Education of healthcare professionals for preventing pressure ulcers

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 methods: 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 We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional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.

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.

Conflict of interest statement

Alison Porter‐Armstrong: received Cochrane Fellowship funding from the HSC Research and Development Division of the Public Health Agency (Northern Ireland) to perform this review. Zena Moore: received honoraria for speaking at professional meetings for 3M, Molnlycke and Smith & Nephew. Ian Bradbury: none known. Suzanne McDonough: none known.

Figures

1

Study Flow Diagram

2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

References

References to studies included in this review Bredesen 2016 {published data only}

Hayes 1994 {published data only} James 1998 {published data only} Rantz 2012 {published data only} Van Gaal 2010 {published data only} References to studies excluded from this review Danchaivijitr 1995 {published data only} Esche 2015 {published data only} Rantz 2001 {published data only} Shannon 2012 {published data only} References to ongoing studies IRCT2017080935602N1 {published data only} NCT02270385 {published data only} Additional references Agreda 2007 Anderson 2008 Bates‐Jensen 2009 Beeckman 2008 Bennett 2004 Bergstrom 1987 Brem 2010 Byrne 1996 Coleman 2014 David 1983 Dealey 2007 Demarre 2011 DoH 2009 Elliott 2008 EPOC 2018 Gefen 2008 Gethin 2005 Graves 2005 Gunningberg 2008 Guyatt 2011 Higgins 2011a Higgins 2011b HIS 2011 Kaltenthaler 2001 Kwong 2011 Lefebvre 2011 Liberati 2009 Magnan 2008 Mahoney 1965 Melzack 1975 Moore 2011 Moore 2013 Norton 1975 NPSA 2010 NPUAP 2013 NPUAP/EPUAP/PPPIA 2014 Oemar 2013 Pope 1999 RCN 2001 Reddy 2006 Review Manager 2014 [Computer program] Ryan 2006 Schultz 2010 Schünemann 2011 Shapcott 1999 SIGN 2018 Sterne 2010 Stinson 2013 Stroupe 2011 Thomas 2010 Thomas 2012 Tweed 2008 Vanderwee 2007 VanGilder 2009 References to other published versions of this review Porter‐Armstrong 2015