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An Innovative Teaching Strategy for Pressure Ulcer Documentation: The Case for Computer-Based Learning
Pressure ulcers are present in 1.6 million patients in the acute care setting.1 The estimated average cost to manage a pressure ulcer is $37,000, which includes additional nursing time, supplies for dressings, medications, nutritional services, and physician fees.1
Patients who develop pressure ulcers in the hospital usually have increased length of stay, increased cost, and pain.1 Nurses need to accurately document the presence of a pressure ulcer and its characteristics to effectively provide patient care. Without the pressure ulcer documentation, a hospital may be found negligent if litigation is pursued.2 Beitz, Fey, and O’Brien2 found that many nurses need continued staff development to better assess and document wounds and pressure ulcers. With computer-based learning, staff educators and nurses can “click it and fix it” to provide education for an unlimited number nurses at any given time in the day.
According to Cooper,3 all wounds must be accurately assessed and documented to provide a baseline for recommended treatment and evaluation. Cooper also notes that without adequate documentation, healthcare providers cannot determine the effectiveness of treatments provided. Documentation for wound assessment should include location and size of the wound, presence of undermining or tunneling, condition of the wound bed, amount of exudate, presence of odor, and periwound condition.4
Deficits in documentation for pressure ulcers were identified by the Moses Cone Health System 2001 Prevalence Study.5 The data for two system hospitals reflected only three nursing units with complete documentation of pressure ulcers; the remaining 16 nursing units had inadequate or no documentation for pressure ulcers.
Moses Cone Health System consists of three acute care hospitals, one women’s hospital, one behavioral health hospital, and three long-term care facilities located in two counties. The challenge was to provide education to all nurses across the system in a timely manner without drastically disrupting patient care. A computer-based learning (CBL) module on identifying and documenting wounds called “Identifying Pressure Ulcers and Wounds” provided a potential solution.
Computer-based learning allows the participant to complete information at his/her own pace without the assistance of an instructor. This instructional method can provide graphics and illustrations for the visual learner — images that may later be recalled in clinical practice.6 Nurses can obtain knowledge, complete mandatory competencies, and enhance professional development by completing CBLs.7 Computer-based learning also can cut cost by allowing the learning modules to be completed on any nursing department during downtime.
Other advantages associated with CBL include 24-hour/day accessibility, self-paced learning, time savings, and consistent presentation of content.8 Computer-based learning is also beneficial because the evaluations can be automated and content can be revised quickly.9
Disadvantages associated with CBL are cost for the software, learner anxiety related to computer use, and the impersonal method of learning.10 Additionally, some nurses felt it was difficult to obtain timely answers to questions as they related to the content in the CBL.
To educate nurses within our health system on wound identification and documentation, a CBL was developed using Microsoft PowerPoint for identifying pressure ulcers and wounds. Targeted to staff nurses, the objectives for the CBL included defining the term pressure ulcer, recognizing the stages of pressure ulcers, and identifying partial- and full-thickness wounds. Wound types covered in the CBL included pressure ulcers of various stages, partial-thickness skin tears, and full-thickness abdominal wounds. The content was obtained from recent literature and referenced at the conclusion of the CBL. A six-question post test was developed related to stated objectives.
Graphics and pictures, provided with written permission by the National Pressure Ulcer Advisory Panel (https://www.npuap.org), were inserted both to stimulate the learner and help him/her more accurately identify types of wounds. For example, the definition of each pressure ulcer coincided with the picture of that wound.
Once the computer-based lesson was completed, participating nurses completed the post test and received an immediate score. According to an evaluation of post test results, 2,181 nurses completed the CBL in 2003 with an average score of 89%. Chart audits on wound documentation completed by Wound Ostomy Continence Nurses before implementation of the CBL indicated that documentation was accurate in 69% of the charts in 2002. Improvement in documentation was evident after chart audits were repeated 2 months after implementation of CBL with average scores equaling 90% for 2003. As a result of these improved scores, every new nurse must complete this CBL module during orientation.
Results of the post test scores were reviewed 1 month after implementation. The review included a question analysis that indicated nurses correctly answered each question at a rate of 80% or greater. In addition, this CBL was also cost-effective for the hospital system because nurses did not need to leave their unit and attend a formal class. The content for all CBLs in Moses Cone Health System are reviewed and revised 2 years after implementation.
Conclusion
The CBL module “Identifying Pressure Ulcers and Wounds” was created to meet the needs of nurses throughout a specific healthcare system but similar computer learning modules can be developed and used in a variety of healthcare settings. Computer-based learning offers nurses the opportunity to acquire knowledge in a self-directed, convenient, cost-effective manner. Most importantly, it can target a specific area of instruction and have a positive impact on care, as evidenced by our improvement to 90% documentation.
1. Pieper B. Mechanical forces: pressure, shear, and friction. In: Bryant R, ed. Acute and Chronic Wounds. St. Louis, Mo.: Mosby; 2000:221–225.
2. Beitz J, Fey J, O’Brien D. Perceived need for education vs. actual knowledge of pressure ulcer care in a hospital nursing staff. Dermatol Nurs. 1999;11(2):125–134.
3. Cooper D. Assessment, measurement, and evaluation: their pivotal roles in wound healing. In: Bryant R, ed. Acute and Chronic Wounds. St. Louis, Mo.: Mosby; 2000:41–83.
4. Rolstad B, Ovington,L, Harris A. Principles of wound management. In: Bryant R, ed. Acute and Chronic Wounds. St. Louis, Mo.: Mosby;2000:88–112.
5. Hill Rom. Prevalence for Moses Cone Hospital and Wesley Long Hospital. Unpublished raw data. 2001.
6. Neafsey P. Computer-assisted instruction for home study: a new venture for continuing education programs in nursing. The Journal of Continuing Education in Nursing. 1997;28(4):164–172.
7. Tronni C, Prawlucki P. Designing a computer-based clinical learning lab for staff nurses. Computers in Nursing. 1998;16(3):147–149.
8. Ferrell D, DeBoard C. Make computer-based training user-friendly. J Nurs Admin. 2003:33suppl:30–31.
9. Bove L. Computer-assisted education for critical care nurses. Critical Care Education. 2001;13(1):73–81.
10. Wolford R, Hughes L. Using the hospital to meet competency standards for nurses. Journal for Nurses in Staff Development. 2001;17(4):182–187.
