Educational campaign to increase
knowledge of pressure ulcers
ABSTRACT
Background: A pressure ulcer (PU) steering group was set up in Zhongda
Hospital in China to develop a campaign to increase knowledge of PUs,
to improve management and reduce incidence. Method: Questionnaires
were completed by 275 nurses to ascertain their knowledge of PUs. The
initial questionnaire indicated that the nurses had insufficient knowledge
of PUs. The steering group then ran a campaign focusing on standardising
the management of PUs. The measurement of PU knowledge for all nurses
was tested after 2 years of training. Results: After 2 years, the nursing
staff’s knowledge of PUs had improved. Usage of the Braden scale had
risen from (60.0±22.9) to (88.0±9.0) and showed a statistically significant
difference (p<0.01). Moreover, the rate for patients reported as being at
high risk of developing a PU had increased from 0.98% in 2012 to 1.24% in
2013, while the occurrence rate of PUs in the hospital had decreased from
0.09% in 2012 to 0.05% in 2013. Conclusion: The campaign significantly
enhanced the knowledge of PUs and improved the ability of nursing staff to
evaluate PU risks, resulting in a decrease in the occurrence of PUs.
Key words: Pressure ulcer ■ Steering group ■ Braden scale ■ Occurrence rate
P
ressure damage is caused by sustained pressure
exerted on the skin, soft tissues, muscle, and bone
leading to the development of localised ischaemia,
followed by a cascade of processes resulting in
necrosis (Raju et al, 2015). This subsequently forms the
pressure ulcer (PU) (Chou et al, 2013; Coleman et al, 2013).
Areas of the body commonly predisposed to PUs include the
sacrococcygeal region, heels, elbows, shoulders, back of the
head, knees, thighs, and toes (Shannon et al, 2012).
PUs are a high-prevalence problem in hospitalised
patients. There is little research into the prevalence of PUs
in China. However, it is thought to be lower than that
in European countries (Jiang et al, 2014). The incidence
of hospital-acquired PUs in the UK and Europe is
Haixia Feng, Nurse Director, Department of Nursing Management,
Zhongda Hospital, School of Medicine, Southeast University, China
Guohong Li, Chief Nurse, Department of Nursing Management,
Zhongda Hospital, School of Medicine, Southeast University, China
Cuirong Xu, Deputy Chief Nurse, Department of Nursing
Management, Zhongda Hospital, School of Medicine, Southeast
University, China
Changping Ju, Chief Nurse, Lishui County People’s Hospital,The
Group Hospital, Zhongda Hospital, School of Medicine, Southeast
University, China
Accepted for publication: July 2015
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high and costly, despite the fact that most are believed
to be preventable (Guy et al, 2013). PUs also cause a
significant economic burden. In the UK estimates of
the mean costs for treating PUs range from £1214 for
a category 1 pressure ulcer to £14 108 for a category 4
pressure ulcer (Dealey et al, 2012). PUs not only cause
a financial burden but also prolong recovery leading to
other medical complications depending on the patients
comorbidities,decreasing patients’ quality of life, even
potentially causing death (Yatabe et al, 2011; Dealey et al,
2012; Amir et al, 2013). Therefore, scientific management of
pressure ulcers is a significant issues for nursing managers
(Van Den Kerkhof et al, 2011), as well as an important
evaluation indicator for the quality of patient care in
hospital appraisal and ranking by the National Ministry of
Health in China (Liu et al, 2013). If patients develop a PU
because of improper nursing, the hospital would lose points
and this would then impact on its rank among hospitals
(Teng et al, 2015). In recent years, owing to the increased
number of patients and rapid expansion of beds in Chinese
hospitals, a large number of nurses have been recruited into
acute clinical care.
Despite the fact that the theories behind the development
of PUs have been updated, there is a lack of specialist
knowledge in PU prevention and management among the
general nursing staff in China (Jiang et al, 2009). Nursing
staff cannot properly recognise the patients who are at high
risk of developing PUs, nor make good use of preventative
methods to avoid the occurrence of PUs. These potential risks
can lower the quality of patient care because of the lack of
education, knowledge and training in PU management for
general nurses in China.
Therefore, to avoid these potential risks and to further
standardise PU management, a PU steering group was set
up in the authors’ hospital. This group included head nurses
from critical departments, such as neurology, neurosurgery,
rehabilitation, thoracic surgery. As a result of their stronger
coordinated organisation skills, clinical experience, and
independent problem-solving abilities, the head nurses were
recruited to ensure the implementation of the PU project
(Jiang et al, 2012).
A registered nurse with training and expertise in wound
care should receive standardised training, including academic
course work, continuing education hours or contact hours on
basic and advanced wound care and wound bed preparation
(or a national certificate in wound care from wound care
organisations) (Corbett, 2012).
The goal of the PU steering group was to carry out
British Journal of Nursing 2016, Vol 25, No 12: TISSUE VIABILITY SUPPLEMENT
 RESEARCH

an educational programme, including standard assessment, Table 1. Awareness of preventative postures among
reporting, consultation, prevention, following-up treatment, nursing staff from different departments (n = 275)
and a series of training sessions on PU management. All
Department False (%) True (%) χ2 P value
staff completed the training and were then awarded the
practical certificate. Internal 36(32.14) 54(33.13)
medicine

Surgical 56(50.00) 100(61.35) 11.11 0.0039

Background department
There are 1914 beds and 46 nursing units in Zhongda Others 20(17.86) 9(5.52)
Hospital Southeast University, Nanjing, China, with 1480
nursing staff in total working there. In November 2011,
Table 2: Awareness of Braden Scale among nursing
the nursing unit and staff structure changed, and a new staff in different age groups (n=275)
PU steering group was set up with a group leader, a group
deputy leader, six core members, and a wound care nurse as Age (years) False (%) True (%) χ2 P value
the consultant. There are 38 liaison officers from all relevant 18–25 59(27.44) 31(51.67)
departments.
26–30 91(42.33) 14(23.33)
Training 31–35 25(11.63) 7(11.67) 13.65 0.0085
All core members of the PU steering group attended online
36–39 13(6.05) 3(5.00)
wound training courses organised by the Health Human
Resources Development Center of the Ministry of Health ≥ 40 27(12.55) 5(8.33)
(HHRDC) in China. HHRDC was established in December
1998 because of the prevalence of PUs. It is approved and Table 3: Awareness of Braden Scale among nursing
supported by the Office of Central Institutional Organization staff with different professional titles (n = 275)
Commission, which aims to strengthen the construction of Professional
the health professional team and human resources for health title False (%) True (%) χ2 P value
in China.The core members of the steering group received
Nurse 102(47.44) 41(68.33)
their qualifications. In addition, they also participated in
wound study groups and learned about the latest pressure ulcer Senior nurse 78(36.28) 12(20.00)
8.39 0.0151
guidelines and other relevant information. Members of the Nurse-in- 35(16.28) 7(11.67)
steering group were given clearly stipulated responsibilities, and charge
educational campaign plans to ensure that they were equipped
with the ability to mentor others regarding pressure ulcers. Table 4: Awareness of Braden Scale among nursing
staff in different departments (n = 275)
Methodology  Department False(%) True(%) χ2 P value
Initial questionnaire
A total of 275 female nurses who mainly work in the Internal 75(34.88) 15(25.00) 10.56 0.0051
operating room and emergency department) employed at medicine
the hospital (with an average age of 36±2.1 years) were Surgical 124(57.67) 32(53.33)
selected to complete an initial questionnaire assessing their department
knowledge of pressure ulcers in December 2011. The Others 16(7.45) 13(21.67)
questionnaire was based on relevant literature and consisted
of multiple choice questions (Vanderwee et al, 2007; Zhao et
al, 2010; Jankowski and Nadzam, 2011; Moore and Cowman, Table 5: Awareness of the pressure ulcer healing
2012; Gunningberg et al, 2013). The questionnaire was put process among nursing staff with different professional
titles (n = 275)
together by the members of the PU steering group after
intensive training, The questionnaire was carried out through Professional
a combination of self-completion and interviews. The title False (%) True (%) χ2 P value
questionnaire contained questions relating to staff background Nurse 62(62.00) 81(46.29)
and a total of 16 items: knowledge related to pressure ulcer
Senior nurse 25(25.00%) 65(37.14)
prevention (9 items), pressure ulcer evaluation (3 items), and 6.42 0.0403
criteria for pressure ulcer treatment and cure (4 items). A total Nurse-in- 13(13.00) 29(16.57)
of 280 questionnaires were handed out and 275 validated charge
questionnaires were collected (a 98% response rate), with the
help of some researchers (research nurses) who had received department was analysed by the χ2 test. A difference of
training on data collection. p<0.05 was set as the threshold for statistical significance. The
EpiData 3.1 was used for data entry. Data were statistically survey results show that awareness of preventative postures for
analysed using the SPSS 16.0 software. The correct ratio to the pressure ulceration was low among the nursing staff (Table 1),
answers of the questionnaire in the nurse staff from different nursing staff had little knowledge of the Braden Scale (Tables

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Table 6: Awareness of the pressure ulcer treatment
and effective nursing criteria among nursing staff in
different department (n = 275)
Department False(%)
Internal 24(43.64)
medicine
Surgical 17(30.91)
department
Others 14(25.45)
Figure 1: Assessment of Braden Scale
The target populations: patients who are
bed-bound, paraplegic, (faecally) incontinent,
in a wheelchair, post-surgery, malnourished,
critically ill, unconscious
Assess the situation of nutrition intake
1. Observe temperature feeling by using ice
bag or warm water
2. Stimulate ill limbs with swabs
3. Judge the level of patient’s perception
4. Raise the bed to achieve semi-recumbent
position
5. Judge whether the patient is affected by
shear force and friction or not
Assess the translation, capability and spatial
extent of affected limb
Pay attention to observing whether skin and
bed are moist
Low-level risk: 15–17 points
Mid-level risk: 12–14 points
High-level risk: 11 points or less
1. Inform patient and family members and
ask for signature
2. Sign the matron’s name and the
responsible nurse’s name
3. Execute prevention nursing following the
guidebook
4. Report to nursing group and nursing
department
2, 3 and 4). The Braden Scale is one of the assessment tools
selected to assess the PU risk in the hospital (Pancorbo-
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Hidalgo et al, 2006).The awareness of pressure ulcer treatment
methods (Table 5) and criteria (Table 6) were low among
nursing staff. Meanwhile, there were significant differences
between the nursing staff from different departments, and
True(%) χ2 P Value
those with different professional titles and age groups because
66(41.25) of differences in training (p<0.05).
Owing to lack of knowledge of nursing staff on pressure
79(49.38) 12.63 0.0018 ulcer assessment and treatment, as well as other training related
to pressure ulcers, the steering group established a programme
to train 38 PU liaison officers who would play a guiding
15(9.37)
role in promoting knowledge of pressure ulcer assessment in
the hospital.
Subsequently, ‘Pressure Ulcer Activity Season’ was promoted
throughout the hospital as a way to train all nursing staff.
Nursing staff of different levels (from junior to senior) and
Self-introduce from different departments attended specific training modules.
Perform hand hygiene Meanwhile, all relevant training course materials were sent to
the pressure ulcer QQ group (an online communication tool
similar to Skype) to facilitate the exchange of ideas and self-
learning. The steering group, including the 38 liaison officers,
patients with pressure ulcers, and their families could all join
Bedside assessment
the group. At the end of the training, a knowledge contest
about pressure ulcers was held for all hospital staff with the aim
of strengthening the effects of training and stimulating their
Key points of observation passion for learning (Eskes et al, 2014).
The steering group established a standardised procedure
of pressure ulcer administration, including the Braden
Scale evaluation, reporting, consultation and discussion, and
treatment. Members of the steering group were divided into
groups in which an assigned person was responsible for the
pressure ulcer consultation, report forms collection, training for
pressure ulcer knowledge, and media reports of the educational
campaign, ensuring all standardised practice procedures had
been followed (Figure 1).
Bedside inspection
A wound-dressing nurse in the hospital with an
internationally recognised qualification offered an outpatient
wound service on every Wednesday afternoon. One of
the PU liaison officers attended the outpatient services
to work with the nurse to follow up outpatients. These
patients received consultations. This also included making
appointments for discharged patients to see doctors in the
Statistics points
outpatient wound clinic, guiding the treatment course, and
providing care instructions for PU patients.
All PU liaison officers were responsible for following up
on the cases of patients with pressure ulcers and for gathering
images of the wounds over 3 to 5 days. The liaison officers
Appropriate treatment were also asked to share this information with the pressure
ulcer QQ group so that the nursing staff could learn from
the different case studies.
Meanwhile, a case contest was held in the hospital and a
case report model was formulated. After screening, ten typical
cases were selected for the final contest. Sharing clinical
cases promotes the application of the nursing staff ’s pressure
ulcer knowledge into clinical practice, improves their
Perform hand hygiene
ability to deal with complex wounds, and enhances mutual
and take a record
information exchange.
The nursing staff ’s awareness of various pressure ulcer-
associated information was compared before and after the
educational campaign. Braden Scale precision rates, report
British Journal of Nursing 2016, Vol 25, No 12: TISSUE VIABILITY SUPPLEMENT
 RESEARCH

rates of high-risk pressure ulcers, and the occurrence rates of measures, furthermore, they have increased knowledge in
pressure ulcer within the hospital as a whole were evaluated. treating wounds. Therefore, the work of the steering group has
been beneficial to PU management at the hospital.
Statistical analysis After the training, prevention was considered as more
Data analysis was conducted using SPSS16.0 software. All important than treatment by nurses (Rosen et al, 2006; Chou
geometric data were expressed as mean ± standard deviation. et al, 2013). Nurses knew how to assess properly and prevent
The ratio of the correct answers to the questionnaire among PUs. They positively reported high-risk pressure ulcer cases
nursing staff from different department was analysed using the and paid more attention to high-risk cases to prevent the
χ2 test. occurrence of pressure ulcers
In addition, nurses also realised the importance of nutritional
balance for pressure ulcer prevention (Ohura et al, 2011; Brito
Results, outcomes and discussion  et al, 2013).When possible nutritional requirements must be
Comparison of knowledge before and addressed and corrected in line with the wishes and plan of
after the campaign care for each individual (Cereda et al, 2011).The frequency and
Before the campaign, 275 nurses were questioned and they quantity of patient feeding has been enhanced, and influenced
provided correct answers only 47% of the time. After the
campaign, another 312 nurses were investigated and the rate of Table 7: Nursing staff’s awareness of pressure ulcer
correct responses increased to 81%. The nurses’ knowledge of knowledge before and after the pressure ulcer steering
pressure ulcer postures, evaluation, prevention and treatment group’s campaign
had improved (Table 7). Correction
Before the campaign, 98 nurses were questioned on Time Case rate(%) false χ2 P value
their use of the Braden Scale and the rate of usage was Before 275 129(46.9) 146(53.1)
60.0±22.9. The evaluation of use of Braden Scale took over 73.64 < 0.001
10 minutes so the sample size is smaller than for the initial After 312 253(81.2) 59(18.8)
questionnaire. After a series of educational activities, 82 nurses
were questioned and their rate of usage was 88.0±9.0, which Table 8: Nursing staff usage of Braden Scale before and after the
is statistically different from before the campaign (p<0.01) pressure ulcer steering group’s educational campaign
(Table 8).
Age (years)
The reporting rate of pressure ulcers significantly increased Time Cases Total score (mean ± SD) t P value
from 2012 to 2013 (Table 9). The occurrence rate of the
pressure ulcers decreased significantly from 2012 to 2013 Before campaign 98 60.02 ± 22.9 31.0 ± 1.3
11.1 <0.001
(Table 10). After campaign 82 88.02 ± 9.0 32 ± 2.1

Changes in practice
Table 9. Reporting ratio of high-risk pressure ulcers in 2012 and 2013
Before the campaign, the survey showed that most nurses
were not aware of the method beyond the standard methods Ratio of high-
of prevention and treatment on PU in the hospital. Through a Extreme and risk patients in
Number high-risk patients Discharged total discharged
series of lectures, prompted assessments, quality control circle
Time of reports n (%) patients cases (%)
activities on different topics, and knowledge contests, the
steering group helped nurses learn new information (Tew et First half year 185 129 (69.73) 18 150 1.02
al, 2014). (2012)
The group also established some procedures such as for the Second half 209 165 (78.9) 19 622 1.06
use of Braden Scale evaluation, reporting for unavoidable PUs year (2012)
and the PU consultation process. First half year 228 191 (83.7) 21 039 1.08
The total score of the questionnaire involved in PU (2013)
increased significantly from 60.02 ±22.9 to 88.0±9.0. All
Second half 268 228 (85.1) 22 709 1.18
nurses in the hospital updated their PU knowledge. Nurses can year (2013)
now identify the patients at high risk and make use of effective

Table 10. Occurrence of pressure ulcers from 2012 and 2013

Indiscernible Transferred patients
Pressure patients within the from other hospitals Discharged Morbidity Occurrence
Time ulcer cases hospital n (%) n (%) patients (%) rate (%)

First half year (2012) 85 14 (16.47) 71 (83.53) 18 150 0.46 0.07

Second half year (2012) 98 12 (12.24) 86 (87.76) 19 622 0.50 0.06

First half year (2013) 102 11 (10.78) 91 (89.22) 21 039 0.48 0.05

Second half year (2013) 105 6 (5.71) 99 (94.29) 22 709 0.46 0.03

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 by the steering group.
The nurses now pay close attention to out-of-bed activities
for patients, by instructing patients on how they can get
into a wheelchair, sit at the edge of a bed with support, sit
across a chair with support, and use a walking aid to reduce
complications caused by immobilisation (Moody et al, 2004;
Peterson et al, 2008).
The members of the steering group usually arrange a
consultation within 2 hours of receiving the application
They often make quick assessments, give instructions about
the wound dressing, and gather images. The pressure ulcer
liaison officer in the department is also informed to observe
the process of PU care. Every week, wound care nurses visit
patients who require consultations with the on-duty liaison
officer. If a wound does not heal on discharge from hospital,
with the patient’s consent, their contact information and home
address are recorded. The patient is then asked back to the
outpatient clinic for further dressing of the wound until the
wound heals (Pieper, 2012).
As already reported (Bergquist-Beringer et al, 2011;
Dahlstrom et al, 2011; Tew et al, 2014), a trained nurse can
make a correct evaluation, identifying various category of
pressure ulcers. Education of PU knowledge has been found to
be related to lower hospital-acquired pressure ulcers (HAPU)
rates (Choi et al, 2013).
The nurse–patient relationship
After receiving training from the pressure ulcer steering
group, nursing staff recognise the importance of PU
evaluation and their ability to evaluate PUs has improved.
As a result, they are able to identify the critical stage of PU
development at an earlier stage and analyse relevant factors
of ontogenetic PUs to take targeted preventative measures
to reduce their occurrence (Rapp et al, 2010; Iizaka et
al, 2013). Moreover, owing to the standardisation of the
treatment regime for patients at high risk of PUs and an
enhanced communication platform (Ashby et al, 2012; Ausili
et al, 2013; Wong et al, 2014), nursing staff understand the
importance of informing patients and their family members
in advance about the risk of PUs. This can be seen in the
significant increase in the number of signatures obtained
on communications about pressure ulcers (in China, when
a nurse communicates with the patients and their family
members about PUs, there will be signatures to prove this
process). In-depth discussions on PUs with patients and their
family members also allowed them to recognise the scientific
and professional knowledge of the nurses and promotes the
degree of cognition and compliance for PU nursing, resulting
in a consensus of care between colleagues. It is important for
hospitals that health professionals work to reduce the risk of
PUs (Coleman et al, 2013; Ham et al, 2014).
Conclusion
The PU steering group’s educational campaign has enabled
nursing staff to engage more in PU management. Nurses
were able to master updated PU prevention and treatment-
related knowledge (Bolton et al, 2014). As a result, they can
take effective measures to prevent the occurrence of pressure
ulcers and advance healing. Meanwhile, the campaign has
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also established a set of in-house pressure ulcer regimens and
procedures. This promotes a continuous and dynamic process
for the management of pressure ulcers, and has improved the
level of clinical care in the hospital.  BJN
Declaration of interest: none
Acknowledgement: this work was supported by Jiangsu Province
Health Management Department of China (Nos. H201431).

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Fundamental Aspects of Infection

Prevention and Control
About the book
Infection prevention and control is a
vital for all practitioners to understand
major aspect of healthcare provision
how to ensure safe, hygienic and eff
and thus it is
ective patient
Fundamental Aspects of
care in their daily practice. This practic

Infection Prevention
al, handy text aims to provide essent
Infection prevention and control is a major aspect of healthcare ial information
Infection Prevention and Control

on infection prevention, control and

Fundamental Aspects of

management in any health care setting

.
The book will be an invaluable tool
provision and thus it is vital for all practitioners to understand
to help staff reduce avoidable health
infections. It provides healthcare practit care associated
ioners with a basic understanding of

and Control
how to ensure safe, hygienic and effective patient care in their
agents, their physiology, classications
management of infections, presenting
and transmission. It also covers the
infectious
clinical
best practice guidelines and precau
daily practice. This practical, handy text aims to provide essential
measures as well as useful tips and
tools to safeguard patients from infectio
tionary
ns. In
addition, it presents the practical consid
information on infection prevention, control and management in any
infections, such as staff roles and respon
erations for the management and treatm
sibilities, environmental hygiene, steriliz
ent of
management of invasive devices and ation,
health care setting. much more.
Edited by Vinice Thomas
The content is designed be clear, concise
and highly practical. The user-friendly
features learning outcomes, checkli format
sts, tables, bullet points and practic
The book will be an invaluable tool to help staff reduce avoidable
throughout. Chapters include relevan al examples
t case studies, reective practice activiti
es and
discussion questions to aid learning.
health care associated infections. It provides healthcare practitioners
with a basic understanding of infectious agents, their physiology,
About the editor
classifications and transmission. It also covers the clinical
Vinice Thomas is Assistant Director
of Nursing/Clinical Governance at Harrow
management
Care Trust andof infections,
acted presenting
in the role of Directo
the Infection Control Team. She had
best
r of Infection Preven practice guidelines
Primar y
tion and Control, managing
and
worked within the Chief Nursing Offi
precautionary measures
England’s Directo asHCAI
rate as part of the well as useful tips and
cer for tools to safeguard
and Cleanliness division as a Portfol
responsible for supporting NHS Trusts io Manager
patientscontro
from infections.
l proces ses. In addition,
across the countrit presents
y to strengthen theirthe practical
infectio n
considerations for the management and treatment of infections, such
as staffPart
roles andsfulresponsibilities,
of the succes Fundamental Aspects of Nursin environmental hygiene, sterilization,
g series aimed at providing nurses
with clinical, practical guidelines to
management
Fundamental of invasive
Aspect devices and much more.
better treat patients. Other titles in
s of Palliative Care Nursing 2nd edition
the series include:
Fundamental Aspects of Research for
Nurses
Fundamental Aspect
s of Long-Term Conditions
The content is designed be clear, concise and highly practical. The
user-friendly format features learning outcomes, checklists, tables,
Edited by Vinice Thomas

bullet points and practical examples throughout. Chapters

ISBN 1-85642 include
*Low cost for landlines and mobiles

-415-4

relevant case studies, reflective practice activities and discussion

questions to aid learning.
ISBN-13: 978-1-85642-415-8; 234 x 156 mm; paperback;
9 7 8 250
1 8 5 6 pages;
424158

publication 2010; £24.99

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es

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