A Quasi-Experimental Evaluation of an Education Program for the Use of Electrical Stimulation Therapy to Heal Pressure Injuries

Electrical stimulation (E-Stim) involves applying low levels of electrical current. Despite high-level recommendations for E-stim use in many pressure injury (PrI) best practice treatment guidelines, clinicians seldom use E-Stim. Purpose: This quasi-experimental design study aimed to determine whether an educational program could improve health care providers’ knowledge and attitudes regarding the use of E-Stim for treating PrIs in community-dwelling individuals with spinal cord injury living in 1 region of Ontario, Canada. Methods: An educational intervention based on a university-level continuing education program was developed as part of a multifaceted  knowledge mobilization project. Health care providers (eg, nurses, physicians, and allied health professionals) from multiple agencies were invited to participate. The instructional series included 8 online modules on background theory and knowledge and a hands-on workshop that familiarized participants with the equipment necessary to deliver E-Stim. Knowledge (percentage of correct answers using a knowledge test developed by the research team) and attitudes (assessed using the E-Stim Attitude Survey in which items were scored using a 5-point Likert scale (where 0 indicated a negative attitude and 5 a positive attitude) were evaluated 3 times (pre-education, post-online, and post-workshop). Data were aggregated into unit-weighted averaged composites of 3 attitude subscales (resources, evidence-based practice, and education), which were compared before and after educational sessions using a linear mixed effect model.  Results: Among the 83 participants, a significant increase in knowledge scores was noted from pre-education (55.9%) to post-online (78.4%) and post-workshop (78.0%) (X² [2] = 89.34; P <.001). A significant increase in attitude scores was noted across time points (resources: X² [2] = 27.32, P <.0001; evidence-based practice: X² [2] = 38.93, P <.0001; and education: X² [2] = 92.88, P <.0001). For the evidence-based practice subscale, attitude increased significantly post-online (t[127] = 6.03, P <.0001). For the resources subscale, a significant increase was detected after post-workshop (t[113] = 5.23, P <.001]. Conclusions: Online education increased health care providers’ knowledge about E-Stim; however, hands-on workshops were required to change certain attitudes about the use of E-Stim for wound healing. Further research is required to evaluate 1) whether a change in knowledge and attitude scores translates to a practice change for health care providers and 2) the potential importance of ongoing coaching and mentorship for a sustainable change in the clinical setting. 

Pressure injuries (PrI), also known as pressure ulcers, are a common complication that occurs across all sectors of health care, including hospitals, long-term care, and home and community care.^1,2 Prevalence and incidence studies have shown PrIs result in a decreased quality of life^3-5 and increased mortality rates.^6-8 PrIs also place a large financial burden on the health care system: PrI care has been estimated to have a monthly cost of $4750 CAN for individuals with a spinal cord injury (SCI) who live in the community, and the hospital cost of a single PrI can range from $11 000 to $90 000 CAN.^9-11 Given the high cost to patients and the health care system, it is imperative to utilize evidence-based interventions to maximize healing rates in patients with a PrI. 

Electrical stimulation (E-Stim) involves applying low levels of electrical current in or around a wound for the purpose of promoting wound closure. A recent extensive systematic review¹² identified 18 systematic reviews and 33 well-designed controlled clinical trials that evaluated the effect of E-Stim on healing of common wound types; most of the included studies concluded E-Stim accelerates wound size reduction and increases the likelihood of complete wound closure compared to either placebo and/or standard wound care (SWC), as defined by local best practice guidelines, in chronic wounds.^13-16 E-Stim is strongly recommended for the treatment of PrIs in several national and international best practice guidelines.^17-20 A large interdisciplinary panel assigned E-Stim treatment the highest level of evidence (Level 1a) in a recently updated version of the Registered Nurses Association of Ontario (RNAO) guidelines for the assessment and treatment of PrIs.^17-20 

Despite the recommendation of this key wound care resource that is used across Canada, there has been little uptake for the use of E-Stim in clinical practice. In a knowledge translation study by Lala et al,²¹ one of the most commonly cited barriers to the implementation of E-Stim was the lack of knowledge and competency in providing the treatment. Community care providers also perceived a lack of awareness of E-Stim and few opportunities to obtain of training and skill in E-Stim application techniques.

To date, educational programs for PrIs have focused on the nursing profession and implementing practices that address PrI prevention.^22-28 In 2010, Strand and Lindgren²² assessed nurses knowledge, attitudes, and perceived barriers and opportunities toward PrI prevention in an intensive care unit (ICU) setting in a Swedish hospital. Of the 146 completed questionnaires, 47% of respondents correctly staged PrIs, and the authors noted that several respondents did not answer some of the knowledge questions. Perceived barriers to PrI prevention included lack of time for interventions, such as turning schedules, and the severity of patient illness in the ICU setting. Opportunities for knowledge and access to pressure-redistribution equipment were most commonly reported as facilitators for best practices. The authors concluded that raising knowledge among nursing staff, as well as making PrI prevention a priority in daily care, was an important organizational challenge in the ICU. 

In 2004, Gunningberg et al²³ investigated the effect of a PrI prevention program among 20 registered nurses (RNs) from hospital and community settings in Sweden. The educational program consisted of a multidisciplinary team approach and included 40 hours of lecture and 40 hours of practice. Knowledge, as well as documentation and prevention strategies, was assessed immediately before and after an educational program and then 8 months after attending the educational program. Knowledge was measured using a questionnaire, and documentation was evaluated by conducting chart reviews. PrI prevention strategies used by nurses were assessed by interviewing the head nurse before and 8 months after the education program to determine nursing change in practice. The authors found a significant increase in knowledge about PrI prevention after the educational program and at the 8-month follow-up (P <.001); 55% of the RNs had implemented new routines based on the education they received. However, documentation on patient risks and treatment interventions for the prevention of PrIs were still lacking after the program. 

In 2004, Sinclair et al²⁴ assessed the difference in knowledge immediately after and 3 months following a PrI prevention workshop among 595 RNs and 59 licensed practical nurses working at 1 of 3 specific hospitals in Canada. The researchers assessed change in knowledge using a modified version of the Pressure Ulcer Knowledge Assessment Tool (PUKAT),²⁹which included 53 items on PrI staging, wound description, and risk assessment and prevention. Knowledge scores were significantly higher after attending the 3.5-hour workshop compared to preworkshop scores; knowledge scores decreased at the 3-month follow-up in relation to the scores immediately after the workshop.²⁴ The authors²⁴ concluded that the education for evidence-based practice in PrI prevention is effective and suggested that ongoing staff education for PrI prevention and treatment is both necessary and important. 

Change in practice is recognized to require not only increased knowledge, but also advances in practitioners’ perceptions and attitudes toward the practices, such as their perceived competency to deliver an intervention. Several studies^22-28 have evaluated change in knowledge over time but did not address practitioner attitude toward the practice change. To further evaluate the uptake of PrI prevention programs, knowledge, attitude, and practice (KAP) surveys have been developed. These KAP surveys help identify what people know (knowledge), how they feel (attitude), and what they do (practice).³⁰

Källman and Suserud²⁵ used a questionnaire to assess RN and nursing assistant (NA) knowledge, attitudes, and practices as well as perceived possibilities and barriers regarding PrI prevention in community and hospital care settings in Sweden. The 154 participating nurses were found to have generally good knowledge about the prevention and treatment of PrIs, although in terms of practice only 37% said they have a strategy in place at work for PrI prevention. The authors concluded that given the low number of reported PrI prevention strategies, the quality of care provided to the patients was compromised and could lead to PrI development. 

A cross-sectional, multicenter study by Demarré et al²⁷ evaluated the association between knowledge and attitudes of nurses and NAs (N =145) and compliance with PrI prevention guidelines in residents (N =615) at long-term care homes in Belgium. PrI prevention was defined as fully compliant if all preventative measures in bed and when seated were applied, partly compliant if some measures were applied in bed and/or while seated, and no prevention compliance as the total absence of any adequate preventative measure. Knowledge and attitude were assessed using a random sample of at least 5 nurses from 18 participating long-term care wards. The PUKAT and Attitude Towards Pressure Ulcers (APuP) instruments were used, both of which have been validated in the literature.^29,31 The mean knowledge scores were 29% for nurses and 29% for NAs. The overall attitude score was 75%. The authors concluded that attitudes of nurses and NAs toward PrIs were strongly associated with the application of fully compliant PrI prevention guidelines, while knowledge was not. Collectively, these studies suggest that positive attitudes toward PrI prevention may contribute to compliance with clinical practice guidelines in PrI prevention more than knowledge scores. 

The challenges of promoting practice changes that involve adopting the use of new advanced technologies are increasingly recognized.³² Members of the Canadian Association of Wound Care³² reviewed research literature and identified several additional factors that needed to be considered (eg, what and when to introduce advanced therapies in the management of diabetic neuropathic foot ulcers in Canada). Some additional challenges associated with introducing new advanced therapies include having resources to locate and purchase specialized equipment and accessories and knowing how to properly operate and maintain the devices. 

Using E-Stim as an advanced therapy for PrIs is a practice change that has additional challenges because 1 person or a particular health care profession seldom possesses the knowledge and expertise regarding E-Stim and wound care; the implementation of an E-Stim program often requires interprofessional collaboration. 

The purpose of this study was to develop and evaluate an interprofessional educational program for the implementation of E-Stim in PrI treatment. Specifically, the goals were to:

1) Evaluate provider baseline knowledge and attitudes toward the use of E-Stim for wound healing; 

2) Develop an interprofessional E-Stim education program that optimizes the use of online technology; and

3) Evaluate the effect of the E-Stim education program on practitioner knowledge and attitude toward the use of E-Stim for wound healing. 

Setting. The educational program in this study was developed as part of a multifaceted knowledge mobilization project aimed to implement E-Stim for treating PrIs in community-dwelling individuals with SCI living in 1 region of Ontario, Canada.²¹ The overall aim of the E-Stim Collaboration Project was to support home care services in a way that promoted uptake and use of E-Stim therapy for the treatment of people living with PrI and SCI. 

Participants. As part of the E-Stim Collaboration Project, an awareness campaign was conducted to engage providers in all health care sectors including the community, homecare, long-term care, hospitals, and private clinics. Multiple agencies that contracted health care providers from several different professions and disciplines (eg, nurses, physical therapists, occupational therapists, personal support workers) to provide home care in this region were visited by a research team member who provided information about the E-Stim Collaboration Project and extended an invitation to participate in the E-Stim Education Program. Inclusion criteria were health care providers who were willing to obtain education about E-Stim. Exclusion criteria were participants who did not complete the online modules, attend the hands-on workshop, or finish the knowledge test and/or attitude questionnaire. 

All participants who took part in the educational program signed written consent after reading a letter of information. The study was approved by the ethics review committee of Western University Health Science Research Ethics Board of London, Ontario, Canada (HSREB File Number 107778). Informed written consent was obtained from all participants to share pooled results of completed tests and surveys. Before beginning the education, general characteristics were collected about the participant’s professional background, education, and experience in providing wound care. Demographic data were collected using an online questionnaire with multiple choice selection and included profession, years of experience, sector, role in wound care, province of practice, percent of time spent in wound care, work hours, and level of wound education (see Table 1).

Development of the E-Stim education program. An education program for the use of E-Stim on PrIs was developed to address core competencies for skilled application based on a university-level continuing education program that was delivered successfully over the past 20 years. The educational program included components of a recently produced clinical practice guideline¹⁷ and incorporated feedback from several key stakeholders. A model of care for healing PrIs with E-Stim was developed by Lala et al²¹ that took into account implementation barriers, including inadequate training and education. In this knowledge mobilization study, 29 stakeholders, including hospital and community administrators and practice leaders, hospital and community frontline care providers, and SCI consumers with recent or prior experiences with PrIs, noted a lack of awareness, knowledge, training, and skills surrounding the use of E-Stim in treating PrIs across the continuum of care. The stakeholders expressed a preference for educational resources that would be readily accessible on demand and available in both electronic and print format. They also wanted an opportunity to have hands-on practice with E-Stim application techniques and experience manipulating specialized E-Stim equipment and accessories. The E-Stim education program was developed based on this stakeholder input and used a case-based approach to promote advanced clinical decision making and critical thinking. A peer-led practical skills evaluation was used to test hands-on skills required to use E-Stim in a safe and effective manner.

Creation of E-Stim online modules. Eight (8) modules were created using a secure online learning platform associated with Western University and were developed to allow participants to review material at their own pace and on their own schedule. Online learning allowed for increased access for participants and reduced the time required for the face-to-face component of the educational program. The online modules consisted of background theory and knowledge using narrated PowerPoint presentations that were organized into 8 recorded lectures totaling approximately 4 hours. Table 2 describes the content contained in the 8 modules. 

Hands-on workshop. After participants completed the online modules, they were invited to participate in 1 of 7 hands-on workshops that were offered over a 1-year period. The hands-on workshops were led by 2 Clinician Researchers who collectively had more than 45 years’ experience using E-Stim for wound treatment. The main objective of the hands-on workshop was to develop the clinical skills required to apply E-Stim to patients with PrIs. The face-to-face class section also allowed practitioners from different professional backgrounds and clinical experiences to work together to identify cases where E-Stim is appropriate and to design E-Stim treatment protocols that are feasible to administer and likely to produce the best healing outcomes. 

The specialized equipment and supplies (eg, electrodes, leads) required for the delivery of E-Stim to wounds were available during the hands-on workshop. Wound healing fundamentals, including local wound care, understanding wound etiologies, and aseptic techniques, were embedded throughout the hands-on session.^17-20 Participants were made aware of the risks and benefits of applying electrical energy to wounds and participated in case studies to screen clients for known contraindications and precautions. After a brief demonstration of E-Stim application techniques, participants set up E-Stim equipment and applied electrical current to realistic latex wound models. Participants also were encouraged to experience the sensation of E-Stim to diminish fears and describe expected sensations to their patients. This was followed by a peer evaluation that was supervised by 2 of the study researchers to confirm participants completed all the application steps in a safe and effective manner. 

Another key component of the workshop was a review of wound dressings that are compatible with E-Stim. Participants were exposed to samples of different types of wound dressings and products. Selection and rationale of the most appropriate dressing for each case was developed via interactive case discussions. Patient scenarios were developed and reviewed during the hands-on workshop to test participant understanding of electrical principles and how changing the E-Stim set up or wound environment can affect electrical current flow. 

At the end of the workshop, the clinicians were invited to participate in a Community of Practice, which continued to meet monthly to share experiences and discuss challenges regarding E-Stim implementation via a secure web-based online video/audio link. The Community of Practice was developed as part of the E-Stim Collaboration Project and provided an online forum to link more than 150 clinicians across Canada working in this field. 

Instruments.

Knowledge Test. Knowledge about principles of electricity, mechanism of action, and research evidence was measured using a multiple-choice test. The knowledge test was either administered online, where 10 questions were randomly selected from a pool of 25 multiple choice questions, or on paper, where all 25 questions were included in an in-class quiz (post-workshop). Knowledge questions were developed by the research team and pilot-tested during a prestudy education session. The percentage of correct answers was tabulated.

E-Stim Attitude Survey (EAS). An attitude survey was developed by the research team to understand the attitudes participants had toward the use of E-Stim on PrIs and their willingness to incorporate an advanced therapy into practice. The survey was based on the APuP instrument,³¹ a 13-item questionnaire used to assess health care provider attitude toward PrI prevention. The APuP was developed and validated by Beeckman et al³¹ for PrI prevention programs and adapted to include content related to E-Stim.

 Survey questions were grouped into 3 subscales to define participant attitude: 

1. Education: Attitude toward the importance of knowledge and skills for the use of E-Stim in practice;

2. Evidence-based practice: Attitude toward research evidence and the ability of E-Stim to stimulate/accelerate the healing of pressure injuries; and

3. Resources: Attitude toward resources and equipment needs when using E-Stim in clinical practice. 

The EAS consisted of 14 items measured on a 5-point Likert scale with answer options that included strongly agree, agree, neutral, disagree, and strongly disagree. Statements were phrased so they presented both positive and negative attitudes toward E-Stim. The education subscale consisted of 5 items, the evidence-based practice subscale consisted of 4 items, and the resources subscale consisted of 5 items. Internal consistency measured using Cronbach’s alpha was calculated for each subscale using the 83 nonexpert study participants and found to be acceptable for education (α = 0.74), evidence-based practice (α = 0.76), and resources (α = 0.74).

Timing of evaluations. Knowledge tests and the EAS survey were evaluated at 3 time points throughout this study: before commencing with the education (pre-education), after completing the online modules (post-online), and after completing the hands-on workshop (post-workshop). Participants were given access to the online modules, pre-education test, and survey when they registered for the hands-on workshop and asked to complete the evaluations before starting the workshop. All participants completed the pre-education and post-online on the computer, and the post workshop test and survey were completed using a paper tool that was provided at the end of the workshop. Tests and surveys were administered electronically via the online education system for pre-education and post-online evaluations. Data were aggregated from the online evaluations and paper tools across the 3 time points onto a large spreadsheet for data analysis. Anonymity was not maintained because the post-workshop evaluations were collected in person to allow the primary researcher to compare the results of participants over the 3 time points. Minimum and maximum time between each stage of the testing varied. 

Data analysis. Demographic information describing the type and amount of clinical experience was collated and analyzed using descriptive statistics (see Table 1). Knowledge was assessed using the percentage of correct answers on the knowledge test. EAS results were converted to numeric scores to analyze the data. The survey consisted of 14 items measured on a 5-point Likert scale, with responses that included strongly agree, agree, neutral, disagree, and strongly disagree. The Likert scale was converted into numeric scores, with 0 equaling a more negative attitude to 5 equaling a more positive attitude. Attitudes were assessed using the subscales education, evidence-based practice, and resources. A weighted average was calculated for each of the subcategories. To evaluate the impact of the education program on knowledge and on the 3 subscales of the attitude questionnaire, a separate linear mixed effects model was fit to each of the 4 dependent variables. Time of measurement (pre-education, post-online, post-workshop) was included in the model as a fixed effect, and participants were included as a random effect. Utilizing a linear mixed effects model facilitated use of all available data without the need for list-wise deletion of participants with missing data or interpolation of these missing data points.³³ The statistical significance of the fixed effect was identified by comparing this model to a null model in which the dependent variable was predicted only by random error. In the event of a statistically significant fixed effect, post-hoc testing was performed on all possible pairwise comparisons using t tests with degrees of freedom estimates that were calculated using a Satterthwaite³⁴ approximation. All statistical analyses were performed in R³⁴ (R core team, University of Auckland, New Zealand), with linear mixed effects analyses conducted using the lme4³⁵ and lmerTest³⁶ packages. Post-hoc pairwise comparisons were completed using the lsmeans package.³⁷ 

Participant characteristics. Of the 87 participants who completed both the online modules and the hands-on workshop education program, 83 were included for data analysis (ie, 83 completed the APuP at baseline), but only 74 provided demographic information. Most participants were RNs (32), followed by physiotherapists (20), enterostomal therapists (8), occupational therapists (6), registered nurse practitioners (5), other (2), and physicians (1). Nine (9) participants did not report their occupation. Most participants (41) worked in a hospital environment and in a full-time capacity (58). Participants had a variety of background knowledge in wound management, but the majority (42) had attended either inservices or a 1- to 2-day workshop as their highest level of wound care knowledge. Post-hoc analysis was not completed on demographic variables. All participants were included in the analysis.  

Knowledge. 

Baseline scores. The mean baseline knowledge score for participants before participating in the E-Stim education program was 55.6% ± 7.3%, with 42 of the 83 participants achieving a score of 50% or less. Participants were most challenged by E-Stim knowledge questions pertaining to the biological mechanisms by which E-Stim stimulates cellular processes of tissue repair and how certain clinical scenarios affect electrical current flow. For example, participants were given a multiple-choice question that asked how E-Stim improves blood flow and tissue oxygenation. They also were provided with clinical scenarios and asked how they would modify their treatment plan based on the clinical findings — for example, how would E-Stim treatment change if the electrode became dislodged?

Change in knowledge scores. Mean scores for the knowledge tests for the 3 time points are presented in Figure 1. Mean scores were 55.5% ± 7.3% pre-education, 78.4% ± 8.0% post-online, and 78.0% ± 6.9% post-workshop. Using the mixed effects model, the effect of time was statistically significant (P <.001). Post-hoc evaluation showed a statistically significant increase in knowledge after completing the online modules (t [14]) = 9.18; P <.0001). Knowledge scores were also higher when participants had completed the hands-on workshops compared to pre-education (t [141] = 9.81; P <.0001). 

Attitudes.

Baseline attitudes. Of the 83 participants, 56 (67.5%) agreed that providing E-Stim to patients with delayed wound healing is important (see Figure 2). No participants disagreed with the statement “The individuals I see with open wounds could benefit from E-Stim.” However, the majority of patients had a low perceived competency for the application of E-Stim in clinical practice, and 69 participants (83.1%) agreed with the statement “I need more hands-on practice and clinical experience with E-Stim before I could incorporate into my practice.” Fifty-two (52) participants (62.7%) agreed with the statement “I do not feel I have the advanced knowledge and skills that are required to apply E-Stim to wounds.” Fifty (50) respondents (60.2%) provided a neutral response to “the cost to provide E-Stim to patient is too high,” and 59 (71.1%) were neutral to the statement that negative pressure wound therapy was more appropriate for their clients than E-Stim.

Change in attitude scores. Mean scores for the EAS subscales of education, evidence-based practice, and resources over time are shown in Figure 3. Post-hoc analysis revealed a progressive and significant increase in attitude scores related to the education subscale over all 3 time points: between pre-education and post-online (t [140] = 7.08; P <.05); between pre-education and post-workshop (t [136] = 10.98; P < .05); and between post-online and post-workshop surveys (t [140] = 3.13; P <.05). 

For the evidence-based practice subscale, attitude scores increased significantly after the online modules were completed (t [127] = 6.03; P <.05). Attitude scores toward E-Stim also improved over baseline after the hands-on workshops were completed (t [122] = 4.86; P <.05), but no further improvement in attitude scores was detected between post-online and post-workshop. 

For the resources subscale, a significant increase in attitude scores toward E-Stim was not detected until after the hands on workshop (pre-education and post-workshop: t [113] = 5.22; P <.05; post-online and post-workshop: t [115] = 4.07; P <.05). No significant difference was noted in the attitude scores for the resources subscale between baseline and after completing the online modules. 

The results of this study demonstrated that a customized online education program increased knowledge about E-Stim in a group of multidisciplinary health care providers. Subsequent completion of a hands-on workshop was required to change certain attitudes about E-Stim use for wound healing. 

To the authors’ knowledge, this is the first research study to evaluate knowledge and attitudes regarding the use of E-Stim by health care providers involved in the treatment of PrIs. Assessment of knowledge and attitudes for the use of an evidence-based intervention such as E-Stim is important given the many barriers associated with the implementation of advanced therapies.²¹ This study showed that a 4-hour online education program could significantly improve clinician knowledge regarding E-Stim. Clinicians could independently complete this online program when it was convenient, and the background information provided as part of the instruction could be referenced in the future when required by the clinician. 

Interestingly, no further increase in knowledge was detected after completion of a hands-on session. This was expected, given the theoretical knowledge component of the educational program was delivered via online modules, and the background information was not repeated during the hands-on workshop. It is also possible changes in knowledge scores were not able to be detected after the hands-on workshop because the test was administered differently pre- and postworkshop — that is, the paper-based test with all 25 multiple choice questions that was administered after the workshop may have been more difficult than baseline tests where only 10 questions were selected randomly. 

Attitudes about E-Stim measured before commencing education identified certain misconceptions and practice behaviors that contribute to relatively poor uptake of E-Stim despite strong and consistent recommendations in best practice guidelines. Some of these misconceptions include the lack of E-Stim availability and high costs of E-Stim treatment. E-Stim devices are easily available for purchase in Canada at a nominal cost and come in compact, lightweight forms that run on AAA batteries. A cost effectiveness study using decision analytic modeling study by Mittmann et al³⁸ evaluated the incremental cost-effectiveness from the public payer perspective of E-Stim plus SWC versus SWC alone in a population of persons in Canada with Stage 3 or Stage 4 spinal cord PrIs. A decision analytic model was constructed for a 1-year time horizon. Model inputs for the clinical probabilities and direct health system and medical resources were based on a randomized controlled trial³⁹ of E-Stim plus SWC versus SWC alone. The researchers³⁸ found that E-Stim plus SWC were associated with better outcomes and lower costs than SWC alone. A 16.4% increase was noted in healed PrIs, along with a cost savings of $224 at 1 year. The researchers³⁸ concluded E-Stim plus SWC was a dominant strategy. 

Although knowledge can be improved using online modules, the hands-on experience was needed in order to consolidate the knowledge and to change certain attitudes. The education subscale score of the assessment instrument, which measured attitudes about the importance of E-Stim knowledge, increased after the online education was provided and continued to improve after the hands-on workshop. This demonstrated that attitudes toward the importance of E-Stim knowledge can be optimized when a combination of online instruction and a face-to-face skills workshop is provided. 

The evidence-based practice subscale score that measured attitudes toward research evidence and E-Stim effectiveness increased after completing the online modules but did not change after the hands-on workshop. The lack of change in this portion of the attitude survey was considered likely because information about clinical research and best practice recommendations was only included in the online modules and not part of the hands-on workshop. 

The resources subscale measured attitudes toward E-Stim resources and equipment needs; scores did not improve until after the hands-on workshop was completed. The authors believe this occurred because the hands-on workshop was offered as an opportunity for participants to observe and use the specialized equipment and supplies that were available to them for E-Stim treatments. Copies of order forms that demonstrated how what and how to obtain the equipment in their practice also were provided. 

Previous studies^23,24 have shown an increase in nurses’ knowledge of PrI prevention after educational workshops, but they did not evaluate attitudes. Likewise, the studies that evaluated attitudes of health care providers toward PrI practices did not assess whether an educational program can change attitudes.^22,25-28,40 The current findings demonstrate the importance of providing a combination of knowledge and skills and having a hands-on workshop. As such, negative attitudes and barriers to E-Stim implementation could be overcome by having the equipment available for participants to use during the workshop and attain a better understanding of the time and steps required for E-Stim set up. The current authors also required all course participants to demonstrate they were able to manipulate the equipment and set up all the supplies appropriately during the hands-on workshop. 

The challenges involved in achieving practice change and encouraging clinicians to adopt new approaches into clinical care are well documented in the literature.^41-45 This has fueled the emergence of a new area of research called implementation science. Despite numerous frameworks and established processes to identify and address barriers and involve end users, sustained practice change remains elusive. The authors believe this study experience suggests that filling knowledge gaps and addressing concerns about competency using an innovative and accessible education program is only part of the underlying problem with integrating new treatments into wound care practice. 

This study addressed the barrier of training and education for the implementation of E-Stim for the management of PrIs. However, several other barriers to implementation also exist, such as lack of interdisciplinary collaboration and communication, lack of funding, lack of time and staff, and lack of system support.²¹ Another limitation was use of the online modules. Although this instructional venue allowed for participant flexibility in partaking of the online education, variability existed in the time taken for individuals to review the education as well as the time between taking the online education and participating in the hands-on workshop and the testings. 

In addition, the knowledge tests and attitude scores were collected on a group of providers who volunteered to attend optional continuing education programs that were provided nearby at no cost to the participant or agency. Therefore, the results represent the attitude scores of motivated and interested persons and are likely positive relative to all providers providing community-based wound care in this region. The attitude survey used in this study did not allow participants to expand on or explain their responses. Therefore, the authors were unable to explore some of the positive or negative attitudes about E-Stim. For example, it is not clear why the majority of providers were undecided (neutral) when deciding whether NPWT or E-Stim is the more appropriate advanced therapy for PrIs, despite clear recommendations that favor use of E-Stim that are outlined in the RNAO best practice guidelines.

A quasi-experimental study was conducted to evaluate an education program for the use of E-Stim to treat PrIs that included online modules and a hands-on workshop. The study found that education delivered using online modules that includes theoretical background and a critical review of clinical research evidence can increase health care providers’ knowledge about E-Stim. However, a hands-on workshop session was required to improve certain attitude scores toward E-Stim. These findings suggest that face-to-face clinical skills education is required to address implementation of best practice interventions. Further research is required to evaluate whether a change in knowledge and attitude scores translates to a practice change for health care providers and the potential importance of ongoing coaching and mentorship for a sustainable change in the clinical setting. 

Dr. Orr is the Program Lead, South West Regional Wound Care Program, Ontario, Canada. Dr. Houghton is a Professor, School of Physical Therapy, Western University,  London, Ontario, Canada. Dr. Holyoke is the Director, Saint Elizabeth Research Centre , Markham, Ontario. Dr. Lala is a physiotherapist, St. Joseph’s Health Care London, London, Ontario. Please address correspondence to: Lyndsay Orr, PT, MClSc-WH, PhD, School of Physical Therapy, Western University, Elborn College, 1201 Western Road, London, Ontario N6G 1H1; email: Lyndsay.orr@lhins.on.ca.