Effects of a Just-in-Time Educational Intervention Placed on Wound Dressing Packages

J Wound Ostomy Continence Nurs. 2010;37:1-6. Published by Lippincott Williams & Wilkins WOUND CARE Effects of a Just-in-Time Educational Intervention Placed on Wound Dressing Packages A Multicenter Randomized Controlled Trial Dea J. Kent, MSN, RN, NP-C, CWOCN PURPOSE: I compared the effects of a just-in-time educational intervention (educational materials for dressing application attached to the manufacturer s dressing package) to traditional wound care education on reported confidence and dressing application in a simulated model. SUBJECTS AND SETTINGS: Nurses from a variety of backgrounds were recruited for this study. The nurses possessed all levels of education ranging from licensed practical nurse to master of science in nursing. Both novice and seasoned nurses were included, with no stipulations regarding years of nursing experience. Exclusion criteria included nurses who spent less than 50% of their time in direct patient care and nurses with advanced wound care training and/or certification (CWOCN, CWON). Study settings included community-based acute care facilities, critical access hospitals, long-term care facilities, long-term acute care facilities, and home care agencies. No level 1 trauma centers were included in the study for geographical reasons. METHODS: Participants were randomly allocated to control or intervention groups. Each participant completed the Kent Dressing Confidence Assessment tool. Subjects were then asked to apply the dressing to a wound model under the observation of either the principal investigator or a trained observer, who scored the accuracy of dressing application according to established criteria. RESULTS: None of the 139 nurses who received traditional dressing packaging were able to apply the dressing to a wound model correctly. In contrast, 88% of the nurses who received the package with the educational guide attached to it were able to apply the dressing to a wound model correctly ( 2 107.22, df 1, P.0001). Nurses who received the dressing package with the attached educational guide agreed that this feature gave them confidence to correctly apply the dressing (88%), while no nurse agreed that the traditional package gave him or her the confidence to apply the dressing correctly ( 2 147.47, df 4, P.0001). CONCLUSIONS: A just-in-time education intervention improved nurses confidence when applying an unfamiliar dressing and accuracy of application when applying the dressing to a simulated model compared to traditional wound care education. Introduction Appropriate wound care, which includes accurate selection and application of a variety of wound care products, is a key responsibility for the individual wound care clinician and health care facility. Wound care is especially challenging when provided by multiple caregivers with varied educational and experiential backgrounds. Educating multiple persons to deliver competent wound care may appear especially overwhelming for agencies that lack a wound care specialist to ensure adequate education for all involved staff or lay care providers. Seaman and colleagues 1 suggest that innovative dressings may help caregivers improve wound-healing outcomes. However, this is true only when dressings are selected and applied appropriately. Ayello and colleagues 2 demonstrated a need for increasing both the quality and quantity of education related to wound care. Nevertheless, little research has been completed that evaluates the efficacy of educational strategies to promote appropriate selection and application of wound care products. Clinical decision making is a complex process that involves the intersection of a number of factors, including knowledge of wound healing, local and systemic factors that influence wound healing, specific wound care interventions, and past experience. 3 Nurses must make multiple decisions when caring for an individual patient and that influence patient outcomes such as wound healing. 4 Rycroft-Malone and associates 5 found that protocol-based care increased nurses independence and autonomy. Verdu 6 found that decision trees assist nurses to make complex clinical decisions, including the selection of appropriate wound dressings. Dea J. Kent, MSN, RN, NP-C, CWOCN, Manager, Wound Ostomy Clinic, Riverview Hospital, Noblesville, Indiana. Correspondence: Dea J. Kent, MSN, RN, NP-C, CWOCN, PO Box 386, Sharpsville, IN 46068 (deajkent@aol.com). DOI:10.1097/WON.0b013e3181f1826b Copyright 2010 by the Wound, Ostomy and Continence Nurses Society J WOCN Published Ahead of Print 2010 1

2 Kent J WOCN 2010 Educational Intervention Advances in the application of informatics in health care have led to a teaching technique commonly labeled just-in-time education. 7 This model is adapted from the business world and is based on the concept that learning is facilitated when the education is provided in a timesensitive manner (ie, education delivered at the moment it is most needed). This approach to education allows for customization of content 8 and provides the learner with tools that enhance their ability to provide effective care. Just-in-time education also allows the learner to be more self-directed. 9 There are many examples of just-in-time education in the everyday world, such as reading directions for an over-the-counter medication at the time of purchase. Wound care specialists have developed a variety of tools, including decision trees for selection of appropriate pressure redistribution surfaces and algorithms for selecting an appropriate dressing, that have proved useful for assisting generalists manage wounds. Just-in-time education may prove useful for wound care if it can be made available when a dressing is applied. One company that manufactures dressings (Medline Industries, Inc, Mundelein, Illinois) has developed a packaging system based on the concept of just-in-time education (Figure 1). Instructions for appropriate dressing use are attached to each package. This study was undertaken to assess the effects of this educational resource. Specifically, I examined nurses reported confidence in their ability to provide appropriate care using an unfamiliar dressing and an objective assessment of nurses ability to apply the dressing correctly to a wound model. Methods This randomized controlled trial compared self-reported confidence levels in providing wound care and applying a dressing to a model in 2 groups of nurses. Study procedures were reviewed and approved by my facility s institutional review board, and all participants gave informed consent. Nurses FIGURE 1. Educational guide attachment on dressing package (photograph). were recruited through informal announcements made on various units including medical/surgical units, emergency departments, surgery, day surgery, and long term acute rehabilitation unit, home health care agencies, and long term care facilities. Nurses with wound care certification (CWOCN, CWON, and CWCN) and advanced practice nurses were excluded from participation. In addition, nurses who spent less than 50% of their time in direct patient care were excluded. I excluded these nurses since direct patient care is not the focus of their routine responsibilities and their participation may have introduced confounding variables into the study. Nurses were randomly allocated to a control group receiving traditional wound education, or the intervention group receiving just-in-time education. Simple random allocation was completed by allowing each nurse to choose a colored card. Cards were 1 of 2 colors; selection of 1 color led to allocation to the control group, and selection of the other color resulted in allocation to the intervention group. Participants had no knowledge of which dressing the colored cards represented. No compensation was provided to participants, and the company who designed the innovation had no input into the design, concept, or implementation of the study. However, the company did supply dressings, free of charge, needed to conduct the study. Study Setting The study was conducted at 8 facilities in central Indiana, including community hospitals, critical access hospitals, long-term acute care units, long-term care facilities, and home health agencies. The long-term acute care units and home health agencies were used in the pilot study only, due to staff availability. Facilities were selected that were geographically near the principal investigator. Each facility was contacted and the appropriate administrator was approached about allowing me to solicit involvement in the study. Once management approval was given, site visits for the recruitment of subjects were completed. Instruments Data were collected using 2 tools: (1) the Kent Dressing Confidence Assessment, a rating scale/questionnaire to assess the nurses feeling of confidence in dressing application; and (2) a structured criteria form to be used to evaluate each nurse s ability to accurately apply the dressing to the wound model (Figures 2 and 3). The Kent Dressing Confidence Assessment is a questionnaire used to measure nurses confidence in wound dressing application; I developed the tool prior to data collection. It was evaluated by a panel of researchers, with expertise in wound care and instrument development, and professional educators. The tool was then revised in order to obtain consensus as to measurement criteria, wording, and general presentation. Following content validation by the panel, the tool was further evaluated in a pilot study involving 34 nurses. Each nurse randomly selected 1 of the test dressings and completed the questionnaire. Demographic information was

J WOCN Volume 37 Kent 3 FIGURE 2. Kent Dressing Confidence Assessment. collected on the nurses involved in the pilot study, and they were interviewed to determine if they found the questionnaire clear and understandable. They were also asked to provide suggestions for improving wording of any items they found confusing. All participants indicated they found instrument items clear, concise, easy to read, easy to complete, and easy to understand. The Kent Dressing Confidence Assessment contains 10 questions; each item is answered via a 5-point scale, strongly agree, agree, neutral, disagree, or strongly disagree. Each item is scored individually. I then developed a form using information from the educational packaging that specified correct criteria for dressing application. This form contained 4 application criteria; each of the criteria had to be demonstrated by the nurse in order for the dressing application to be scored as correctly applied (Figure 3). Study Procedures I selected a dressing that was not familiar to study participants in order to enable a more accurate assessment of the effect of the educational intervention on application and self-reported confidence with application. The control group received the unfamiliar dressing in a standard package with instructions to actually apply the dressing to the wound model. Scissors and gauze were made available for use, and the participants were told they could use any item they thought necessary to apply the dressing. The nurses were not asked to secure any secondary dressing in place. Rather, they were instructed to apply the secondary dressing according to package instructions. Participants were allowed to ask questions, but no information about how to apply the dressing was given by the principal investigator (D.K.) or trained observer. The intervention group was managed in an identical fashion, but they received the unfamiliar dressing in a package with an attached instruction sheet (Figure 1). Each participant completed the Kent Dressing Confidence Assessment tool (Figure 2). Subjects were then asked to apply the dressing to a wound model under the observation of either the principal investigator (D.K.) or a trained observer, who scored the accuracy of dressing application according to established criteria (Figure 3). The trained observer was a nurse trained in providing wound care and dressing application. I taught the observer to score the subject based on the 4 criteria for correct dressing application and on how to interact with subjects during data collection. I evaluated training by direct observation of the data collector prior to data collection. In order to avoid education among participants, I allowed only 1 participant in the study room at any time. Subjects were asked to not to speak of any part of their experience in the study room until all data were collected at that facility. Data Analysis Proportions and chi-square analysis were used to determine whether the educational intervention affected nurses FIGURE 3. Criteria for dressing application.

4 Kent J WOCN 2010 reported confidence when applying a novel dressing and their observed performance when applying the dressing to a model. Chi-square findings were validated with the Fisher exact test. Results One hundred seventy-three nurses participated in the study. Among the control and intervention groups, there were 43 licensed practical nurses and 130 RNs, including diploma (n 7), associate degree (n 65), bachelor s degree (n 55), and master s degree (n 3) RNs. The most common category of work experience was category B (2-5 years) among the nurses. Forty-one nurses worked in a long-term care facility, 13 worked in home health care, 18 worked in long-term acute care, and the remaining 101 nurses worked in the acute care hospital (Table 1). No statistically significant differences were found when groups were compared based on educational preparation, care setting worked, or years of experience. Confidence With Dressing Application Dressing application confidence was evaluated via 3 items from the Kent Dressing Confidence Assessment: (1) item 5 that queried correct dressing application; (2) item 7 that queried safe application of the dressing; and (3) item 9 that queried confidence when correctly applying the dressing. Significantly, fewer control group subjects agreed that they could correctly apply the dressing (item 5) (4% vs 100%, 2 173.00, df 4, P.0001). Significantly, fewer control group subjects agreed that they could safely apply the dressing as compared to subjects receiving just-in-time education (item 7) (4% vs 91%, 2 160.07, df 4, P.0001). Fewer nurses in the control group agreed that they felt confident with dressing application when compared to nurses in the intervention group (item 9) (19% vs 88%, 2 147.47, df 4, P.0001) (Table 2). Dressing Application None of the 62 nurses in the control group were able to apply the dressing to the wound model correctly as compared to 68 of 77 nurses (88%) in the intervention group who were able to apply the dressing correctly ( 2 100.694, df 1, P.0001) (Figures 4 and 5). The most common dressing errors were as follows: (1) failure to trim the dressing to fill the wound cavity two-third full (100%); (2) failure to remove the blue cover (carrier sheet) on the dressing (68%); and (3) overpacking the wound by scrunching the entire dressing up in the wound bed (100%). Reported data does not include pilot study groups. TABLE 1. Demographic Information Control Group, N Intervention Group, N Group Comparison Total Licensure 2 0.1549 N 173 LPN 21 22 df 1 RN 59 71 P.69 Education 2 1.6162 N 173 LPN 21 22 df 1 Diploma RN 4 3 P.20 ADN RN 33 32 BSN RN 21 34 MSN RN 1 2 Experience, y 2 0.1274 N 173 1 12 8 df 1 2-5 20 22 P.72 6-10 13 17 11-15 9 23 16-20 19 19 21-25 4 3 26 3 1 Care setting 2 2.8728 N 173 Acute care 46 55 df 3 ECF 4 22 P.41 Home care 19 9 Long-term acute care 11 7 Abbreviations: ADN, advance degree nurse; ECF: Extended Care Facility; LPN, licensed practical nurse.

J WOCN Volume 37 Kent 5 TABLE 2. Questionnaire Results % Agree Kent Dressing Confidence Assessment Plain Package (n 80) Package With Instructions (n 93) The package directions on the wound dressing package: 1. Provides directions about use of the dressing 0 100 2. Defines 1 or more uses of the dressing 0 100 3. Indicates instructions for application of the dressing 0 100 4. Indicates the method for removing the dressing 0 100 5. Explains how to apply the dressing correctly 0 100 6. Defines the change frequency of the dressing 0 100 7. Allows me to apply the dressing safely 0 90 8. Educates me about specific precautions in relation to the dressing 0 96 9. Gives me confidence that I can correctly apply the dressing 0 88 10. Will change my nursing practice in relation to 0 71 application of wound dressings Discussion Findings from this study provide evidence that use of a just-in-time educational intervention (placement of an instructional guide for application in the individual dressing packages) enhances application technique and reported confidence when applying a previously unfamiliar dressing. More subjects in the intervention group reported confidence that they could safely and correctly apply the dressing than did control group subjects, and this perception was validated when subjects were asked to apply the dressing to a model. I reviewed the literature and found no other studies demonstrating the efficacy of the just-in-time educational technique in wound care. Poskus 10 reported that a just-intime intervention improved accuracy of a swallowing protocol. Similarly, Grasso and colleagues 11 found that personal digital assistants (an electronic device designed to deliver just-in-time education) that accessed a drug database significantly reduced the rate of medication errors in 1 facility. Al-Saleh and Williamson 12 also found that personal digital assistants provide the ability to find information quickly and promote safe patient care, as well as confidence in undergraduate nursing student. Although this study did not directly measure dressing application in a clinical practice setting, more subjects receiving the intervention were able to accurately apply an unfamiliar dressing accurately to a model than were subjects given traditional education. In addition, 71% of nurses who received the just-in-time educational intervention reported they would change their practice based on the package insert. It is not known why the remaining 29% responded that they did not feel that the intervention would prompt them to change their practice. Some participants stated that they frequently provide wound care based on physician orders, without really thinking about the purpose of a particular dressing. Others expressed that dressing application is relatively intuitive, and they simply glanced through the educational guide instead of reading it, as observed by the investigator. However, since accurate application of this type of dressing falls within the scope of nursing practice, this response presents a challenge to wound care nurses when educating peers about wound care. I attributed application failures in the control group to a lack of knowledge about dressing application, since no information was available on the dressing package itself. Factors contributing to dressing application failures for intervention group subjects may include an assumption that they could apply the dressing correctly without consulting directions, or a history of topical dressing packages without just-in-time information aiding accurate application. Limitations Study limitations include using a model for dressing application rather than direct observation in clinical practice. In addition, although subjects were instructed not to discuss dressing application with other study participants, it was not possible to ensure that subjects did not discuss FIGURE 4. Successful dressing application results, n 68.

6 Kent J WOCN 2010 More than 70% of nurses reported that placement of an educational guide on wound dressing packages would change their practice when delivering wound care. FIGURE 5. Dressing application failures, n 71. application outside the research setting. I did not include pilot study dressing application data in the overall results. The outcomes were similar for this portion of the study, but the focus was on validation of the Confidence Assessment Tool and the study procedures. Conclusions Just-in-time education, in the form of education on a dressing package, improved both nurses confidence in application of an unfamiliar dressing and their accuracy when applying the dressing to a simulated model. Study findings provide evidence that manufacturers of wound dressings should apply just-in-time educational techniques by placing an educational guide on all dressing packages in order to enhance the accuracy and safety of application and, ultimately, its efficacy in wound healing. KEY POINTS Just-in-time education in the form of an educational guide on wound dressing packages led to increased nursing confidence in a broad sample of nurses with varying educational backgrounds and numbers of years of experience. Just-in-time education in the form of an educational guide on wound dressing packages led to increased safety and accuracy when applying an unfamiliar dressing in a simulated model. ACKNOWLEDGMENTS The author thanks Medline Industries for supply of dressings/packaging for the study. The author also thanks St. Joseph Hospital, Kokomo, Indiana, for supporting this study as well as Mark Smith, St. Vincent Hospital, Indianapolis, Indiana, for statistical analysis of the data. References 1. Seaman S, Herbster S, Muglia J, Murray M, Rick C. Simplifying modern wound management for nonprofessional caregivers. Ostomy Wound Manag. 2000;46:18-27. 2. Ayello E, Baranoski S, Salati D. Wound care survey report. Nursing. 2005;35:36-45. 3. Banning M. A review of clinical decision making: models and current research. J Clin Nurs. 2007;17:187-195. 4. Twycoss A, Powls L. How do children s nurses make clinic decisions? Two preliminary studies. J Clin Nurs. 2006;15:1324-1335. 5. Rycroft-Malone J, Fontenla M, Bick D, Seers K. Protocol-based care: impact on roles and service delivery. J Eval Clin Pract. 2008;14:867-873. 6. Verdu J. Can a decision tree help nurses to grade and treat pressure ulcers? J Wound Care. 2003;12:45-50. 7. Yensen J. Just-in-time resources on demand. http://www.langara. bc.ca/vnc/ksu/ksu.htm#_toc11. Accessed May 25, 2008. 8. Barr R, Tagg J. Just-in-time education: learning in the global information age. http://knowledge.wharton.upenn.edu/. Published December 2002. Accessed June 5, 2008. 9. Bongiorni B, Spicknall M, Horsmon A, Cohen P. On-demand education to meet marine industry professional development needs. J Ship Prod. 1999;15:164-178. 10. Poskus K. Triumphs and challenges of implementing a nursing bedside swallow screening tool: a stroke coordinator s perspective. Perspect Swallowing Swallowing Disord (Dysphagia). 2009;18: 129-133. 11. Grasso B, Genest R, Yung K, Arnold C. Reducing errors in discharge medication lists by using personal digital assistants. Psychiatr Serv. 2002;53:1325-1326. 12. Al-Saleh M, Williamson K. EBP and patient safety: using PDAs in nursing education classes. Paper presented at: Summer Institute on Evidence-Based Practice; 2009. http://www. acestar.uthscsa.edu/institute/su09/documents/al-saleh_000.pdf. Accessed January 29, 2010.