PDF Archive

Easily share your PDF documents with your contacts, on the Web and Social Networks.

Share a file Manage my documents Convert Recover PDF Search Help Contact

Pressure ulcer .pdf

Original filename: Pressure ulcer.pdf
Title: Older adults knowledge of pressure ulcer prevention: a prospective quasiexperimental study

This PDF 1.6 document has been generated by Arbortext Advanced Print Publisher 9.0.114/W / PDFlib PLOP 2.0.0p6 (SunOS)/Acrobat Distiller 7.0 (Windows), and has been sent on pdf-archive.com on 04/11/2015 at 03:21, from IP address 173.74.x.x. The current document download page has been viewed 600 times.
File size: 202 KB (12 pages).
Privacy: public file

Download original PDF file

Document preview


Older adults’ knowledge of pressure ulcer prevention: a prospective
quasi-experimental study
Irene Hartigan

MSc, RNT, H.Dip, BSc, RGN

Lecturer, School of Nursing and Midwifery, University College Cork, Cork, Ireland

Siobhan Murphy


Lecturer, School of Nursing and Midwifery, University College Cork, Cork, Ireland

Mary Hickey


Clinical Nurse Manager and Registered General Nurse, St. Finbarr’s Hospital, Cork, Ireland

Submitted for publication: 2 August 2010
Accepted for publication: 7 January 2011

Irene Hartigan
School of Nursing and Midwifery
Brookfield Health Science Complex
University College Cork
Telephone: 00 353 21 4901623
E-mail: i.hartigan@ucc.ie

H A R T I G A N I . , M U R P H Y S . & H I C K E Y M . ( 2 0 1 2 ) Older adults’ knowledge of
pressure ulcer prevention: a prospective quasi-experimental study. International
Journal of Older People Nursing 7, 208–218
doi: 10.1111/j.1748-3743.2011.00274.x
Aim. To test an evidence base patient education leaflet to evaluate older adults’
knowledge of pressure ulcers and prevention strategies.
Background. The increasing population of older adults living in the community
managing chronic health conditions are at risk of pressure ulcer development.
Education leaflets are a useful adjunct to reinforce healthcare professional’s verbal
information to promote healthy lifestyles choices. However, little is known of the
effectives of pressure ulcer prevention educational leaflets for older adults.
Methods. A quasi-experimental uncontrolled pre-test, post-test study of participants’ knowledge of pressure ulcer and preventative strategies was conducted.
Community dwelling older adults (n = 75) were recruited to this study. Older
adult’s knowledge was measured pre- and postdistribution of an education intervention. A risk assessment scale was recorded to identify whether this cohort of
older adults were actually at risk of developing pressure ulcers.
Conclusion. The results indicate that an education leaflet enhanced patients’
knowledge relating to pressure ulceration. Printed education materials increase
knowledge and understanding which may lend to older adults adopting healthy
Implications for practice. An education leaflet can help older adults and their
carers to be more empowered as active participants in reducing the incidence of
pressure ulceration.

Key words: chronic health conditions preventative strategies, health literacy,
nursing, older adults, pressure ulcers

The prevention of pressure ulcers is not a new issue in older
adult nursing. Worldwide pressure ulceration continues to

be a persistent source of burden to patients and healthcare
Economically, pressure ulcers are catastrophic for health
care. Pressure ulcers have a significant impact on health 2011 Blackwell Publishing Ltd

Older adults’ knowledge of pressure ulcer prevention

related quality of life and cause substantial burden to patients
(Fox, 2002; Bennett et al., 2004; Hobbs, 2004; Briggs &
Flemming, 2007). The prevalence of pressure ulcers from a
sample of 5000 hospitalised patients in five European
countries ranged from 8% in Italy to 22.9% in Sweden
(Clark et al., 2004). Similarly in Ireland, a recent point
prevalence study of pressure ulceration in three university
teaching hospitals was 18.5% (Gallagher et al., 2008).
Pressure ulcers contribute greatly to older adults’ morbidity,
mortality and reduce their quality of life especially those who
are nutritionally compromised, immobile, incontinent and
cogitatively impaired (Bergquist, 2003; Brillhart et al., 2006;
Santamaria et al., 2009). Pressure ulcers are a non-communicable condition and known worldwide to be preventable
and avoidable in many cases (Allman, 1997; Whitfield et al.,
2000; Lyder et al., 2002). Yet, they continue to cause both
physical and psychological suffering for patients in hospitals
and at home (Collins, 2001; Brillhart, 2006; Madhuri et al.,
Although individuals of any age can develop pressure
ulcers, they are more common in certain patient groups such
as older people (Whittington & Briones, 2004). It is expected
that by 2030, one in four Irish people will be over 65 years of
age (McDermott-Scales et al., 2009). Coupled with people
living longer and the expected rise in chronic health conditions such as cardiovascular disease (Yazdanyar & Newman,
2009), hyperlipidaemia (Aslam et al.,2009), obesity (Chapman, 2008), diabetes and mobility problems (Cigolle et al.,
2009), many of these conditions are major predisposing risk
factors for the development of pressure ulcers (Department of
Health and Children, 2007). The European Pressure Ulcer
Advisory Panel (EPUAP) and the National Pressure Ulcer
Advisory Panel (NPUAP) (2009) identify four factors that
impact on an individual’s risk of pressure ulcer development
namely nutritional indicators, skin moisture, advanced age as
well as perfusion and oxygenation.
Health literacy has the potential to promote healthy
lifestyles behaviours. Nurses are well placed to provide
education that meets the individual needs of specific groups
such as older adults. McKenna and Scott (2007) stipulate that
patient’s knowledge, behaviour and attitudes are influenced
by the provision of information. Providing pressure ulcer
information in the form of patient education may influence
patient’s self-management of their own healthcare.

Literature review
The development and availability of health information
literature relating to chronic health conditions promotes
awareness which in turn can empower patients to maximise
2011 Blackwell Publishing Ltd

their health (Mancuso, 2008). Knowledge and education
programs have been shown to reduce the incidence and
severity of pressure ulcers (Leary, 1990; Moody et al., 1998;
Bergquist & Frantz, 1999; Lyder et al., 2002; Robinson
et al., 2003; Hobbs, 2004). Consequently, there is a growing
demand from patients to be provided with verbal, written,
pictorial or digital/multimedia information that supports and
enables patients to self-manage and make informed health
choices for themselves (Johnson et al., 2003). Health literacy
is characterised by the Joint Committee on National Health
Education Standards (EPUAP Review 2002) as the individual’s capacity to obtain, interpret and understand basic health
knowledge and to apply this knowledge to enhance their own
health. The predominant mediums for dissemination of
health literacy are verbal and written formats which have
been proven to be successful in improving knowledge,
reducing hospital admissions and increasing satisfaction in
the provision of patient and carer education (Johnson et al.,
2003; Wolf et al., 2005). A Cochrane review identified 23
studies that examined the effectiveness of printed education
material in improving patient outcomes. Of these, 12 studies
were randomised controlled studies comparing two groups of
patients. This Cochrane review highlighted that printed
educational material is a common method for disseminating
information to patients. Despite many limitations to the
studies mentioned in this review, printed educational material
demonstrated an effect (Farmer et al., 2010). Printed educational material has also been used for the provision of
important aspects of cancer care. A systematic review of
randomised control trials identified 10 studies that evaluated
methods of educating cancer patients or their families.
Written information featured as the most common educational intervention method and had a significant effect on
knowledge amongst cancer patients (McPherson et al.,
2001). Several qualitative studies have demonstrated that
providing written information to patients improves patient
confidence, decreases recovery time, reduces anxiety and
improves adherence to treatment regimes (Gibbs et al., 1989;
Devine & Westlake, 1995; Johnson, 1999; National Health
and Medical Research Council, 2000; Johnson & Sandford,
2005). Printed education leaflets have also proven to be
effective for reminding women to register for pap-smear
screening for cancer prevention (Paul et al., 2003). The
content and design characteristics of the pap-smear leaflet
were not found to play a significant role in the effectiveness of
the printed leaflet (Paul et al., 2003). The effect of printed
education material in the prevention of pressure ulcers has
not been examined, and little evidence exists regarding
nurses’ contributions to health literacy (Mancuso, 2008).
Nurses need to develop and provide education in a format

I. Hartigan et al.

that best meets the individual needs of specific groups, such as
older adults.
Clinical practice guidelines for the prevention and treatment of pressure ulcers have been developed in many
countries around the globe; EPUAP in Europe, NPUAP in
the USA, National Institute of Clinical Excellence (NICE) in
the UK, the Scottish Intercollegiate Guidelines Network
(SIGN) and National Best Practice and Evidence Based
Guidelines for Wound Management in Ireland. The effectiveness of pressure ulcer prevention patient education
programmes is not known, and it is unclear whether
interventions such as providing written information are
implemented in practice (Ardblaster, 1998; O’Brien et al.,
2003). A recent study by Paquay et al., (2010) demonstrated
adherence by nurses and patients to the Belgian Guidelines
for prevention of pressure ulcers after an education programme. Despite the positive outcomes of this study, the
effects were only short to midterm in duration. Thus, further
research is proposed to examine older adults’ basic knowledge of pressure ulcers and their prevention, as well as
determining the effectiveness of giving a pressure ulcer
education leaflet to older adults.

This study was designed as a prospective quasi-experimental,
uncontrolled pre-test, post-test study of pressure ulcer
prevention education. The aim of this study was to use an
evidence base patient education leaflet to measure the
knowledge of older adults in relation to pressure ulcers and
prevention strategies. The pressure ulcer prevention leaflet
was given to an at-risk population over a 1-week period.
Data collectors administered the pre- and post-tests. All data
collectors, who were nurses, were instructed on the process of
data collection.

Setting and sample
The study setting was an assessment and treatment centre
which is dedicated to older adults under the governance of
the Irish Health Service Executive. Patients aged 65 years and
over who live in their own homes are referred to the centre
following discharge from acute or rehabilitation hospitals in
the region. This centre has a vital role in supporting early
discharge from the acute services and maintaining older
people in their own homes. Nurses, doctors, physiotherapists,
occupational therapists, speech and language therapists,
clinical nutritionist and podiatrist provide prescribed profes210

sional services. Patients’ appointments are once weekly, and
they attend the centre for appointments of 2–4 hours
duration depending on the number of services they require.
In this study, the convenience sample was recruited from this
centre for older adults. According to the NICE guidelines
(2005), this population is representative of an at-risk group
for pressure ulcers firstly because they are older adults and
secondly as they have recently been ill or suffered injury at an
older age. All patients attending the assessment and treatment
centre (n = 97) during a 1-week period formed the potential
study population. Patients with a Mental Test Score (MTS) of
seven or greater out of a total of 10 comprised the study
population (n = 91). However, a further 16 patients declined
to consent, resulting in a total of 75 older adults who agreed
to participate in this study.

The intervention developed for this study is a patient
education leaflet titled ‘Preventing Pressure Ulcers, a guide
for patients and their carers’ (Appendix 1). Following a
literature review, the content to include in this leaflet was
determined and emanated from the principles of EPUAP and
NPUAP (2009). The intervention leaflet begins with a
definition of pressure ulcers, followed by a diagram of the
body depicting the eight most likely areas to develop pressure
ulcers. The leaflet also provides a selection of strategies the
older person or carers can implement when alerted to the
possibility of pressure ulcer development. The order and
presentation of text and images were carefully chosen to
emphasise preventative information and to attract the reader.
Sentences were concise and personalised while bullet points
were used to alert readers to actions, such as ‘Eat plenty of
protein (e.g. meat, fish, eggs)’ and ‘Don’t rub or massage your
pressure area’. This A4 size, Z folded leaflet was designed to
be used as a guide for both patients and carers in their home.
A review and critiquing process was conducted by an
expert panel consisting of consultant geriatricians, doctors
and nurses. Service-users, who were not study subjects but
who attended the centre, were consulted to determine the
readability and ability to understand the intervention by an
older adult population. Suggestions received from both the
expert panel and service users contributed to the final version
of the intervention. The readability of the leaflet was
calculated using the Flesch–Kincaid Grade Level (Flesch,
1974), which is built into Microsoft Word. The readability is
calculated from the number of words, syllables and sentence
length in the leaflet and the final score indicates comprehension difficulty. A typical score of 8.2 would indicate that the
text is expected to be understandable by an average student
2011 Blackwell Publishing Ltd

Older adults’ knowledge of pressure ulcer prevention

in 8th grade in the USA which is equivalent to 6th Class in
Primary School in the Republic of Ireland. The Preventing
Pressure Ulcers, a guide for patients and their carers’ leaflet
scored 5.5. This translates to a reading age of an 8–10 year
old, indicating ease of reading and understanding of the
content of the intervention.

Measurement instrument
A patient knowledge of pressure ulcer prevention measurement instrument consisting of 13 questions was developed
specifically for this study. This measured older adults’
knowledge of pressure ulcers and prevention strategies. From
review of EPUAP and NPUAP (2009), content to be included
in the measurement instrument was determined, and this
contributed to its content validity. Each question included,
directly mirrored the content and order of information in the
education leaflet. Thus, the content of the instrument
logically and comprehensively addresses items of interest.
The relationship between the European guidelines and the
measurement instrument demonstrates strong correlation
between the gold standard of pressure ulcer information
and the instrument establishing a degree of criterion validity.
An expert panel consisting of consultant geriatricians,
doctors, nurses and service users was approached to review
the instrument. Specific members of the expert panel were
invited to contribute as they had extensive international
clinical and research expertise in caring for and educating
older adults. This further contributed to the content and the
construct validity of the measurement instrument as minor
typographical changes were made and the number of questions were reduced by two. In addition, the panel was
cognisant of how relevant and clear the instrument questions
were and this informed face validity. Consequently, the 11
questions emanated from key sources pertaining to patients’
knowledge of pressure ulcer preventative strategies. Examples
include ‘what foods might help to prevent developing a
pressure ulcer?’ and ‘what parts of the body are at risk of
developing a pressure ulcer?’ With the exception of the
second question, which required a tick-box multiple closed
response, remaining questions required the data collector to
document the words given in response to each question by
each participant.

ily returned consent forms during their appointment. Patients
who decided not to participate in this study were informed
that their care would not be comprised in any way. On
patients’ next appointment, data collectors administered the
pre-test instrument to those that had given consent and
assured their anonymity and confidentiality. Demographic
details including age, gender and primary diagnosis were
obtained. The instrument was administered to each participant by a nurse data collector who sat with the older adult
and asked each question individually and documented their
responses verbatim. The data collector also conducted and
documented a pressure ulcer risk assessment on each participant using the Medley scale (1987) (Appendix 2). This scale
was chosen as it is the scale routinely used within this local
health service and calculates the participant’s risk for
pressure ulcer development. On completion of the pre-test
instrument, participants were given the education leaflet and
encouraged to read and learn about pressure ulcer prevention. Each participant was reminded that the same 11
questions would be asked again on their return appointment
in 7 days. Thus, the time frame to read and learn from the
leaflet was the same for all participants. The post-test
instrument was administered by any one of the four nurse
data collectors who again documented the patients’ responses.

The patients in this study were all older adults who were
living at home with a chronic illness. Pre-test data were
collected from 75 patients who consented to participate in
this study. The post-test was not conducted on 19 patients as
they did not return on their next appointment or where
discharged from the assessment and treatment centre. Thus,
56 participants had data collected both at the pre- and posttest study times which allowed for comparison between data
sets. The age range of participants was 66–99 years with a
mean age of 79.9 (SD ± 6.5) years of which 64% were
female. The majority of patients (92%) demonstrated full
cognition as they achieved a score of 10 out of 10 on MTS
while the remaining 8% had a score of seven or greater.
Table 1 presents the gender distribution and primary

Table 1 Study sample characteristics

Data collection
For the duration of 1 week, all older adults arriving to the
assessment and treatment centre received a written invitation
to participate in this study. A data collector provided detailed
explanation of the study protocol, and participants voluntar 2011 Blackwell Publishing Ltd

Age category


cardiac failure



I. Hartigan et al.

Participants’ choice of words to describe the signs and
symptoms of pressure ulcer formation is displayed in Table 3.
These are presented in three categories.
Overall, participants reported one or more sign of pressure
ulcer formation. Figure 2 demonstrates that those who had
no knowledge of signs of pressure ulcer formation in the
presurvey increased in the post-survey results. It is also
evident that there was an increase in the number of signs for
pressure ulcer formation in the post-survey as each participant was able to recall a greater number of signs demonstrating an increase in knowledge.
Participants were asked to identify how long does pressure
need to persist when either sitting or lying for a pressure ulcer
to occur? Table 4 identifies that 32% (n = 18) were unable to
answer this question in the presurvey, and this only reduced
to 11% (n = 6) in the post-survey. Participant’s knowledge of
the duration of pressure for pressure ulcer formation ranged
from 1 hour to several weeks. This implies that participants
equate pressure ulcer formation to duration of sustained

Did not know what Knew what a PU Did not know what Knew what a PU
a PU was
a PU was



Figure 1 Knowledge of what is a pressure ulcer.

diagnosis of the study sample based on the following three
age categories: 66–75, 76–85 and >85 years.
Pressure ulcers had been previously experienced by 7% of
the study sample. The Medley scale identified that 59% of
participants were at low risk of developing a pressure ulcer,
38% of patients were at medium risk and 3% at high risk.
The pre-test survey results identified that 32% (n = 18) of
patients did not know what a pressure ulcer was or what it
may look like. Whereas the post-test survey results identified
that only 9% (n = 5) of patients did not know what a
pressure ulcer was or what it may look like (Fig. 1).
Table 2 displays a breakdown of participants’ knowledge
of the most common sites for pressure ulcer development
prior to and post the intervention. The post-test survey
identified that the majority of patients could identify possible
anatomical body areas where a pressure ulcer would be most
likely to occur. There is an obvious improvement in knowledge of most common sites except for the hip. The buttock
was known by the majority of participants as the area most at
risk of pressure ulcer development at both the pre- and post
Prior to receiving the leaflet, 77% (n = 43) of participants
could identify what might cause a pressure ulcer and this
increased to 89% (n = 50) post test. The key causes of
pressure ulcers were reported as sitting or lying in the same
position for too long, friction, dry skin, poor washing of the
skin, wrinkled sheets, incontinence and being overweight.

Table 3 Signs and symptoms of pressure ulcer formation as identified
by participants
Change in
skin tone

Change in
skin sensation

Change in skin

Rough surface


Break in the skin


No knowledge of signs


Identified 1 sign

Identified 2 signs

Identified 3 signs

Figure 2 Knowledge of signs of pressure ulcer formation.

Table 2 Knowledge of most common sites for pressure ulcer development
Most common










2 (4%)
5 (18%)

14 (25%)
30 (54%)

2 (4%)
7 (13%)

6 (11%)
6 (11%)

34 (61%)
44 (79%)

11 (20%)
29 (52%)

2 (4%)
9 (16%)

15 (27%)
22 (39%)


2011 Blackwell Publishing Ltd

Older adults’ knowledge of pressure ulcer prevention
Table 4 Pre-test and post-test findings of pressure ulcer prevention
No. of participants

Did not know how long it took for a PU
to develop
Identified 1–12 hours for PU formation
Identified 12–48 hours for PU formation
Identified days to weeks for PU formation
Did not know how to prevent PU when in
Did not know how to prevent PU when in



18 (32)

12 (21)




12 (21)


13 (23)

PU, pressure ulcer.

pressure as opposed to the intensity of the pressure. When
sitting in a chair, 21% (n = 12) of patients did not know how
to prevent a pressure ulcer, whereas this figure reduced to
9% (n = 5) in the post-test survey data.
The majority of patients 86% (n = 48) did not know what
foods help prevent a pressure ulcer before receiving the
education leaflet compared with 36% (n = 20) after receiving
the leaflet. When asked who could give advice with regard to
pressure ulcer prevention, 82% (n = 46) of participants
identified both nurses and doctors as key information
providers with 18% (n = 10) identifying carers and pharmacists.

WHO Europe (2006) advocates self-care in preventing and
controlling non-communicable conditions. Despite worldwide acknowledgement that pressure ulcers are preventable
and avoidable, older people continue to be at risk. Education
of patients and caregivers must be the objective, especially for
those who are at risk of developing pressure ulcers. Printed
education materials increase awareness and knowledge. They
also help individuals adapt healthy behaviours (Bull et al.,
2001). EPUAP supports this opinion and advocates for
studies to investigate the impact of individualised structured
education programmes. The results of this study suggest that
education leaflets are an effective method of delivering health
literacy for older adults. Providing pressure ulcer education is
necessary for prevention as it is assumed that greater
awareness of pressure ulcers will prompt adults to reduce
the risk factors for pressure ulcer formation. Research also
demonstrates that patients only recall and comprehend 50%
of verbal medical information from doctors (Bertakis, 1997;
2011 Blackwell Publishing Ltd

Crane, 1997; Roter, 2000), and often communication levels
are too complex for patients to understand (Farrell et al.,
Education leaflets contribute to participants’ confidence in
managing their health and the perception that they can
control their environment (McKenna & Tooth, 2006).
However, education leaflets can only marginally influence a
patient’s knowledge, attitude and behaviour. Changing
patients’ attitude and behaviour regarding pressure ulcer
prevention would require patients’ participation in activities
that promote health and wellbeing, such as adopting healthy
behaviours like increasing mobility and healthy eating (Lorig,
2001). Therefore, older adults take an informed active role in
their own health by engaging with health professionals who
provide both verbal and written health education. Despite
this study determining an increase in knowledge of pressure
ulcers, actual measures of preventative behaviours and
attitude would have greatly informed the effectiveness of
the education leaflet. It is assumed that older adults acquire
pressure ulcers because they are old. However, the evidence
demonstrates that issues such as poor mobility and inadequate nutrition have a more significant contribution to
pressure ulcer formation than age alone (Mathus-Vliegen,
2004). Nurses are well placed to influence healthy lifestyle
behaviours as they can provide education about and support
of healthy living and illness prevention (Sheriff & Chenoweth, 2006). Given the rising numbers of older people,
promoting individual responsibility builds on older adults
self-care capacity and capability to make informed decisions
in relation to preventing and managing common age-related
illness such as pressure ulceration.
The results of this study are encouraging, as they demonstrate the extent of pressure ulcer knowledge gained from
providing people with an education leaflet. The sample in this
study was representative of community dwelling older adults
who are managing chronic health conditions at home yet at
risk of developing pressure ulcers. The incidence of stroke,
atrial fibrillation and congestive cardiac failure in this study
sample concurs with national prevalence of coronary heart
diseases on the island of Ireland (Balanda et al., 2010).
According to various pressure ulcer risk assessment scales,
coronary heart diseases are associated with greater risk of
pressure ulceration. As the population of older adults is
predicted to increase, interventions such as education leaflets
need to be developed and empirically tested to reduce the
physical and economic burden of pressure ulcers. Community
dwelling older adults are at risk of pressure ulcer development, and these study findings demonstrate the effectiveness
of a simple yet evidence base intervention that can help
prevent pressure ulcers. Nurses have many opportunities

I. Hartigan et al.

when interacting with older adults to provide education on
illness prevention and encourage a proactive approach to
offset disability and achieve healthy well-being. Johnson and
Sandford (2005) stipulate that education leaflets are a
valuable adjunct to verbal information as they assist patients
to remember key strategies. Education leaflets also aid
reinforcement of healthy lifestyle choices and create greater
body awareness.
Development of the education leaflet ‘Preventing Pressure
Ulcers, a guide for patients and their carers’ is an example of
an effective nursing action directed at preventing pressure
ulcers and promoting maximum well being of older adults.
Education leaflets are a convenient means of delivering health
literacy to older adults while they are simultaneously availing
of other health services. Health literacy involves a person
being able to understand basic health information so that
they have options to make informed decisions about their
own health. Healthcare professionals need to consider
delivering verbal or written education in formats that concur
with a patient’s ability to understand. This approach was
implemented in developing the intervention as McKenna and
Scott (2007) stipulate the need to tailor information to the
target population, so content can be easily read and understood. Furthermore, Weinman et al. (2009) highlighted that
many patients in the UK could not identify the location of key
body organs. These issues informed the content of the leaflet
in which a simple body diagram was included, clearly
outlining anatomical body areas most at risk of pressure
ulceration. Thus, the content of ‘Preventing Pressure Ulcers,
a guide for patients and their carers’ provided older adults
with education pertaining to prevention of pressure ulcers
using diagrams and text. Furthermore, pressure relieving
techniques were presented in words only in the leaflet to
inform study participants that increased duration and intensity of pressure on the at-risk body parts significantly
contributes to pressure ulcer formation. Presenting this
concept in word format alone did not impact on participants’
knowledge. Therefore, we would recommend that this is an
area needing revision to clearly demonstrate that the association between the duration and intensity of pressure creates a
greater risk of pressure ulcer formation. The inclusion of a
diagram and/or equation would be a suggestion to improve
the explanation of the physics of pressure ulcer formation.
Empowering patients through various health literacy
sources is positively correlated with happiness (Angner et al.,
2009). Other technological mediums are also available such
as web learning, but this can be overwhelming as the quantity
and quality of web interface is dependant on the technological ability of the older adult as well as the resources to
support this technology. Designing and developing other

mediums such as education leaflets can enhance nurses’
contribution to health literacy research (Hobbs, 2004). The
low cost of designing and printing the education leaflet
further suggests that this is an optimal choice for educating
older adults who may want to learn in their own time and
at their own pace (Bernier, 1993). Health literacy should
include a variety of delivery formats that compliment
individual patient capacity to understand and interpret the
education. This education leaflet is one example of a
providing and reinforcing education to older adults at risk
of pressure ulcer development.

Limitations of the study
Results of this study are confined to a small population of
older adults attending an assessment and treatment centre;
hence, the results are not generalisable. Participant’s education levels were not collated as years of education are a poor
predictor of older adults reading ability (McKenna & Scott,
2007). To enhance future study findings, actual literacy skills
should be measured to determine the reading ability of
participants (Wilson & McLemore, 1997). The study findings
did demonstrate an increase in patients’ knowledge; however,
the knowledge retention interval was relatively short
(1 week) suggesting that knowledge needs to be examined
over longer time intervals and amongst diverse populations.
A longitudinal study would estimate the effects of education
over time. Furthermore, recruiting a control group would
further enhance the study findings. This study could, however, be used as a pilot project to a randomised control trial
as further reliability and validity testing of the study
instruments needs to be established.

Providing education for patients and carers is a responsibility
of healthcare professionals and should be a consistent
objective to improve health outcomes for the increasing
population of older adults who are at risk of pressure ulcers.
The increase in chronic health conditions and the effects of
ageing on the skin increases older adults risk of pressure
ulcers. Pressure ulcers reduce patients’ quality of life because
of the pain and suffering which is associated with their
exclusion from participating in everyday social activities. The
EPUAP supports educating older adults and suggests it should
be achieved through structured, organised, comprehensive
education programmes. Providing preventative education
leaflets can empower patients to actively participate and take
responsibility for their own health and thus reduce the
incidence of pressure ulcers.
2011 Blackwell Publishing Ltd

Older adults’ knowledge of pressure ulcer prevention

Implications for practice
• ‘Preventing Pressure Ulcers, a guide for patients and
their carers’ could be introduced as an approach to
reach beyond the clinical environment and into the
homes of older adults at risk of pressure ulcers.
• Timely and readable communications between patients
and nurses can improve health care outcomes for older
• Education leaflets are a useful adjunct to reinforce
health lifestyle choices.
• Nurse needs to be able to determine patients’ actual
health literacy abilities when providing information to
ensure they have the capacity to understand.
• Recognising patients’ health literacy can be a challenge
as it can be influenced by a number of factors such as
formal education, ethnicity and cognitive decline.

The contributions of the older adults attending the Assessment and Treatment Centre at St. Finbarr’s Hospital, data
collectors and Consultant Geriatricians are greatly appreciated by the authors.

Allman R.M. (1997) Pressure ulcer, prevalence, incidence, risk
factors and impact. Clinics in Geriatric Medicine 13, 421–426.
Angner E., Midge N.R., Kenneth G.S. & Allison J.J. (2009) Health
and happiness among older adults: a community-based study.
Journal of Health Psychology 14, 503–512.
Ardblaster G. (1998) Pressure sore incidence: a strategy for reduction. Nursing Standard 12, 49–54.
Aslam F., Hague A., Lee V.L. & Foody J. (2009) Hyperlipidemia in
older adults. Clinics in Geriatric Medicine 25, 591–606.
Balanda K.P., Barron S., Fahy L. & McLaughlin A. (2010) A systematic approach to estimating and forecasting population prevalence on the Island of Ireland. Institute of Public Health in Ireland,
Available at: http://www.inispho.org/publications/makingchronicconditionscountexecutivesummary (accessed 20 May 2010).
Bennett G., Dealey C. & Posnett J. (2004) The cost of pressure ulcers
in the UK. Age and Ageing 33, 230–235.
Bergquist S. (2003) Pressure ulcer prediction in older adults receiving
home health care: implications for use with the OASIS. Advances
in Skin & Wound Care 16, 132–139.
Bergquist S. & Frantz R. (1999) Pressure ulcers in older adults receiving home health care: prevalence, incidence and associated risk
factors. Advances in Wound Care 12, 339–351.
Bernier M.J. (1993) Developing and evaluating printed education
materials: a prescriptive model for quality. Orthopaedic Nursing
12, 39–46.

2011 Blackwell Publishing Ltd

Bertakis K.D. (1997) The communication of information from physician to patient: a method for increasing patient retention and
satisfaction. Journal of Family Practice 5, 217–222.
Briggs M. & Flemming K. (2007) Living with leg ulceration: a synthesis of qualitative research. Journal of Advanced Nursing 59,
Brillhart B. (2006) Pressure sore and skin tear prevention and
treatment during a 10-month program. Rehabilitation Nursing 30,
Bull F.C., Holt C.L., Kreuter M.W., Clark E.M. & Scharff D. (2001)
Understanding the effects of printed health education materials:
which features lead to which outcomes? Journal of Health Communication 6, 265–279.
Chapman I. (2008) Obesity in old age. Frontiers of Hormone Research 36, 97–106.
Cigolle C.T., Blaum C.S. & Halter J.B. (2009) Diabetes and cardiovascular disease prevention in older adults. Clinics in Geriatric
Medicine 25, 607–614.
Clark M., Bours G. & DeFloor T. (2004) The prevalence of pressure
ulcers in Europe. In Pressure Ulcers: Recent Advances in Tissue
Viability (Clark M. ed). Quay Books, London, pp. 230–235.
Collins F. (2001) Sitting: pressure ulcer development. Nursing Standard 15, 54–58.
Crane J.A. (1997) Patient comprehension of doctor-patient communication on discharge from the emergency department. Journal of
Emergency Medicine 15, 1–7.
Department of Health and Children (DoHC) (2007) Tackling
Chronic Disease: A Policy Framework for the Management of
Chronic Disease. Department of Health and Children. Stationary
Office, Dublin.
Devine E. & Westlake S. (1995) Effects of psychoeducational care
provided to adults with cancer: meta-analysis of 116 studies.
Oncology Nurses Forum 22, 1369–1381.
European Pressure Ulcer Advisory Panel (EPUAP) (2002) Summary
report on the prevalence of pressure ulcers. EPUAP Review 4,
Farmer A.P., Le´gare´ F., Turcot L., Grimshaw J., Harvey E., McGowan J.L. & Wolf F. (2010) Printed educational materials: effects
on professional practice and health care outcomes. Cochrane
Database of Systematic Reviews Issue 10.
Farrell M., Deuster L., Donovan J. & Christopher S. (2008) Pediatric
residents’ use of Jargon during counselling about newborn genetic
screening results. Pediatrics 122, 243–249.
Flesch R. (1974) The Art Readable Reading. Haper & Row, New
Fox C. (2002) Living with a pressure ulcer: a descriptive study of
patient’s experiences. British Journal of Community Nursing 10,
Gallagher P., Barry P., Hartigan I., McCluskey P., O’Connor K. &
O’Connor M. (2008) Prevalence of pressure ulcers in three university teaching hospitals in Ireland. Journal of Tissue Viability 17,
Gibbs S., Waters W. & George C. (1989) The benefits of prescription
information leaflets. British Journal of Clinical Psychology 27,
Health Service Executive (2009) National Best Practice and Evidence
Based Guidelines for Wound Management in Ireland. Health
Service Executive. Stationary office, Dublin.


I. Hartigan et al.
Hobbs B.K. (2004) Reducing the incidence of pressure ulcers:
implementation of a turn-team nursing program. Journal of
Gerontological Nursing 30, 46–51.
Johnson A. (1999) Do parents value and use written health information? Neonatal, Pediatric and Child Health Nursing 2, 3–7.
Johnson A. & Sandford J. (2005) Written and verbal information
versus verbal information only for patients being discharged from
acute hospital settings to home: systematic review. Health Education Research 20, 423–429.
Johnson A., Sandford J. & Tyndall J. (2003) Written and verbal
information versus verbal information only for patients being
discharged from discharged from acute hospital settings to home.
Cochrane Database of Systematic Reviews 4.
Joint Committee on National Health Education Standards (2005)
National Health Education Standards: Achieving Health Literacy. American School Health Association ERIC No ED
386418, Kent.
Leary C.B. (1990) Use of the nursing process to develop unit-specific
quality assurance plans. Journal of Nursing Quality Assurance 4,
Lorig K. (2001) Patient Education: A Practical Approach, 3rd edn.
Sage Publications, Thousand Oaks, CA.
Lyder C., Shannon R., Empleo-Frazier O., McGeHee D. & White C.
(2002) A comprehensive program to prevent pressure ulcers in
long-term care: exploring costs and outcomes. Ostomy Wound
Management 48, 52–62.
Madhuri R., Sudeep S., Gill P. & Rochon A. (2006) Preventing
pressure ulcers: a systematic review. JAMA 296, 974–984.
Mancuso J.M. (2008) Health literacy: a concept/dimensional analysis. Nursing & Health Sciences 10, 248–255.
Mathus-Vliegen E.M.H. (2004) Old age, malnutrition, and pressure
sores: an ill-fated alliance. Journals of Gerontology. Series A,
Biological Sciences and Medical Sciences 59, 355–360.
McDermott-Scales L., Cowman S. & Gethin G. (2009) The prevalence of wounds and their nursing management in a community
setting in Ireland. Journal of Wound Care 18, 405–417.
McKenna K. & Scott J. (2007) Do written education materials that
use content and design principles improve older people’s knowledge? Australian Occupational Therapy Journal 54, 103–112.
McKenna K. & Tooth L. (2006) Client education: an overview. In
Client Education: A Partnership Approach for Health Practitioners
(McKenna K. & Tooth L. eds). University of NSW Press, Sydney,
pp. 1–12.
McPherson C.J., Higginson I.J. & Hearn J. (2001) Effective methods
of giving information in cancer: a systematic literature review of
randomized controlled trials. Journal of Public Health 23, 227–
Moody B.L., Fanale J.E., Thompson M., Vaillancourt D., Symonds
G. & Bongsoro C. (1998) Impact of staff education on pressure
sore development in elderly hospitalized patients. Archives of
Internal Medicine 148, 2241–2243.
National Health and Medical Research Council (2000) How to
Present the Evidence for Consumers: Preparation of Consumer
Publications. Commonwealth of Australia, Canberra.


National Institute for Health and Clinical Excellence (NICE) (2005)
The management of pressure ulcers in primary and secondary care.
Clinical Guideline Number 29. London UK 1–245.
National Pressure Ulcer Advisory Panel (NPUAP) (2009) Available
at: http://www.npuap.org/ (accessed 27 January 2010).
O’Brien M.A., Freemantle N., Oxman A.D., Davies D.A. & Herrin J.
(2003) Continuing education meetings and workshops effects on
professional practice and health care outcomes. Cochrane Database of Systematic Reviews Issue 3.
Paquay L., Verstraete S., Wouters R., Buntinx F., Vanderwee K.,
Defloor T. & Van Gansbeke H. (2010) Implementation of a
guideline for pressure ulcer prevention in home care: pretest-posttest study. Journal of Clinical Nursing 19, 1803–1811.
Paul C.L., Redman S. & Sanson-Fisher R.W. (2003) Print material
content and design: is it relevant to effectiveness? Health Education
Research 18, 181–190.
Robinson C., Gloekner M., Bush S., Copas J., Kearns C., Kipp K.,
Labath B., Lonadier R., Lopez M., Nelson L., Newton S. & Wentz
D. (2003) Determining the efficacy of a pressure ulcer prevention
program by collecting prevalence and incidence data: a unit-based
effort. Ostomy Wound Management 49, 44–51.
Roter D.L. (2000) The outpatient medical encounter and elderly
patients. Clinics in Geriatric Medicine 16, 95–107.
Santamaria N., Carville K., Prentice J., Ellis I., Ellis T., Lewin G.,
Newall N., Haslehurst P. & Bremner A. (2009) Reducing pressure
ulcer prevalence in residential aged care: results from phase 2 of
the PRIME trial. Wound Practice and Research 17, 12–22.
Sheriff J.N. & Chenoweth L. (2006) Promoting healthy ageing for
those over 65 with the health check log: a pilot study. Australasian
Journal on Ageing 5, 46–49.
Weinman J., Yusuf G., Berks R., Rayner S. & Petrie K.J. (2009) How
accurate is patients’ anatomical knowledge: a cross-sectional,
questionnaire study of six patient groups and a general public
sample. BMC Family Practice 10, 43.
Whitfield M.D., Kaltenthaler E.C., Akehurst R.L., Walters S.J. &
Paisley S. (2000) How effective are prevention strategies in reducing
the prevalence of pressure ulcers? Journal of Wound Care 9, 261–266.
Whittington K.T. & Briones R. (2004) National prevalence and
incidence study: 6-year sequential acute care data. Advances in
Skin & Wound Care 17, 490–494.
WHO Europe (2006) Gaining health. In the European strategy for
the prevention and control of non communicable diseases. 56th
session. Regional Committee for Europe, Copenhagen, Denmark.
Available at: http://www.euro.who.int/document/E89306.pfd
(accessed 24 January 2010).
Wilson F. & McLemore R. (1997) Patient literacy levels: a consideration when designing patient education programs. Rehabilitation
Nursing 22, 311–317.
Wolf M.S., Gazmararian J.A. & Baker D.W. (2005) Health literacy
and functional health status among older adults. Archives of
Internal Medicine 165, 1946–1952.
Yazdanyar A. & Newman A.B. (2009) The burden of cardiovascular
disease in the elderly: morbidity, mortality, and costs. Clinics in
Geriatric Medicine 25, 563–577.

2011 Blackwell Publishing Ltd

Related documents

PDF Document pressure ulcer
PDF Document ijar an analysis of foot trophic ulcers
PDF Document nursing practice launch flyer final
PDF Document physician dispensing improving med adherence older adults
PDF Document negative pressure wound therapy market
PDF Document shah et al 2013

Related keywords