The study adopted a nonequivalent control group, pretest/post test design and was conducted in 3 selected teaching hospitals in 3 (Oyo, Osun, and Lagos) of the 6 states in the southwest geopolitical zone in Nigeria. The hospitals included the University College Hospital (UCH) and Lagos State University Teaching Hospital (LASUTH), Ibadan; and Obafemi Awolowo University Teaching Hospital Complex (OAUTHC), Ile Ife. The hospitals were under 2 main clusters based on proprietorship: state government-owned and federal government-owned, publicly funded institutions. All of the hospitals are large tertiary institutions, with a minimum of 300 beds each. Ethical approval was sought and obtained from the Health Research and Ethics Boards of each institution.
A purposive sampling of the hospital was conducted based on inclusion criterion of providing care for patients with complex health problems. Balloting was done to determine which hospitals served as intervention and control groups. The intervention group (IG) included nurses from LASUTH and UCH, and the control group (CG) included nurses from OAUTHC. To limit inadvertent influence of treatment condition on the CG, the IG was completely separate from the CG.
Participating wards also were selected purposively to reflect patients with health problems that would likely place them at risk for PUs; as such, all nurses from the surgical (orthopedics), medical, and neurological wards (except nurses on vacation) were invited to participate.
Testing instrument. The Pressure Ulcer Knowledge Test (PUKT)43 was used to assess knowledge and information acquisition at the 3 testing time points. The tool is composed of 47 items that measure respondents’ knowledge of risk factors, preventive strategies, and PU staging. Correct Yes/No responses are scored 1 and incorrect responses of Yes, No, or I don’t know are scored 0. The maximum score is 47 (100%).
The PUKT has been used in other countries9,44 with reported good reliability levels. A pilot survey was conducted in a different state teaching hospital (Ogun state) among 111 nurses 6 months before the main study to examine the feasibility of the study and to test the reliability of the testing tool.16 Findings from the pilot study led to the revision and rewording of some items in the instrument for clarity and in relation to the care environment. For example, in the local hospital, nurses use water-filled gloves to elevate the heels. Therefore, the item in the original document that reads Heel protectors relieve pressure on the heels was reworded to read A heel protector such as water-filled glove effectively relieves pressure on the heels. In addition, the item that relates to the appointment of a governmental panel to study PU risk, prevention, and treatment were removed because it was not applicable to Nigeria. This was the first time the PUKT was validated in Nigeria. The reliability coefficient was found to be 0.82.
General procedure. In each setting, with the support of the Director of Nursing services, the pretest (paper-and-pencil PUKT) was administered to all participants at the same time. This was to ensure the uniformity of nurses’ entry behavior and to establish their level of PU knowledge at baseline (T1) to accurately examine the effect of the program. Each participant signed a register to document attendance. The researcher recruited and trained 3 research assistants (RAs) to assist with participant registration and to monitor and retrieve completed questionnaires.
Study group procedure. The nature, purpose, and procedure of the study were explained to nurses who provided written consent for participation. The IG participants (UCH and LASUTH) were invited to attend the educational workshop organized in the respective hospitals.
The program was structured to accommodate various nursing schedules because it was not possible to take all nurses off the wards at the same time to attend the 4-hour workshop. In UCH, the nurses were divided into 2 groups. Each group attended the workshop for 5 consecutive days. In LASUTH, all participants attended the same 5-day workshop facilitated by a labor conflict that decreased patient load.
Intervention fidelity was maintained because the module curriculum was followed strictly by the principal investigator, who also delivered all the sessions.
The interactive educational program. Participants were provided the program of events for each day. They were encouraged to choose an identification number to facilitate analysis in matching each participant’s pretest with post test scores, to assess full participation, and to easily identify missing questionnaires. The intervention was an interactive lecture that involved small group discussions and brainstorming. Participants were grouped based on the wards where they work to facilitate continual cooperative work on the wards. During the first 15 minutes of each module, participants brainstormed on specific questions and answers and shared experiences and practical ideas on PU prevention. The remaining period was used for lectures and discussion on current trends regarding PU prevention and related clinical correlations. For example, the researcher projected pictures of different stages of PUs and participants were asked to determine the stages. This helped actively involve participants in the sessions. Lectures were projected using PowerPoint® slides. The principles of adult learning34 guided the interaction with the participants (ie, learners connect learning with past experience). To facilitate this connection, the researcher also displayed different skin care products (eg, dimethicone-based barrier creams and sprays, dressings, foams, and corn starch) to stimulate discussions on nurses’ practices. At the end of the sessions, paper versions of the PowerPoint® slides were provided to participants. The level of each respondent’s participation was not documented or measured.
All modules were presented by the principal investigator in the 2 hospitals. Each session lasted for 4 hours per day. The curriculum consisted of 5 modules as shown in Table 1.
Assessment. A pencil-and-paper PUKT was readministered on day 5 as an immediate post test (T2). The test was completed under supervision, and participants did not refer to the paper versions of the slides. Completed tests were retrieved on the spot. Participants were informed they would be invited to a third round of testing after 12 weeks (T3).
Participants returned to their respective wards but maintained the groupings to facilitate cooperative problem-solving while providing care. Over the 12-week between-test period, the researcher reinforced what was covered in the module with hands-on demonstrations. At the end of 12 weeks, participants were contacted by telephone, Short Message Services, and email for the second post test. The same test (PUKT) was administered at all 3 time points.
Control group procedure. The CG also was provided study details. The PUKT questionnaire was distributed to the participants to examine their baseline knowledge. The participants engaged in a general 1-day, 4-hour discussion on their usual practices for PU prevention. The session was facilitated by the RAs under the supervision of the principal investigator. This was followed by a second test (T2). Participants were contacted for the second post test at 3 months (T3).
At the end of the third data collection (which marked the end of the study), the CG was provided the same package of educational materials as the IG on PU prevention for ethical reasons.
Data analysis. Data from the PUKT instrument were collected and entered into a database, the Statistical Package for Social Sciences (SPSS) (Version 17.0, Chicago, IL), for analysis. Data were checked to ensure consistency and to determine where information was missing. A complete case-wise analysis was performed for missing data because the proportion of missing data categorized as Missing Completely at Random (MCAR) was <10% and was observed only at the 3-month post test (T3). Descriptive statistics using absolute number and relative frequencies (percentages) to describe the sample characteristics were used. Means and standard deviations were computed to ascertain nurses’ PU knowledge scores. A paired sample t-test was used to compare the differences in knowledge between IG and CG pre- and post intervention. Cohen’s d was calculated to determine the strength of the intervention effect. The effect of selected demographic variables on participants’ knowledge scores was examined using ANOVA, and the effect size (eta squared) also was computed. The level of significance was set at α = 0.05%