1. Howe, Lynn RN, MS, CEN, CCRN


AIM: This article details an educational program designed to utilize nonlicensed personnel (certified nursing assistants [CNAs] and nursing assistants [NAs]) in the prevention of pressure ulcers and improved skin care in a 250-bed acute care facility in a suburban setting. The article is divided into 2 parts: A and B. Part A addresses the educational program, which was part of a major initiative for improving patient outcomes that included a review and standardization of skin care products and protocols. Part B addresses productivity enhancement and cost savings experienced because of changing bathing and incontinence care products and procedures.


BACKGROUND: The educational program included instruction on time-saving methods for increasing productivity in bathing and incontinence care, and effectively promoted the importance of proper skin care and pressure ulcer prevention techniques.


METHODS: Methods incorporated into the educational training targeted different reading and comprehension levels, ranging from the use of PowerPoint slides, hands-on return demonstration, and group discussion related to pressure ulcer staging and wound treatment. These educational methods provided the participants with significant reinforcement of each day's learning objectives. Productivity enhancement and cost savings are addressed in part B, as well as the results of a time-motion study.


RESULTS: Because of the program, CNAs/NAs were empowered in their integral caregiver roles. This program was part of a larger, major process improvement initiative, but the rate of acquired pressure ulcers declined from 2.17% in 2002 to 1.71% in 2003. This educational program was considered a contributor to the improved patient outcomes.


Article Content


Pressure ulcers are a significant clinical concern across the health care continuum. It is estimated that 1.3 to 3 million adults have pressure ulcers that have an impact on clinical, functional, and economic outcomes.1 In many cases, pressure ulcers can be prevented and Stage I deterioration halted.2


The educational department of a 250-bed acute care hospital located in a suburban setting collaborated with nursing leadership and recognized an opportunity for improvement in the rate of acquired pressure ulcers, although rates were within the industry standard. As a result, the nursing leadership team was challenged to develop novel approaches to skin care and improvement of patient outcomes. A needs assessment identified opportunities to improve education regarding pressure ulcer prevention and skin and wound care. Process and product standardization were targeted to reduce variability for bathing and incontinence practice.


A study conducted by Needleman et al3 showed that nursing aides provided 21% of total nurse-hours in patient care. This is a significant amount of patient care time that could be maximized to enhance outcomes. The researchers focused on the certified nursing assistant (CNA)/nursing assistant (NA) as an underutilized resource and sought to educate and utilize the ancillary staff in an effort to empower the CNA/NA through education, enhance communication, improve skin care, and prevent pressure ulcer development. To save time and standardize processes and products, the bathing procedure underwent a transition from traditional patient cleansing with basins, soap, and water, to the use of premoistened cleansing and moisturizing washcloths in a warmable package (Comfort Bath, Cleansing Washcloths, Sage Products Inc, Cary, IL). Incontinence care was simplified from a highly variable multistep cleansing and protection process (soap and water, foams, sprays, lotions, and ointments) to a single-step cleansing washcloth that delivered a 3% dimethicone skin protectant (Comfort Shield Incontinence Care Washcloths, Sage Products Inc).


The key objective of the educational program was to effectively promote a hospital-wide awareness of skin care and significantly empower the CNAs/NAs in their integral role within patient skin care. The first section of this article describes the content, rationale, and success of the educational program and how it was delivered to the CNA/NA in relation to maintenance of skin integrity, the prevention of skin breakdown, and relevant wound care information (part A).


The productivity enhancement and cost-savings experienced by changing bathing and incontinence care products and procedures are outlined in part B. The focus was to support the CNAs'/NAs' role by streamlining the process and providing the products needed for effective skin care, including instruction in the time-saving use of the bath and incontinence products. At the same time, goals also included enhanced patient satisfaction and increased communication between licensed and nonlicensed personnel.



On a learning needs assessment, the nursing staff identified the need for a comprehensive skin care educational program. Although the CNA/NA was an important caregiver, he or she lacked continuing education in skin care and pressure ulcer prevention, and the caregiver's time and expertise were not being utilized efficiently.


The educational presentation was developed and provided by the Department of Education and Training. NAs were compensated to attend a mandatory 8-hour educational session; 250 CNA/NA staff attended the training, with 98% attendance of the total nursing staff. All registered nurses and CNA/NA staff were required to attend separate training courses; however, the topics of these courses were identical. The courses were adjusted for educational and comprehension levels of the licensed versus nonlicensed staff.


Various methods were incorporated into the training to target different reading and comprehension levels, ranging from the use of PowerPoint slides, hands-on return demonstration, group discussion, and "games" related to pressure ulcer staging and treatment. These educational methods provided the participants with significant reinforcement of daily learning objectives and empowered the participants with knowledge.


Validating the CNA/NA Role in Patient Care

The integral role of the CNAs/NAs in patient care, specifically pressure ulcer prevention and skin care, was reinforced in several ways. Initially, the researchers noted the current knowledge base for the CNA/NA is expansive, and acknowledged the perceived lack of "credit" given to the CNA/NA for his or her vital, yet often underappreciated role. Discussions focused on expectations placed on the CNAs/NAs in today's hospital environment.


All aspects of patient skin care were the focus for the day, with this information being the same information as that provided to registered nurses. The educational program covered the following areas in detail: age-specific components of skin injury; multiple skin risks; shear and friction; turning and repositioning; education on different equipment for use assisting with skin care; education on wound stages, prevention, and treatments; education on specialty beds; education on the difference between surgical wounds, vascular wounds, and pressure ulcers; and descriptions of products and their appropriate use. Notably, this educational course was meant to empower nonlicensed staff through enhanced knowledge. The CNA/NA was not educated to grade, stage, or treat skin injuries or wounds. The purpose of the program was to educate all staff appropriately and emphasize the important role of the CNAs/NAs in pressure ulcer prevention and enhanced communication with licensed staff regarding patient skin integrity. Previous educational programs had outlined the importance of nutrition in pressure ulcer prevention.


In a demonstration skills laboratory, the CNAs/NAs participated in a simulated laboratory, where they practiced appropriate patient positioning, use of specialty beds, and offloading of pressure points. Because it is difficult to measure the competence of an NA in a classroom setting, competency was validated at the bedside by a nurse educator. The educator used a skills checklist (Table 1) to ensure the following: (1) the NA incorporated his or her education in relation to his or her scope of the patient care role (checklist included factors such as appropriate repositioning, pressure point relief, etc); (2) the judgment of the NA was correct regarding the patient's skin; and (3) the NA appropriately communicated his or her observations to the licensed nursing staff.

Table 1 - Click to enlarge in new windowTable 1. NURSING ASSISTANT COMPETENCY CHECKLIST

General response surveys demonstrated the CNA/NA participants responded positively to being challenged with higher expectations of patient care. Regardless of socioeconomic status or educational level, we found the majority of class participants expressed feelings of pride and dignity when their nursing services were acknowledged, and they desired to meet challenges for improved patient care.


Most CNAs/NAs did not realize the importance of health care-acquired injuries and their impact on the patient in terms of complications and increased length of stay. Lengthy discussions centered on the direct and indirect costs associated with pressure ulcer injuries. The legal and financial importance of documentation was also discussed.


Open group discussions were held regarding the effects of patients with skin breakdown on staff's ability to adequately care for all patients assigned to them, including focus on time impact, patient outcomes, and impact on staff (eg, higher acuity patients affect direct caregiver's time and increased stress levels). Following the educational course, CNA/NA staff were provided with a time for reporting each shift specifically with regard to skin integrity observations and patient-caregiver interactions related to such.


Anatomy and Physiology

Basic anatomy and physiology of the skin were reviewed, with emphasis on geriatric age-specific considerations. We incorporated physiological changes that occur with aging of the skin, stressing precautions needed for appropriate care of geriatric and pediatric patients.


The physiological wound healing process was reviewed in detail, along with the multiple variables that affect the healing process, such as type of wound, patient age, general health, nutrition, certain drugs, comorbidities, and infections. Nutritional factors for pressure ulcer prevention were considered, stressing the need for good nutrition to promote wound healing.


Braden Scale

To assist in the CNAs'/NAs' comfort level with wounds and empower them through knowledge, they were educated on how the licensed nursing staff used the Braden Scale for Predicting Pressure Sore Risk to identify risk factors.4 Photographs were used, and each participant was required to return-demonstrate the proper staging of 3 separate "test" pressure ulcer wounds. Notably, the CNAs/NAs did not stage wounds, and wound staging was undertaken by licensed nursing personnel, but the CNAs/NAs learned how the process worked.


Product Discussion

Discussions focused on proper product use and wound treatment. The following products and their indications were discussed: cleansers, barrier films, ointments, foams, hydrogels, transparent films, hydrocolloids, moisture barriers, alginates, and debriding agents. Although CNAs/NAs are not permitted to administer or utilize certain products, participants were educated and empowered by seeing how these products were used and applied.



Participants were given an overview of data collection and statistics for process improvement, as well as the reporting structure. The National Database of Nursing Quality Indicators was reviewed to assist the CNAs/NAs in understanding that the care they provide is reflected in the overall performance ratings of the hospital.



The section on preventative care reiterated the importance of repositioning every 2 hours and methods for avoiding shearing and friction during lifting and moving procedures. Staff were instructed how to verify proper head-of-bed elevation because more than 30 degrees is contraindicated in patients at risk for pressure ulcer development. Appropriate skin care regimens were reviewed, as well as the negative impact of incontinence and the need to ensure cleanliness of linens and clothes. Repositioning in the bed and wheelchair were discussed, with recommendations for a shift in position every 15 to 30 minutes while up in a chair, as well as the suggested use of protective devices such as water cushions. Myths were dispelled, such as the rubbing of reddened areas being beneficial for circulation. As an incentive after group discussion, participants won scratch-off lottery tickets if they correctly verbalized actions that would prevent skin breakdown.


Observational Instruction

The NAs were then trained in appropriate observation of a wound for empowerment purposes. This was accomplished by explaining wound locations, wound size and appearance, the importance of odor, and the appearance of the surrounding skin and wound drainage. The various types of wound drainage (serous, sanguineous, serosanguineous, purulent) were described, and the clinical necessity for appropriate reporting and communication with licensed personnel were assessed.


Wound Dressings

Although dressing the wound is a function of the licensed nurse, NAs were educated on certain types of dressings and the science behind why various dressings work. The dressing types reviewed were closed drainage systems, dry dressings, wet-to-dry dressings, wet-to-moist dressings, secure dressings, and applications of heat and cold.


Nursing Assistant Satisfaction/Cultural Change

The researchers stressed the role of the CNA/NA as a primary caregiver. A strategic initiative was introduced to improve patient satisfaction, encouraging the return of high-quality evening care with back rubs, direct patient contact via touch, and turning rounds.


Because of this educational program, the CNA/NA participants reported increased satisfaction and a clearer understanding of their integral role as a member of the health care team. The participants were motivated to use their newfound skill set and education in wound prevention and skin care, and believed administration was listening to and addressing their concerns. Because of the educational program and its successes, the program was incorporated into orientation training, and reporting procedures between nonlicensed and licensed staff were altered to enable the CNA/NA staff an opportunity to communicate any concerns related to patient skin integrity.



To complement the educational program, nurse educators standardized skin and wound care products. Although a comprehensive skin care protocol existed, many products were available as therapeutic alternatives, and staff voiced confusion over the appropriate prevention and treatment. This resulted in a lack of consistency in practice and the additional cost of stocking multiple skin care products. The impact of standardizing products was measured in caregiver time, job satisfaction, patient satisfaction, product cost comparison, and patient skin outcomes.


Patient bathing and incontinence care were the 2 areas that showed the most potential for streamlining products and provided the most dramatic impact on time efficiency. Baths were traditionally given with a basin, disposable washcloth, and a pH-balanced, no-rinse cleanser (Aloe Vesta 2-n-1, ConvaTec, Princeton, NJ). After the bathing process was changed to the use of premoistened cleansing washcloths, NAs reported morning care time was significantly reduced. This time saving was later validated in a time-motion study that showed the basin bath process required an average time of 14 minutes to the prepackaged bath time of 6 minutes (P < .0001). Patients expressed satisfaction with warmth, skin softness, and a feeling of cleanliness with the prepackaged washcloth, whereas many felt the basin bath cooled off too quickly and saturated the bed sheet and gown with water. Patients also commented on the assistant's response time and attentiveness, as they were not busy with other patients and activities.


Before product and process standardization, incontinence care consisted of multiple cleansing product choices and even more lotion and skin protection variability. The change to the single-step cleansing washcloth, which delivered a 3% dimethicone skin protectant, was as readily accepted as the prepackaged bathing washcloth. NAs expressed verbal and written gratitude that the administration had taken their concerns and workload into consideration while making product decisions.


A cost comparison was conducted using data from materials management to determine the annual product costs for bathing and incontinence care (Table 2). Cost savings were derived from the standardization of bathing and incontinence product utilization. Effects of the education program and the standardization of skin care products were demonstrated by the rate of acquired pressure ulcers, which declined from 2.17% in 2002 to 1.71% in 2003.


Result of Time-Motion Study

The hypothesis for the time-motion study was as follows: patient bathing with a nonrinse bath takes less time than traditional bathing. This was an observational study conducted to ascertain the impact a disposable bathing product would have on patient bathing time. A total of 31 patients were selected, and every other patient on the unit (unit census 31) was assigned to be bathed by either disposable, nonrinse bathing method (n = 16) or traditional basin bathing method (n = 15). There were no inclusion or exclusion criteria. Data were assessed with regard to bathing time and patient mobility.


Table 3 outlines the results of the time-motion study. The average bathing time of a traditional bath was 14 minutes compared with the nonrinse bath average time of 6 minutes. A t test revealed a significant difference between bathing times (8-minute difference between bathing times; P < .0001). The traditional bathing group graded bathing time and patient mobility as 33% low severity, 40% medium severity, and 27% high severity. The disposable, nonrinse bathing group graded bathing time and patient mobility as 50% low severity, 19% medium severity, and 31% high severity.

Table 3 - Click to enlarge in new windowTable 3. RESULTS OF TIME-MOTION STUDY: WASH TIME (AVERAGE TIMES REPORTED)

A data analysis categorized patients according to mobility level and for each severity group. The disposable product saved 6 to 10 minutes, depending on the category. A t test analysis indicated a significant difference for all severity groups except the highest. A crossover analysis was conducted on patients (n = 5) getting both nonrinse and traditional bathing and determined that, in patients bathed using both methods, the traditional method took, on average, over 6 minutes longer (paired t test: P = .002; Table 3).


The results of the time-motion study consistently supported the hypothesis that the disposable, nonrinse bath method takes less time than the traditional bathing method. Although the study group was small (n = 31), there was a significant difference between the average bathing time between the 2 groups.



The Centers for Medicare & Medicaid Services conducted a multimedia broadcast in 2004 titled "State of Science in Wound Care Management."5 Several challenges and issues were identified for wound and pressure ulcer management, and strategies for pressure ulcer prevention were discussed, including education of staff regarding the goals of care, physiology of wound healing, guidelines for wound and pressure ulcer management and assessment, and the physiology of wound healing. Our educational program for the CNA/NA corresponds directly to these recommendations and empowers the CNA/NA through expanded education in an effort to utilize the NAs' role for preventative and observational care with a view toward improved clinical, functional, and economic outcomes. Furthermore, the standardization of processes and products for skin care reduced caregiver confusion, streamlined patient skin care, and enhanced staff productivity.


Defining Public Health Needs for Similar Educational Programs

Studies place prevalence rates in hospital patients between 3% and 11%, with the medical and surgical intensive care unit population accounting for the highest prevalence of pressure ulcers.6-9 A study by Graves et al10 found that pressure ulcers have a significant independent effect on excess length of hospitalization, exceeding expected length of stay based on admission diagnosis. Patients with pressure ulcers had a median excess length of stay of 4.31 days. Economic models have revealed a Stage I wound costs about 1 per day, a Stage II wound jumps to 1300 to 3700, and a Stage III wound scan cost up to 50,000.11,12 These voluminous costs are a clear indication of the need for a novel pressure ulcer prevention program.


In response to this public health issue, national initiatives, as well as regulatory and accreditation agencies, have focused on the prevention of pressure ulcers by the assessment of a patient's risk and requiring action to address that risk.13 In addition, the Joint Commission outlines various interventions for pressure ulcer prevention, which include, but are not limited to, educational programs, skin inspection, skin cleansing, care of dry skin, use of moisture barriers, and massage (Table 4).14 Although the Joint Commission's patient safety recommendations are specifically related to long-term care, one of its preventive strategies for pressure ulcer prevention is educational programs that are developed, implemented, and evaluated using the principles of adult learning. Many of the recommendations for pressure ulcer prevention translate well to an acute care environment.

Table 4 - Click to enlarge in new windowTable 4. Pressure Ulcer Prevention Action Plan

Health care agencies that implement focused skin care protocols to prevent pressure ulcers and intervene as early as possible have demonstrated reductions in the prevalence and incidence of pressure ulcers.14 One study15 involving prepackaged bathing in critically ill patients reported effectiveness in cleansing compared with basin baths. In addition, significantly fewer products and time were utilized, cost was lower, and nurses' ratings were improved with the prepackaged bath. The study concluded that the prepackaged bath is a desirable form of bathing critically ill patients who cannot bathe themselves.


A separate study16 found that a multidisciplinary approach to pressure ulcer prevention and patient care is necessary and should include education and training of patient care staff, as well as training of hospital patients and caregivers in treatment and preventative plans. Furthermore, a Magnet institution17 found that the overall rates for nosocomial pressure ulcers declined housewide when nonlicensed personnel are trained in the following areas: (1) definition of a pressure ulcer, (2) appearance of a pressure ulcer, (3) risk factors for pressure ulcer development, and (4) prevention of pressure ulcers.



Respected guidelines have been published for pressure ulcer prevention, such as the Agency for Healthcare Research and Quality (AHRQ [formerly known as the Agency for Health Care Policy and Research]) guidelines18 for pressure ulcer prevention, and are meant to be implemented in a cost-effective and productive manner. The empowerment through education of NAs can enhance their ability to be proactive in pressure ulcer prevention, observation, and reporting; this is an adjunctive effort in the ongoing clinical effort for pressure ulcer prevention.


Educational sessions for NAs should stress skin care and include the importance of turning and positioning for bedbound patients, the need for repositioning and padding for those seated in chairs, and communication to the appropriate licensed/medical personnel at the first signs of skin abnormalities. The preventative use of moisture barriers and skin protectants significantly reduces the incidence of pressure ulcers and supports the AHRQ clinical practice recommendations. Other hospitals are invited to adopt the model presented in this article for education of the ancillary members of the health care team and are encouraged to use their nursing team to the fullest extent possible in pressure ulcer prevention and management.



The author thanks Kersten Hammond for assistance with development of this manuscript.




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