INTRODUCTION

Pressure injuries (PIs) are an important health problem frequently seen in individuals with acute or chronic diseases.1,2 Although PIs are largely preventable, their care and treatment are difficult, long, and costly. They prolong the patient’s duration of hospitalization, leading to increased care and treatment costs. Pressure injuries also lead to pain and infection; delay recovery; decrease the quality of life of the patient; cause loss of labor, activity, and earnings; and decrease the patient’s self-esteem and body image.2–5

The incidence of PIs varies between 0.4% and 38% in acute care units, between 2.2% and 23.9% in long-term care units, and between 0% and 17% in home care units, whereas their prevalence varies between 10% and 18% in acute care units, between 2.3% and 28% in long-term care units, and between 0% and 29% in home care units.6,7 Treatment costs of PIs vary between USD $1.3 billion and $8.5 billion per year.8 In their study conducted in 2019, Padula et al8 reported that more than USD $26 billion is spent on PI treatment in the US per year.

Pressure injuries are a quality indicator of the healthcare system, and PI prevention and treatment require a multidisciplinary team approach in which holistic care is provided. Nurses are important members of the health team and, because they provide uninterrupted care to the patient, play a large role in PI prevention. Nurses must carefully evaluate the complex risk factors that may lead to PIs and plan appropriate interventions.7,9,10 The most effective step in reducing the incidence of PIs is the identification of the factors that cause wounds and thus prevent wound formation. The most effective treatment method for PIs is to prevent their development.11–13

An effective PI prevention program requires the following: a team approach, appropriate and adequate training, patient adherence, and provision of a means to reduce pressure.7 All health personnel, patients who are at risk, and patients’ families should be trained on risk assessment and PI prevention. These trainings should include topics such as the etiology of PIs, risk assessment tools and their application, skin assessment, selection and use of support surfaces, development and implementation of individual skin care programs, positioning of the patient to reduce tissue destruction, and analysis of the data obtained. Patients who are at risk of PI or have recently developed PIs should be provided with written and verbal information on how to prevent PIs.6,7 Given the role of the nurse in patient education, it is important that nursing students learn this information during their schooling.

The internet is a source of information, communication, and learning opportunities.9,14 It gives nursing students and nurses the opportunity to share information, cooperate with other health professionals, and learn new things and provides different education options for educators.15,16 Because the internet can be used interactively, it is considered a high-quality education tool whereby individuals can receive education whenever they want.17 In recent years, the use of web-based education methods in nursing education has increased.15 Nursing students today, who are more likely to be “digital natives,” frequently expect the use of technology for education and training: web-based education is a model that responds to this demand.

Web-based education enables an asynchronous learning process (ie, a learning process that carries out individual and social learning beyond the boundaries of time and space with the support of various devices).18 Computer-aided education systems and web-based applications provide significant benefits to educators and students in nursing education.15 Uslu19 investigated the effectiveness of a web-based training developed for nurses and reported that 40% of the nurses considered the web training to be adequate. In the study by Taşocak et al,20 nursing students felt that theoretical courses could be taught by distance education. Instructional technologies may enrich the learning environment by bringing together various resources and increasing visual interest, which may motivate students and increase their academic achievement.17,21–23

The aim of the present study was to investigate the effect of web-based teaching on nursing students’ PI knowledge levels.

METHODS Study Design and Sample

The present study had a posttest-only control group design and was conducted with first-year students studying in the Nursing Department in the Faculty of Health Sciences of a university in Turkey during the 2017–2018 academic year. No sampling method was implemented. All students (N = 147) in in the PI course (taught by the same instructor using the traditional classroom lecture method) were invited to participate in the study.

Students were included in the study if they volunteered to participate, had a computer, and could access the internet. Because there was no difference in their first-semester academic achievements, the students in classrooms A and B were assigned to the experimental and control groups, respectively.

Data Collection

The researchers developed the Pressure Injuries Questionnaire based on the current literature. For the content validity of the questionnaire, the researchers obtained expert opinion from colleagues who have a doctorate in nursing and work in the field of PIs. The questionnaire was finalized in line with the recommendations of the experts. The questionnaire was pilot tested with a group of students who were not included in the sample.

The content of the web-supported teaching material to be used by the experimental group was prepared as a training booklet based on the current guidelines.6,7,24 It was submitted to the experts for review and revised in line with their opinions. The content in the revised training booklet was prepared as a PowerPoint presentation (Microsoft Inc) and uploaded to an international information-sharing website that was accessible with a password.

The students in both classrooms learned about PIs with the traditional teaching method for 3 hours a day for 2 days. For students in the control group, The Pressure Injuries Questionnaire was administered as a posttest immediately after the traditional lecture was completed. For the experimental group, once the lecture was completed, the students then had access to the web-supported teaching material for 7 days using the password to enter the website. The Pressure Injuries Questionnaire was administered to the experimental group as a posttest at the end of the 7 days.

Data Collection Tools Descriptive Information Questionnaire

This questionnaire was prepared by the researchers and consists of six questions related to the student’s age, sex, school from which they graduated, first-term general academic grade point average, whether they have experience working as a nurse, and whether they participated in training on PIs.

Pressure Injuries Questionnaire

The researchers developed this questionnaire based on the current literature and considering the students’ learning objectives. The questionnaire consists of 30 items in two sections: a general information section and a prevention and treatment section. The 15 questions in the general information section relate to the definition and stages of PI and factors facilitating PI development. The 15 items in the prevention and treatment section ask how to prevent PIs, what precautions should be taken for PI prevention, and how to treat PIs.

Data Analysis

The data were encoded and analyzed using the SPSS program (IBM Corp). In the analysis of the data, arithmetic mean, percentages, Student t test, and χ2 test were used. P < .05 was considered statistically significant.

Ethical Approval

The researchers obtained written permission to conduct this study from the University Non-Interventional Clinical Research Ethics Committee (decision no. GO 2018/6, decision date: July 3, 2018). Students who agreed to participate in the study provided written informed consent.

RESULTS

A total of 106 students (86 women [81.1%]) in classes A and B had access to the internet and agreed to participate in the study. The mean age of the participating students was 19.23 (SD, 1.79) years, and their general academic grade point average was 3.03 (SD, 0.4; Table 1). All 106 students answered all questions.

Table 1. - STUDENTS’ DEMOGRAPHIC INFORMATION Variable n (%) or Mean (SD) Sex  Female 86 (81.1)  Male 20 (18.9) Age, y 19.23 (1.79) First-term grade point average 3.03 (0.40) Type of high school  General high school 7 (6.6)  Anatolian high schoola 71 (67)  Science high school 1 (0.9)  Other 27 (25.5)

aStudents with higher scores on the high school entrance examinations are admitted to Anatolian high schools, and English education is predominant. These students are considered to have high academic achievement.

The rate of correct answers was 97.55% in the experimental group (n = 53; mean, 27.01 [SD, 1.29]) and 85.15% in the control group (n = 53; mean, 24.69 [SD, 1.84]), which was a statistically significant difference (t = 7.468, P < .001). Further, in comparing the rates of correct responses to specific questions, the experimental group had a higher rate of correct responses to questions 3, 4, 6, 8, and 11 in the general information section and questions 15, 17, 21, and 24 questions in the prevention and treatment section in comparison with the control group (P < .05; Table 2).

Table 2. - EVALUATION QUESTIONS AND PERCENT OF CORRECT ANSWERS BY GROUP Experimental Group (n = 53) Control Group (n = 53) No. Evaluation Questions Answer, T/F Correct, n (%) Incorrect, n (%) Correct, n (%) Incorrect, n (%) χ 2 P General information 1 A PI is a localized tissue injury that occurs in the skin and subcutaneous tissues under the influence of pressure, friction, tearing, and other factors. T 53 (100) — 53 (100) — 2 PIs affect the patient’s quality of life and increase the cost of healthcare. T 53 (100) — 53 (100) — 3 Depending on the damage to the soft tissue due to pressure or friction, a purple or chestnut color on intact skin indicates deep-tissue damage. T 49 (92.5) 4 (7.5) 37 (69.8) 16 (30.2) 8.874 .003 4 The presence of erythema on intact skin that does not fade with pressure, usually on bony prominences, indicates a stage 2 PI. F 49 (92.5) 4 (7.5) 30 (56.6) 23 (43.4) 17.940 .000 5 Full-thickness tissue loss, including bone, tendon, and muscle, indicates a stage 4 PI. T 53 (100) — 51 (96.2) 2 (3.8) 2.038 .153 6 The wound cannot be staged if the wound bed is covered with scab (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black). T 50 (94.3) 3 (5.7) 41 (77.4) 12 (22.6) 6.290 .012 7 Pressure is the most important factor in the formation of PIs. T 53 (100) — 52 (98.1) 1 (1.9) 1.010 .315 8 Pressure has an inverse ratio with time; high pressure affects the tissue in a short time, whereas low pressure acts for a longer time. T 50 (94.3) 3 (5.7) 35 (66) 18 (34) 13.361 .000 9 The areas with the most common PIs are the areas with heavy bony prominences. T 53 (100) — 53 (100) — 10 The risk of developing PIs is low in people who are incontinent of urine and stool or who sweat excessively. F 53 (100) — 51 (96.2) 2 (3.8) 2.038 .153 11 Most PIs occur within 24 to 48 h of inactivity. T 53 (100) — 44 (83) 9 (17) 9.835 .002 12 Hospital-acquired PIs usually develop within the first 2 wk after hospitalization. T 49 (92.5) 4 (7.5) 44 (83) 9 (17) 2.192 .139 13 Diseases that affect blood and oxygen transport to tissues and limit movement play a role in the development of PIs. T 53 (100) — 52 (98.1) 1 (1.9) 1.010 .315 14 PIs develop more rapidly and tissue healing is delayed in patients with malnutrition. T 53 (100) — 50 (84.3) 3 (5.7) 3.087 .079 Protection and treatment 15 All patients should be evaluated for the risk of PI development. T 46 (86.8) 7 (13.2) 33 (62.3) 20 (37.7) 8.398 .004 16 Risk assessment scales are used to assess the risk of PI formation. T 53 (100) — 52 (98.1) 1 (1.9) 1.010 .315 17 The nutrition status of patients at risk of developing PIs is evaluated, and appropriate nutrition is provided. T 53 (100) — 48 (90.6) 5 (9.4) 5.248 .022 18 Pain should be evaluated in patients with PIs and pain management applied. T 44 (83) 9 (17) 43 (81.1) 10 (18.9) 1.011 .603 19 A sliding sheet, sliding board, or lifting method should be used to change the patient’s position. F 52 (98.1) 1 (1.9) 48 (90.6) 5 (9.4) 2.827 .093 20 The safety, mobility, and comfort of the patient while lying and sitting should be ensured. T 53 (100) — 53 (100) — 21 Every 4 h, the patient should be positioned on his/her side at a 90° angle F 39 (73.6) 14 (26.4) 26 (49.1) 27 (50.9) 6.722 .010 22 If the patient has developed a PI, measures should be taken to prevent new wounds. T 53 (100) — 53 (100) — 23 PI prevention interventions and treatment should be recorded. T 52 (98.1) 1 (1.9) 51 (96.2) 2 (3.8) 0.343 .558 24 If there is a rash on the skin, a moisturizing cream should be used. F 34 (64.2) 19 (35.8) 21 (39.6) 32 (60.4) 6.386 .011 25 The skin should be kept clean and dry. T 53 (100) — 53 (100) — 26 To prevent dryness on the skin, the skin should be moistened with wet cotton. F 34 (64.2) 19 (35.8) 28 (52.8) 25 (47.2) 1.399 .237 27 Patients with malnutrition should be evaluated, supported, and protected. T 53 (100) — 53 (100) — 28 If the patient’s health condition is serious, he or she should not be repositioned in bed. F 52 (98.1) 1 (1.9) 47 (88.7) 6 (11.3) 3.824 .051 29 Excessive moisture formation from incontinence, sweating, and wound drainage should be prevented. T 50 (94.3) 3 (5.7) 46 (86.8) 7 (13.2) 1.767 .184 30 Nurses and caregivers are educated about PIs and prevention methods. T 53 (100) — 53 (100) —

Abbreviations: F, false; PI, pressure injury; T, true.

All of the students in both groups gave correct responses to three items in the general information section (questions 1, 2, and 9) and to five items in the prevention and treatment section (questions 20, 22, 25, 27, and 30; Table 2).

In the experimental group, the item with the lowest correct response rate was “If there is a rash on the skin, a moisturizing cream should be used” (64.2%). In the control group, the item with the lowest correct response rate was “The patient should be positioned on his/her side at a 90-degree angle every 4 hours” (49.1%).

DISCUSSION

In the present study, students’ overall correct response rate on the PI questionnaire differed significantly between the experimental group (97.55%) and the control group (85.15%). Students in the experimental group could access the PI education material for 7 days following the classroom lecture, without limitations on time or place; this access increased the knowledge level of the web-based education group.

Previous research investigating the PI knowledge levels of nursing students using the Pressure Ulcer Knowledge Assessment Tool demonstrated low knowledge levels: 29%,25 61%,26 and 51%.27 In these studies, participants’ scores on the “protection from pressure injuries” item were relatively low.25–27

In the present study, the rate of the correct responses given to the questions in the prevention and treatment section by the students was 91.3% in the experimental group and 83.5% in the control group. In previous studies of PI classification, approximately 30% of participants could not distinguish a stage 1 PI.9,27,28 In contrast, in the present study, the correct response rates for questions about PI stages were 92.5% in the experimental group and 56.6% in the control group. Further, in the study by Simonetti et al,27 only 20% of the participants stated the importance of checking skin integrity and observing a patient at risk, and 52% stated the importance of repositioning of the patient. Similarly, only 31% of participants in the study by Usher et al29 stated the importance of repositioning. However, in the present study, all students in both the experimental group and the control group stated the importance of ensuring the safety, mobility, and comfort of the patient in bed and while seated in a chair and the importance of keeping the skin clean and dry.

The present finding that the experimental group scored more highly on the PI knowledge test than the control group supports the previous literature on web-based education. Bredesen et al14 reported that students participating in an e-learning program for PI classifications achieved more successful results than did the students receiving classroom instruction. Beeckman et al10 also obtained more successful results with the e-learning method. Tschannen et al28 stated that the combination of education in the clinical setting, face-to-face education, and e-learning improved participants’ knowledge level of PIs. Studies have indicated that watching digital media before attending the related lesson, practicing more in the classroom and laboratory, and being supported visually are all important measures for drawing students’ attention.21,22,29 These results indicate that increased use of e-learning methods could help overcome deficiencies in PI education in nursing undergraduate programs.21,22,29–33

Limitations

The present study included only the students of the Faculty of Health Sciences Nursing Department in a single province in Turkey. Therefore, the results cannot be generalized. Further, the authors have data only on the number of logins to the web-based education and cannot tell if every student logged in; individual students may have logged in several times and others not at all.

CONCLUSIONS

Providing web-supported education to nursing students in addition to teaching through conventional education methods positively contributed to the students’ learning. As a result, the authors recommend that laboratories, simulations, clinical teaching, and e-learning applications all be included in undergraduate nursing programs in addition to theoretical courses. Nurses with inadequate knowledge of PI prevention may increase the incidence of PIs. By adding an e-learning component to nursing education and in-service training programs, students will gain more knowledge about PIs. Future research on the effects of e-learning should include different sample groups, use different e-learning methods, and test participants’ knowledge level using valid and reliable measurement tools.

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