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National Clinical Guideline Centre (UK). The Prevention and Management of Pressure Ulcers in Primary and Secondary Care. London: National Institute for Health and Care Excellence (NICE); 2014 Apr. (NICE Clinical Guidelines, No. 179.)
16.1. Introduction
The prevention, assessment and management of pressure ulcers requires a comprehensive, multidisciplinary approach for the understanding of the multifactorial causes and treatment approaches beyond the focus of the pressure ulcer itself. The purpose of training and educating healthcare professionals is to ensure both individual understanding and a team approach with shared knowledge, skills and attitudes towards the prevention (and management) of this condition. The prevention of pressure ulcers is becoming ever more important given an increase in the number of; older adults in the population, people with a disability and people being cared for in the community. People at risk of and who develop pressure ulcers exist within the entire healthcare framework, from people in their own home, to people in long term facilities such as residential and nursing home environments and those in acute care hospital settings. A range of healthcare professionals are likely to be involved in the care of a person at risk, including nursing staff, doctors, allied health professionals and healthcare assistants. Training and education needs to address at risk populations across the age spectrum from neonates to older people with particular focus on specific groups such as individuals with spinal injuries. In addition, training to aid healthcare staff to recognise the change in a persons' risk status, for example because may be at a higher risk due to a change in clinical status or because of a pre-existing condition which may mean they are at greater risk of developing a pressure ulcer, is equally important. Traditionally, the roles and responsibilities of managing pressure ulcers in all settings have been seen to rest with nursing staff. Education for nursing students is included in the undergraduate curriculum and is embedded in their training and development. On the other hand curricula coverage for undergraduate medical students is variable with little mention of pressure ulcer management in postgraduate education for doctors. Some specialities such as geriatric medicine have clearly identified training in their curriculum but . the delivery of most post graduate training for doctors is opportunist, with doctors often learning through their association with nursing staff in ward environments. It is this gap that was identified as needing addressing.
The GDG were therefore interested in identifying what training and education should be provided for healthcare professionals in order to prevent the occurrence of pressure ulcers.
16.2. Review question: What training and education is required for healthcare professionals to prevent the occurrence of pressure ulcers?
For full details see review protocol in Appendix C.
16.2.1. Clinical evidence (adults)
A search was conducted for qualitative studies looking at training and education of healthcare professionals involved in patient care where pressure ulcers may be a risk.
Seven studies were included in the review: Athlin 2010 7, Blanche 2011 21, Jankowski 2011 98, Justham 2002 102, Meesterberends 2011 128, Middleton 2008 129 and Samuriwo 2010 171.
Evidence from these are summarised in the qualitative studies checklist below (see Table 113). See also the study selection flow chart in Appendix D and study evidence tables in Appendix G and exclusion list in Appendix J.
Table 113
Qualitative studies checklist: healthcare professional education and information.
16.2.1.1. Clinical summary of findings
Three main themes were identified relating to the training and education of healthcare professionals involved in patient care where people may be a risk of a pressure ulcer developing. These were identified from studies with people with pressure ulcers, including individuals with spinal cord injury, in both nursing homes and in the community:
- Perceived causation of pressure ulcers.
- Attitude towards pressure ulcers.
- Recommendations for education of healthcare professionals involved in the care of patients with pressure ulcers.
Some of these themes overlap.
Theme 1. perceived causation of pressure ulcers
Understanding pressure ulcer risk was 1 of 6 main topics identified in the development of a manual aimed at helping people at risk of developing a pressure ulcer and occupational therapists understand the development of pressure ulcers.21 This is a theme common to Chapter 15 ‘Information for patients and their carers’. It was recognised that many healthcare professionals, as well as people at risk and their carers, need to have a greater understanding of the causes of pressure ulcers.
Theme 2. attitude towards pressure ulcers
Two studies 7 102 described the attitudes of healthcare professionals towards people with pressure ulcers.
In a study7 of nurses in Sweden with at least 5 years' experience, it was found that pressure ulcers and preventative interventions were often given low status, as they were seen as mainly a concern of less qualified staff. Early signs of pressure ulcers, for example erythema, were not judged as pressure ulcers and not reported on admission to or discharge from hospital. Pressure ulcers were reported to be connected with shame and guilt which often led to neglect and lack of treatment. Pressure ulcers were considered to be relatively uncommon which healthcare professionals recognised may mean they were not noticing them.
A UK study 102 described how pressure ulcer prevention was not seen as the responsibility of radiography staff. It was found that there was a low awareness of pressure ulcers among radiographers as they consider most procedures to pose little threat. Radiography course providers considered that the prevention and care of pressure ulcers should be given more attention in undergraduate training and that all radiographers should have regular updates on the importance of pressure ulcers.
Theme 3. recommended improvements to the education of healthcare professionals involved in the care of patients with pressure ulcers
Four studies 98 128 129 171 described specific issues relating to pressure ulcer education, either identifying knowledge gaps or making recommendations for future learning for healthcare professionals.
One study 129 which aimed to develop and implement a service model for people with spinal cord injury living in rural regions of Australia, highlighted that most health professionals ‘showed a lack of knowledge and self-confidence in most if not all areas’ of practice relating specifically to people with this type of condition.
In a US study 98 whose aims included developing tools to evaluate pressure ulcer prevention programmes and protocol implementation, identifying gaps in pressure ulcer prevention programmes and disseminating learning, the roles of all members of the healthcare team were evaluated, as well as an overall evaluation of how the management of patients with pressure ulcers could be managed. Key barriers identified included: education regarding skin care supplies and products and the education of doctors. The key recommendations for pressure ulcer education included: education regarding skin care supplies and products, staff education relating to the pressure ulcer protocol, increasing the participation of nursing assistants, developing and implementing a wound education resource manual, identifying a ‘physician champion’ to assist with the education of doctors about pressure ulcer prevention and train-the-trainer nurses for unit-based education. An important theme from this study was the multidisciplinary team approach (team building; pressure ulcer prevention; peer education (for example, using the correct skin care products), life equipment, beds, protective devices; patient advocacy). Education on risk score accuracy was also identified as being important.
One study 128 investigated pressure ulcer guideline dissemination and implementation in Dutch nursing homes, and reported findings relating to the education of staff on pressure ulcer prevention and treatment. There was no obligation for the nursing staff to follow a specific amount of education in any of the homes. They were free to choose subjects of interest which may or may not have included pressure ulcer care . Therefore, not all staff received a specific number of hours of education in this area. There was a perception that knowledge of nursing staff regarding pressure ulcer care was lacking, there were many nursing trainees and nursing assistants, but relatively few qualified staff. Some nurses and nursing assistants perceived that there was not enough education in the area of pressure ulcer care. They also reported that education should be offered more frequently and should be mandatory.
A UK study 171 to determine the value that nurses (16 participants ranging from second year nursing students to senior nurse managers) place on pressure ulcer prevention and how this value is formed found post-registration education to be ‘invaluable’ and equipped them for their current role. They reported a ‘desire to keep updated’ yet interestingly the education appeared to affect the participants only after they had had personal experience of an individual with a pressure ulcer.
16.2.2. Economic evidence (adults)
No economic evaluations were identified that directly addressed what training and education is required to prevent pressure ulcers. However, the GDG did consider 4 studies (5 papers)121,123,124,226,227 which assessed the cost-effectiveness of various education programmes compared to no education, or to standard training. These studies were discussed because the interventions have an explicit focus on education, rather than on a more complex protocol or intervention. However they were not formally included in the review because they do not directly answer the review question. These studies are summarised below for information.
Makai and colleagues124 constructed a Markov model to evaluate a quality improvement strategy, which was based around a training and education programme. Learning sessions were focused on quality improvement methods and preventative nursing measures, however no further details were provided. The study revealed a decrease in pressure ulcer incidence and an increase in quality of life. However health care costs also increased, and results showed that the QIC was not cost-effective at the £20,000 per QALY gained threshold over a 2 year time horizon.
Lyman and colleagues123 evaluated a quality improvement process which was based around a tailored protocol and in-service education programme, in combination with a heel protective device. The authors found a reduction in pressure ulcer incidence leading to a reduction in costs. A reduction in pressure ulcer incidence was also found by Lyder and colleagues,121 who investigated the of a series of educational sessions for nurses and physicians on treatment and prevention of ulcers.
Nurses were educated on the use of the Braden scale, various skin care products, and nursing assistants educated on basic pressure ulcer prevention. Although pressure ulcer incidence decreased, costs remained high.
Xakellis and colleagues226,227 investigated the impact (in terms of costs and pressure ulcers developed) of mandatory staff education as part of a protocol for the prevention of pressure ulcers. Education was focused on risk assessment and associated stratification of preventative interventions. Costs remained largely the same (a decrease in treatment costs was balanced out by higher intervention costs), but the incidence of pressure ulcer development had decreased the year after the protocol was implemented. Two years later, however, initial reductions had not been sustained.
16.2.3. Clinical evidence (neonates, infants, children and young people)
No qualitative studies were identified. Recommendations were developed using a modified Delphi consensus technique. Further details can be found in Appendix N
16.2.4. Economic evidence (neonates, infants, children and young people)
No economic evaluations were identified.
16.2.5. Evidence statements
16.2.5.1. Clinical
- The qualitative evidence found was high quality, as population, methods and analyses were all generally well-reported. A thematic analysis was conducted to identify the main themes relating to training and education requirement of healthcare professionals in order to prevent the risk of pressure ulcers. One theme was the perceived causation of pressure ulcers, and it was found that healthcare professionals need to have a greater understanding of the causes of pressure ulcers. Another theme was attitude towards pressure ulcers, with pressure ulcers and preventative interventions often given a low status and it was generally less qualified staff left to deal with pressure ulcer prevention. Early signs of pressure ulcers were often not noted as being pressure ulcers. The final theme was recommendations for improvement of education of healthcare professionals which identified that there was a lack of knowledge and self-confidence in health care practitioners in the provision of prevention of pressure ulcers. More education was required, and it was thought that this should be conducted more frequently and should be mandatory. it was identified that a multidisciplinary team approach, education on the correct use of skin care products, equipment, beds, protective devices risk score accuracy were required. The following was recognised as being useful; increased participation of nursing assistants, development and implemention of a wound education resource manual, a physician lead to assist with education and training of doctors and nurses.
16.2.5.2. Economic (adults)
No evidence was identified.
16.2.5.3. Clinical (neonates, infants, children and young people)
No evidence was identified.
16.2.5.4. Economic (neonates, infants, children and young people)
No evidence was identified.
16.3. Recommendations and link to evidence
The GDG considered that the following recommendations on the training and education of healthcare professionals was likely to be applicable for all populations (neonates, infants, children, young people and adults) and therefore, recommendations apply to all age groups.
| Recommendations |
|
|---|---|
| Relative values of different outcomes | This recommendation was based on the evidence from 2 qualitative reviews on patient information provision and healthcare practitioner training and education, therefore no outcomes are stated in the protocol as the outcomes are established through a review of the qualitative papers. |
| Trade off between clinical benefits and harms | The recommendation was developed using the themes found in the health-care practitioner training and education qualitative review, which included that health care practitioners need to have a greater understanding of the causes of pressure ulcers. Knowledge of pressure ulcers and confidence in provision of prevention care was lacking. Pressure ulcers and their prevention were often given a lower status and left to less qualified staff to deal with. Early identifiers of pressure ulcers were often not being recognised. It was acknowledged that more education for healthcare professionals was required, and that this would need to be more frequent and obligatory. A multidisciplinary team approach was identified as being necessary. Education regarding the correct use of skin care products, equipment, beds, protective devices, risk score use and accuracy were also required. A wound education resource manual, and a physician lead to assist with the education and training of doctors and nurses was thought to be useful. The recommendation was also based upon the themes found in the patient information qualitative review. It was noted that before having a pressure ulcer many patients did not have a lot of knowledge about pressure ulcers therefore highlighting the need for patients to receive appropriate information about how to prevent pressure ulcers. Awareness of risk varied and again was higher in those who had experienced a pressure ulcer. Those who did not believe they were at risk did not participate in preventive behaviours. Some patients had the knowledge of what to do but did not use it. It was thought that staff consistency in reinforcing preventative measures were important to ensure patients would continue prevention routines. Prevention awareness needs to be continuous and routines regularly performed. Generalised knowledge of pressure ulcers and prevention techniques were seen to be required to ensure lasting motivation to pressure ulcer prevention. Identifying the patients preferred method of learning was also stated as being important. The GDG felt that all healthcare professionals would benefit from receiving specific training in the prevention of pressure ulcers and agreed, via informal consensus, what this should involve. During this discussion, the group agreed that basic training, covering the causes of pressure ulcers, consideration of who is likely to be at risk and how best to identify pressure ulcer damage would allow for healthcare professionals to identify the risk of potential pressure ulcer development in a timely and effective manner. Additionally, the GDG felt that healthcare professionals should receive training on what steps to take to prevent new or further pressure damage and information on who to contact for further information and action. The GDG felt that the benefits of providing training to healthcare professionals included an improvement in care and an increased understanding of where further information can be obtained, and therefore prevention of significant numbers of pressure ulcers, of varying severity. Therefore, it was acknowledged that any impact upon resources for providing training was likely to be outweighed by the benefits. The GDG highlighted that it was important for staff of all levels to receive training in pressure ulcers prevention, as the prevention of pressure ulcers was the joint responsibility of all healthcare professionals. The GDG also noted that this training may be beneficial to other members of staff, for example, hospital porters, who have contact with patients and other individuals in settings in which NHS care is provided. There may be situations in which non-healthcare professionals (for example, non-clinical staff such as social care staff who may be responsible for transporting people who have a pressure ulcer) in contact with people at significant risk of developing pressure ulcers would benefit from training, particularly on the causes of pressure ulcers. No evidence was identified on healthcare professional training and education specifically aimed at educating healthcare professionals on preventing pressure ulcers in neonates, infants, children and young people. The GDG considered that the training requirements of healthcare professionals for preventing pressure ulcers in these populations were likely to be similar to those in adults and therefore, no separate recommendations were developed for these populations. |
| Economic considerations | No economic studies were formally included in the review, however the GDG did discuss several economic evaluations of training programmes (compared to no training): all programmes led to a reduction in pressure ulcers, and the majority were cost neutral or cost reducing. However, it was not possible to draw clear conclusions about the cost-effectiveness of various training components from these studies, as the description of the training given was vague in all cases, and cost-effectiveness would be highly dependent on the preventative interventions used. The GDG acknowledged the costs of training, but felt that the benefits of appropriate care (in terms of reduced pressure ulcer incidence, increased healing and improved quality of life) would outweigh this initial cost when averaged over the amount of patients who would benefit. No economic evaluations were identified which compared specific elements of training programmes, therefore the GDG expect the most clinically effective training programme to be the most cost-effective. |
| Quality of evidence | The evidence came from qualitative studies, which included questionnaires, interviews, participant observations, surveys and group discussions. The qualitative evidence found was generally of high quality as the population was well reported in all papers, methods and analyses were well reported in the majority of papers. The populations in the studies included members of the multidisciplinary team working on a variety of hospital wards, rehabilitation centres, nursing homes and students on a radiography course. |
| Other considerations | NICE clinical guideline 138 ‘Patient experience in adult NHS services’ includes recommendations on the provision of information to patients and their carers. |
| Recommendations |
|
|---|---|
| Relative values of different outcomes | This recommendation was based on the evidence from 2 qualitative reviews on patient information provision and healthcare practitioner training and education, therefore no outcomes are stated in the protocol as the outcomes are established through a review of the qualitative papers. |
| Trade off between clinical benefits and harms | The recommendation was developed using the themes found in the health-care practitioner training and education qualitative review, which included that health care practitioners need to have a greater understanding of the causes of pressure ulcers. Knowledge of pressure ulcers and confidence in provision of prevention care was lacking. Pressure ulcers and their prevention were often given a lower status and left to less qualified staff to deal with. Early identifiers of pressure ulcers were often not being recognised. It was acknowledged that more education for healthcare professionals was required, and that this would need to be more frequent and obligatory. A multidisciplinary team approach was identified as being necessary. Education regarding the correct use of skin care products, equipment, beds, protective devices, risk score use and accuracy were also required. A wound education resource manual, and a physician lead to assist with the education and training of doctors and nurses was thought to be useful. The GDG noted that there were healthcare professionals such as social care staff who have regular contact with people who are at increased risk of developing a pressure ulcer. The GDG highlighted that this was likely to include staff in the community, as well as primary and secondary care. The GDG felt that it was important that these individuals received enhanced training, which include the training elements previously outlined, as well as further training focusing on the needs of people at increased risk. The GDG agreed, via informal consensus, what aspects of care this enhanced training should include. The GDG felt that this should reflect the increased likelihood that these people would develop a pressure ulcer, including a focus on how to carry out a risk and skin assessment, the importance of repositioning and more detailed knowledge of pressure redistributing devices. Additionally, the GDG felt that the training should provide information on how to engage with people at increased risk of developing a pressure ulcer and their carers, and information on where to go for further help. No evidence was identified on healthcare professional training and education specifically aimed at educating healthcare professionals on preventing pressure ulcers in neonates, infants, children and young people. The GDG considered that the training requirements of healthcare professionals for preventing pressure ulcers in these populations were likely to be similar to those in adults and therefore, no separate recommendations were developed for these populations. |
| Economic considerations | No economic evaluations were formally included in the review, however the GDG did discuss several economic evaluations of training programmes (compared to no training): all programmes led to a reduction in pressure ulcers, and the majority were cost neutral or cost reducing. However, it was not possible to draw clear conclusions about the cost-effectiveness of various training components from these studies, as the description of the training given was vague in all cases, and the economic impact would be highly dependent on the preventative interventions used. The GDG acknowledged the costs of training, but felt that the benefits of appropriate care (in terms of reduced pressure ulcer incidence, increased healing and improved quality of life) would outweigh this initial cost when averaged over the amount of patients who would benefit. No economic evaluations were identified which compared specific elements of training programmes, therefore the GDG expect the most clinically effective training programme to be the most cost-effective. |
| Quality of evidence | The evidence came from qualitative studies, which included questionnaires, interviews, participant observations, surveys and group discussions. The qualitative evidence found was generally of high quality as the population was well reported in all papers, methods and analyses were well reported in the majority of papers. The populations in the studies included members of the multidisciplinary team working on a variety of hospital wards, rehabilitation centres, nursing homes and students on a radiography course. |
| Other considerations | Recommendations on the provision of information to patients and their carers can be found in NICE clinical guideline 138 ‘Patient experience in adult NHS services’.. |
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