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Pressure Ulcer Prevention Education

Pressure ulcer prevention education programs for individuals with SCI provide knowledge and emphasize behaviours intended to reduce the risk of pressure ulcer occurrence (Bogie 1995; Rodriguez & Garber 1994; Schubart et al. 2008). Although there is much diversity about specific educational programming conducted across various settings, typical approaches in inpatient rehabilitation include structured programs, often delivered in group lecture formats (question and answer), augmented by unstructured, informal “just-in-time” education delivery and content driven educational materials such as pamphlets, information sheets, websites or binders (Lawes et al. 1985; Wolfe et al. 2012). Typically this education is delivered while the individual is an inpatient at a time when they and their family are adjusting to a diagnosis of SCI and are likely suffering from information overload. Under these circumstances, an individuals’ ability to appreciate the knowledge and behaviours necessary to prevent pressure ulcers over their lifetime is likely compromised (Garber et al.1996; Potter et al. 2004; Schubart et al. 2008). With shorter lengths of stay, there is less time to deliver prevention education and fewer opportunities for reinforcement of acquired knowledge. This means that individuals with SCI are being discharged with potentially less information on pressure ulcer prevention (Garber et al.1996). As well, there is little data on the specific education needs required by individuals with SCI at risk for pressure ulcer formation (May et al. 2006; Schubart et al. 2008).

Table: Pressure Ulcer Prevention Education Post SCI

Table: Systematic Review on Pressure Ulcer Prevention Education

Discussion

Overall, most investigations have demonstrated that specific educational programming can be beneficial for pressure ulcer prevention in persons with SCI, although there are a relatively small number of studies in this area. This aligns with results reported by Gelis et al. (2012) in a systematic review of therapeutic patient education directed toward persons at chronic risk of pressure ulcer formation, with 5 of 6 studies in this review involving persons with SCI. These authors noted a low level of evidence (Level 2 resulting in Grade B recommendations), acknowledging the relative immaturity of the literature in this area. Additionally, Gelis et al. (2012) noted limitations associated with biomedical thinking resulting in clinicians focusing on “educating” their patients (i.e., dissemination strategies) rather than adopting more behavioural approaches (Jones et al. 2003) or those that are grounded in adult learning principles as noted by May et al. (2006).

Although the various and specific educational experiences imparted over an inpatient rehabilitation stay are difficult to characterize, two studies have reported knowledge gains in pressure ulcer prevention methods associated with general inpatient rehabilitation programming as assessed at admission versus discharge, as well as at a later follow-up (May et al. 2006; Thietje et al. 2011). Thietje et al. (2011) did not specify particular aspects of the educational programming provided, however, they noted that significant knowledge gains were achieved by discharge and maintained at 30 months with patients identifying rehabilitation physicians, physiotherapists and nurses as the most important knowledge resources as well as in-hospital special courses.

Following discharge, general practitioners and physiotherapists were identified as the most important SCI knowledge resources. May et al. (2006) reported similar findings in knowledge gain at discharge and retention at 6 months post discharge as assessed by a customized multiple choice questionnaire developed by a clinical nurse educators and former patients. Notably, May et al. (2006) did characterize a main component of the educational experience provided to patients as involving an 8 week lecture series with classes held twice a week with content including pressure sore prevention techniques along with many other topics relevant to persons with SCI. Skin care, along with bladder and bowel care, was consistently reported by patients as the most important issue in relation to a variety of topics usually deemed relevant within SCI rehabilitation (May et al. 2006). Perhaps the most significant finding associated with this study was that problem-solving ability, as assessed using a qualitative Life Situation Scenario approach, was only marginally improved from admission to discharge and many patients continued to demonstrate poor problem-solving ability (i.e., applying knowledge to behavioural actions) at discharge. May et al. (2006) noted that the lecture series approach was likely not effective in this regard as it did not incorporate adult learning strategies (e.g., focus on perceived learning needs, readiness to learn, active learning).

Other studies have tested the effectiveness of more specific educational programming. For example, Brace and Schubart (2010) and Schubart (2012) have conducted pre-post, pilot studies examining the effectiveness of an interactive eLearning program designed to prevent pressure ulcers in persons with SCI as applied during inpatient rehabilitation (n=18) or following discharge to home (n=14), respectively. In each case, knowledge as assessed by performance on a customized test about this topic was significantly improved immediately after completing the online module. In addition, Schubart (2012) reported that participants rated aspects of the program’s ease of use and utility very high as well as providing positive self-reports on perceived knowledge gain and improved self-efficacy about pressure ulcer prevention.

In an RCT conducted by Garber et al. (2002), inpatients awaiting pressure ulcer surgery were randomly assigned to an intervention group (n=20) that received four 1-hour sessions of enhanced education on the prevention and management of pressure ulcers. Information presented at the sessions included education regarding preventative strategies such as skin inspection, weight shifts/turns, nutrition and pressure redistribution surfaces for the bed and wheelchair, as well as pressure ulcer etiology. The control group (n=21) received standard education regarding preventative practices. After discharge, the groups were followed for two years or until recurrence of pelvic pressure ulcer. Improvement on the pressure ulcer knowledge test was noted in both groups upon discharge from hospital; however, it was significantly different between the groups (p<0.03), with those in the intervention group gaining more knowledge about preventing pressure ulcers. No significant differences were noted on the multidimensional Health Locus of Control Scale and the Health Beliefs Questionnaire between the two groups at discharge. Two years post treatment, it was noted that both groups had retained most of the knowledge they had gained during their hospitalization, but the level of knowledge retained by the control group was below that of the treatment group: 60.8% versus 68% on the pressure ulcer knowledge test.

In a parallel study, Rintala et al. (2008) randomized similar subjects into three groups: Group 1 (N=20) had received enhanced education sessions. Group 1 was followed through structured monthly telephone contact where they were questioned regarding skin status, pressure ulcer preventative behaviors and reminded of behaviors they were not using. Group 2 (N=11) were contacted monthly by mail to assess skin status only and group 3 (n=10) were contacted every three months by mail to assess skin status. If those in groups 2 and 3 had not responded in two weeks, they were contacted by telephone. Group 1 had a significantly longer time before recurrence of pressure ulcers (19.6 months, p=0.002) while no significant difference was reported between group 2 or 3. For persons who had not had previous pressure ulcer surgery, the enhanced education and structured follow-ups extended their ulcer free time. As well, less people in group 1 had a recurrence of a pressure ulcer (33.3%) versus group 2 (60%) and group 3 (90%).

In summary, those individuals who received an enhanced education and structured follow-up, showed more improvement on the pressure ulcer knowledge test at discharge, retained more of this knowledge 2 years post intervention and had fewer recurrences of pressure ulcers. For those individuals who went on to have a recurrence, time to recurrence was much longer. Of note, this latter study is the only investigation described in this section to include an assessment of health status as well as to include behavioural aspects to their intervention. In general, this research could be strengthened considerably by adopting more fulsome outcome measurement approaches to evaluate the effectiveness of interventions (i.e., assessing behavior change directly in addition to its impact on health) as well as by incorporating theory-based behavior change strategies as parts of an intervention.

The 2013 Canadian Best Practice Guideline for Prevention and Management of Pressure Ulcers in People with SCI provided a Level IV recommendation (based on studies of self-management approaches used within various chronic diseases) to promote self-management for people with SCI by helping them to learn, consistently apply, and incorporate into their daily lives the effective and appropriate pressure ulcer prevention strategies.

Conclusion

There is level 1b evidence (from two randomized controlled trials and three pre-post studies; Rintala et al. 2008; Garber et al. 2002; May et al. 2006; Brace & Schubart 2010; Schubart et al. 2012) that providing enhanced pressure ulcer prevention education is effective at helping individuals with SCI gain and retain this knowledge.

There is level 4 evidence (from two pre-post studies; Schubart et al. 2012; Brace & Schubart 2010) that online eLearning modules may improve knowledge on prevention of pressure ulcers among persons with SCI.

There is level 1b evidence (from one randomized controlled trial; Rintala et al. 2008) that providing enhanced pressure ulcer education and structured follow-up is effective in reducing recurrence of pressure ulcers especially in those individuals with no previous history of pressure ulcer surgery.

  • Structured pressure ulcer prevention education, helps individuals post SCI gain and retain knowledge of pressure ulcer prevention practices.

  • Research is needed to determine the specific educational needs of individuals with SCI required to reduce the risk of pressure ulcer formation.

  • More research is needed to determine the best approaches of pressure ulcer prevention education to reduce pressure ulcers post SCI.