Nurses’ Management of Patients with Pressure Ulcers in Selected Health Facilities in Murang’a County, Kenya

Pressure ulcers are a common health problem in hospitalized patients, especially among patients with chronic illnesses and those with reduced mobility. The prevalence of pressure ulcers varies with health care settings and is highest in critically ill patients ranging between 15-20%. They affect the quality of life of patients and caregivers and have been associated with heavy financial burdens, extended hospital stays, higher morbidity and mortality. Inadequate prevention measures and lack of active management of pressure ulcers in early stages especially in high-risk patients result in recurrence and complicated pressure ulcers. In view of this, a descriptive cross-sectional study was conducted in Murang’a County, Kenya in selected health facilities with the objective of determining the management of patients with pressure ulcers. The study population was composed of one hundred and twenty-four (124) nurses working in medical and surgical wards in selected health facilities. Semi-structured questionnaires, observational checklists and focused group discussions were used to collect data. The qualitative data from the focus group discussions and observational checklist were transcribed and a summary written. The relationship between nurse’s knowledge, nurse-oriented factors and institutional factors affecting management of pressure ulcers among nurses were examined using Pearson correlation analysis and multiple regression analysis. The median age of the respondents was 37 years with at least 112 (90.3%) having diploma level of education, and 63 (50.9%) were from the medical department. The majority of the nurses (93.6%) agreed pressure ulcers can be avoided, while 58.1% preferred pressure ulcer risk assessment tools compared to 27.5% who preferred clinical judgment in the management of pressure ulcers. The majority of nurses (87.5%) who had adequate knowledge on the management of pressure ulcers mentioned immobility and bedridden patients, stroke, spinal injury, dry skin, stool and urine incontinence as major contributors to pressure ulcers. Regarding pressure ulcer risk assessment, 62.9% of nurses assessed patients for pressure ulcers though they relied on clinical judgement as 93.9% indicated there was no risk assessment scale in the wards and 5.1% were not sure. On institutional factors 61.3% of the nurses indicated that health facilities were lacking pressure ulcer reducing devices and those that had pillows and a few ripple mattresses. Regarding guidelines in the management of pressure ulcers, 75.8% of nurses indicated they were not available in the hospital. The study found an association between age and knowledge increasing the odds of effective management age (AOR = 6.83, p = 0.001); experience (AOR = 4.08, p = 0.01), and education (AOR = 22.9, p = 0.000). The nurse-oriented factors increasing the odds of effective management of pressure ulcers include nurse’s positive attitude on prevention of pressure ulcers (AOR = 2.3, p = 0.040) and nurse use of pressure ulcer risk assessment tool (AOR = 4.3, p = 0.010). On institutional factors, nurses trained on management of pressure ulcers were 4.47 times likely to effectively manage patients with pressure ulcers. Nurses who lack in-service training about pressure ulcers were less likely to effectively manage patients with pressure ulcers (AOR = 0.11, p = 0.000).  The study concludes that the nurses had adequate knowledge in management of pressure ulcers, the nurses-oriented factors and institutional factors also influence the management of pressure ulcers


INTRODUCTION
Pressure ulcers are a prevalent health issue in nearly all health care settings. Their development is multifactorial, making it a complex health issue (Waugh, 2014). The ulcers develop especially in patients with other ailments, therefore complicating the management of disease and increasing hospital stay and health care costs. The UK National Health Service reports that 186,617 patients are managed for pressure ulcers every year leading to an estimated financial burden of over £4,000 by each pressure ulcer per year (Hope, 2014).
Prevention of pressure ulcers is the best approach and forms an integral part of nursing inpatient care. Pressure ulcers result in reduced quality of life of patients and caregivers, increase morbidity, mortality, and length of hospital stay (NICE, 2014). 85 -90% of pressure ulcers are largely avoidable with the cost of treatment been higher compared to prevention (Cooper, 2015, Hope, 2014. Pressure ulcers are commonly found in bony prominences. The injuries are as a result of bodyweight been hard-pressed between a bony prominence and a hard surface (Repić & Ivanović, 2014). Hippocrates (460-370 B.C.) associated pressure ulcers with paraplegia, bladder and bowel dysfunction (Agrawal & Chauhan, 2012). Immobility, neurologic conditions, ageing and nutritional deficiency have been associated with increased risk of developing pressure ulcers (Waugh, 2014).
The prevalence and incidence of pressure ulcers vary depending on the care setting. The highest rates are found in intensive care units ranging between 15 to 20% due to limited mobility and systemic illnesses. Facility acquired rates for critical care units range from 8.8 % in cardiac care to 10.3 % in surgical intensive care units (Cuddigan, 2012). According to the International Pressure Ulcer Prevalence surveys, the incidence rate in a neurological intensive care unit for stage 2 or greater pressure ulcers is 12.4% (Thomas & Compton, 2013). In Mexico, the point prevalence rate in second-level hospitals was found to be 17% with stage II pressure ulcers been the most common (Galván-Martínez et al., 2014).
Though pressure ulcers are widespread, it's rarely researched in developing countries. In a study conducted in Felegehiwot Referral Hospital in Bahir Dar, Ethiopia, the prevalence rate was found to be 12.8% among hospitalized patients, the length of stay in hospital and the age of the patient was reported as contributing factors (Gedamu, Hailu & Amano, 2014).
In Kenya, pressure ulcers prevalence rate of 4.2% in Kenyatta National Hospital and 68% at Nairobi spinal injury were reported with paraplegic patients being at highest risk of pressure ulcers development (Nangole, Khainga & Kiboi, 2009). In a study conducted in St. Mary's Hospital Mumias, Butere/Mumias district a prevalence rate of 13.5% was reported among patients in medical and surgical wards (Geerligs, Bouten & Laperre, 2004). The study was carried out in Murang'a County, Central, Kenya which has 271 health facilities. There is no published research management of patients with pressure ulcers in Murang'a County.

METHODS
A descriptive cross-sectional study design was used to gather information on the management of pressure ulcers among nurses in selected health facilities in Murang'a County, Kenya. The study population included nurses taking care of pressure ulcer patients in Murang'a District Hospital, Maragua District Hospital, Kiriaini Mission Hospital, Githumu Hospital, Kangema, Kenol Hospital, Makuyu and Muriranjas sub-district hospitals in Murang'a County.

Inclusion and Exclusion Criteria
Nurses working in any of the selected hospitals' medical and surgical wards and nurses who had worked in the ward for at least 4 months were eligible for inclusion in the study. Nurses working in any of the selected hospitals' medical and surgical wards that did not consent to participate in the study and those on leave were excluded from the study.

Sampling Technique and Size Determination
Murang'a County was purposively selected as it had both County and sub-County hospitals with medical and surgical wards well distributed within the region. Total population sampling was used to purposively select nurses in medical and surgical wards since pressure ulcers patients are majorly found in these wards and the sample is small.
Using the Fishers formulae (1998) below, the sample size will be calculated as follows = 2 2 where: n is the desired sample size; Z is the normal standard deviation at the required confidence level which is 95% (standard value of 1.96); p is the percentage of the population with the desired characteristics; q is 1-p which represents the target population not having the particular characteristics; d is the level of statistical significance (degree of freedom = 0.05) = 1.962 2 * 0.5 * 0.5 0.05 2 = 384 East African Journal of Health and Science, Volume 3, Issue 1, 2021 With the estimated total population (N) been less than 10,000, the formula: = (1+ ) will be used to adjust the sample size, where; N is the total population of nurses working in medical and surgical wards in the selected hospitals (estimated at 180); nf is the adjusted sample size (when the population is less than 10,000); n is the desired sample size (when the population is more than 10,000).

Research Instruments
The main instrument used for the study was semistructured questionnaires with both open-ended and close-ended questions. Focused group discussions were also used don the nurses who did not complete questionnaires.
The minimum sample size for this study was 120 study participants. 132 semi-structured questionnaires were issued, but only 124 were usable for the purpose of this study (n = 124). The findings describe the sociodemographic characteristics of the study participants, the nursesoriented factors, the knowledge level of nurses in the management of pressure ulcers and the institutional factors that influence the management of pressure ulcer patients.

Sociodemographic Characteristics of the Respondents
The median age of the respondents was 37 years. The results indicated 85 (68.5%) were married, 73 (58.9%) has experience of over five years, 91 (73.4%) were permanent employees, at least 112 (90.3%) had a diploma level of education. The summary is presented in Table 1 below.

Experience, Training and the Ward of Practice
The majority of the respondents 122 (98.4%) had served a patient with pressure ulcers, 63 (50.9%) worked in the medical department and 89 (71.8%) had taken a course on wound care. The summary is presented below in Table 2.

Attitude and Management of Pressure Ulcers
The study wanted to understand respondents' attitudes that determine the management of pressure ulcers. On whether pressure ulcers can be avoided,  Table 3).

Level of Knowledge and Management of Pressure Ulcers
The study provided 16 questions to assess the level of knowledge on the management of pressure ulcers. The mean score was 78.38% with a standard deviation of 10.61. The nutritional needs of highrisk patients were best scored with all the respondents identifying a high protein diet as essential in the management of Pressure ulcers. On the use of hot water and soap and the effect on drying the skin and increasing the risk for pressure ulcers were poorly scored with only 20.5% answering correctly. The summary of the respondents' scores is as presented in Table 4 below.

Patients at a High-Risk of Developing Pressure Ulcers
The study aimed at understanding whether the respondents were aware of patients at a high risk of developing pressure ulcers. Through open-ended questions, the respondents identified bedridden patients, chronically ill, the elderly, and patients suffering from stroke, spinal injury been at a higher risk. Others identified to be at a higher risk of developing Pressure ulcers included those with dry skin, immobile, malnourished, patients with tractions, paralyzed, obese with other comorbid, stool and urine incontinence. However, some mentioned lack of sleep, ignorance of caregivers, and weight loss as factors causing pressure ulcers which were not correct.

Figure 1: Individuals at a higher risk of developing pressure ulcers Earliest Signs of Developing Pressure Ulcers
On the earliest signs of developing pressure ulcers, most nurses were able to identify reddening of skin and blisters. However, other responses included bleeding, being emaciated, and joint sores showing less knowledge. Nurses were able to identify signs of an infected wound with responses including foul smell, fever, greenish colouration, and presence of pressure ulcers.

Respondent's Current Practice in Management of Pressure Ulcers
The study found that there were no risk assessment scales in the wards with as 116 (93.9%) of the respondents indicated. Despite there being no risk assessment scales, 78 (62.9%) of respondents performed pressure ulcer risk assessment on patients using clinical judgement, of these 68 (54.9%) performed pressure ulcer risk assessment on patients daily and on admission ( Table 5).
The study found that 90 (72.6%) of the respondents used massaging to prevent pressure ulcers, and 120 (96.8%) repositioned patients to prevent pressure sores. Out of these, 79 (63.7%) of the respondents repositioned the patients every 2 hours. In addition, 65 (52.4%) had served 6-10 patients with pressure ulcers in the past one month and 20 (16.1%) of the respondents had used special mattresses in preventing pressure sores among their patients ( Table 5).

Pressure Ulcers Devices Available in Health Facilities
The majority of nurses (61.3%) in the study indicated that health facilities lacked pressure ulcers reduction devices. However, 21% just had pillows that were being improvised and 17% had ripple mattresses.

Pressure Ulcers Guidelines, Special Diet and Training Available in Health Facilities
Despite sufficient knowledge on the management of pressure ulcers among nurses, the results also revealed 75.8% of the respondents indicated there is the absence of guidelines in the management of pressure ulcers, 60.5% indicted patients are not given a special diet and 77.4% indicated nurses are not trained on the management of pressure ulcers in the facilities.

Improvement of Management of Pressure Ulcers
On the number of nurses in a given shift, the study found that the average nurse to patient ratio was 1:15 with some nurses even serving a whole ward in a shift. The study wanted to understand institutional factors that influenced nursing management of pressure ulcers patients. The results revealed that a majority of nurses (65%) understand the combination of staffing, CMEs, coordination between teams and use of devices increases improved care. However, only 23% reported having received training on pressure ulcers. This is illustrated in Figure 3 below:

Respondents' Oriented Factors
The results indicate that age was statistically associated with the management of pressure ulcers in Murang'a County ( (6,124) 2 = 52.67, p = 0.000). Marital status was statistically associated with the management of pressure ulcers with single nurses scoring higher than married ones ( (2−124) 2 = 14.20, p = 0.001). The lower scores among single nurses correspond with the young age, whose scores were lower. Experience was statistically associated with the knowledge on the management of pressure ulcers ( (3,124) 2 = 35.10, p = 0.000. Nurses whose experience exceed five years had higher scores on the management of pressure ulcers. The results revealed there was a statistically significant association between employment status ( (2,124) 2 = 12.30; p = 0.01, and the level of education ( (2,124) 2 = 7.568; p = 0.023 on the management of pressure ulcers. There were more permanent employees (73.6%) whose scores was above median compared to contractual nurses (37%), while degree score higher than diploma and diploma scored higher than certificate nurses. The summary is presented in Table 7 below. On prevention of pressure ulcers, 93.5% agreed that the ulcers were avoidable ( 2 = 3.3, (1), = 0.069 displaying a positive attitude in management of Pressure ulcers. Respondents who agreed that documentation of pressure ulcers is essential scored better in the knowledge assessment compared to ( 2 = 2.626, df (1), p = 0.105). Respondents who believed clinical judgment is better than pressure 2 = 14.68, df (2), p = 0.01. Respondents who believed clinical judgment is better than pressure ulcer risk assessment tool scored below the median.

Respondents' Level of Knowledge
There was no evidence of documentation of patients identified as having an increased risk of developing pressure ulcers observed. The results indicated that an experience in performing pressure ulcer risk assessment on patients and the frequency of assessment statistically influenced nurse's level of knowledge on the management of pressure ulcers. The summary of the results is presented in Table 9 below.

Association between Institutional Factors and Management of Pressure Ulcers
The study found that there were statistically significant higher odds of improper management of pressure ulcers when nurses have a heavy workload, lack of universal guidelines for prevention; lack of in-service training about pressure ulcers; when they have uncooperative patients; presence of other priorities other than pressure ulcers; and when their inadequate knowledge about pressure ulcers. The summary is presented in Table 10 below: During the FGDs, the nurses also revealed the lack of any standardized guidelines and risk assessment tools for use in management and assessment of pressure ulcers as one nurse put it "Do the risk assessment tools exist? I have never heard of such guidelines, but if they would help in management of the pressure ulcers its good we adopt" (Maragua Level 4, FGD respondent). The majority of the nurses' contributions in the FGDs were confirmed by our observations; that the facilities did not have a pressure reducing devices. Most facilities used pillows to elevate the patients, the pillows were found to be few and some had hard surfaces. One of the nurses stated, "we barely have any pressure reducing device, the pillows are few, this ward has three and I have only seen one ripple mattress here that is often in the stores" (Murang'a Level 5, FGD respondent).

Multivariate Analyses: Factors Influencing the Management of Pressure Ulcers among Nurses
Binary regression analysis was carried out to determine the effect of predictor variables on the dependant variable while controlling for confounding and to determine whether the independent variable predicts the dependant variable. The researcher conducted a chi-square test of association to understand significant factors influencing effective management. The researcher conducted binary logistic regression to extract the adjusted odds ratio. The results revealed sociodemographic factors were positively statistically significant in increasing the odds of effective management of pressure ulcers include: Age (AOR = 6.83, CI: 2.11-13.245, p = 0.001); experience (AOR = 4.08, CI: 1.421-11.687, p = 0.01), and education (AOR = 22.9, CI: 3.63-44.79, p = 0.000). Older nurses were 6.8 times more likely to manage pressure ulcers effectively compared to younger nurses; respondents with experience of more than 3 years were 4 times more likely to manage pressure ulcers effectively compared to those with less than 3 years of experience.
The study also found that nurses with a diploma level of education were 22 times more likely to manage pressure ulcers effectively compared to nurses with a lower level of education. The nurses oriented factors increasing the odds of effective management of pressure ulcers included: nurse's positive attitude on prevention of pressure ulcers which increased the odds of managing pressure ulcers effectively by 2.3 times compared to those with negative attitudes (AOR = 2.3, 1.014-5.182, p = 0.040), and nurses use of pressure ulcer risk assessment tool were 4.3 times of managing pressure ulcers effectively compared to nurses not using the tool (AOR = 4.3, CI 4.698-10.814, p = 0.010). On institutional factors, nurses trained on management of pressure ulcers were 4.47 times likely to effectively manage patients with pressure ulcers. Nurses who lack in-service training about pressure ulcers were less likely to effectively manage patients with pressure ulcers by 0.11 times compared to nurses with in-service training (AOR = 0.11, CI: 0.038-0.293, p = 0.000).

Respondents' Oriented Factors that Determine Management of Pressure Ulcers
The first objective was to establish respondentsoriented factors that determine the effective management of pressure ulcers. The age (p = 0.001); experience (p = 0.01), and education level (p = 0.000) of a nurse was found to be significant in increasing the odds of effective management. The empirical findings revealed nurses are optimistic that pressure ulcers can be avoided even though the prevention is time-consuming. The respondents also preferred pressure ulcer risk assessment tools to clinical judgment despite there being no assessment tool available for use in the wards. This disagrees with a study by Kaddourah, Abu-Shaheen and Al-Tannir (2016), where 10.7 % of participants which included nurses and other health professionals, reported Pressure ulcers prevention as a timeconsuming procedure. The respondents also reported their clinical judgment been better than the use of available Pressure ulcers risk assessment tools.
Working experience of more than 5 years was found to be significant, this agrees with a study conducted in Mzuzu Central Hospital in Mzuzu, Malawi where nurses with more than four years' experience were found to have good attitudes and upheld professionalism. Nurses with fewer years of experience may still be adapting to the new environment (Nyirenda & Mukwato, 2016).
The study revealed that none of the respondents had used a pressure assessment tool in admission or during assessments as a majority were not aware of the existence of such a tool and the health facilities had not adapted the risk assessment tool in patients' management. This is comparable to a study conducted in Ethiopia on the prevention of pressure ulcers which revealed that more than three fourth of nurses did not use a risk assessment scale (Nuru et al., 2015).
A greater percentage of respondents 71.5% repositioned immobile patients every two hours to relieve pressure and promote blood circulation. Results from multivariate analyses revealed that respondents-oriented factors are significant in the effective management of pressure ulcers. Sharp et al. (2019) noted that Pressure ulcers continue to develop in elderly patients despite the 2-hourly repositioning. The study results agree with a study conducted by Bergstrom et al. (2014), whose results found repositioning of patients significant in reducing pressure ulcers. This is also in line with the NPUAP-EPUAP which recommends repositioning of patients every 2 hours (NPUAP-EPUAP-PPPIA, 2014).
The study revealed that documentation is important in the communication of care while managing Pressure ulcers. This agrees with a study by Waugh, 2014 which found that documentation and adherence to set guidelines depends on the personal attributes of the nurse. An individuals' attitude determines their expectations; persons with a positive attitude often demonstrate positive behaviour (Kaddourah et al., 2016;Ajzen et al., 2005).

Level of Knowledge on Management of Pressure Ulcers among Nurses
The study provided respondents with 16 questions to assess the level of knowledge on the management of pressure ulcers. The mean score was 78.38 per cent meaning the majority of nurses had sufficient knowledge on the management of pressure ulcers. The study is comparable to other studies; in a study conducted to assess the knowledge and attitudes of health professionals towards pressure ulcers at a rehabilitation hospital at King Fahad Medical City (KFMC), Riyadh, Saudi Arabia, 75 % of nurses were found to have adequate knowledge (Kaddourah et al., 2016). Likewise, the score was higher than that of a study by Islam (2010) where nurses in Bangladesh had 57.79 % on knowledge on Pressure ulcers prevention and that of a study conducted on nurses' knowledge to pressure ulcer prevention in public hospitals in Ethiopia which was found to be 73.3 % (Ebi, Hirko, & Mijena, 2019). The study participants scored higher compared to a study conducted in Sweden, where the knowledge score of staff nurses was 61% and 59.3% for the registered nurses ( Gunningberg et al., 2015).
The majority of respondents had knowledge on patients at a higher risk of developing pressure ulcers elderly, immobility and bedridden patients, patients with tractions, chronically ill, paralyzed, obese with other comorbid, stroke, spinal injury, dry skin, stool and urine incontinence as major factors causing pressure ulcers. However, some nurses mentioned lack of sleep, ignorance of caregivers, and weight loss as factors causing pressure ulcers. This compares with a study conducted by Murphy et al. (2014) which described an increase in noncommunicable diseases such as diabetes, obesity and cardiovascular diseases that results in reduced mobility among the population of persons over 65 years thereby predisposing patients to Pressure ulcers. Monfre (2016) described elderly patients aged 70 years and above as the most common age group with pressure ulcers incidence. The study results also agree with a multisite study conducted in the USA and Canada health facilities which reported patients with cardiovascular disease and dementia as having the highest risk of developing Pressure ulcers (Bergstrom et al., 2014).
On the earliest signs of developing pressure ulcers, the respondents were able to identify reddening of the skin and blisters formation. However, some responses such as bleeding, being emaciated, and joint sores showed less knowledge. Early signs of pressure ulcers are described as stage 1 in the NPUAP as having non-blanchable erythema of intact skin which can also be painful, firm, soft, warmer or cooler as compared to adjacent tissue (NPUAP, 2016). Signs of an infected ulcer known to nurses included foul smell, fevers, greenish colouration, and purulent. Increasing pain and size of the ulcer, purulent drainage and odour are described as signs of an acute infection (Kirman, 2017;Levine et al., 2013).
The study also found that respondents had served 6-10 patients with pressure ulcers in the past one month; the majority of those had performed pressure ulcer risk assessment using their own clinical judgement as most had indicated a lack of risk assessment scales in the wards. In a discussion paper by Coleman et al. (2014), risk assessment scale such as Braden and Norton scales have been highly criticized as time-consuming and limited due to their inability to directly identify those at risk of developing Pressure ulcers, many hospitals are still using them (Coleman et al., 2018).

Institutional Factors Affecting Management of Pressure Ulcers among Nurses
Pressure reducing devices modifies the patient microclimate such as temperature, friction, moisture and spreads the tissue load over a larger surface area, thereby reducing the weight over bony prominences (Monfre, 2016). Some of the institutional factors affecting the management of pressure ulcers include the lack of pressure ulcers reducing devices causing nurses to improvise pillows in elevation of patients. With only a few ripple mattresses available in the health facilities, more equipment and pressure reducing devices need to be purchased to support patient care. The findings compare with a randomized clinical trial conducted in Brazil, which found reduced incidences of Pressure ulcers among moderate or higher risk critically ill patients who used viscoelastic support surfaces (Bueno de Camargo et al., 2018). This also agrees with the findings of a study conducted in Ethiopia on the prevalence and risk factors associated with Pressure ulcers which reported pressure-relieving devices as significant in reducing the prevalence of Pressure ulcers (Bereded, Salih & Abebe, 2018).
The average nurse to patient ratio was 1:15 in every shift with some respondents been allocated a whole ward due to staff shortage as cited by 95.2% of the nurses. These resulted in a heavy workload and most were unable to give the expected care in the prevention of pressure ulcers. This was higher than that reported by Ebi et al. (2019), where 54.7% of health professionals including nurses reported heavy workload as a challenge in the prevention of pressure (Bereded et al., 2018).
Most facilities lacked guidelines on the prevention of pressure ulcers as per the observations made. Specific to the study 75.8% of the nurses reported the absence of guidelines in the management of pressure ulcers, while the remaining 24.2 % were not sure if the guidelines existed. This is comparable to a study conducted by Nuru et al. (2015) on the practice of nurses towards prevention of pressure ulcers where 89.9 % of the nurses were not using any existing guidelines on risk assessment and prevention of pressure ulcers.
Continuous training on the management of pressure ulcers and review of prevention guidelines can provide the nurses with updated knowledge on pressure injury prevention and management (Dalvand et al., 2018). Porter-Armstrong (2018) stated that PU continuous education aims at behaviour modification of nurses', equipping them with current knowledge on management of PU thereby eliminating patient's suffering. Specific to this study 77.4% of the nurses indicated that they had not been trained in the management of pressure ulcers on the job. The findings are comparable with other studies. In a study in Ethiopia on nurses' knowledge of pressure ulcer prevention in public hospitals, lack of programmed training and formulated guidelines about PU prevention in hospitals were seen to significantly affect the practice of Pressure ulcers prevention (Ebi et al., 2019).

CONCLUSIONS
From the first objective, the study concludes that nurses-oriented factors that determine effective management of pressure ulcers includes the work experience, their attitude towards effective management of pressure ulcers, preference of use of pressure ulcer risk assessment tool to clinical judgment and the practice of repositioning immobile patients every two hours to relieve pressure and promote blood circulation.
From objective two, the study concluded that the majority of respondents have sufficient knowledge on the management of pressure ulcers even though they still face numerous institutional challenges in managing patients.
In the third objective, the study concluded that the institutional factors affecting management of pressure ulcers include; lack of pressure ulcers reducing devices, heavy workload and staff shortage with a higher nurse to patient ratio, lack of universal guidelines on prevention and management of pressure ulcers and lack of on-job training on emerging trends in the management of Pressure ulcers.

Recommendations
Based on the findings from the study, the following recommendations have been made to: • The health facilities' management committees and the nurse leaders need to nurture new nurses into the profession who may be having challenges adapting to new environments to promote positive attitudes. Continuous creating awareness on nursing core values and professionalism to all nurses. The nurse managers to support health facilities in the adoption of universal guidelines and Pressure ulcers risk assessment tools.
• The health facilities management committees should support an increase in respondents' knowledge on the management of Pressure ulcers through encouraging CMEs, provision of journals and the internet to update them on current nursing practice on Pressure ulcers management. The County government can also support the nurses through scholarships for training in wound care, research funding, and offer study leave for nurses willing to study further in pressure ulcers management.
• The County government through the department of health and all health facilities management committees to develop policies that support and prioritize management of Pressure ulcers through; hiring of more qualified nurses to reduce the nurse-patient ratio and in the purchase of pressure reducing devices such as overlays, cushions.

Further Research
Based on findings and the scope of this study, the following have been suggested as areas of further research: • Effectiveness of the various approaches used in the management of pressure ulcers within the health facilities in the County.
• Studies on the prevalence of pressure ulcers in various county hospitals.
• Effectiveness of various pressure reducing devices