INTRODUCTION

The incidence of pressure injuries (PIs) is high, with approximately 3 million cases worldwide.1 The overall PI prevalence is estimated to be 12.8% in hospitalized adult patients2 and varies by setting, with prevalence rates as high as 27% in neonates,3 12% to 18% among ICU patients,4 13.1% in patients admitted to palliative home care settings,5 and 3.9%6 to 8.9%7 among patients in acute care settings.

Pressure injuries can cause pain, odor, and disability, reducing quality of life8 and extending the length of hospital stay by an average of 4 days9 in an adult population and 14 days3 in a pediatric population. By increasing the need for care resources, PIs represent a major economic burden for healthcare systems worldwide. The annual US expenditure for hospital-acquired PIs is estimated to be $26.8 billion.10 Data from Australia report annual PI-related healthcare costs in public hospitals of $9.11 billion.11 These costs are predicted to rise dramatically in the upcoming years due to the aging population and growing incidence of obesity.

Although PI prevention is a multidisciplinary responsibility, nurses play a pivotal role because they offer 24-hour patient care12 and PI prevention is a key indicator of nursing standards.13 It is important that nurses have the appropriate knowledge and skills to prevent and treat PIs. Evidence demonstrates that nurses’ knowledge and skills vary between different PI prevention domains, such as identifying prevention protocols,14 classifying and assessing PI risk, and planning preventive activities.15,16

Low levels of PI knowledge are reported not only among nurses but also among nursing students.17–20 It may be that nursing students do not receive sufficient education on PIs during their undergraduate curriculum.21 Different instruments have been used to measure PI knowledge and skills.22 Assessments of nurses’ and nursing students’ PI knowledge using the Pressure Ulcer Knowledge Assessment Tool (PUKAT) have obtained a mean score range between 39.7% and 58.5%, which is described as insufficient.17,18,23–26 The lowest scores primarily related to PI prevention,17,18,24 whereas the highest score was generally nutrition knowledge.17,23 Only one study found the highest score for the “risk assessment” theme.24

Knowledge deficits can be improved by specific training programs.27 It is important to support knowledge development for nursing students with an adapted curriculum21 and using specific educational methods.17,25 Both nurses and nursing students must be trained in PI prevention and management. Evidence demonstrates an increase in nurses’ knowledge of PI prevention and treatment following PI trainings.28–30

To address this fact, the chair of wound care of the Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts of Western Switzerland, developed a blended-learning unit that combined e-learning and a practical workshop to improve first-year bachelor’s degree in nursing students’ PI knowledge and skills. This scenario was developed to align with the learning outcomes provided by the level 5 curricula for nurses of the European Wound Management Association.31 This study evaluates bachelor’s degree in nursing students’ baseline PI knowledge and the evolution of their knowledge over time following a blended-learning unit and clinical practice.

METHODS

Using a quasi-experimental design, the authors collected data over three time points between October 2021 and February 2022.

Participant Recruitment and Study Setting

All 220 nursing students from the first semester of a French-speaking University of Applied Sciences and Arts of Western Switzerland were invited to participate. The researchers provided oral information about the project in class as well as via an online forum. Students were invited to fulfill the questionnaire at the three time points. Participation was voluntary, and the assessment had no impact on their course.

Bachelor’s Degree in Nursing Curricula

In Western Switzerland, the bachelor’s degree in nursing content is prescribed by the same educational framework, which defines the minimum content.32 The bachelor’s degree in nursing is a 3-year program, representing a workload of 180 European Credits Transfer Accumulation System, of which 60 are allocated to clinical practice. In the University of Applied Sciences and Arts of Western Switzerland, the chair of wound care implemented a specific approach to wound care education over a period of 3 years, including education on PIs, skin tears, diabetic foot and leg ulcers, and malignant fungating wounds.33

Participants’ Education Background

Bachelor’s degree in nursing students arriving at the University of Applied Sciences and Arts have a heterogeneous background from their previous training. Because of regulations, most students access the first-year bachelor’s degree in nursing after a preparatory year. This preparatory year contains 2 hours of theoretical courses on PIs and 8 hours of workshops. During the workshops, the students practice positioning to prevent PIs, clinical examination of the skin, and how to hydrate the skin to prevent dryness. During this year, they also have two 14-week clinical experiences: one in a professional environment and one in a healthcare environment. Other students directly access the first-year bachelor’s degree in nursing after completing healthcare/nurse assistant courses or specific equivalencies.

Pedagogical Scenario

A blended-learning unit with a flipped classroom approach was developed to promote a theoretical and practical approach to learning. Learning outcomes of the e-learning and workshops are described in Table 1. All students began with an e-learning lesson based on recent literature and the latest consensus document, which covered PI classification,34 prevention, and treatment and highlighted specificities of PIs related to medical devices. This interactive unit was designed using Articulate Storyline and reviewed by nurses with a Certificate of Advanced Studies in wound care for content validity. The e-learning unit included text where important information was highlighted and pictures to illustrate PI classification and specific positions to prevent PIs. Integrated videos explained specific aspects of PI prevention. Students could access the e-learning unit at any time and had 2 hours to complete it.

Table 1. - LEARNING OUTCOMES FOR EACH EDUCATION MODALITY E-Learning Workshop - Explain the pathophysiology of PI - List and define the different categories of PI - Identify PI categories - Orally transmit the wound assessment and classify the PI using professional terminology - Differentiate IAD from PI - Practice a PI dressing (categories 1 and 2) while respecting the quality-of-care criteria and relationship with the patient - List the risk factors for PI - Use the evaluation tools linked to a clinical vignette - Assess the patient’s risk - Transfer the knowledge acquired during the theoretical courses concerning PI and IAD - Propose preventive and therapeutic measures according to the person’s needs and environment - Explain to the patient the risk factors for PI and recommendations for good practice - Propose ways of educating people and their entourage on the principles of prevention and PI management

Abbreviations: IAD, incontinence-associated dermatitis; PI, pressure injury.

After the e-learning was complete, the researchers divided students into 22 subgroups with 10 students each. A workshop design was used to implement the theory into practice. Each 4-hour workshop was tutored by a wound care nurse specialist with a certificate of advanced studies in wound care. To ensure equity between groups, wound care nurse specialists received a paper tutorial and a 15-minute explanation about the workshop’s pedagogical intentions. During the workshop, students could practice on high-fidelity wound care models with all stages of PIs on the basis of a clinical situation.

Following the theoretical part of the bachelor’s degree, nursing students participate in a 6-week clinical practice (internship) in different settings, such as hospital units, home care, or nursing homes. To support learning, students can ask questions at any time in a specific forum where both students and lecturers can respond.

Data Collection

All data were collected using the Moodle learning platform (Cyberlearn) via online surveys. Data were collected at three time points: at baseline before the blended-learning unit (T0), after the blended-learning unit (T1), and after 6 weeks of clinical practice (T2). Figure 1 provides an overview of data collection.

Figure 1.:

TIMELINE OF DATA COLLECTION

Sociodemographic questionnaire

At baseline, students completed a sociodemographic questionnaire that included questions about age, highest academic level achieved, years of professional experience in health, and setting of professional experience. Students had the option not to answer these questions.

The PUKAT

At all three time points, students completed the PUKAT 2.035 to measure their PI knowledge. The PUKAT is a valid and reliable tool to measure knowledge about PIs22 that is appropriate for use with nursing students.36 It contains 25 questions across six themes: (1) etiology, (2) classification and observation, (3) risk assessment, (4) nutrition, (5) prevention of PI, and (6) specific patient groups. The PUKAT 2.0 has satisfactory psychometric properties;35 the level of difficulty (0.12–0.91), discrimination index (0.02–0.34), quality of the response alternatives (0.01–0.70), and test-retest procedure (0.69) are good.35

The English version of the PUKAT 2.0 was translated and culturally adapted to Swiss French using a translation and a back-translation process.37 Two bachelor’s degree nurses working as assistant lecturers at the university independently translated the PUKAT from English to Swiss French. Outputs were compared and clarified if needed. Then, two independent nurses provided a back-translation. Differences were highlighted and discussed, and consensus was reached between wound care experts and a dietitian. Because there were only slight differences, no pilot test was needed. The translated questionnaire was used with all students.

Data Analysis

Data were extracted from the learning platform, cleaned, and anonymized prior to statistical analysis using Stata 16 (StataCorp). Data were analyzed using descriptive statistics. The researchers included data only from participants who responded at all three time points. Differences in scores among the three time points were identified using an analysis of variance test, and t tests were used to compare scores before and after the blended learning (T0-T1), before the blended learning and after clinical practice (T0-T2), and after the blended learning and after clinical practice (T1-T2). Effect size was calculated with Cohen d adapted to paired data when the t test showed significant differences (P < .05).

Ethics

This study was approved by the director of the University of Applied Sciences and Arts Western Switzerland, Geneva, and dean of the nursing faculty. The researchers followed principles defined in the Declaration of Helsinki, as well as national guidelines for research. Participation was entirely voluntary and had no impact on student evaluation. The return of a completed questionnaire indicated consent to participate. Because this study did not involve treatment or personal data and data were anonymized prior to analysis, no ethical approval was required according to the Human Research Act (HRA)38 and the Research Ethics Committee (2022-00891).

RESULTS General Demographic Characteristics

Of a total of 220 enrolled first-year nursing students, 21 students responded at all three time points, resulting in a participation rate of 9.5%.

The mean age of the participants was 25.4 (SD, 7.5)years (range, 19–47 years), and the highest academic degree reported was a master’s degree in another discipline. One participant indicated not having any clinical experience; the majority (n = 12) had 1 or more years of professional experience in different healthcare settings before the start of the bachelor’s degree in nursing program. The clinical practice locations varied, but no participants had previous experience on a surgical or medical unit. Table 2 provides an overview of participants’ academic achievement and previous clinical experiences.

Table 2. - ACADEMIC AND CLINICAL EXPERIENCE OF PARTICIPANTS, N = 21 Characteristic n (%) Highest academic level attained High school 3 (14.28) Nurse assistant with a federal diploma in vocational education and training 4 (19.05) Federal vocational baccalaureate 10 (47.62) Bachelor’s 2 (9.52) Master’s or PhD 1 (4.76) Other 1 (4.76) Duration of professional health experience, y None 1 (4.76) <1 8 (38.10) 1–2 4 (19.05) 3–4 4 (19.05) ≥5 4 (19.05) Setting of professional experience Home care 4 (19.05) Nursing home 7 (33.33) Pediatrics/maternity 3 (14.29) Readaptation 3 (14.29) Outpatient clinic 1 (4.76) Other 3 (14.29)
Changes in PUKAT Scores Over Time

At all three time points, students scored lowest on prevention knowledge (34.5%, 49.4%, and 52.4% at T0, T1, and T2, respectively) and highest on risk assessment (64.5%, 81%, and 83.5% at T0, T1, and T2, respectively). Table 3 outlines the percentage of correct answers over the total scores and themes. The results per item are available in the Supplemental Table (https://links.lww.com/NSW/A167).

Table 3. - PUKAT TOTAL SCORES AND SPECIFIC THEME SCORES Variables T0 T1 T2 n (MD) Mean (SD) Range Correct Answers, % n (MD) Mean (SD) Range Correct Answers, % n Mean (SD) Range Correct Answers, % Total score 20 (1) 11.45 (2.09) 7–15 45.8 20 (1) 14.8 (3.47) 10–21 59.2 21 16.24 (3.51) 11–25 65 Theme Etiology 21 2.52 (1.17) 0–5 42 21 3.09 (1.18) 1–5 51.5 21 3.52 (1.40) 0–6 58.7 Classification and observation 20 (1) 2.25 (0.91) 0–4 56.3 20 (1) 2.6 (0.94) 1–4 65 21 2.81 (0.87) 1–4 70.3 Risk assessment 21 1.29 (0.56) 0–2 64.5 21 1.62 (0.59) 0–2 81 21 1.67 (0.48) 1–2 83.5 Nutrition 21 1.52 (0.93) 0–3 50.7 21 2.19 (0.81) 1–3 73 21 2.48 (0.75) 1–3 82.7 PI prevention 21 2.76 (1.51) 0–6 34.5 21 3.95 (1.75) 1–8 49.4 21 4.19 (1.81) 0–8 52.4 Specific patient 21 1.19 (0.51) 0–2 59.5 21 1.38 (0.50) 1–2 69 21 1.57 (0.51) 1–2 78.5

Abbreviation: MD, missing data; PI, pressure injury; PUKAT, Pressure Ulcer Knowledge Assessment Tool.

At baseline (T0), only two students (9.5%) selected the correct answer for why a ring cushion (donut) should not be used for PI prevention, and one student (4.8%) knew the importance of not securing the blanket under the mattress. In contrast, 16 students (76.2%) correctly selected the appropriate positioning protocol.

After completion of the blended-learning unit (T1), four students (19.1%) indicated the correct use of bed linen, and five (23.8%) knew why a ring cushion should not be used for PI prevention.

After the 6 weeks of clinical practice (T2), the item with the fewest correct answers was the proper use of the blanket, with only two students (9.5%) answering correctly. Although students scored highest on risk assessment (83.5%), they also scored well on nutrition (82.7%).

Total PUKAT scores increased from 45.8% correct at baseline to 59.2% after the blended-learning unit and 65% after clinical practice (F2,58 = 19.08; P = .00). This increase was statistically significant before and after the blended-learning unit (T0-T1; 95% CI, −4.89 to −1.81; P = .00) and before the blended-learning unit and after clinical practice (T0-T2; 95% CI, −6.64 to −3.26; P = .00), with respective Cohen d effect sizes of −1.02 and − 1.37. The increase in mean score between T1 and T2 was not significant (95% CI, −3.49 to 0.29; P = .09). Figure 2 illustrates the evolution of total scores over time.

Figure 2.:

PUKAT SCORE EVOLUTION OVER TIMEAbbreviation: PUKAT, Pressure Ulcer Knowledge Assessment Tool.

DISCUSSION

This project highlights the difficulties in obtaining longitudinal student participation. The response rate over the three time points was low (9.5%), even though students received a precontact and a reminder e-mail at each measuring point, as recommended in the literature.39 However, despite the small sample size, the results show a statistically significant increase in students’ PI knowledge after participation in a blended-learning unit and clinical practice. These results align with an integrative review suggesting that e-learning and face-to-face teaching could enhance clinical skills40 and research noting that well-structured and well-designed blended learning can impact students’ success.41,42 Regarding PI knowledge specifically, the literature confirms that an intervention combining face-to-face and virtual training improves nurses’ knowledge.43

The finding that students had insufficient PI knowledge measured at baseline (T0) before the blended-learning unit was not surprising because participants started their nursing education 1 month prior to this study. The knowledge score after conducting the blended-learning unit and the clinical practice reached 65%, which is higher than the recommended knowledge score of 60%.17,18,24,44 However, these results could be influenced by reusing the same questionnaire at all three time points.45

The results highlight the challenges with developing knowledge about PI prevention and support previous research about nursing students17,18,23–26 and nurses,46,47 indicating that knowledge about prevention is insufficient. The authors determined that PI prevention was probably not sufficiently highlighted during the blended-learning unit. For example, students did not practice the use of ring cushions or sheets, which could explain their low scores on the related PUKAT questions.

The theme of risk assessment obtained the highest percentage of correct answers over the three time points. These numbers are confirmed in another study using the same measurement tool (PUKAT 2.0).24 During the workshop, risk assessment tools were discussed to highlight similarities and discrepancies, which could support knowledge evolution and explain students’ good understanding of the available tools.

According to Beeckman et al,36 the PUKAT could be used in undergraduate nursing education to identify low-scoring themes and items. This was also the case using the French translation. Identifying the themes with the lowest scores will help the department improve the blended-learning unit and adapt the current curricula to meet students’ education needs. Future workshops will include a stronger focus on PI etiology and prevention and will clarify the difference between incontinence-associated dermatitis and PIs.

Strengths and Limitations

To the authors’ knowledge, this is the first study to follow nursing students over three time points to evaluate knowledge evolution after a blended-learning unit and clinical practice. The use of a standardized tool enhances the validity of the results and helps improve future teaching modalities by obtaining real-world data. One limitation of this research is that there was no psychometric validation of the French version of the PUKAT 2.0. In addition, this quasi-experimental study did not include a control group. The low response rate may be because students could complete the survey at home after receiving a reminder, potentially introducing a participation bias. However, a statistical comparison between groups and the respondents at each time point supports the validity of the findings.

CONCLUSIONS

This research found that nursing student knowledge about PIs increased after a blended-learning unit in combination with clinical practice. Students exhibited a low level of knowledge about PI prevention over the time points. Therefore, the nursing curriculum needs to be updated to include more information about PI prevention, which could influence the quality of care provided to patients across settings. Further research is needed to evaluate the long-term retention of knowledge and how bachelor’s degree in nursing students will use it in clinical practice.

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