Exploring the Effect of Educating Certified Nursing Assistants on Pressure Ulcer Knowledge and Incidence in a Nursing Home Setting

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Ostomy Wound Management 2016;62(9):42–50
Cathy L. Wogamon, DNP, MSN, FNP-BC, CWOCN


The certified nursing assistant (CNA) is the caregiver who frequently identifies the first signs and symptoms of pressure ulcers (PUs) in the long-term care setting. A quality improvement effort was implemented to explore the effect of a 1-hour CNA education program about early identification, treatment, and prevention of PUs on PU knowledge, PU incidence, and PU prevention interventions, including skin checks. All 33 CNAs employed in a care facility for residents 55+ years old were invited to participate.

CNA demographic and PU education variables were obtained. PU knowledge was assessed using the Pressure Ulcer Toolkit questionnaire before, immediately after, and 3 months following the educational intervention about PU prevention. PU incidence data were abstracted from monthly quality assurance reports for the 3 months pre-intervention and 3 months post intervention. Patient medical records were mined for data on turning/repositioning, skin checks, and informing care staff of suspicious areas of skin for the 3 months pre- and post educational intervention. Data for percent of short-stay residents (<90 days) with PUs were collected via the quarterly Medicare Nursing Home Compare Quality Measures report for this facility before and 3 months after the educational intervention. Pre-intervention and post-intervention PU incidence was statistically analyzed using the t-test. The CNA demographic survey was administered using an anonymous pencil-and-paper format and hand-tabulated by the primary investigator. Of the 31 CNAs surveyed (mean age 32 years [range 18–65], mean years of experience 7.7 years [SD = 8.1, range 0.5–40], 26 (84%) reported they received training regarding PU prevention in the classroom during their initial CNA training, and 81% received on-the-job training at some point in their careers regarding PU prevention. The Quality Indicator report showed a reduction from 5 PUs to 0 (12.3%) in the 3 months pre-intervention to 0% in the 3 months post-intervention. CNA reporting of skin breakdown increased by 68% from 8 reports to 17. CNA training regarding PU identification and prevention measures did not significantly improve knowledge scores, but the rate of PU development was significantly lower and the number of documented skin assessments and PU interventions higher after the education program. Additional studies to evaluate the effect of CNA education on the rate of PU development in nursing homes are warranted.  


An estimated 2.5 million patients will develop pressure ulcers (PUs), and of that number, 60,000 patients will die from related complications.1 The highest incidence of PUs occur in the elderly population; 70% PUs occur in persons 70 years or older.2 PU development has several consequences, including but not limited to increased risk for mortality, emotional and psychological impact on patient, financial burden on the patient and health care, and increased work demand on staff. Medicare data3 show PUs account for up to $2.41 billion dollars annually in excess health care dollars. 

The certified nursing assistant (CNA) often is the caregiver who initially identifies the first signs and symptoms of PUs in the long-term care setting. According to a review of the literature,4 if appropriately educated the CNA can have a significant impact on PU prevention. The National Pressure Ulcer Advisory Panel (NPUAP) guidelines5 for PU identification and prevention were developed to assist nursing staff with staging PUs. Although this information is key when assessing skin breakdown or precursors to skin breakdown, a descriptive study6 shows it is rarely taught to the CNAs who are the personnel most likely to assess the beginning signs of skin breakdown. The same descriptive study also states that until recently, CNAs have been enlisted to assist patients with PUs when they develop without understanding how they develop or measures to prevent them. A review of literature2 indicates that by providing education, creating heightened awareness regarding PU prevention measures, and facilitating specific interventions by staff, PU occurrence can be reduced. Thus, one may assume that educating CNAs about early identification of problem areas with the skin and PU prevention measures would have an effect on the rate of PU development. 


PU incidence. Residents of long-term care facilities are at risk for the development of PUs. Contributing factors include limited mobility, incontinence, history of PUs, and use of psychotropic medications.7,8 Results of a prospective, comparison cohort study by De Souza and de Gouveia Santos7 found a Stage II PU or higher incidence rate of 39.4% among residents in long-term care facilities. A cross-sectional prevalence and prevention study8 measuring PUs in a long-term care setting found inactivity and immobility are associated with PU development.  

PU prevention protocols. Quality improvement (QI) processes and protocols often are utilized to reduce PU incidence in many settings, including long-term care, and can be effective if implemented properly. In an evaluation study, Chaves et al9 examined PU protocols from 24 home care agencies utilizing a checklist to assess for quality and completeness; as a result, a strong need for consistent standard protocols for PU prevention in the home care setting was recognized. A QI project conducted by Lyman10 examined a QI process that included a standardized heel-offloading protocol to reduce the incidence of heel PUs in a long-term care facility that resulted in a 95% reduction in heel ulcers as well as an estimated cost savings between $12 400 and $1 048 400. A quasi-experimental study by Thompson et al11 assessed a care intervention incorporating a body wash and skin protectant into skin care protocols in 2 rural long-term care facilities; the prevalence and incidence of Stage I and Stage II PUs decreased significantly (N = 60 prevalence, P = 0.24; N =19 incidence, P = 0.01) along with healing time of current ulcers.

PU prevention programs. The implementation of PU prevention programs can decrease the incidence and prevalence of PUs in acute and long-term care settings. A QI project by Asimus et al12 found a PU prevention educational program implemented in the hospital setting reduced the number (as well as severity) of PUs from 884 (29.4%) to 611 (23.8%) to 344 (13.0%) over 3 consecutive years. A pre/post observational study Horn et al13 assessed various QI efforts such as improving routine CNA documentation, identifying residents at high risk for PU development, and providing staff education and access to timely clinical information in long-term care facilities to determine their impact on clinical outcomes. The number of facility-acquired PUs for all stages decreased 62%, attributed to these QI efforts. In a randomized, controlled, prospective evaluation, Shannon et al14 investigated the impact of PU prevention training programs on incidence in moderate to very high risk residents in 2 nursing and rehabilitation centers; PU incidence decreased by 67% in a 6-month period, with an estimated annual net cost savings of $240 000. 

Educational intervention effectiveness.  Adherence to following a PU prevention program care guideline can be improved by implementing an education program for patients and caregivers. A quasi-experimental design study by Sinclair et al15 implemented and evaluated a standardized education workshop for licensed practical nurses (LPNs) and registered nurses (RNs) in 3 acute care hospitals to assess knowledge before and after education at 3 time points: immediately before, immediately after the workshop, and 3 months later. The study revealed an evidence-based PU education program can effectively increase RNs and LPNs general knowledge regarding PUs. Adherence to the program improves outcomes for the patients, leading to reduced incidence of PUs. An implementation study16 utilizing a pre/post-test design sought to determine 1) if adherence to a pressure reduction program in families of patients in 5 home care nursing agencies can decrease prevalence and severity of PUs and 2) to examine the determining factors for the application of measures for PU prevention. The home care agency nurses provided education to the 6287 study participants regarding pressure redistribution methods and thereafter measured adherence to the program. The number of families adhering to the pressure reduction program increased from 10% to 13%, and the proportion of families who did not adhere to protocol decreased from 45% to 36%.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)17 and the Centers for Medicare and Medicaid Services (CMS)3 have implemented guidelines to help reduce the incidence of PUs in long-term care facilities; the recommendations include educating CNAs regarding PU prevention techniques. 

The purpose of this study was to explore the effects of an educational intervention for CNAs on early identification of skin at risk, turning and repositioning compliance, earlier reporting of skin issues, and the incidence of PU development in the long-term care facility. 


Setting. This project was conducted in a long-term care facility located in rural North Florida. The facility has a maximum capacity of 60 residents and services persons 55 years of age and older. Approval was obtained from the management company, Healthtique Group, Charleston, SC, and Florida State University, Tallahassee, FL. IRB approval was obtained before beginning the study. Written informed consent was obtained from all study participants. All participant data were de-identified.

Sample. All full-time and part-time CNAs (33 English-speaking or bilingual) were required to attend an educational session and were recruited for study participation via flyers placed at various locations in the facility. Those who chose to participate were invited to arrive 30 minutes before the educational presentation to complete the questionnaire.  

Instruments. Study participants completed a demographic survey and pre-test before the educational presentation. The paper-and-pencil survey included age, gender, race, marital status, how many months/years they had worked with the elderly, how many months/years they had been a CNA, how much PU training they received in their original CNA program, the length of their CNA program, and what on-the-job training they received regarding PU prevention. The pre-test and 2 PU prevention post-tests were obtained from the Pressure Ulcer Toolkit from the Agency for Healthcare Research and Quality.18 This paper-and-pencil Toolkit consists of 11 statements on PU prevention measures to which participants respond on a scale from strongly agree (5) to strongly disagree (1). Statements 1, 6, 7, and 11 are reverse-scored; minimum score was 35, maximum 55. The CNAs were informed their information would be kept confidential, they would receive free training that would be beneficial to their practice, and the results would be presented as aggregate data in a nonjudgmental manner. 

Intervention. The NPUAP guidelines5 for providing education to caregivers was utilized to develop and present the educational program; topics included identifying the cause of and risk factors for PUs, differentiating the stages of PUs, positioning to decrease risk of PUs, documentation, and reporting of pertinent data (see Figure 1). The 1-hour, evidence-based educational intervention was provided as an in-service to all shifts on Mondays, Wednesdays, and Fridays for 2 weeks. It comprised a PowerPoint presentation and lecture by the researcher. The intervention was offered twice on each shift to allow working CNAs the opportunity to participate. The session was videotaped and utilized in orientation for new employees hired for the duration of the study, but these employees were not included in the study data. owm_0916_wogamon_figure1

Data collection. PU incidence data were collected 3 months before the intervention from the quality assurance monthly wound report. This information was de-identified and did not require consent from specific residents. Data also were collected regarding PU incidence from the Medicare Nursing Home Compare Quality Measures report for this facility regarding percent of short-stay residents (<90 days) for the 3 months before the intervention and 3 months post intervention. The Quality Measures report is a publicly published quarterly report that includes data on the incidence (percentage) of short-stay residents with PUs that occur during that quarter. 

Clinical data. Pre- and post-intervention data in the form of flow sheets were collected via data mining by the researcher from CNA daily charting in the electronic medical record. These data were utilized to determine whether turning and repositioning in the bed and repositioning in the chair were occurring at least every 2 hours and that daily skin checks were performed each shift. Skin check issues (blanchable redness, nonblanchable redness that resolves with repositioning, skin breakdown, and any areas of concern) reported to nursing were collected 90 days pre-intervention and 90 days post-intervention from hand-documented skin check entries. 

Participant scores. Pre- and post tests were scored from paper/pencil surveys and were tabulated to an Excel spreadsheet. Each participant was assigned a number for their pre-test sheet and told to remember that number for the post-test. The participant then completed the post-test with the same numbered sheet as their pre-test. Scores were totaled and compared between the 2 sheets (pre minus post test scores). A negative difference indicated no knowledge increase while a positive difference indicated knowledge increase.

Data entry and analysis. Data for analysis were entered from the paper/pencil instruments to Excel spreadsheets and included descriptive statistics on demographics, daily interventions, PU incidence, and pre- and post-test answers scores and comparisons. Pre-intervention and post-intervention PU incidence was compared utilizing IBM SPSS Statistics for Windows, Version 20.0 (Armonk, NY). A pre-test/post-test analysis was conducted using the t-test comparing the scores of the 2 tests. The number of PUs per stage were compared pre-intervention and post-intervention and demonstrated in a table format. Descriptive data provided included CNA years of experience (mean and standard deviation), educational background (percent distribution at each level), CNA training regarding PUs, turning and repositioning compliance, and reporting of skin breakdown. 


Of the 33 English-speaking or bilingual CNAs who attended the intervention, 31 (mean age 32 years, range 18–65 years; mean years of experience as a CNA 7.7 [SD 8.1] years, range 0.5–40 years) completed the demographic survey, 33 completed the pretest, 18 completed the immediate post-test, and 18 completed the 3-month post-test (see Table 1). Fifteen (15) employees had left the facility (sought employment elsewhere) and did not complete the 3-month post-test. owm_0916_wogamon_table1

Pre-test demographic data showed 26 (84%) received instruction on PU prevention in the classroom during their initial CNA training and 25 (81%) received on-the-job training at some point in their careers regarding PU prevention. CNA educational programs varied in length from 0.5 to 36 months (mean 10.7 months) (see Table 2). owm_0916_wogamon_table2

No significant change in knowledge scores was noted between the pre-test (mean score 46.1) and post-test (mean score 47.5) scores (P = 0.5387). The Quality Indicator report showed a reduction from 5 (12.3%) facility-acquired PUs among an average of 58 residents in the 3 months pre-intervention to 0 during the 3 months post-intervention period. According to documentation, turning and repositioning compliance was 100% post intervention. CNA reporting of skin breakdown increased from 8 notations to 18 notations pre- and post intervention, respectively. Before the intervention, 3 out of 8 (37.5%) of the CNAs did not report skin breakdown until it had already developed into a PU; post-intervention, 10 patients with areas of blanchable redness and 7 patients with areas of nonblanchable redness that resolved within 24 hours with repositioning were reported. 


A significant decrease in the rate of facility-acquired PUs was observed up to 3 months after a 1-hour educational intervention for CNAs. In addition, CNA reports of skin issues increased 68%, from 8 reports pre-intervention to 17 reports post-intervention. The results of this study are consistent with the literature reporting the implementation of PU prevention programs and pre/post educational interventions regarding PU prevention measures can decrease the incidence as well as the severity of PUs in long-term care settings.12-15,19 Studies incorporating the NPUAP guidelines for educating CNAs have not been published. In addition, the decrease in PU incidence appears to underscore the need to educate the CNAs who provide daily care for the elderly patient. 

Although PU incidence was lower post-education, no statistically significant improvement in knowledge scores in this CNA population regarding PU was observed. Other studies showed a decrease in PU incidence, but also showed an improvement of knowledge scores.12,16,20 The difference between the observations in this study and previously published studies could be related to the small sample size, because average scores improved, if only slightly. 

Two descriptive studies6,21 found education regarding PU prevention is lacking among professional caregivers. In addition, the time span between the pre-test and post-test was shorter (6 weeks) for a quasi-experimental study22; in the current study, the post-test time span was 3 months. 

The results of a quasi-experimental study15 that provided education only to licensed nursing personnel and measured PU prevention and treatment knowledge at 3 intervals (pre-intervention, immediately after the intervention, and 3 months post-intervention) showed significantly higher testing scores immediately after the intervention but significantly lower scores at the 3-month post-intervention testing, which is comparable to the results of this study. Such results imply a need for quarterly educational programs for CNAs.

The significant increase in reporting of skin issues by CNAs during the post-intervention period combined with a decrease in the incidence of PUs suggest education may help improve outcomes of care. PU education could be provided to CNAs at hire and quarterly in addition to the mandatory annual requirement. Education can be enhanced further through bedside teaching regarding PU prevention techniques and identification of problem skin issues. It would be cost-effective to implement this training in any setting because many facilities require mandatory PU prevention training. 


A few limitations of the study should be taken into consideration. First, PU incidence may improve or worsen based on resident risk factors and facility variables. In this study, none of these variables was controlled. Secondly, the small size of the sample could impact the results.


Although pre-test and post-test knowledge scores of CNAs who participated in a 1-hour educational program were not statistically significantly different, the incidence of PUs was significantly lower during the 3 months after the education intervention. CNA reporting of skin issues increased significantly post-intervention, and no PUs developed. CNA training regarding PU identification and prevention measures may help reduce PU incidence rates in the long-term care setting. Studies with a larger sample of CNAs and more rigorous control of other resident and facility PU risk factors are needed. n



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Dr. Wogamon is an Advanced Registered Nurse Practitioner, Outpatient Wound Clinic, Lake City VA Medical Center, Lake City, FL. Please address correspondence to: Cathy L. Wogamon, DNP, MSN, FNP-BC, CWOCN, 610 South Marion Street, Lake City, FL 32025; email: doc_wog@yahoo.com.