Building and implementing a comprehensive educational program: Complicated Pressure Ulcers

by Kathy Wittington, RN, MS, CWCN
Adapted from the principles outlined in the Building and Implementing a Comprehensive Educational Program in the Glycemic Control Resource Room, by Dave Wesorick, Cherri Lattimer, Nancy Skinner, Robert Rushakoff, Greg Maynard.

According to the U.S. Department of Health and Human Services, a comprehensive education program for healthcare providers (MDs, nurses, PTs, etc.) should include (but not be limited to):

• Etiology and pathology.
  
• Risk factors.
  
• Uniform terminology for stages of tissue damage based on specific classification.
  
• Principles of wound healing.
  
• Principles of nutritional support with regard to tissue integrity.
  
• Individualized program of skin care.
  
• Principles of cleansing and infection control.
  
• Principles of postoperative care including positioning and support surfaces.
  
• Principles of prevention to reduce recurrence.
  
• Product selection (i.e., categories and uses of support surfaces, dressings, topical antibiotics, or other agents).
  
• Effects or influence of the physical and mechanical environment on the pressure ulcer and strategies for management.
  
• Mechanisms for accurate documentation and monitoring of pertinent data, including treatment interventions and healing progress.¹

A comprehensive educational program usually involves educating the staff as well as the patients.

1. Treatment of pressure ulcers. U.S. Department of Health and Human Services. Publication Number 95-0652, 1994. Available at: http://www.npuap.org/resources.

Staff education

The role of education in quality improvement is complex. Educational efforts alone do not usually result in major changes in practice, as the other sections of this resource room have made very clear. However, it would be ridiculous to believe that an institution could enact major changes in the attitudes, knowledge, and practices of its staff without some kind of information transfer. How much the success of a quality improvement effort depends on education is contingent on the complexity of the intervention. For example, if the goal of a quality improvement effort were simply to decrease the number of patients at risk of pressure ulcers, a simple electronic reminder system might be effective, which might not require any education beyond what is stated in the reminder. However, if the goal is to change practice in more substantial ways, particularly if the desired change depends on the acquisition of new knowledge, education takes on a more important role. Remember that educational efforts are a continuous process. A plan must be put into place for new physicians and care team members as well as for ongoing training for existing staff.

When developing educational materials for use in a quality improvement project, a few rules should be kept in mind:

1. Direct educational efforts toward imparting both general and institution-specific knowledge, the former to support the initiative and the latter about the practical applications of the interventions (such as familiarity with an order set or institutional policy).
2. Define the target audience (and the objectives for them). Educating people about what they do not need to know is wasteful, but failing to educate even a few of those who do need to know can undermine the success of the project. Recognize that educational efforts often need to be directed toward people from many professions and with different levels of training. Identify educational objectives that are both general and institution specific for each component of the audience.
   
3. Do not reinvent the wheel. In many cases, at least some of the necessary educational materials (especially the general knowledge part) may already exist.
   
4. Plan the delivery. Creating the educational materials is the easy part. The hard part is assuring that the content finds its way into the knowledge base of all the right people. If the project is small (e.g., focused on only a single unit or service), this is less of an issue. But for bigger projects (e.g., spanning an entire institution), getting the message to everyone can be difficult. Easy access to training is a key factor. Usually, the most cost-effective way to accomplish broad-based training is Internet- or intranet-based learning modules, often augmented with hands-on or lecture ma­te­ri­als. However, even if the educational materials are widely accessible, it might still be difficult to make sure all key personnel participate. Some methods to optimize participation include:
   
   
   1. Make participation mandatory for important topics. Mandatory participation is fairly common among nursing, pharmacy, and ancillary staff and is usually well accepted. It is more difficult to mandate physician staff to participate in educational programs, particularly at institutions that use the open medical staff model, but it may be possible if the education is directed toward a discrete group whose leadership is committed to the project (e.g., a residency program).
   2. Make the educational program as enjoyable as possible. Regardless of whether the training is mandatory, educational programs are more effective if they are concise, clear, case based, and interactive.
   3. Create other incentives for participating if the education cannot be made mandatory. The incentives offered usually depend on the resources available. An example of a common incentive is offering an educational presentation as part of a program that includes a nice dinner. Hospitalist groups or other providers may get recognition or a competitive advantage for certification or full participation in training. CME, CEU, and Pharmacy educational credits may by valuable for many learners.
   
   
5. Evaluate and track the participation and performance of staff in the educational program and the impact of the educational program as a whole. Even the best educational module will have no effect on those not exposed to it. Keeping track of who has and has not been educated will allow the latter to be identified for special intervention. If the process is mandatory, the intervention might be disciplinary, but even for nonmandatory programs, the QI team might be able to come up with innovative ways of making sure that everyone is educated. For example, members of the QI team could provide abbreviated, one-on-one education for noncompliant members of the target group (academic detailing). The worst-case scenario would be to post an educational module on the Internet and just assume that everyone has completed it. Modern Web-based learning modules allow evaluation of performance on questions as well as tracking participation.

In the future, hospitals might require completion of some educational modules as part of the credentialing process for its professionals. Many hospitals already use this type of online education for topics that are mandated by regulatory agencies (such as infection control or fire safety) because they can be tracked and reported. This mechanism is appealing from a QI standpoint, where the success of a project often hinges on the education of many, diverse people.

Now how might this framework be applied in the context of a quality improvement project aimed at improving the management of complicated pressure ulcers for inpatients?

Identify the target audience and the learning objectives

Treatment, diagnosis, and prevention of complicated pressure ulcers (stages III and IV) in inpatients require a broad educational effort for nearly all nurses, pharmacists, and physicians.

Objectives for physicians

See the AHCPR Supported Guide and Guidelines for more information. Recommendations from the AHCPR Guidelines on Pressure Ulcer Education include Prevention and treatment, assessing tissue damage, and monitoring outcomes. http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hsahcpr&part=A5462#A5463 Accessed October 26, 2009.

It may also be appropriate to create similar lists for clerks or others who may be part of the project. As you review the objectives and desired core knowledge/skill sets, define again who among your staff needs this training.

Don’t reinvent the wheel: what resources are available?

Nursing and physician groups and professional societies have educational slide sets on prevention and treatment of pressure ulcers (WOCN, AAWC, NPUAP). Wound care companies also offer pressure ulcer education online at their Web sites as well as live programs. Many of the education programs are accredited for nurses, MDs, physical therapists, and case managers (www.kci1.com, www.MHCwoundcare.com).

Planning the education

We advocate mandatory education for most of those on the inpatient nursing and physical therapy staff who will be relevant to the project. Scheduling and logistics of the educational program can be challenging, but Web-based learning modules can make them easier.

Mandatory training of all pertinent inpatient staff may not be feasible, but targeting pulmonary critical care physicians, hospitalists, and surgeons can go a long way toward having a more standardized and rational mode of pressure ulcer prevention and care.

Evaluating and tracking performance of staff

Create a roster of all those on staff who needing the training, stratified by type of care provider and whether each person’s participation is mandatory or optional.

To try to evaluate not only participation but also actual performance and comprehension, use questions in your educational program that address core knowledge areas. Map out the time lines for delivery, and plan incentives/strategies for reaching voluntary participants. The overall impact of your program can be assessed in part by the progress you make toward better prevention, assessment, and treatment of complicated pressure ulcers.

Patient/caregiver education: building/implementing a comprehensive educational program

Patient education is especially important in the management of immobility and the complications associated with it (pressure ulcers), for which self-management is the rule. Creating a com­pre­hensive inpatient educational program is a complex task that must include the following steps:

1. Assess the patient.
2. Define which knowledge is essential for the patient.
   
3. Decide who will teach the patient.
   
4. Teach the teachers.
   
5. Decide what will trigger the educational effort.
   
6. Make sure the educational program has been successful.

1. Assess the patient. To be successful, an educator must assess the learner’s current knowledge, cognitive abilities, and motivation to learn. A health care professional cannot simply walk into a patient’s room and begin lecturing on pressure ulcers (or any topic). Rather, first assess what the patient already knows and is able (and willing) to learn. Nonadherence to medication and treatment regimens is often related to a patient’s health literacy, knowledge level, motivation, and willingness to change, which need to be assessed as part of a comprehensive educational program. With changes in a patient’s disease status, living circumstances, therapies, and other adherence-related factors come expected changes in both knowledge and motivation. Hospitals wishing to achieve excellence in patient education will need to incorporate patient assessment into their educational initiatives. More information and tools pertaining to patient assessment can be found in the Case Management Society of America’s Case Management Adherence Guidelines and at the CMAG Web site.
2. Define what knowledge is essential for the patient to know. Pressure ulcer education cannot take place solely in the hospital. Trying to teach everything about diabetes can easily overwhelm inpatients, especially if pressure ulcers are not the primary reason for the hospitalization. However, some skills and knowledge are considered essential for patients or their caregivers to understand in order to be able to appropriately manage their pressure ulcers at home. These essential skills/knowledge are to:
   • Understand the basic definition of pressure ulcers.
   • Understand the availability and variety of treatment options.
   • Understand the pain, discomfort, cost, life style changes, and outcomes of treatment

   Ideally, each hospital would identify the essential diabetes information that all patients must know and use this foundation of knowledge to build a patient education tool that allows both an educational assessment of the patient and documentation of the education. Many online resources provide high-quality information for patient education. Some of these can be found in the Education Resources and Patient Education sections of the cSSSIs Resource Room.

3. Decide who will teach the patient. Although it would be ideal for the patient’s nurse to do all the teaching, many nurses lack the expertise to do this well. Some hospitals try to get around this problem by hiring trained wound care nurses to teach patients. Hospitals will need to develop programs to ensure that nurses can educate patients, not about every aspect of pressure ulcers, but about the essentials.
   
4. Teach the teachers. The best way to ensure that hospitalized patients will learn what they need to know is to standardize the educational process. As noted above, the first step is to identify who will be the patient’s educator. These educators (usually nurses) must then be given the knowledge and tools they need to educate patients in a standardized way. Therefore, providing excellent education to patients in most hospitals depends on providing excellent education to nurses. Nursing education in this area will be enhanced by tools to standardize the educational approach.