Setting. The educational program in this study was developed as part of a multifaceted knowledge mobilization project aimed to implement E-Stim for treating PrIs in community-dwelling individuals with SCI living in 1 region of Ontario, Canada.21 The overall aim of the E-Stim Collaboration Project was to support home care services in a way that promoted uptake and use of E-Stim therapy for the treatment of people living with PrI and SCI.
Participants. As part of the E-Stim Collaboration Project, an awareness campaign was conducted to engage providers in all health care sectors including the community, homecare, long-term care, hospitals, and private clinics. Multiple agencies that contracted health care providers from several different professions and disciplines (eg, nurses, physical therapists, occupational therapists, personal support workers) to provide home care in this region were visited by a research team member who provided information about the E-Stim Collaboration Project and extended an invitation to participate in the E-Stim Education Program. Inclusion criteria were health care providers who were willing to obtain education about E-Stim. Exclusion criteria were participants who did not complete the online modules, attend the hands-on workshop, or finish the knowledge test and/or attitude questionnaire.
All participants who took part in the educational program signed written consent after reading a letter of information. The study was approved by the ethics review committee of Western University Health Science Research Ethics Board of London, Ontario, Canada (HSREB File Number 107778). Informed written consent was obtained from all participants to share pooled results of completed tests and surveys. Before beginning the education, general characteristics were collected about the participant’s professional background, education, and experience in providing wound care. Demographic data were collected using an online questionnaire with multiple choice selection and included profession, years of experience, sector, role in wound care, province of practice, percent of time spent in wound care, work hours, and level of wound education (see Table 1).
Development of the E-Stim education program. An education program for the use of E-Stim on PrIs was developed to address core competencies for skilled application based on a university-level continuing education program that was delivered successfully over the past 20 years. The educational program included components of a recently produced clinical practice guideline17 and incorporated feedback from several key stakeholders. A model of care for healing PrIs with E-Stim was developed by Lala et al21 that took into account implementation barriers, including inadequate training and education. In this knowledge mobilization study, 29 stakeholders, including hospital and community administrators and practice leaders, hospital and community frontline care providers, and SCI consumers with recent or prior experiences with PrIs, noted a lack of awareness, knowledge, training, and skills surrounding the use of E-Stim in treating PrIs across the continuum of care. The stakeholders expressed a preference for educational resources that would be readily accessible on demand and available in both electronic and print format. They also wanted an opportunity to have hands-on practice with E-Stim application techniques and experience manipulating specialized E-Stim equipment and accessories. The E-Stim education program was developed based on this stakeholder input and used a case-based approach to promote advanced clinical decision making and critical thinking. A peer-led practical skills evaluation was used to test hands-on skills required to use E-Stim in a safe and effective manner.
Creation of E-Stim online modules. Eight (8) modules were created using a secure online learning platform associated with Western University and were developed to allow participants to review material at their own pace and on their own schedule. Online learning allowed for increased access for participants and reduced the time required for the face-to-face component of the educational program. The online modules consisted of background theory and knowledge using narrated PowerPoint presentations that were organized into 8 recorded lectures totaling approximately 4 hours. Table 2 describes the content contained in the 8 modules.
Hands-on workshop. After participants completed the online modules, they were invited to participate in 1 of 7 hands-on workshops that were offered over a 1-year period. The hands-on workshops were led by 2 Clinician Researchers who collectively had more than 45 years’ experience using E-Stim for wound treatment. The main objective of the hands-on workshop was to develop the clinical skills required to apply E-Stim to patients with PrIs. The face-to-face class section also allowed practitioners from different professional backgrounds and clinical experiences to work together to identify cases where E-Stim is appropriate and to design E-Stim treatment protocols that are feasible to administer and likely to produce the best healing outcomes.
The specialized equipment and supplies (eg, electrodes, leads) required for the delivery of E-Stim to wounds were available during the hands-on workshop. Wound healing fundamentals, including local wound care, understanding wound etiologies, and aseptic techniques, were embedded throughout the hands-on session.17-20 Participants were made aware of the risks and benefits of applying electrical energy to wounds and participated in case studies to screen clients for known contraindications and precautions. After a brief demonstration of E-Stim application techniques, participants set up E-Stim equipment and applied electrical current to realistic latex wound models. Participants also were encouraged to experience the sensation of E-Stim to diminish fears and describe expected sensations to their patients. This was followed by a peer evaluation that was supervised by 2 of the study researchers to confirm participants completed all the application steps in a safe and effective manner.
Another key component of the workshop was a review of wound dressings that are compatible with E-Stim. Participants were exposed to samples of different types of wound dressings and products. Selection and rationale of the most appropriate dressing for each case was developed via interactive case discussions. Patient scenarios were developed and reviewed during the hands-on workshop to test participant understanding of electrical principles and how changing the E-Stim set up or wound environment can affect electrical current flow.
At the end of the workshop, the clinicians were invited to participate in a Community of Practice, which continued to meet monthly to share experiences and discuss challenges regarding E-Stim implementation via a secure web-based online video/audio link. The Community of Practice was developed as part of the E-Stim Collaboration Project and provided an online forum to link more than 150 clinicians across Canada working in this field.
Knowledge Test. Knowledge about principles of electricity, mechanism of action, and research evidence was measured using a multiple-choice test. The knowledge test was either administered online, where 10 questions were randomly selected from a pool of 25 multiple choice questions, or on paper, where all 25 questions were included in an in-class quiz (post-workshop). Knowledge questions were developed by the research team and pilot-tested during a prestudy education session. The percentage of correct answers was tabulated.
E-Stim Attitude Survey (EAS). An attitude survey was developed by the research team to understand the attitudes participants had toward the use of E-Stim on PrIs and their willingness to incorporate an advanced therapy into practice. The survey was based on the APuP instrument,31 a 13-item questionnaire used to assess health care provider attitude toward PrI prevention. The APuP was developed and validated by Beeckman et al31 for PrI prevention programs and adapted to include content related to E-Stim.
Survey questions were grouped into 3 subscales to define participant attitude:
1. Education: Attitude toward the importance of knowledge and skills for the use of E-Stim in practice;
2. Evidence-based practice: Attitude toward research evidence and the ability of E-Stim to stimulate/accelerate the healing of pressure injuries; and
3. Resources: Attitude toward resources and equipment needs when using E-Stim in clinical practice.
The EAS consisted of 14 items measured on a 5-point Likert scale with answer options that included strongly agree, agree, neutral, disagree, and strongly disagree. Statements were phrased so they presented both positive and negative attitudes toward E-Stim. The education subscale consisted of 5 items, the evidence-based practice subscale consisted of 4 items, and the resources subscale consisted of 5 items. Internal consistency measured using Cronbach’s alpha was calculated for each subscale using the 83 nonexpert study participants and found to be acceptable for education (α = 0.74), evidence-based practice (α = 0.76), and resources (α = 0.74).
Timing of evaluations. Knowledge tests and the EAS survey were evaluated at 3 time points throughout this study: before commencing with the education (pre-education), after completing the online modules (post-online), and after completing the hands-on workshop (post-workshop). Participants were given access to the online modules, pre-education test, and survey when they registered for the hands-on workshop and asked to complete the evaluations before starting the workshop. All participants completed the pre-education and post-online on the computer, and the post workshop test and survey were completed using a paper tool that was provided at the end of the workshop. Tests and surveys were administered electronically via the online education system for pre-education and post-online evaluations. Data were aggregated from the online evaluations and paper tools across the 3 time points onto a large spreadsheet for data analysis. Anonymity was not maintained because the post-workshop evaluations were collected in person to allow the primary researcher to compare the results of participants over the 3 time points. Minimum and maximum time between each stage of the testing varied.
Data analysis. Demographic information describing the type and amount of clinical experience was collated and analyzed using descriptive statistics (see Table 1). Knowledge was assessed using the percentage of correct answers on the knowledge test. EAS results were converted to numeric scores to analyze the data. The survey consisted of 14 items measured on a 5-point Likert scale, with responses that included strongly agree, agree, neutral, disagree, and strongly disagree. The Likert scale was converted into numeric scores, with 0 equaling a more negative attitude to 5 equaling a more positive attitude. Attitudes were assessed using the subscales education, evidence-based practice, and resources. A weighted average was calculated for each of the subcategories. To evaluate the impact of the education program on knowledge and on the 3 subscales of the attitude questionnaire, a separate linear mixed effects model was fit to each of the 4 dependent variables. Time of measurement (pre-education, post-online, post-workshop) was included in the model as a fixed effect, and participants were included as a random effect. Utilizing a linear mixed effects model facilitated use of all available data without the need for list-wise deletion of participants with missing data or interpolation of these missing data points.33 The statistical significance of the fixed effect was identified by comparing this model to a null model in which the dependent variable was predicted only by random error. In the event of a statistically significant fixed effect, post-hoc testing was performed on all possible pairwise comparisons using t tests with degrees of freedom estimates that were calculated using a Satterthwaite34 approximation. All statistical analyses were performed in R34 (R core team, University of Auckland, New Zealand), with linear mixed effects analyses conducted using the lme435 and lmerTest36 packages. Post-hoc pairwise comparisons were completed using the lsmeans package.37