Pressure Ulcer Prevention Education: Creative Ways to Engage Staff

Pressure ulcers are known to increase a patient’s risk of morbidity and mortality; thus, preventive care is paramount in ensuring optimal patient care and quality of life. Additionally, prevention of hospital-acquired conditions, including pressure ulcers, has become a national priority in light of the Centers for Medicare & Medicaid Services’ recent regulation change regarding nonpayment for hospital-acquired conditions.¹ As such, staff education on preventive practice has become mandatory in many long-term care facilities; however, delivering informative, impactful, and enjoyable training can be challenging. Published studies and our own experiences demonstrate that making educational programming fun produces better outcomes in staff knowledge and overall quality of care. In this article, we share some creative ideas on how to make your training sessions more entertaining and memorable so that the goal of minimizing pressure ulcers is easier to achieve.

Researchers have examined the level of staff knowledge on pressure ulcer prevention in various clinical studies; however, these studies lack design consistency, limiting our ability to draw conclusions from them. In a 1993 study, Volgelpohl and Dougherty² reviewed textbooks from nursing schools and found that some nursing students may be exposed to as few as 200 lines of text related to pressure ulcers during their training. The authors noted that the information tended to be dispersed over three to seven chapters, was incomplete, and was sometimes inaccurate.

A review of the literature reveals several reports of success in decreasing nosocomial pressure ulcers after implementation of an educational program, when combined with other key changes.^3-5 Any educational program should extend to the patient and his or her family or caregiver. Other key strategies to prevent pressure ulcers include a heightened emphasis on risk assessment; proper use of skin care regimens; implementation of measures to control pressure, friction, shear, and moisture; and proper nutrition and hydration.³ Sinclair and colleagues⁵ conducted a quasi-experimental study to determine the efficacy of using a standardized, evidence-based educational workshop to educate registered nurses (RNs) and licensed practical nurses (LPNs) on pressure ulcer prevention. Participants’ level of knowledge was evaluated before and after the workshop using an adapted version of the Pressure Ulcer Knowledge Test, which consists of true/false questions. Immediately following the intervention and at a 3-month follow-up, the RNs’ and LPNs’ knowledge had significantly improved. This improvement is indicative of the effectiveness of education and suggests that ongoing staff training on pressure ulcer prevention and treatment is both necessary and important. More evaluative studies are needed to assess the impact of standardized, evidence-based education on nurses’ knowledge, and, ultimately, on how this impacts practice. 

Program Design: “Make it Fun or Don’t Bother” 

To make training more interesting and impactful, I (Ms. Oakley) adopted the “Make it fun or don’t bother” motto while working as a treatment nurse at a long-term care facility in New York. This is because I recognized that after a long day of giving care to residents, the staff needed something much more engaging and stimulating from my inservice to make the education meaningful. I recalled an important aphorism, which was first described by Ann Algier in her 1979 book Everything You Need to Know About Learning⁶: 

You remember approximately 10% of what you read.

You remember approximately 20% of what you hear.

You remember approximately 30% of what you see.

You remember approximately 50% of what you hear and see.

You remember approximately 90% of what you do.

With these facts in hand and a thorough knowledge of what needed to be taught, I designed a program that truly engaged the staff and made a difference in pressure ulcer prevention and treatment in my facility. The following describes each component in my plan to improve my staff’s knowledge of pressure ulcers and how to prevent and manage them.

Communication and Teamwork

To be an effective educator, I began by fostering open communication among team members. Giving staff the freedom to discuss their concerns and obstacles to providing quality care without fear of a punitive response is critical to determining how care can be improved. All levels of staff involved in patient care were invited to attend the sessions and were taught the importance of involving multiple disciplines in preventing and treating skin breakdown. For example, even the activities personnel played an important role in the care of patients with ischial pressure ulcers by making sure that these patients did not spend too much time in their wheelchairs. One way this was achieved was by having this staff bring these residents down to the activity room last for events (eg, Bingo) and bring them back to their rooms first following these events, enabling these residents to be helped back into bed more quickly as a measure to relieve pressure on their ischium. 

The Value in Doing, Not Telling

Class content, whenever possible, was always demonstrated rather than lectured. For example, patient repositioning and turning was practiced on fellow students in a vacant room, rather than just being talked about. To demonstrate the need to keep linen smooth under our patients, students were seated on bunched up incontinence briefs and catheters during class time and told not to move. These experiences helped students understand the importance of procedures that might have otherwise seemed arbitrary.

Constant Visual Reminders

Slogans, such as “Inspect every nook and cranny of your residents’ fanny,” were frequently used to keep everyone focused and having fun. Posters containing these slogans and other teaching points were created and posted at the nursing station and in staff areas, including staff restrooms. These posters provided staff with ongoing reminders of key points. 

Fun and Games

Games were designed to teach the key curricula points in a fun and engaging way. “Fanny Feud,” “Butt Bingo,” and “Wheel of Wounds” were highly successful in keeping staff attentive and in fostering a teamwork atmosphere. Small prizes were awarded to staff, along with stickers and badges to be worn proudly on their uniforms. When teaching about the prevention of sacral pressure ulcers and diabetic foot ulcers, I made fun and relevant candy rewards in the shape of behinds and feet for class participants. To make these candies, I melted chocolate into molds in these shapes and added red sprinkles to represent the wound. Molds like these can be purchased online and in a variety of craft stores. My teaching sessions also began with humor in the form of icebreakers. For example, attendees were asked to tell three things about themselves, two that were truths and one that was a lie. Fellow students had to guess which one was the lie. 

Patient Outcomes During the Program

Over the 5-year period that this program was in place, the nosocomial pressure ulcer rate dropped from 13% to 3%, and the number of unstageable heel ulcers that were incorrectly categorized as Stage I or Stage II with blisters dropped to zero. Very few staff members complained about having to attend these training sessions. Actually, the staff seemed to look forward to them, and these sessions generated quite the buzz on the units, which is exactly what is needed to keep the day-to-day focus on the tasks required to prevent skin breakdown. If your training session is forgettable, so is the lesson. Therefore, being creative and involving the staff in the learning process is a great way to educate them on this important topic. 

Disclosures

The authors report no relevant financial relationships.

References

1. Centers for Medicare & Medicaid Services. Hospital-acquired conditions. www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html. Accessed July 16, 2012.

2. Volgelpohl TS, Dougherty J. What do nursing students learn about pressure ulcers? A survey of content on pressure ulcers in nursing school textbooks. Decubitus. 1993;6(2):48-50, 52.

3. Delmore B, Lebovits S, Baldock P, Suggs B, Ayello EA. Pressure ulcer prevention program: a journey. J Wound Ostomy Continence Nurs. 2011;38(5):505-513.

4. Finlay K, Smith J, Abrams S, Evangelista M. The impact of education on pressure ulcer prevention. J Wound Ostomy Continence Nurs. 2004;31(3S):S3-S4.

5. Sinclair L, Berwiczonek H, Thurston N, et al. Evaluation of an evidence-based educational program for pressure ulcer prevention. J Wound Ostomy Continence Nurs. 2004;31(1):43-50.

6. How to study actively. Academic Skills Center. Dartmouth College. 2001. www.dartmouth.edu/~acskills/docs/study_actively.doc. Accessed July 13, 2012.

Ms. Oakley will be presenting on her educational initiative at the Wild on Wounds conference, September 14, 2012, Caesars Palace, Las Vegas. Visit www.woundseminar.com for more information on the conference.