Close the nurse knowledge gap.

Evidence indicates that the cost of preventing hospital-acquired pressure injuries (HAPI) is significantly lower than the cost to treat. However, despite available best practice guidelines, nurses’ knowledge of both risk and preventive strategies varies and the incidence of pressure injuries (PIs) worldwide remains stagnant. A hospital in New York responded to its high HAPI rate by evaluating nurse PI knowledge and implementing an ed­ucational plan designed to address gaps among both experienced and new nurses. (See The cost of HAPI.)

The why

At the end of June 2019, the HAPI rate at Glens Falls Hospital (GFH), a 291-bed community hospital in northern New York, was 0.68 per 1,000 patient days. This incidence rate is calculated based on all identified HAPIs assessed and verified by a wound care nurse. GFH identified HAPI reduction as a priority because PIs staged at 2 or greater serve as nurse-sensitive indicators that affect a patient’s pain and suffering and outcomes and also impact payment for care.

The existing HAPI prevention education included lengthy modules assigned to each nurse. The wound care nurse and the clinical nurse educators wanted to streamline the curriculum to focus on knowledge gaps and reduce the time and burden of the modules by eliminating common information nurses already know. As such, the GFH team conducted a study aimed at uncovering nurse PI knowledge.

The how

To assess clinical nurses’ PI knowledge and prevention strategies, the wound care nurse and educator team asked newly employed nurses to complete the Pieper-Zulkowski Pressure Ulcer Knowledge Test (PUKT). This standardized, validated instrument includes 72 items used to determine baseline PI knowledge. The team also included demographic items designed to describe the nurse population. Administering PUKT to new nurses during orientation allowed them to determine common knowledge among nurses as they enter the organization, which then helped address gaps.

The team received permission from the PUKT test creators and instructions for use. The test’s 72 questions include three subscales: prevention (28 questions), staging (20 questions), and wounds (24 questions). Test takers can respond “True,” “False,” or “Don’t know.” Demographic questions included primary work area, job category, years in practice, age, gender, highest degree, certification, and PI education and learning history. After receiving internal review board approval, the team launched the study in November 2019.

Participants

The wound care nurse and educators obtained a convenience sample of newly employed clinical nurses during their initial orientation. The new nurses received an invitation letter explaining the study’s purpose, its voluntary nature, and a contact for questions or concerns. Before receiving any PI education, the team sent participants a paper copy of the demographic sheet, the PUKT, and an envelope to submit results.

When the COVID-19 pandemic emerged, data collection slowed or stopped periodically. In August 2021, after a preliminary analysis of the surveys received, the team decided to stop data collection; more surveys might have led to slight changes in the results, but the general trends wouldn’t have varied. The final sample size consisted of 47 complete tests.

The results

The wound care nurse and educator team used descriptive statistics to provide baseline data and identify participant characteristics. In addition to analyzing the 72 individual questions, they also analyzed questions within the three knowledge subscales (prevention, staging, and wounds). They determined an average percent of correct scores by subscale, as well as the average total score, and then calculated low (<59% correct), moderate (59% to 79% correct), and high (≥80% correct) knowledge scores. The team also examined correlations between clinical nurse characteristics and the subscale scores.

Respondent characteristics, education history

Most respondents worked full-time in medical/surgical, telemetry, or mother–baby areas; had been in practice for ≤5 years; were female; had a baccalaureate or master’s degree; and were not certified in a specialty area. When asked about their PI education history, most had listened to a lecture or read an article or book on the subject in the previous 2 years. They also had sought PI information online but hadn’t read the National Pressure Injury Advisory Panel and European Pressure Injury Advisory Panel Pressure Injury Guidelines.

Knowledge level

Overall, respondents answered an average of 73.8% of the questions correctly. They demonstrated overall low knowledge (<59% of the respondents answered correctly) on 18 of the 72 questions. The team identified the following knowledge gaps: immobile patients’ shifting weight, use of a specialty bed, PI water cleansing, bacterial immunity to silver dressings, use of donut devices/ring cushions, and use of honey dressings. Respondents demonstrated high knowledge (≥80% answering correctly) on 37 questions. Questions related to nutritional assessment, skin blanching, heel blisters, incontinence care, self-care for patients with spinal cord injuries, and PI from nasal cannulas yielded a 100% correct response rate. Of the three subscales (prevention, wound, and staging), the wound subscale had a statistically significant lower average percent correct compared to the others (68.4% wound, 76.0% prevention, and 77.4% staging) and a higher average number of “Don’t know” responses. (See Demographic and education history connection.)

The application

After examining the knowledge gaps identified during the survey, the GFH wound care nurse determined that the wound subscale, which had the lowest score and the most “Don’t know” responses, indicated the need for additional education on the wounds nurses see in everyday practice. The wound care nurse disseminated the study findings to the nursing leadership team, which renewed its goal to reduce HAPI as part of the 2022 nursing strategic plan.

The wound care nurse focused on rounding on the inpatient units to assist with skin assessments, reinvigorated the clinical nurse skin team, and provided education opportunities targeted at filling the knowledge gaps. In September 2022, the HAPI rate dropped to 0.23 per 1,000 patient days (a 66% decrease).

Recognizing the wound care nurse’s efforts, the nurse leaders acknowledged that sustaining the improvement would require additional resources from an expert who could provide coaching while nurses cared for patients with PIs. The hospital had one full-time wound care nurse and now recognized that adding another would benefit patient care.

In September 2022, a part-time wound care nurse was hired, which provided the full-time nurse with more time to participate in interdisciplinary rounds, attend shared leadership councils, and regularly distribute HAPI data. The additional wound care nurse increased access to PI expertise and at-the-elbow education for bedside nurses. During new nurse orientation, the wound care nurses provided PI identification and prevention education to ensure every nurse had the same baseline knowledge.

In addition, GFH rents specialty beds for patients with special needs, including those with a high risk for PI. These bed rentals present a significant expense. To address knowledge gaps related to their use, the wound care nurses created an ordering guide and provided in-service education on all specialty mattresses to ensure that they’re ordered and used appropriately.

In response to the lack of PI knowledge among less-experienced nurses, GFH offers shadowing experiences with the wound care nurses to nursing students from the local community college, who represent most of the newly licensed nurses hired into the organization. This early enrichment helps to ensure these new nurses begin their careers with adequate PI knowledge. In addition, GFH requires that all nurse residents shadow one of the wound care nurses for at least 4 hours. These shadowing experiences focus on the following:

• Baseline knowledge of skin assessment
• Risk assessment strategies using the Braden Scale, an evidence-based risk-assessment tool
• PI prevention measures
• PI management.

Take responsibility

Hospital leadership must recognize that competency varies among newly hired nurses, whether they’re experienced or newly licensed. Organizations taking responsibility for filling knowledge gaps ensure a culture of safety. At GFH, our findings prompted the implementation of staff-driven PI education and initiatives to achieve improved patient outcomes.

Casia Tomlinson is a wound care coordinator at Glens Falls Hospital in Glens Falls, New York. Patricia Edwards is a consultant in North Andover, Massachusetts. Laura Pfeifer is the assistant vice president of nursing operations at Glen Falls Hospital

American Nurse Journal. 2024; 19(1). Doi: 10.51256/ANJ012406

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Key words: hospital-acquired pressure injury, HAPI, nurse education