With the physiological effects of aging, the elderly are particularly at risk for developing impaired skin integrity. TCunning epidermis, capillary fragility, and an eroding dermal-epidermal junction combined with nutritional, mobility, and polypharmacy issues (Loescher, 1995) place the older adult at risk for pressure ulcers, skin excoriation due to moisture, skin tears, and venous stasis ulcers.
With changes in the health care delivery system, including the introduction of unlicensed assistive personnel, it becomes advantageous for health care institutions to focus on the prevention of skin alterations. Traditional didactic presentations to teach caregivers often do not actively engage the learner, resulting in only shortterm application of the material. The challenge faced by staff development and clinical nurse specialists is to facilitate lasting implementation of required standards. An interactive workshop was subsequently developed to address these issues. This article discusses the development of an educational program and its effects on patient outcomes.
An 8-hour workshop was developed using teaching methodology adapted from Bandura's Social Cognitive learning Theory (1977) with content guided by the Agency for Health Care Policy and Research (AHCPR, 1992, 1995), National Pressure Ulcer Advisory Panel (NPUAP, 1989), and Wound, Ostomy and Continence Nurses Society (WOCN, 1993) researchbased standards, and implemented by the presenters' innovative teaching materials. Essential pieces of Bandura's theory include modeled performances, verbal instructions, formulation of symbolic conceptions, observation, cognitive and enactive rehearsal, and motivational processes to promote integration of new skill development. The workshop was team taught by two medicalsurgical Clinical Nurse Specialists. An overview of skin anatomy and function is followed by the physiological impacts of aging on the skin and supporting structures.
The causes of skin alterations are divided into the natural segments of moisture, pressure, friction, and shear. While the use of slides and case discussions occur, the emphasis is placed on active participation using items commonly found in any grocery store. Described below are some of the activities that promote retention of essential concepts.
1) Apply zinc oxide to a small area on the back of the hand. Apply water mixed with food coloring. Observe. Allow participants to describe observations in current and expected clinical practice.
2) Chew a piece of bubble gum. Mold into the shape of an ostomy stoma. Place on a piece of cardboard or a manila folder. Pouch the "stoma" using the correct procedure. Discuss implications of improper pouching.
3) Break a jelly donut in half. Apply zinc oxide as the moisture barrier to the area surrounding the jelly on the left half of the donut. Irrigate both "wound" halves using proper technique. Compare each half of the "wound edges" to determine the effect and damage caused by moisture.
4) Using a glue stick, lightly apply adhesive to the upper edge of a plastic sandwich bag. Apply this to a piece of cardboard or a manila folder. Place cardboard into a hospital patient wash basin. Have the participant fill the bag with yellow colored water or chocolate pudding. Observe results. Discuss the clinical implications of not emptying drainage pouches when 1/3 to 1/2 full (Figure 1).
1) Make a "skin tear" in a plum using scissors. Each plum can have a flap type tear and a fissure type tear. Instruct participants to apply different types of dressings and adhesive tapes to die "skin tears" and attempt removal (Figures 2A and B).
Figure 1 . Moisture.
2) Give each participant an onion. Have them use a washcloth to give the onion a "bath" (Figure 3). Have them "boost the patient in the bed" action with the onion. Both of these activities will flake and remove the frail onion skin. Repeat these activities after applying mineral oil or another type of friction reduction agent to the onion. Repeat the exercise using a protective covering such as a sock.
1) Place a 2-foot long piece of wax paper on a wedge pillow that is up against a wall. Have the participant sit on the wax paper. The wax paper will show the shearing forces as evidenced by the crinkles and horizontal wrinkles. Discuss the pattern that is created and relate the damage to elderly skin that shearing causes.
2) Have participants apply a shearing force to a slice of watermelon. Compare pre-shear with post-shear effects on the "collagen fibers" and "cells" in the watermelon.
1) To demonstrate the tactile sense of boggy heels, a precursor to extensive pressure damage, have participants feel a soft, ripe kiwi fruit. A tomato that has been bruised also works well.
2) Participants should make fist with both hands. To demonstrate the time /pressure relationship that impacts on pressure sore severity, have participants sit on their fists and measure the amount of time before they shift to remove the pressure or feel discomfort.
Figures 2A & B. Friction.
3) One or more days prior to the workshop make a "wound" out of flour /salt dough mixture (4 cups flour, 1 cup salt, 11/4 cup water). Paint the wound base with red tempura paint. Prior to baking at 400° for 30 minutes, sculpt the "wound" to include undennining and tunneling - each an important assessment finding. Once cool, apply a scented oil such as balsam or cinnamon and repaint the wound base with black paint. Immediately before the pressure segment of the workshop, apply one tablespoon of custard style banana yogurt. Give each participant a "wound" and allow them to demonstrate assessment and documentation principles (Figures 4A and B). Discuss likely causes of the wound and prevention strategies that could have been employed to prevent the wound from occurring. Using products frequently available to caregivers, have the participants discuss and implement appropriate treatment strategies.
Figure 3. Friction.
The following helpful hints should help others to run interactive programs.
*The facility must have ample space for each participant to move. Table seating works well with a 2-foot wide work space.
*Buy fruit at least 3 days prior to the workshop.
*Unripe fruit will not bruise to the right consistency.
*Have enough supplies for each participant.
*If everyone is unable to obtain active rehearsal experience, long-term retention will be reduced.
*To lower costs, bargain with your suppliers. Stale donuts and overripe fruit work the best and your grocer will be glad to sell them to you at a lower price. Damaged good such as open packages can be found in bargain bins. If you do not see a damaged item you need, ask your grocer if it is available out of sight from traditional consumers.
*Allow one instructor for every 15 people. During interactive experiences, the instructor must be able to give immediate feedback to correct inappropriate technique or the misguided application of knowledge.
*Have "baby wipes" available so participants can wipe materials off their hands without leaving the room.
Figures 4A & B. Pressure.
*The classroom should be in close proximity to a sink and large trash containers to facilitate clean up.
*Some participants experience redness or itchiness if they apply adhesive tape to their skin.
*Above all, have fun!! Participants are able to think up other creative experiences - some work and others do not - do not be afraid to try.
The workshop has been attended by 248 members of the nursing staff, including RNs and multiskilled patient care assistants. Patient outcomes were measured by the incidence of skin alterations. Data collection to determine incidence included hospital rounds with chart review and patient inspection twice a week by the Clinical Nurse Specialists and weekly rounds by a designated unit staff nurse for 1 year pre- and post-workshop. All skin alterations attributed to friction, shear, moisture and pressure were included during data collection using a data sheet developed by the Clinical Nurse Specialists based on the AHCPR guideline recommendations. Data were reviewed and tabulated by the Clinical Nurse Specialists and the hospital Skin Care Team Committee using descriptive statistics.
Overall findings included: 1) a 38% decrease in the incidence and 78% decrease in the severity of heel pressure ulcers; 2) a 22% decrease in skin tears; 3) an overall 42% decrease in all nosocomial skin alterations; and 4) an increase in staff ability to document and initiate appropriate prevention and treatment strategies. The incidence of nosocomial skin alterations has decreased from 4% preworkshop to 0.9% postworkshop, indicating improved application of critical thinking skills in ulcer prevention management. Nosocomial incidence continued at 1.0% monthly for the 15 months following the workshops, denoting long-term retention of knowledge requisition.
Workshop participants consistently rated an average score of 4.98 on a 1 (low) to 5 (high) Likert Scale (n=248). This workshop has been given at other facilities, including home health, subacute, and skilled nursing facilities with similar success. One institution reported a pre-workshop incidence of pressure ulcers of 25% with a long-term reduction to 3% to 5% monthly incidence.
The application of Bandura's Social Cognitive Learning Theory coupled with clinical practice guidelines yields positive results for patients, a reduction in treatment costs to the institution, and enhanced satisfaction on the part of the nursing staff.
- Agency for Health Care Policy and Research. (1992). Pressure ulcers in adults: Prediction and prevention (Clinical Practice Guidelines. Number 3. Publication no. 92-0047). Washington, D.C.: US Department of Health and Human Services.
- Agency for Health Care Policy and Research. (1995). Treatment of pressure ulcers (Clinical Practice Guidelines. Number 15. Publication no. 950652). Washington, D.C: US Department of Health and Human Services.
- Bandura, A. (1977). Social learning theory. Englewood Cliffs, N.J.: Prentice Hall.
- Loescher, LJ. (1995). The dynamics of skin aging. Progressions, 7(2), 3-13.
- National Pressure Ulcer Advisory Panel. (1989). Pressure ulcer prevalence, cost, and risk assessment: Consensus development conference statement. Decubitus, 2(2), 24-28.
- Wound, Ostomy, and Continence Nurses Society. (1993). Professional practice manual. Costa Mesa, CA: Author.