Pressure ulcers (PUs) impact approximately 2.5 million people in the United States every year and have a negative impact on both patient and financial outcomes (Berlowitz et al., 2011). Complications associated with PUs range from pain, prolonged treatment, decreased function, disfigurement, and life-threatening infections (Russo, Steiner, & Spector, 2008). PUs have been deemed a never event, or serious reportable event, by the National Quality Form (n.d.) and the Centers for Medicare and Medicaid Services (2008). Specifically, hospitals are no longer reimbursed for any Stage 3, Stage 4, or unstageable pressure ulcers acquired during a health care stay (National Quality Forum, n.d.). PUs are preventable, and nurses are at the forefront of their risk recognition, assessment, and early intervention. Accurate ongoing skin assessment is essential in the overall prevention and treatment of PUs (Moore, 2005; Wound Ostomy and Continence Nurses Society™, 2011). However, overall documentation of PUs is often inaccurate and inconsistent, particularly in relation to staging (Alvey, Hennen, & Heard, 2012; Gunningberg, Fogelberg-Dahm, & Ehrenberg, 2009; Stremitzer, Wild, & Hoelzenbein, 2007). Reliability of PU staging has remained low, despite multiple educational efforts aimed at improving staging accuracy (Briggs, 2006; Kelly & Isted, 2011). Where the gap in knowledge related to staging of ulcers begins remains unclear. Do nurses learn about staging in nursing school but then forget? Or do faculty not effectively educate students on accurate PU assessment and staging? The current study sought to determine the effectiveness of an intervention to improve the accuracy of PU staging in prelicensure nursing students.
A wide variation among RNs', nursing students', and other health care providers' ability to accurately stage PUs has been reported (Alvey et al., 2012; Gunningberg et al., 2009; Kelly & Isted, 2011; Stremitzer et al., 2007). Defloor and Schoonhoven (2004) asked 53 clinical experts to stage photographed PUs and reported high levels of agreement in staging using the European Pressure Ulcer Advisory Panel's classification system (k = 0.75). In contrast, Beeckman et al. (2007) sampled 1,452 nurses and asked respondents to classify 20 validated photographs of skin breakdown. The median Cohen's kappa statistic (i.e., comparison between the nurses' assessment and the gold standard) was relatively low (k = 0.33). Bruce, Shever, Tschannen, and Gombert (2012) conducted skin assessment comparisons among nurses by comparing assessments shift to shift. A total of 338 inconsistencies in staging were noted in 236 paired assessments among nurses (some patients had more than one ulcer) over two consecutive shifts, with the highest inaccuracy occurring in the stage II classification of ulcers (35.5%). Beeckman, Schoonhoven, Boucqué, Van Maele, and Defloor (2008) reported the percent agreement among nursing students (n = 214) to be low (30% to 35%) between the control and experimental groups prior to an educational intervention.
In light of the significant variation in staging accuracy, several educational programs have been implemented, with the intention of improving PU staging by nurses; however, no significant sustainable improvements have been noted (Briggs, 2006). Kelly and Isted (2011) evaluated nurses' ability to accurately stage a PU pre- and postimplementation of a PU-focused education session. Using photographs of PUs, nurses were asked to categorize the PU. After implementing an education session related to a new PU and risk assessment and prevention policy, nurses (n = 93) correctly staged only 56% of the ulcers reviewed. Subsequently, an extensive training that consisted of didactic and written materials was completed, with only a small increase in the accuracy of staging among nurses (n = 91, 62%). The most difficult ulcers to stage were stage II (first training session = 56%; second training session = 69%) and stage III ulcers (first training session = 43%; second training session = 58%). Similarly, Briggs (2006) reported the accuracy of PU staging among nurses (n = 52) to be poor; only 7.7% of respondents in the posttest correctly staged 80% or more of the ulcers, despite the implementation of a focused educational program.
A limiting factor in the success of educational programs aimed at improving PU staging may be the lack of foundational knowledge related to wound pathophysiology, risk assessment techniques, and accurate classification and treatment of developed ulcers. Undergraduate nursing programs often fail to provide comprehensive PU education (Bergquist-Beringer et al., 2009). In the study by Ayello, Zulkowski, Capezuti, and Sibbald (2010), faculty (n = 77) reported content deficiencies in the education of PU staging, with only 87% of faculty reporting covering this content, 85.7% covering PU risk assessment with a validated tool, 62.7% covering incidence and prevalence rates, 61% to 74% covering use of cushions and redistribution surfaces, and 58% covering regulatory issues. Failure to provide adequate educational content related to PUs in undergraduate programs may be one reason for the continued difficulty in reducing the development of PUs in health care settings.
Integrating active learning strategies into the curriculum has shown promise for improving nursing student competency (Shin, Sok, Hyun, & Kim, 2015). Active learning allows students to experience course content by engaging in role-play, simulation, or other hands-on activities allowing them to develop the critical thinking skills necessary for practice (Hoke & Robbins, 2005). Although active learning initiatives requiring student engagement in PU activities within health care settings during clinical rotations has been implemented, evaluation of the success or improved accuracy in PU staging is anecdotal at best. Cotter and Trevellini (2012) described the Skin Champion Program, which includes students' assessment of patients' skin in partnership with skin care champions to determine the presence of a PU. Those authors believed that the active learning strategy increased students' knowledge of the identification of ulcers, staging, and risk factors, although no specific data were provided. The current study is the first to determine the effectiveness of an active learning PU intervention to improve the reliability of PU staging in prelicensure nursing students.
The current study used a comparison approach to determine the impact of an active learning intervention on PU staging accuracy. Institutional review board approval was received prior to the start of the project. A convenience sample of prelicensure nursing students enrolled in a foundational clinical course at two 4-year universities was used. A total of 180 students were enrolled in the courses, including 128 students at University A and 52 students at University B.
All students received a standard 2-hour lecture on skin integrity and PU prevention and management, including content related to skin integrity, risk factors for PU development, assessment tools, staging, wound healing, and complications. The control group (n = 103) received only the standard lecture, whereas the intervention group (n = 55) participated in an active learning intervention, in addition to receiving the standard lecture. Twenty-two of the 180 students enrolled in the courses did not participate in the intervention and did not complete the follow-up PU staging tool. Students volunteered to participate in the intervention at University A, whereas participation at University B was determined by clinical site (i.e., those students who were assigned clinical rotations at the participating hospital were included in the intervention group).
Pressure Ulcer Active Learning Intervention
The active learning intervention consisted of (a) completion of the National Database of Nursing Quality Indicators® (NDNQI®) online educational modules on PU identification and staging, and (b) participation in Skin Day at a respective local hospital, which included assessing the skin of every patient in the hospital to detect the presence of a PU. The NDNQI Pressure Ulcer Training program developed by Bergquist-Beringer and Davidson (2015) consists of four modules on PU staging, wound types, PU survey guide, and community- and hospital-acquired PUs. The training was originally developed to help nurses to accurately identify and stage PUs during the NDNQI prevalence data collection days (Bergquist-Beringer et al., 2009).
After completing the NDNQI modules, students participated in a nearby hospital's Skin Day. Skin Day refers to the monthly surveillance of PU risk, prevalence, and incidence required by hospitals contributing to the NDNQI database. Prior to participation in Skin Day, students were provided with a brief orientation to the Skin Day process. On arrival to the hospital on Skin Day, students were assigned to work collaboratively with a skin liaison (i.e., nurses who have advanced training in skin assessment and PU staging). Working with the skin liaisons, students conducted chart abstractions, assessed each patient's skin, and documented the presence of any breakdown.
To determine the impact of the interventions on the accurate staging of PUs, students were tested on their ability to accurately identify the PU stage by completing the PU staging tool. The staging tool consists of 29 pictures of PUs, with basic descriptions of each wound and its location. The tool was developed in collaboration with a certified wound, ostomy, and continence nurse, who provided de-identified photographs of wounds at various stages. The tool was tested with a small sample of certified wound, ostomy, and continence nurses (n = 3) to ensure the accurate identification of staging of each of the pictured PUs. Discrepancies were discussed, and revisions to the PU descriptions were made to improve clarity. Further validation was attained with an additional certified wound, ostomy, and continence nurse prior to the use of the tool in the current study. The tool was uploaded to an electronic survey using Qualtrics software, and students were able to access it during lecture time at the end of the semester in their respective courses. Students were asked to view the PU pictures and descriptions and then to stage the severity of the PUs according to the National Pressure Ulcer Advisory Panel's (2007) staging guidelines.
Descriptive statistics were computed to determine the overall accuracy of staging PUs among nursing students. The scores of the students in the intervention group were compared with the control group, using analysis of variance to determine the impact of the intervention.
A total of 158 nursing students participated in the current study, with 103 in the control group (University A, n = 78; University B, n = 25) and 55 in the intervention group (University A, n = 27; University B, n = 28). The average score of the tool for all students (n = 158) was 64% (SD = 15.3%), with a range of 14% to 93%. Overall, students were better at accurately staging the severity of ulcers that were stage I (90.03%, SD = 17.8%) or stage IV (73.29%, SD = 23.2%). Students had the most difficulty staging ulcers that were stage III (45.95%, SD = 19.9%) or those that were unstageable (52.91%, SD = 29.7%).
As noted in the Table, students participating in the active learning intervention were significantly more accurate in the staging of all PUs, as the correct identification average for the intervention group was 69.47% (SD = 15.2%), whereas the correct identification average for control group was 60.29% (SD = 14.4%, p < .0001). Cohen's d for all stages was calculated and found to have a moderate effect (d = .63). The intervention group was significantly more accurate in staging the severity of stage II PUs (68.36%, SD = 25.4%, p = .001, d = .59) and the classification of suspected deep tissue injury (77.09%, SD = 30.7%, p = .006, d = .483) than the control group (stage II, 52.62%, SD = 27.9%; suspected deep tissue injury, 60%, SD = 39.5%). Although not significant, students in the intervention group were able to more accurately stage the severity of ulcers in all other staging classifications (i.e., unstageable, stage IV, stage III, stage I). Stage III PUs were the most difficult to identify for both student groups, with a correct identification average of 47.27% (SD = 16.9%) for the intervention group and 45.24% (SD = 21.3%) for the control group.
Comparison of Pressure Ulcer Staging Accuracy Among Student Groups
The purpose of the current study was to determine the effectiveness of an intervention to improve the accuracy of PU classification and staging in prelicensure nursing students. This is the first known study to evaluate the impact of an experiential learning activity related to the accuracy of PU staging among prelicensure nursing students. The intervention allowed students to apply the information they learned from the online training modules and to engage in the skill they were attempting to develop through the assessment of patients' skin during Skin Day. Students participating in the active learning intervention more accurately identified PUs on the staging tool. Specifically, students in the intervention group were significantly better at classifying ulcers at all stages than the control group (69% versus 60%, p < .0001). Furthermore, students in the intervention group were able to more accurately classify stage II ulcers (68% versus 52%, p = .001) and deep tissue injuries (77% versus 60%, p = .006). Those two classifications have been reported in other studies as being difficult (Bruce et al., 2012; Kelly & Isted, 2011). Students' participation in Skin Day provided them with the opportunity to assess multiple wounds, discuss staging with wound experts, and validate their perception of the actual stage of the ulcer. That exposure to wound experts may have provided students with the finite, clinical insights that differentiate stage II and deep tissue injuries from other ulcer classifications.
Despite the improvement in staging accuracy in the intervention group, the overall accuracy remains low, with an average of 63% for the correct identification for all stages. The low percentage may be related to the methodology of evaluating student competency, which included photographs and wound descriptors, although much of the previous literature has used this methodology. Another reason for improvement in the intervention group may be due to the students being asked to complete the nongraded tool during a scheduled lecture at the end of the semester.
Although not an initial objective of the study, the hospital staff welcomed the students' assistance during Skin Day. Wound, ostomy, and continence nurses enjoyed collaborating with and providing education to the students regarding PU prevention and treatment. In addition, the students provided much-needed assistance in turning all of the bed-ridden patients in the facility, thus making the process more efficient.
A noteworthy limitation of this study was the failure to include a choice of not an ulcer in the PU staging tool. This may have inadvertently skewed the accuracy of classifying a stage I ulcer. Another limitation includes the generalizability of the study.
Although the current study was conducted at two universities in different geographical locations (one in the midwestern and one in the southern United States), the differences in student demographics may have impacted staging accuracy. Further studies should be conducted to compare a larger number of students with diverse backgrounds.
In addition, it is not clear whether participation in Skin Day or completion of the NDNQI modules improved staging accuracy. A further study may compare multiple interventions, such as Skin Day with and without using the NDNQI modules, and the impact on staging accuracy.
The correct staging of PUs is necessary for adherence to evidence-based guidelines for prevention and treatment. The incidence of PUs in health care settings is a quality metric (Agency for Healthcare Research and Quality, 2016); thus, failure to prevent and subsequently treat ulcers effectively will impact patient and organizational outcomes. Participation in Skin Day provided students with hands-on clinical experience that improved their accuracy in classifying and staging ulcers. Providing students with an active learning educational opportunity may be needed to improve the competency of ulcer classification. This type of experiential educational opportunity should be considered for all students and practicing nurses, as correct staging is necessary for adherence to best practice guidelines and for the ultimate improvement of patient outcomes.
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Comparison of Pressure Ulcer Staging Accuracy Among Student Groups
|Correct Identification Average (% [SD])|
|Pressure Ulcer Stage||Intervention Group (n = 55)||Control Group (n = 103)||p||Cohen's d|
|Stage I||92.27 (15.9)||88.83 (18.8)||.25||.198|
|Stage II||68.36 (25.4)||52.62 (27.9)||.001**||.59|
|Stage III||47.27 (16.9)||45.24 (21.3)||.542||.106|
|Stage IV||77.45 (30.7)||71.07 (21.9)||.099||.27|
|Suspected deep tissue injury||77.09 (31.8)||60 (39.5)||.006*||.483|
|Unstageable||58.91 (0.32)||49.71 (21.1)||.063||.307|
|All stages||69.47 (15.2)||60.29 (14.4)||<.0001**||.63|