Effects of PechaKucha Presentation About Prevention of Pressure Injury on Knowledge of Elderly Care Department Students: A Randomized Controlled Study

A pressure injury is a common complication in older patients who have difficulty turning in bed.¹ Vanderwee et al state that the prevalence of pressure injuries among 5947 older people in 5 European countries was 8.3% in Italy, 12.5% in Portugal, and between 21% and 22.9% in Belgium, Sweden, and the United Kingdom.² Seventy percent of pressure injuries occur in people over the age of 70. Pressure injuries in older hospitalized patients cause an increased length of their hospital stay.³ Pressure injuries also reduce quality of life and increase medical expenses.⁴

An elderly care technician has been defined in the regulation on job descriptions of health care professionals and other professionals working in health care, published in Turkey.⁵ The job description of elderly care technicians includes assessing the physical, mental, and social care needs of the elderly and ensuring the protection and maintenance of daily living activities. Elderly care technicians follow up on medical care, that was planned by the health team, and if they detect a problem in the implementation of medical care, they report the situation to the health care professionals. They also support caring family members and encourage the elderly to engage in social activities.⁵ Pressure injury prevention and treatment requires a multidisciplinary health care team that adopts a holistic care approach.⁶ Elderly care technicians work in hospitals and nursing homes as formal caregivers of older people, and as part of this multidisciplinary team. By providing 24-hour patient care to older people, they have a role in the prevention of pressure injuries.^7,8 Therefore, elderly care technicians need to be able to evaluate the risk factors for pressure injuries and to take preventive measures.

 Educational institutions use creative tools to increase learning, strengthen the educational process, and improve learning outcomes.⁹ PechaKucha ([PK] PechaKucha, Inc) is a presentation technique that uses visual and narrative presentation, consisting of 20 slides shown for 20 seconds each, with each presentation being shown for a maximum of 7 minutes in total.^10,11 The PK, derived from the Japanese word for "chitchat," helps to visually present creative work. The concept of PK was first developed in 2003 by Klein and Dytham at a meeting on architecture.^11,12 An effective presentation technique for both presenters and audiences, PK can also be used in lectures.¹³ The PK presentation technique can be considered an innovative teaching technique within the education of health professionals. The main idea of PK is to grab the attention of the audience and allow them to listen dynamically without any loss of transmitted information. The technique, based on explaining the subject of presentation with visual images and minimal written materials, is an effective way to teach and synthesize knowledge.^13,14 Students stated that the lessons with the PK technique were more fun, attractive, interesting, liberating, and creative.^15,16 There are a limited number of studies on the PK technique in the education of health professionals.^13,14 No study could be found on the effect of the PK technique in the education of elderly care technicians. Therefore, the aim of this study was to evaluate effects of the PK presentation offered to elderly care department students about pressure injury prevention.

Design. This was a single-blind, randomized controlled study. Randomization of participants was ensured using Research Randomizer (Social Psychology Network). One of the researchers created a randomized list of participants before the study began. The total number of participants was entered into the program and automatically created the experimental and control groups. The intervention group received the PK presentation in the study. The control group received traditional classroom education using PowerPoint presentations.

Participants. The research was conducted between May and October 2022 in an elderly care program in Western Turkey. The sample of the study consists of first-year students in the elderly care department (n = 62). The criteria for including students in the research sample were being ≥18 years of age, accepting voluntary participation in the research, the ability to understand and speak Turkish, being a student of the Elderly Care Program, and not to have received associate degree education in the prevention of pressure injuries. Students who did not meet the inclusion criteria were not included in the study (n = 4). The aim of the study was explained to all participants, and all agreed to participate. The study sample consisted of 58 students. Using the randomization software, 29 students were assigned to each the intervention and control groups. Before taking the Pressure Ulcer Prevention Knowledge Assessment Test, 4 students quit the study. The study was completed with 28 students in the intervention group and 26 students in the control group. Students participating in the pre-test did not know which group they were assigned to. Figure 1 shows measurement tools and sampling losses applied to the groups in detail. In this study, the sample size was calculated using G*Power version 3.1. At the end of the study, the power was 0.93 when the effect size was 0.88 and P = .05.

PK education. The PK technique was used in the presentation on Prevention of Pressure Injuries in the Basic Principles and Practices in the Elderly course given in the spring semester of the first year of the curriculum in the elderly care department. After randomization, the intervention group students listened to the lecture using the PK technique. The course, which was prepared with the PK technique, was explained by a nurse academician supported by intensive visual material and minimal text presented in narrative form. Each of the 20 slides was shown for 20 seconds. The presentation lasted 7 minutes. In the course, pressure injury risk assessment and prevention were visualized using cartoons and pictures (Figure 2).

Traditional education. The traditional PowerPoint technique was used on the students in the control group. This lecture, which consisted of 40 slides, lasted about 45 minutes. On each slide, there were 3 to 4 sentences, each containing 6 to 7 words. The education content of both presentations was evidence-based practices for pressure injury risk assessment, pressure injury staging, and prevention (Figure 3).

Instruments. Study data were collected using the Student Sociodemographic Form and Pressure Ulcer Prevention Knowledge Assessment Instrument.

The Student Sociodemographic Form was developed by researchers using the literature.^13,14 The form consisted of questions such as age, sex, and educational status.

The Pressure Ulcer Prevention Knowledge Assessment Instrument (PUPKAI) was developed by Beeckman et al, and consists of 26 multiple-choice questions under 6 themes associated with pressure injury prevention.¹⁷ The instrument contains 6 subscales: etiology and development, classification and monitoring, risk assessment, nutrition, preventive interventions to reduce the amount of pressure/shear, and preventive measures to reduce the duration of pressure/shear. Each question has 3 responses, 1 of which is correct. The total number of correct answers for each subscale and the entire instrument indicates individual knowledge levels. The maximum score that can be obtained from the instrument is 26, and the acceptable score for proficiency is ≥ 16 (60%).¹⁷ The Cronbach alpha value of the scale developed by Beeckman et al was 0.77, the in-class correlation coefficient was 0.88, and the validity index was 0.78. The validity and reliability of the instrument in the Turkish population were tested by Tulek et al in 2016.¹⁸ The content validity index of the instrument was 0.94. The internal consistency reliability for the overall instrument was determined using the Kuder-Richardson Formula 20 (KR-20) test. The KR-20 value was found to be 0.80.¹⁸ The Turkish version of the PUPKAI (PUPKAI-T) was found to be valid and reliable.

Data collection. The PUPKAI was administered to the students as a pre-test before the presentations. After the pre-test was administered, the students in the intervention group were presented with pressure injury prevention education prepared with the PK technique. The control group was carried out with a traditional PowerPoint presentation. After the presentations given to the intervention and control group, post-test data was collected using the PUPKAI. Four weeks after the intervention and control groups completed their education, the PUPKAI was administered again (post-test 2, Figure 1).  The PK and traditional presentations were made by a nurse academician who has a doctoral degree in surgical nursing and has been trained in the course on pressure injury.  

Data analysis. Data were analyzed by using Statistical Package for Social Science 22 (JMP Statistical Discovery). Descriptive characteristics and influencing factors of the students in both the intervention and control groups were analyzed with numbers, percentages, mean, and chi-square tests. Skewness and kurtosis were utilized to determine whether the data were normally distributed. The Mann-Whitney U test was used to show whether the intervention and control groups were similar in terms of descriptive characteristics.

Ethical approval. The study was approved by the Ethics Committee of Izmir Democracy University (Approval No:  2022/05-08, Date: 27.03.2022) and the Elderly Care Department. Participants were assured that the data obtained would only be used for scientific purposes and publication. Participation in the study was entirely voluntary. Oral informed consent was obtained in accordance with the Declaration of Helsinki. In addition, written and verbal permission was obtained from volunteer students to participate in the study.

The mean age of the 28 students in the intervention group was 20.25 ± 0.24 years (range, 18-24 years). In addition, 71.4% were female, 96.4% were single, 100% were not working, 96.4% had no work experience in the hospital, and 7.2% had received extracurricular education aimed at pressure injury prevention (Table 1). The mean age of the control group was 19.66 ± 0.18 years (range, 18-21 years). Of the 26 students in the control group, 71.7% were female, 100% were single, 100% had no hospital work experience, and 100% had not received education regarding pressure injury prevention.

There was no significant difference between the intervention and control groups in terms of age, sex, marital status, work experience, and receiving education on pressure injury prevention (P > .05; Table 1). The pressure injury prevention information mean score of the elderly care department students who participated in the study was 39.91 ± 13.56 (range, 12-64).

When the PUPKAI-T mean scores of the intervention and control groups were compared after the education, it was found that there was a statistically significant difference between the PUPKAI total mean scores of the intervention group (X ± SD: 47.23 ± 11.62) and the PUPKAI total mean scores of the control group (X ± SD: 36.64 ± 12.41; P < .05). It was determined that there was a statistically significant difference between the intervention group (X ± SD: 50.00 ± 36.00) and the control group (X ± SD: 25.38 ± 13.53) after the education in terms of PUPKAI Risk assessment sub-dimension mean scores (P < .05). It was determined that there was a statistically significant difference between the intervention (X ± SD: 35.71 ± 14.76) and control (X ± SD: 26.15 ± 17.65) groups in terms of PUPKAI Preventive measures to reduce the duration of pressure/shear sub-dimension mean score (P < .05). There was no statistically significant difference between the groups in terms of etiology and development, classification and observation, nutrition, and preventive measures to reduce the amount of pressure/shear sub-dimensions (P > .05).

   Table 2. Comparison of the Intervention and Control Groups' Mean Scores on Knowledge of Pressure Ulcer Prevention

A statistically significant difference was found between the PUPKAI total mean scores of the intervention group (X ± SD: 43.11 ± 13.72) and control group (X ± SD: 36.46 ± 12.76) in the measurement post-test 2 (P < .05). At post-test 2, a statistically significant difference was found between the PUPKAI etiology and development subdimension mean scores of the intervention (X ± SD: 64.16 ± 17.34) and control (X ± SD: 48.46 ± 20.95) groups (P < .05). A statistically significant difference was determined between the intervention (X ± SD: 62.50 ± 35.02) and control (X ± SD: 32.69 ± 34.47) groups in terms of PUPKAI Risk assessment sub-dimension mean scores (P < .05). There was no statistically significant difference between the groups in terms of classification and observation, nutrition, preventive measures to reduce the amount of pressure/shear, preventive measures to reduce the duration of pressure/shear (P > .05; Table 2).

In this study, it was determined that the pressure injury prevention mean scores of the intervention group students who received education with the PK technique were higher than those of the control group in the measurements made immediately after the education (post-test 1) and 4 weeks after the education (post-test 2). In a study conducted in Iran, students answered 50% of the questions correctly on the classification of pressure injuries and 70% of the questions correctly on the prevention of pressure injuries.¹⁹ In previous studies, it was determined that health science students did not have sufficient knowledge about pressure injury prevention.^20,21 In the current study, the rate of correct answers to the questions before the education was 39%, the rate of correct answers to the total scale questions after the education was 36% to 43%, and the rate of correct answers to the sub-dimensions was determined as 31% to 57%. These results determined in the present study are lower than those reported in the literature. In previous studies, the rate of correct answers to the questions about pressure injuries varies between 63% ²², 50% ²¹, and 67%.¹⁹

Elderly care department students receive an associate degree upon completion of their education. However, studies in the literature were generally conducted with nursing students.^19,21,22 The increasing number of hospitalizations of older people brings with it an increase in pressure injuries. To prevent pressure injury increase, elderly care department students should be able to diagnose pressure injuries. In the current study, it was determined that using the PK technique was more effective than the traditional education in the measurements made both immediately after the education and 4 weeks after the education. To prevent pressure injuries, it is necessary to increase the use of the PK presentation technique and similar information-oriented techniques that include visual materials, which increase the permanence of students' knowledge in the long term.

In the current study, it was determined that the group that was trained with PK presentation had a better knowledge total and sub-dimension scores after the education compared to the group that received education with the traditional presentation technique. Guninberg et al stated that nursing students answered the questions about pressure injury classification and risk assessment correctly at a low rate (54.3%).²³ In Simonetti et al's study, students correctly answered 52.8% of questions about risk assessment and 50.7% of questions about preventive measures to reduce the duration of pressure/shear correctly. In Usher et al's study, students correctly answered 58.5% of questions about risk assessment and 48.5% of questions about preventive measures to reduce the duration of pressure/shear.²¹ In the current study, the answers of the students who received PK education about risk assessment and preventive measures to reduce the duration of pressure/shear are consistent with the literature.^21,22 These increases in the pressure injury knowledge score may be related to the visual content and memorability of the PK technique.

In the present study, 4 weeks after the education the total knowledge score, risk assessment, and etiology and development subdimension scores of the intervention group were found to be higher than the scores of the control group. Ursavaş and İşeri stated that after 8 weeks of pressure injury prevention education, students' total and sub-dimension scores on pressure injuries were better than before.²² Yılmazer et al determined that 3 months after the education, the pressure injury prevention knowledge scores of the students who received simulation education were higher than the other students.²⁴ While there was an increase in the knowledge level of the students who received pressure injury education with e-learning, there was no difference in their application skills.²⁵ It was noticed that studies on the long-term effects of education regarding pressure injuries were carried out with simulation education and in-class education. The studies evaluating the presentations made with the PK technique were aimed at evaluating the satisfaction of the students, their experiences, and the content of the presentation.^14,26 In presentations using the PK technique, the fact that the visuals are more prominent and the text is less prominent increases active learning by reducing the possibility of the students preparing for the exams through slides.¹⁶ In the study of Warmuth et al, some students stated that the visual elements and narrative technique used in the PK presentation were more interesting than other techniques and that the PK technique was fun.²⁶ In the current study, it was determined that the PK technique increased the knowledge about pressure injury prevention immediately after the education and 4 weeks after the education. The PK presentation technique can be used in pressure injury prevention education in the curriculum of the elderly care department.

Since the study was performed with elderly care program students at one university in the Western Region of Turkey due to the practicality of collecting data, its results cannot be generalized to the whole population of elderly care program students in the country.

In this study, it was determined that the elderly care department students had a low level of knowledge about pressure injury prevention. In the education of elderly care department students, education should be carried out to increase the level of knowledge about pressure injury prevention. It is necessary to evaluate the attitudes of elderly care department students as well as their knowledge levels on preventing pressure injuries. Future studies can be conducted to evaluate the effects of the education provided on students' attitudes towards pressure injury prevention and their skills in wound care. It is recommended to increase the information-supported, pressure injury prevention and care education, which can use the PK presentation technique and other presentation techniques with visual content in the education of elderly care department students. In addition, studies can be carried out to evaluate the knowledge, attitudes, and skills of the students after graduation.

This work was supported by The Scientific and Technological Research Council of Turkey (2209-A Research Project Support Program for Undergraduate Students, No: 1919B012107017).

¹İzmir Democracy University, Elderly Care Program, Turkey

Assistant Professor, İzmir Democracy University, Elderly Care Program, Mehmet Ali Akman Mahallesi, 13. Sokak No:2 Güzelyalı Konak /izmir

1.kat 119 nolu oda, TURKEY, +905074434926, hale.turhan1986@gmail.com