Effect of training programmes on nurses' ability to care for subjects with pressure injuries: A meta-analysis.

We performed a meta-analysis to evaluate the education effects on nurses' ability to care for subjects with pressure injuries. A systematic literature search up to April 2021 was carried out, and 29 studies included 5704 nurses at the start of the study; 3800 of them were experiment or post-training and 3804 were control or per-training. They were reporting relationships between the education effects on nurses' ability to care for subjects with pressure injuries. We calculated the odds ratio (OR) or the mean difference (MD) with 95% confidence intervals (CIs) to assess the education effects on nurses' ability to care for subjects with pressure injuries using the dichotomous or continuous method with a random or fixed-effect model. Experiment or post-trained nurses had significantly higher knowledge score (MD, 10.00; 95% CI, 7.61-12.39, P < .001), number of nurses with proper knowledge (OR, 20.70; 95% CI, 10.80-39.67, P < .001), practice score (MD, 12.39; 95% CI, 5.37-19.42, P < .001), and number of nurses with proper practice (OR, 3.56; 95% CI, 1.75-7.25, P < .001), attitudes score (MD, 7.46; 95% CI, 2.94-11.99, P < .001) compared with control or pertained nurses. Training may have a beneficial effect on improving the nurses' ability to care for subjects with pressure injuries, which was obvious in improving knowledge, practice, and attitudes post-training. Further studies are required to validate these findings.

confidence intervals

odds ratio

BACKGROUND

Pressure injuries have negative effects on the subjects, nurses, and medical institutions involved. Nurses caring for subjects suffering from pressure injuries work longer hours and therefore feel overloaded. Also, they may experience guilt about the progress of a pressure injury or subject's slow recovery. Moreover, there have been several legal cases associated with unproven nursing negligence after pressure injury incidence. , , , Pressure injuries are one of the most important management problems for medical institutions. In the United States, for occurrence, pressure injury was added to the list of “never events,” which ended compensation for the extra cost of care for stages 3 and 4 pressure injuries recognised through a subject's hospital stay when no pressure injury of any stage or severity existed on admission. , In South Korea, there have been cases in which hospitals have had to reimburse subjects for pressure injuries that happened after hospitalisation. In addition, pressure injuries are one of the indicators to evaluate facility quality, and early detection allows for faster recovery and decreases in needless hospitalisation. Eventually, inhibition, early detection, and proper management of pressure injury are vital for subjects, nurses, and medical institutions. Nevertheless, professional knowledge and skills required to handle pressure injury are essential for nursing staff. Earlier research has revealed that nurses have poor information in this area. Because pressure injury‐associated education is mostly learned at university‐affiliated hospitals, almost 40% of nurses in small‐ and medium‐sized hospitals do not have satisfactory education or knowledge associated with pressure injury care. Also, unique pressure injury is problematic; several stages show tissue damage, and subjects with pressure injuries mostly have multiple comorbidities. Therefore, a full understanding of the diverse stages of pressure injury, clinical decision‐making skills, and visual differentiation capability are predominantly vital in the care of subjects affected by pressure injuries. Most studies about pressure injury training programmes focused on injured subjects. , , Few have inspected the efficacy of pressure injury training on nurses, , , and the results were conflicting to draw a solid conclusion. Therefore, this study aimed to evaluate how education affects nurses' ability to care for subjects with pressure injuries.

METHODS

The present study followed the meta‐analysis of studies in the epidemiology statement, which was performed following an established protocol.

Study selection

Included studies were that with statistical measures of association (odds ratio [OR], mean difference [MD], frequency rate ratio, or relative risk, with 95% confidence intervals [CIs]) between the education effects on nurses' ability to care for subjects with pressure injuries.

Human studies conducted only in English language were considered. Inclusion was not restricted by study size or type. Publications excluded were review articles and commentary and studies that did not supply a degree of relationship. Figure 1 shows the whole study process.

FIGURE 1

Schematic diagram of the study procedure

The articles were integrated into the meta‐analysis when the following inclusion criteria were met:The exclusion criteria for the intervention groups were as follows:

The study was a randomised control trial or a retrospective study.

The target population is nurses

The intervention programme was any training programme about care for subjects with pressure injuries

The study included comparisons between the experiment or post‐training and control or pre‐training

Studies that did not compare nurses' ability to care for subjects with pressure injuries

Studies with nurses' care of subjects other than subjects with pressure injuries

Studies that did not focus on the effect of comparative results.

Identification

A protocol of search strategies was prepared according to the PICOS principle, and we defined it as follow: P (population): nurses; I (intervention/exposure): training programme about care for subjects with pressure injuries; C (comparison): experiment or post‐training and control or pre‐training; O (outcome): change in knowledge, practice, and attitudes; and S (study design): no restriction. First, we conducted a systematic search of Embase, PubMed, Cochrane Library, OVID, and Google scholar till April 2021, by a blend of keywords and related words for the nurse, training program, pressure injury, knowledge, practice, and attitude as shown in Table 1. All detected studies were gathered in an EndNote file, duplicates were removed, and the title and abstracts were revised to eliminate studies that did not show any relationship between the education effects on nurses' ability to care for subjects suffering from pressure injuries. The remaining studies were examined for related information.

TABLE 1

Search strategy for each database

Database	Search strategy
Pubmed	#1 “nurse”[MeSH Terms] OR “training program”[All Fields] OR “pressure injury”[All Fields] #2 “knowledge”[MeSH Terms] OR “nurse”[All Fields] OR “Practice”[All Fields] OR “attitude”[All Fields] #3 #1 AND #2
Embase	“nurse”/exp OR “training program”/exp OR “pressure injury”/exp #2 “knowledge”/exp OR “ICBG”/exp OR “Practice”/exp OR “attitude”/exp #3 #1 AND #2
Cochrane library	#1 (nurse):ti,ab,kw OR (training program):ti,ab,kw OR (pressure injury):ti,ab,kw (Word variations have been searched) #2 (knowledge):ti,ab,kw OR (Practice):ti,ab,kw OR (attitude):ti,ab,kw (Word variations have been searched) #3 #1 AND #2

Screening

Data were abridged on the following bases: study‐related and subject‐related characteristics onto a standardised form; last name of the primary author, period of study, year of publication, country, region of the studies, and study design; population type, the total number of subjects, demographic data, and clinical and treatment characteristics; categories, qualitative and quantitative method of evaluation, information source, and outcome evaluation; and statistical analysis. If a study qualified for inclusion based upon the aforementioned principles, data were extracted independently by two authors. In case of disagreement, the corresponding author provided a final option. When there were different data from one study based on the assessment of the relationship between the education effects on nurses' ability to care for subjects with pressure injuries, we extracted them separately. The risk of bias in these studies is that individual studies were evaluated using two authors who independently assessed the methodological quality of the selected studies. The “risk of bias tool” from RoB 2—A revised Cochrane risk‐of‐bias tool for randomised trials—was used to assess methodological quality. In terms of assessment criteria, each study was rated and assigned to one of the following three risks of bias: low: if all quality criteria were met, the study was considered to have a low risk of bias; unclear: if one or more of the quality criteria were partially met or unclear, the study was considered to have a moderate risk of bias; or high: if one or more of the criteria were not met, or not included, the study was considered to have a high risk of bias. Any inconsistencies were addressed by a re‐evaluation of the original article.

Eligibility

The main result was concentrated on the education effects on nurses' ability to care for subjects suffering from pressure injuries. An assessment of the education effects on nurses' ability to care for subjects suffering from pressure injuries was extracted by forming a summary.

Inclusion

Sensitivity analyses were limited only to studies reporting the relationship between the education effects on nurses' ability to care for subjects with pressure injuries. For subcategory and sensitivity analyses, we compared the experiment or post‐training and control or pre‐training.

Statistical analysis

We calculate the OR and MD and 95% CI using the dichotomous or continuous method with a random or fixed‐effect model. We calculated the I 2 index, and the I 2 index was in the range between 0% and 100%. The I 2 index was about 0%, 25%, 50%, and 75%, which specifies no, low, moderate, and high heterogeneity, respectively. If the I 2 index was >50%, we used the random‐effect; if it was <50%, we used the fixed‐effect. We used stratifying the original assessment per result categories as described previously to complete the subgroup analysis. A P value for differences among subcategories of <.05 was considered statistically significant. Publication bias was assessed quantitatively using the Egger regression test (publication bias is present if P ≥ .05), and qualitatively, by visual inspection of funnel plots of the logarithm of OR versus their SEs. The entire P values were two tailed. Reviewer manager version 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark) was used to do all calculations and graphs.

RESULTS

A total of 2534 unique studies were identified, of which 29 studies (between 2004 and 2021) fulfilled the inclusion criteria and were included in the study. , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

The 29 studies included 5704 nurses at the start of the study; 3800 of them were experiment or post‐training and 3804 were control or per‐training. All studies evaluated the education effects on nurses' ability to care for subjects suffering from pressure injuries.

The study size ranged from 28 to 1217 nurses at the start of the study. The details of the 29 studies are shown in Table 2. Twenty‐five studies reported data stratified to change in knowledge score, 4 studies stratified to the change in the number of nurses with proper knowledge, 10 studies reported data stratified to studies stratified to change in practice score, 6 studies reported data stratified to the change in number of nurses with proper practice, and 5 studies stratified to the changes in attitudes score.

TABLE 2

Characteristics of the selected studies for the meta‐analysis

Study	Country	Total	Experiment	Control
Sinclair, 2004 25	Canada	648	648	648
Tully, 2007 26	Canada	65	65	65
Beeckman, 2008 27	Belgium	426	217	209
Tweed, 2008 28	New Zealand	1125	530	595
Beeckman, 2010 3	Europe	1217	658	559
Van Gaal, 2010 18	Netherlands	326	141	185
Cox, 2011 19	United States	60	40	20
Altun, 2011 29	Turkey	28	28	28
Lissa, 2014 30	India	60	60	60
Nayak, 2014 31	India	30	30	30
Mohamed, 2015 1	Egypt	40	20	20
Bredesen, 2016 32	Norway	42	42	42
Lee, 2016 33	Korea	407	407	407
Awali, 2018 34	Saudi Arabia	100	100	100
Sheikhaboumasoudi, 2018 35	Iran	119	59	60
Delmore, 2018 36	United States	112	55	57
Jeengar, 2018 37	India	40	40	40
Mohamed, 2019 38	Egypt	43	43	43
Okhovati, 2019 39	Iran	80	40	40
Saad, 2020 40	Egypt	50	50	50
Hassan, 2020 41	Pakistan	144	144	144
Ibrahim, 2020 42	Egypt	40	40	40
Awad, 2020 43	Egypt	40	40	40
Mohamed, 2020 44	Egypt	45	45	45
Seo, 2020 45	Korea	60	60	60
Delmore, 2020 46	United States	77	58	77
Ursavaş, 2020 47	Turkey	84	42	42
Liu, 2020 48	China	146	73	73
Gaballah, 2021 49	Egypt	50	25	25
	Total	5704	3800	3804

Experiment or post‐trained nurses had significantly higher knowledge score (MD, 10.00; 95% CI, 7.61‐12.39, P < .001) with high heterogeneity (I 2 = 100%), number of nurses with proper knowledge (OR, 20.70; 95% CI, 10.80‐39.67, P < .001) with no heterogeneity (I 2 = 0%), practice score (MD, 12.39; 95% CI, 5.37‐19.42, P < .001) with high heterogeneity (I 2 = 100%), number of nurses with proper practice (OR, 3.56; 95% CI, 1.75‐7.25, P < .001) with high heterogeneity (I 2 = 88%), and attitudes score (MD, 7.46; 95% CI, 2.94‐11.99, P < .001) with high heterogeneity (I 2 = 96%) compared with control or pertained nurses as shown in Figures 2, 3, 4, 5, 6.

FIGURE 2

Forest plot of the change in knowledge score in experiment or post‐training compared with control or pre‐training nurses

FIGURE 3

Forest plot of the change in the number of nurses with proper knowledge in experiment or post‐training compared with control or pre‐training nurses

FIGURE 4

Forest plot of the change in practice score in experiment or post‐training compared with control or pre‐training nurses

FIGURE 5

Forest plot of the change in the number of nurses with proper practice in experiment or post‐training compared with control or pre‐training nurses

FIGURE 6

Forest plot of the changes in attitudes score in experiment or post‐training compared with control or pre‐training nurses

Selected studies stratified analysis that adjust for the level of education, age, and ethnicity was not performed because no studies reported or adjusted for these factors.

Based on the visual inspection of the funnel plot as well as on quantitative measurement using the Egger regression test, there was no evidence of publication bias (P = .84). However, most of the included studies were assessed to be of low methodological quality. All studies did not have selective reporting bias, and no articles had incomplete outcome data and selective reporting.

DISCUSSION

This meta‐analysis study based on 29 studies included 5704 nurses at the start of the study; 3800 of them were experiment or post‐training and 3804 were control or per‐training. , , , , , , , , , , , , , , , , , , , , , , , , , , , , Experiment or post‐trained nurses had significantly higher knowledge score, number of nurses with proper knowledge, practice score, number of nurses with proper practice, and attitudes score compared with control or pertained nurses. , , , , , , , , , , , , , , , , , , , , , , , , , , , , Nevertheless, the analysis of outcomes should be performed with caution because of the low sample size of most of the selected studies (19 studies were ≤100 subjects) in our meta‐analysis, especially in some parameters; suggesting the need for more studies with a proper sample size to validate these findings or possibly to significantly influence confidence in the effect evaluation.

Pressure injury identification and management is a vital patient safety aspect in hospitals. The tasks and roles of nurses in handling pressure injuries should be highlighted, particularly through the present increase of incorporated nursing care. However, pressure injury‐associated education is given mostly to nurses in advanced practice. Most nurses in general hospitals or home nursing, who care for older adults or patients suffering from chronic situations, lack such training. The need for a consensus is crucial, as it is important for evidence‐based practice and effective nursing.

This outcome aligns with previous studies that showed an increase in nurses' ability after pressure injury training, , , , but opposes another study that showed no significant difference in their ability to differentiate between pressure injury, moisture‐related lesions, incontinence‐related dermatitis, and burns. Although education on pressure injury classification and incontinence‐related dermatitis increase visual identification, discrimination between pressure injury and incontinence‐related dermatitis is still hard. A technique to reinforce this discrimination is essential. Training programmes include theoretical teaching and clinical practice for around 2 hours in a class less than 100 people were predominantly found to be effective. , , , Training programmes that concentrate on problem‐solving and practical application skills, rather than traditional speeches, increase competence in practice. , , , The post‐education knowledge, practice, and altitude levels of participants significantly improved right after the training programmes, however, these effects are expected to significantly decrease with time, recommending that the longer the time interval after the intervention, the more likely participants are to return to their pre‐education baseline. , , , , , , Continuous feedbacks after education and follow‐up are essential. So, further studies are needed to train the nurses and follow them up to evaluate the persistence of education post‐training.

This meta‐analysis showed the relationship between the education effects on nurses' ability to care for subjects with pressure injuries. However, further studies are needed to validate these potential relationships. Also, further studies are needed to deliver a clinically meaningful difference in the results. These studies must comprise larger with more homogeneous samples. This was suggested also in previous similar meta‐analysis studies that showed a similar effect of experiment or post‐training and control or pre‐training in nurses. , , , Well‐conducted studies are also needed to assess these factors and the combination of different levels of education, ages, and ethnicity, because our meta‐analysis study could not answer whether they are associated with the results. In summary, the data suggest that training may have a beneficial effect on improving the nurses' ability to care for patients suffering from pressure injuries, which was obvious in improving knowledge score, number of nurses with proper knowledge, practice score, number of nurses with proper practice, and attitudes score post‐training compared with control or per‐training. Further studies are required to validate these findings.

Limitations

There may be selection bias in this study because many of the studies found were excluded from the meta‐analysis. However, the studies excluded did not satisfy the inclusion criteria of our meta‐analysis. Also, we could not answer whether the results are associated with age and ethnicity or not. The study designed to assess the relationship between the education effects on nurses' ability to care for subjects with pressure injuries was based on data from previous studies, which might cause bias induced by incomplete details. The meta‐analysis was based on 29 studies; 19 studies were small, ≤100. Most of the studies included in the analysis were observational, and the heterogeneity of the articles was relatively high Variables including the level of education, age, ethnicity, and nutritional status of subjects were also possible bias‐inducing factors. Some unpublished articles and missing data might lead to a bias in the pooled effect. Subjects were using different treatment schedules, dosage, and health care systems. Most of the unselected studies were counting or highlighting the level of knowledge without training. Those studies were mostly in developed countries possibly because their nurses are expected to have proper knowledge and training. Most studies were cohort studies, which enrolled nurses at baseline and trained them for the improvement of nurses' ability to care for subjects suffering from pressure injuries; these studies did not adjust for challenging risk such as aetiology and severity, and stage, subject adherence, and treatment.

CONCLUSIONS

Training may have a beneficial effect on improving the nurses' ability to care for patients suffering from pressure injuries, which was obvious in improving knowledge score, number of nurses with proper knowledge, practice score, number of nurses with proper practice, and attitudes score post‐training compared with control or per‐training. However, the analysis of outcomes should be performed with caution because of the low sample size of most of the selected studies in our meta‐analysis, especially in some parameters; suggesting the need for more studies to validate these findings or possibly to significantly influence confidence in the effect evaluation.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

AUTHOR CONTRIBUTIONS

Meng Xiangli: Conception and design. Bao Yan, Huang Dandan, Meng Xiangli: Administrative support. Bao Yan, Huang Dandan, Meng Xiangli: Provision of study materials or subjects. Bao Yan, Huang Dandan: Collection and assembly of data. Bao Yan, Huang Dandan, Meng Xiangli: Data analysis and interpretation. Bao Yan, Huang Dandan, Meng Xiangli: Manuscript writing. Bao Yan, Huang Dandan, Meng Xiangli: Final approval of manuscript. All authors have read and approved the manuscript.