Educating healthcare staff to prevent pressure ulcers

Background

Pressure ulcers, also known as bed sores or pressure sores, are often experienced by those who find it difficult to walk and spend long periods of time sitting or lying down. Pressure ulcers can range from patches of discoloured, painful skin, to open wounds that can take a long time to heal. Pressure ulcers are prone to infection and have a great impact on people's health and well being. To stop these ulcers from developing in people who are at risk, healthcare staff need to be well informed about how to prevent them. It is important to understand what type of information healthcare staff need, how it might best be delivered to them and whether education can prevent pressure ulcers from developing.

Review question

We reviewed the evidence about the effect of the education of healthcare professionals on the prevention of pressure ulcers. We explored all types of education regardless of how it was delivered as long as it focused on preventing pressure ulcers. Healthcare staff included all staff working in pressure ulcer prevention from any professional background. Settings where the care was provided included hospital inpatient and outpatient departments, community clinics, patients' own homes, and residential or nursing care homes.

What we found

In June 2017 we searched for studies evaluating the effect of the education of healthcare professionals on pressure ulcer prevention, and found five relevant studies. Two studies explored the impact of education on the prevention of pressure ulcers. We are uncertain whether education of healthcare professionals makes any difference to the number of new pressure ulcers that develop. This is because the certainty of the evidence within the studies was very low.

Three studies explored the impact of education on staff knowledge of pressure ulcer prevention. The studies compared: education versus no education; components of educational intervention in a number of combinations; and education delivered in different formats. We are uncertain whether education makes any difference to staff knowledge of pressure ulcer prevention, or to the number of new pressure ulcers that develop. This is because the certainty of the evidence within the studies was very low. No study explored the impact of education on the treatment provided by health professionals. Only one study explored the secondary outcomes of interest: pressure ulcer severity, patients' views on their quality of life and carers' views on the patients' ability to carry out daily tasks independently. However, there was not enough information provided within the study to enable our independent assessment of these outcomes.

We examined the certainty of the evidence using the GRADE approach and concluded that all of the evidence was of very low certainty. Therefore we are unable to determine whether education can prevent pressure ulcers. We are also unable to determine whether education affects the knowledge that healthcare staff possess about preventing pressure ulcers.

The evidence of this review is up-to-date as of 12 June 2017.

Authors' conclusions: 

We are uncertain whether educating healthcare professionals about pressure ulcer prevention makes any difference to pressure ulcer incidence, or to nurses' knowledge of pressure ulcer prevention. This is because the included studies provided very low-certainty evidence. Therefore, further information is required to clarify the impact of education of healthcare professionals on the prevention of pressure ulcers.

Read the full abstract...
Background: 

Pressure ulcers, also known as bed sores or pressure sores, are localised areas of tissue damage arising due to excess pressure and shearing forces. Education of healthcare staff has been recognised as an integral component of pressure ulcer prevention. These educational programmes are directed towards influencing behaviour change on the part of the healthcare professional, to encourage preventative practices with the aim of reducing the incidence of pressure ulcer development.

Objectives: 

To assess the effects of educational interventions for healthcare professionals on pressure ulcer prevention.

Search strategy: 

In June 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

Selection criteria: 

We included randomised controlled trials (RCTs) and cluster-RCTs, that evaluated the effect of any educational intervention delivered to healthcare staff in any setting to prevent pressure ulceration.

Data collection and analysis: 

Two review authors independently assessed titles and abstracts of the studies identified by the search strategy for eligibility. We obtained full versions of potentially relevant studies and two authors independently screened these against the inclusion criteria.

Main results: 

We identified five studies that met the inclusion criteria for this review: four RCTs and one cluster-RCT. The study characteristics differed in terms of healthcare settings, the nature of the interventions studied and outcome measures reported. The cluster-RCT, and two of the RCTs, explored the effectiveness of education delivered to healthcare staff within residential or nursing home settings, or nursing home and hospital wards, compared to no intervention, or usual practices. Educational intervention in one of these studies was embedded within a broader, quality improvement bundle. The other two individually randomised controlled trials explored the effectiveness of educational intervention, delivered in two formats, to nursing staff cohorts.

Due to the heterogeneity of the studies identified, pooling was not appropriate and we have presented a narrative overview. We explored a number of comparisons (1) education versus no education (2) components of educational intervention in a number of combinations and (3) education delivered in different formats. There were three primary outcomes: change in healthcare professionals' knowledge, change in healthcare professionals' clinical behaviour and incidence of new pressure ulcers.

We are uncertain whether there is a difference in health professionals' knowledge depending on whether they receive education or no education on pressure ulcer prevention (hospital group: mean difference (MD) 0.30, 95% confidence interval (CI) -1.00 to 1.60; 10 participants; nursing home group: MD 0.30, 95% CI -0.77 to 1.37; 10 participants). This was based on very low-certainty evidence from one study, which we downgraded for serious study limitations, indirectness and imprecision.

We are uncertain whether there is a difference in pressure ulcer incidence with the following comparisons: training, monitoring and observation, versus monitoring and observation (risk ratio (RR) 0.63, 95% CI 0.37 to 1.05; 345 participants); training, monitoring and observation, versus observation alone (RR 1.21, 95% CI 0.60 to 2.43; 325 participants) or, monitoring and observation versus observation alone (RR 1.93, 95% CI 0.96 to 3.88; 232 participants). This was based on very low-certainty evidence from one study, which we downgraded for very serious study limitations and imprecision. We are uncertain whether multilevel intervention versus attention control makes any difference to pressure ulcer incidence. The report presented insufficient data to enable further interrogation of this outcome.

We are uncertain whether education delivered in different formats such as didactic education versus video-based education (MD 4.60, 95% CI 3.08 to 6.12; 102 participants) or e-learning versus classroom education (RR 0.92, 95% CI 0.80 to 1.07; 18 participants), makes any difference to health professionals' knowledge of pressure ulcer prevention. This was based on very low-certainty evidence from two studies, which we downgraded for serious study limitations and study imprecision.

None of the included studies explored our other primary outcome: change in health professionals' clinical behaviour. Only one study explored the secondary outcomes of interest, namely, pressure ulcer severity and patient and carer reported outcomes (self-assessed quality of life and functional dependency level respectively). However, this study provided insufficient information to enable our independent assessment of these outcomes within the review.

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