perform an action [
13], and is an effective self-regulatory strategy to facilitate pre-planned actions [
14]. In a previous study, the group which had higher acceptance intention regarding a smartphone healthcare application tended to perform health-promoting behaviors [
15]. Furthermore, performance intention had a direct effect on actual PU prevention performance, which explained 52.7% of the variance [
16]. Therefore, it is hypothesized that performance of oral mucosa PU prevention can be predicted by identifying the performance intention of nurses.
The intentions were determined by three factors, including attitude, subjective norm, and perceived behavioral control [
17]. Having a positive attitude can increase the likelihood of behavioral change [
18], and is positively related to performance [
19]. Therefore, negative attitudes toward PU prevention may negatively affect preventive care performance [
20]. Furthermore, an individual’s attitude has a direct impact on PU prevention performance intention [
16], and is regarded as an outcome variable, similar to performance intention [
21]. However, a positive attitude alone is not sufficient to ensure PU prevention, and other factors should also be considered alongside it [
22]. Particularly, barriers such as limited staff knowledge and physical skills [
23], work overload due to understaffing, communication strategies, clarity of roles and responsibilities [
24], and lack of resources [
25] often limit adherence to PU prevention guidelines. In addition, teamwork, effective communication [
24], and positive beliefs about consequences or capabilities are known to be facilitators of PU prevention [
23]. Based on the fact that the “fear of adverse consequences” might facilitate positive attitudes and motivate nurses to prevent PUs [
23], a multifaceted approach is required to take into account the barriers and facilitators intrinsic to the organizational context.
It is important to precisely assess and distinguish PUs [
26], as it is a crucial competence for PU preventive care providers [
25]. However, to date, there has been a paucity of research evaluating healthcare workers’ competence in visual differentiation using photographs [
26]. There is insufficient photographic evidence of oral mucosa PUs [
27], which makes it more challenging to evaluate the discrimination ability of healthcare providers. Owing to their poor visibility, early detection of oral mucosa PUs is also difficult. Assessing the impact of visual differentiation ability on performance intention could provide more extensive information [
26] than narrative knowledge using a paper-based survey. Furthermore, most recent empirical studies have treated barriers and facilitators of perceived behavioral control as both direct determinants of intention, and interaction variables [
27,
28]. If the effects of the interaction between attitude, and barriers or facilitators of oral mucosa PU prevention performance intention, are identified, it may indirectly prove the moderating role of barriers and facilitators in the relationship between attitude and intention; and this may further help refine guidelines for intubated patients. Therefore, the current study sought to identify the factors influencing oral mucosa PU prevention performance intention.
4. Discussion
Although several studies have examined attitudes [
36], as well as perceived barriers and facilitators, to performing preventive care of PUs [
23,
24,
37], there are gaps related to the empirical study of oral mucosa PUs. Considering the high incidence rate of oral mucosa PUs [
3,
4,
5,
38], it would be helpful to define the factors influencing the intention to perform oral mucosa PU prevention. Therefore, based on the current study’s results, we focused on the significant factors for oral mucosa PU prevention performance intention.
The mean score of intention to perform oral mucosa PU prevention was 3.68, which was similar to that of 3.57 for general PUs [
16], or 3.80 for fall prevention intentions [
39]. This showed that oral mucosa PUs were perceived as a crucial concern for intubated patients, though oral mucosa PUs have not yet been officially and clinically classified [
40]. Considering general characteristics, ICU nurses had a higher performance intention than nurses in medical/surgical wards. This was consistent with a previous study that showed nurses in ICUs performed PU prevention more frequently than those in surgical wards, as their performance intention had a direct impact on actual performance [
10]. ICU nurses might perceive their patients as a high-risk group for MDRPUs, and have a higher performance intention, because they usually take care of more intubated patients than nurses in wards [
3].
The mean score of attitudes toward oral mucosa PU prevention was similar to that of skin PU prevention in previous studies [
19,
21]. According to recent studies, oral mucosa PU is a common MDRPU [
4], it improves in 2–3 days, and relapses frequently compared to skin PUs [
5]. This shows that nurses perceive oral mucosa PUs as an important health problem. In the current study, the mean scores of barriers and facilitators of oral mucosa PU prevention (barriers = 5.65, facilitators = 5.35) were higher and lower, respectively, compared with those observed in a previous study (barriers = 5.03, facilitators = 5.87) [
21]. The mean score of visual differentiation ability related to oral mucosa PUs was 0.13, which was markedly lower than that of skin PUs in previous studies, which ranged from 0.32 to 0.55 [
26,
41], and that of narrative knowledge related to skin PUs, which ranged from 0.53 to 0.81 [
26]. Although brief descriptions of the characteristics of oral mucosa PU stages were provided in the questionnaire, respondents might not have selected the correct answers for two reasons. First, the oral mucosa consists of two layers, which are the stratified squamous epithelium and the deeper lamina propria, contrary to the three skin layers [
42]. These histological differences make it difficult to discriminate between the oral mucosa PU stages. Second, the nurses might be unfamiliar with identifying PU stages using photographs, instead of using narrative questionnaires. In addition, the stage classification system or photographic data of oral mucosa PUs, which could improve communication among clinicians and monitoring of oral mucosa PUs [
34], remains undeveloped. Therefore, to improve the visual differentiation ability of nurses, the mucosal PU stage system, based on the characteristics of histological differences and healing of the mucous membrane [
43], needs to be officially developed and used as a visual material [
41].
Factors influencing performance intention were attitude and facilitators. This is in line with the findings that attitude affects intention to perform skin PU prevention [
16] and actual performance [
19]. Previous research has also shown a positive relationship between facilitators and performance, which corroborates the current study’s results [
21]. Attitude was defined as behavioral intent and the amount of regard for or against an object, which is affected by knowledge [
13]. This might be influenced by two factors, specifically, the nurses’ formal training in PU prevention [
25], and their nursing priorities in the clinical setting [
25]. Considering how frequently nurses deal with intubated patients [
5], they need to be provided with formal training and information on prioritization for oral mucosa PU prevention. Therefore, educational programs in nursing should include a definition of oral mucosa PUs and a care algorithm for the same. The importance of oral mucosa PU prevention needs to be emphasized [
44].
Based on the item analysis of facilitators, the scores relating to educational opportunities available to the nurses and communication among staff were low. Based on a previous study [
24], availability of educational opportunities, effective cooperation and communication with the medical staff, and proper support for resources and personnel would be important factors to improve oral mucosa PU prevention performance. Therefore, three strategies should be prepared. First, educational opportunities, including regular brief training programs, need to be provided. Brief information, including the fact that oral mucosa PUs are highly affected by mechanical factors, such as the ETT itself and commercial ETT holder use [
4], will greatly increase the likelihood of nurses repositioning the ETT and reducing the use of commercial ETT holders. Second, communication and teamwork training within the multidisciplinary team could be critical facilitators in the prevention of PUs [
23,
24]. Especially, because formal communication occurs in various forms, such as handover and documentation [
21], quality improvement of PU preventive documentation needs to be continued. Third, appropriate RN staffing levels for daily care ensuring patient safety should be implemented. All nursing staff personnel, including RN and nurse aid staff, can contribute to the prevention of hospital-acquired PUs [
45].
A recent study identified perceived behavior control not only had a direct effect on intention, but also interacted with other determinants of intention [
46]. However, this study did not find any interaction effects on intention, which is different from the findings of previous studies. This may be owing to the relatively higher influence of attitude on oral mucosa PU prevention performance than on intention. Meanwhile, facilitators of oral mucosa PU prevention may lead to higher intention. Based on the theory of planned behavior, a favorable attitude provides the motivation to perform the behavior; however, an intention becomes more concrete only when perceived control over the behavior is strong [
17]. It is necessary to derive more stable results by performing repeated studies, as it is difficult to predict the effect of the interaction between attitude and perceived behavioral control on oral mucosa PU prevention performance intention based on this study.
This study has yielded useful data on the factors influencing intention to perform oral mucosa PU prevention. However, it has a number of limitations. First, other factors influencing performance intention, such as anticipated affect, past behavior [
47], interest in PU care [
48], teamwork, communication, and commitment [
49], were not included as input variables. Furthermore, only four factors, namely, attitude, barriers, facilitators, and visual differentiation ability, were considered as independent variables, without considering the participants’ characteristics. Second, when measuring attitudes, we simply replaced general PU with oral mucosa PU, which may have reduced the reliability of the instrument. Therefore, more discursive influencing factors and a more adequate instrument for evaluating intention to perform oral mucosa PU prevention would rectify these limitations.