Patient education materials on pressure injury prevention in hospitals and health services in Victoria, Australia: Availability and content analysis

Abstract

Pressure injuries (PIs) are a common quality indicator for hospital care, and preventing PIs often requires patient engagement; as such, Australian consensus research has recommended that high‐quality education materials be made to patients for PIs via hospital networks. The purpose of the present study was to assess the availability and accuracy of patient education materials on PIs in publicly available hospital websites in Victoria, Australia. Two independent coders assessed 212 websites for content on PI prevention and management, analysing availability and accuracy of PI definitions, risk factors, preventive strategies, referral, visual tools, consumer endorsement, information for family/carers, and translation on community languages. A greater proportion of hospitals did not have any patient education materials on PI prevention publicly available, with private hospitals (compared with public) and metropolitan hospitals (compared to rural) more likely to have materials available on their sites. The available materials contained accurate messages on PI defining characteristics and risk factors for PIs, although there was considerable variability on the availability of other information. Our findings suggest a significant deficit in the availability of educational materials for acute care patients and their families. There is a need for evidence‐based, consumer‐endorsed, uniform materials on all hospital websites to prevent PIs in acute care.

1. INTRODUCTION

1.1. Pressure injury as a public health issue

Pressure injury (PI), also known as a pressure ulcer, was defined as “a localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear,”1 ^(p12). PI imposes a significant economic and social burden to Australia2 and globally.3, 4, 5, 6 The National Pressure Ulcer Advisory Panel, the European Pressure Advisory Panel, and the Pan Pacific Pressure Injury Alliance1 categorise PIs into six clinical stages (ranging from superficial to deep tissue injuries, including suspected deep tissue injury and unstageable PI); and acknowledge the increase of the negative health impacts with the depth of the PI. One of the most common forms of PI are hospital acquired pressure injuries (HAPIs), defined as an area of damage to the skin/underlying tissue that develops during an inpatient hospital stay.7 From 2015 to 2016, the approximate rate of HAPIs in Australia totalled 9.7 injuries per 10 000 hospitalisations.8 The Australian Commission on Safety and Quality in Healthcare9 has identified HAPIs as a serious and preventable hospital‐acquired complication. Prevention and management of HAPIs is addressed in the Australian National Safety and Quality Health Service Standards.9

Australia has a universal health care system whereby health care is delivered, operated, and funded by federal and state governments as well as by the private sector and not‐for‐profit organisations. A minimum standard of care is available to all Australians through a Medicare scheme funded through an income tax levy.10 The state of Victoria, where this study was conducted, is Australia's second‐most populous state with a population of almost 6.5 million. It is home to one of the most culturally diverse societies in the world with almost 30% of Victorians born overseas in over 200 countries and a quarter speaking a language other than English at home.11

PIs are costly, with prolonged hospital stays and the complex care required for healing accounting for a large proportion of the cost burden.12 The estimated annual treatment cost of PIs across Australia is above $983 million, approximately 1.9% of all public health expenditure.12 In addition to health care‐related costs, PIs have a considerable impact on individuals, including pain,13, 14 odour of exudate, higher susceptibility to infection and poorer health outcomes,15 and reduced quality of life.16 The incidence of PIs is considered an indicator of overall health service quality.17, 18, 19, 20

Effective prevention of PIs involves the implementation of PI risk assessment tools, procedures for alleviating pressure on areas that are at risk of tissue breakdown, regular repositioning, appropriate skin care, and optimal nutrition and hydration.1 Although most PIs in the general population are considered preventable when correct prevention strategies are implemented,21 PIs in palliative care patients may be unavoidable as a result of skin failure.22 PI is a common hospital‐acquired complication in the Western world2, 23, 24, 25 and has been linked to poor adherence to prevention strategies across clinical settings.26, 27 Although there are various barriers to clinical practice guideline implementation, Australian28 and international studies29, 30, 31 have reported that nurses' knowledge of PI prevention strategies is often inadequate. On this point, research suggests that nurses generally tend to underestimate the risk of PIs and underutilise PI preventive strategies when compared with nurses with experience in managing PIs.26

1.2. Patient engagement in PI prevention

An area that has not been fully explored, however, is the role of the patients in optimising the management and prevention of PIs.32 Two Australian studies32, 33 reported patient's preference for taking a proactive role in PI prevention and the need for ongoing PI education and dialogue with nurses about PI prevention. In general, improved health literacy enables patients to feel included in their health plan and gives autonomy over their health.34 Patients' improved health literacy has been shown to improve self‐management, encourage adherence to treatment, promote wound healing, and prevent illness in certain target groups.35, 36 Additionally, establishing effective partnerships between practitioners and health care consumers is accepted as an effective means of improving patient‐centred care.37 The role of education tools is an important consideration in efforts to improve health literacy. Educating and involving patients in prevention and management of PIs has been identified as being important in clinical settings in Australia,33, 38, 39 the United Kingdom,40 the United States,41, 42 and other countries.43, 44

In Australia, the content and frequency of consumer education for sustained knowledge and best practices in prevention and management of PIs were included in a list of priority issues45 with patients themselves expressing the need for ongoing education on PI prevention.33 Despite this, there is a dearth of research on patient education on prevention and management of PI. The results of a small number of completed studies show improved treatment outcomes from patient education.46, 47, 48, 49 Conversely, a systematic review found no conclusive evidence that educating patients with spinal injury is an effective preventative measure of PI in this patient group.50 However, this review examined community‐based people with spinal injuries, which may not be applicable to acute inpatient settings where a care bundle partnership between clinicians and patients may be more achievable. A recent systematic review51 reported that complex intervention programmes that included an element of education were more effective in decreasing occurrence of HAPIs than single interventions.

There is a gap in the literature surrounding the potential benefits of improving patient understanding of PI,52 and even fewer strategies for information dissemination. Furthermore, no studies to date have examined the availability and accuracy of PI educational materials for improving patient awareness and involvement in prevention and management of PIs. The aim of the study was to assess the availability of online patient education materials on PI prevention in hospitals and health services in Victoria, Australia, and conduct a content analysis of the identified sources on accuracy of the included messages.

2. METHODS

2.1. Study design and methods

We conducted availability analysis of PI educational materials located on the web pages of health services and hospitals in Victoria, Australia. We then explored the relationship between the availability of PI materials and a range of factors including the funding status of the hospital (private versus public) and location (metropolitan vs rural) using two separate chi‐square tests. We also conducted a qualitative content analysis to evaluate the accuracy of information about PI prevention and management. This method is increasingly used in nursing and health promotion to analyse the content of patient education materials in various health fields.53, 54

2.2. Search strategy

A list of Melbourne Metropolitan public hospitals and health services (https://www.healthcollect.vic.gov.au/HospitalLists/MetroHospitalList.aspx), rural public hospitals and health services in Victoria (https://www2.health.vic.gov.au/hospitals-and-health-services/public-hospitals-victoria), and private hospitals (https://www2.health.vic.gov.au/about/publications/policiesandguidelines/private-hospitals-list) was accessed through the Victoria Government Department of Health website. We then accessed the website of each organisation and searched for information on PIs using the search terms “pressure ulcer,” “pressure injury,” “pressure injuries,” “bedsores,” and “bed sores.” Additionally, we searched other sources including web pages with patient and health education information and educational resources for information on PIs. Primarily, we searched the websites manually, typing the key words in the search box of the hospital/health service website. We also searched through website directory trees and used Google cache searches and Boolean search operators through directories of the site itself.

2.3. Inclusion and exclusion criteria

Information on PIs available on the hospital and health services' websites, including pamphlets, booklets, leaflets, and online information, was included in the analysis. We included all available information on PI prevention and management, including booklets developed by hospitals for admitted patients on admission. Information on PIs for health professionals and information presented as part of hospital reports and educational courses on PI for health professionals was excluded.

2.4. Data analysis and synthesis

2.4.1. Availability analysis

For the purpose of analysis, we considered each hospital individually, rather than considering their health networks. This was because some hospitals provided information for their hospital's services with PIs in their hospitals' sections of their health network's site, but not in others, and a patient would ostensibly first look to the hospital's own site, rather than a health network's site. We assessed availability by checking if the site presented either the information on PIs for patients or if they had information on where a patient could get information directly from the hospital (e.g., we have a brochure available here via request).

To assess the comparative likelihood of having PI materials on their sites, a chi‐square test was chosen. We chose to compare the likelihood of having materials between hospital funding status (private versus public) and between proximity to metropolitan centres (metropolitan versus rural based) as two separate chi‐square tests.

2.4.2. Content analysis

The first author (VT) conducted a pilot round of coding of the non‐randomly selected three educational materials and developed the analytical framework. The developed framework and the materials were shared with other co‐authors, who reviewed, made final adjustments, and approved this framework. Two authors (AB and VT) independently analysed all included materials using the developed analytical framework.

The available materials were coded for (a) availability and accuracy of general information on PIs, including PI explanation or definition, classification/stages of PIs, pressure points, PI risks, and first signs of PI; (b) availability and accuracy of information on preventive strategies, including limiting pressure, reducing friction, skin care, repositioning, early mobilisation, the use of pressure relieving equipment, and nutrition and hydration; (c) availability of messages on PI management; (d) availability of messages on collaboration with health professionals; (e) availability of information for family and carers; (f) availability of visual tools, including images of PIs, images of pressure‐relieving equipment, and figures on pressure points; (g) availability of information on community languages and/or referral to translation and interpretation services; and (h) information on consumers' endorsement of health education material.

Availability of information was coded as either available or not available. The accuracy of health information messages on PI prevention and management was assessed in relation to the clinical practice guideline1 recommendations. Information was synthesised and presented in separate tables according to the main themes as described in the analytical framework. The unit of qualitative content analysis was defined as a message unit, for example, written (in pamphlets, booklets) or verbal (in a video clip) messages related to repositioning, skin care, and nutrition.

2.5. Ethical considerations

We analysed pressure injury prevention materials that were publicly available on hospital websites; and, therefore, the study did not require ethics approval. The details of health services and individual public and private hospitals were de‐identified and replaced with the numbers. No individual or group data and licensed medical images were used in this study.

3. RESULTS

We assessed 212 hospitals for the availability of online patient educational materials on PI prevention and management. Most hospitals were part of a health service network, often sharing the same website. In total, we have assessed 129 public hospitals, of which 72 were rural and 57 metropolitan. Seventy‐six hospitals were independent, with the remaining hospitals part of the 15 health service networks (n = 53). There were 81 websites within the public hospital system due to the sharing of websites by some public hospitals within a health service network.

Furthermore, we assessed 83 private hospitals: 20 rural and 63 metropolitan. There were 46 private hospital websites in total due to sharing of online pages. Of these private hospitals, there were 11 health service networks (containing 65 hospitals), with the remaining 18 appearing to be independent.

3.1. Availability of any information on PIs

In total, our search yielded 23 sources of PI patient education materials, including brochures, leaflets, static websites (where information was displayed on a single webpage), pamphlets, and a video clip (Table 1). Figure 1 shows the availability of patient education materials in relation to hospital funding and location. The results show more than half of the hospital websites accessed (66.5%) did not contain any information for patients on prevention and management of PIs, indicating that only 71 of the 212 hospitals (34.5%) had these materials. Private hospitals were more likely to have patient information about PIs on their website (45 out of 83) than public hospitals (26 out of 103). A chi‐square test showed that there was a statistically significant association between the hospital type and the likelihood of having PI material on their website, χ ² (1) = 26.31, P < .001. Similarly, metropolitan hospitals were more likely to have PI materials on their websites (57 of 120) compared to rural hospitals (14 of 92), and the association between the location type and PI educational material availability was statistically significant χ ² (1) = 24.37, P < .001.

Table 1.

Content analysis of patient education materials on pressure injury prevention in hospitals and health services in Victoria, Australia (N = 23)

Characteristic	Number	Percentage (%)
Formata
Leaflet (single page/front back)	1	4.3
Pamphlet	4	17.4
Booklet (several pages)	8	34.8
Online (including videos)	10	43.5
General information on pressure injuries	23	100.0
Explanation/definition	23	100.0
Classification of stages	5	21.7
Information on pressure points	8	34.8
Risks	23	100.0
First signs	5	21.7
Preventive strategies	23	100.0
Limiting pressure	14	60.9
Reducing friction	12	52.2
Skin care	17	73.9
Repositioning	6	26.1
Early mobilisation and staying active	6	26.1
Using of pressure relieving equipment	11	47.8
Nutrition and hydration	14	60.9
Availability of visual materials	21	91.3
Pressure injury images	3	13.0
Figures with pressure points	8	34.8
Images of pressure relieving equipment	4	17.4
Collaboration with health professionals	6	26.1
Information for family and carers	4	17.4
Endorsement by community group	3	13.0
Information on community languages	2	8.7
Referral to interpreting services	2	8.7

^aWhen same information provided in two modes (eg, online and booklet) was counted as most accessible type to patient (ie, fewest clicks).

Figure 1.

Availability of patient education materials on pressure injury prevention in hospitals and health services in Victoria, Australia. N=212 websites

3.2. Availability and accuracy of PI definition and explanation of stages and risks

All 23 sources provided a PI definition and the key risk factors were outlined. However, very few (n = 5) sources discussed different stages of PIs or provided a classification. The included information was accurate, reflecting the information in the clinical practice guidelines on PI prevention and management.1

3.3. Information on prevention of PIs

All materials included strategies to prevent PI. The most common preventive strategies discussed in the educational materials included instructions on skin care (n = 17), limiting pressure (n = 14), ensuring proper nutrition and hydration (n = 14), reducing friction (n = 12), and the use of pressure relieving equipment (n = 11). Few sources (n = 6) discussed early mobilisation and staying active as PI preventive strategies.

3.4. Information on PI management

Most materials did not include messages on PI management, with only one source presenting information on how to manage a PI, if it were to occur; suggested dressings and elevation indirectly through a video showing a person with a PI.

3.5. Collaboration with health professionals

Six out of 23 educational materials were developed in collaboration with health professionals; and 15 sources encouraged patients to speak to a health professional if uncertain.

3.6. Referral to other online resources

Furthermore, 18 of the 23 materials provided some form of referral to other sources. The most common referral was to the Australian Commission on Safety and Quality in Healthcare; however, this was most commonly discussed as a quality indicator rather than referral for patient information.

3.7. Availability of visual tools

Out of 23 materials, 21 included an image. The most common image was an image of pressure points (n = 8). Three showed at least one image of a PI. Pressure relieving equipment images were much less common, appearing on only four of the assessed materials.

3.8. Consumer endorsement, information for family/carers, and information on community languages

Three sources of educational materials presented evidence to show endorsement by a consumer group. Four sources either provided information in another community language, including Chinese, Arabic, Greek, Italian, Vietnamese, Spanish, and Somali, or referred to a translation service. Four educational sources presented information on PIs targeted specifically for families or carers.

4. DISCUSSION

4.1. Study contribution

Our study aimed to assess the availability and accuracy of online educational materials on PI prevention and management available to patients and their families on hospital websites. Our findings suggest that more than half of the hospitals lack educational materials designed for patients to prevent and manage PIs. In the available patient education resources, the information on PIs, including the main strategies for PI prevention, was accurate and reflect the clinical practice guidelines on prevention and management of PIs.1

Our assessment of the content of materials found that while the information provided was generally accurate there were significant omissions. Ideally, PI materials should contain definitions, classifications, explanations, risks, and signs of PIs to aid early prevention, detection, and treatment. While all identified educational materials contained some form of definition or explanation and included preventative strategies, which were accurate, many lacked other basic information, such as messages encouraging collaboration with health professionals, information for carers, and visual tools. Furthermore, few presented information on community/consumer endorsement or the availability of this information in other community languages.

Appropriate health resources for patients in an online environment and patient education and involvement in PI prevention as part of care bundle may help reducing the incidence of PI,47 although current data suggest hospital websites are lacking uniform consumer‐endorsed materials on this preventable complication. The lack of accessible educational materials for patients may, therefore, contribute to the lack of knowledge, which is a known barrier to active decision‐making and participation in a patient‐centred model of care in addition to the power imbalance in the patient‐professional relationship.55

In general, publications on availability and content of patient education materials on PI prevention are scant. To date, only one study conducted in the United States has assessed the readability and design of patient education materials on PI prevention.56 In Sweden, researchers evaluated patients' knowledge of PI prevention and their participation in care after exposure to information included in the pamphlet on PI prevention.43 To our knowledge, no studies on the topic have been conducted in Australia. Findings of our study have contributed to the scant literature on availability and content of patient education materials designed to prevent and manage PI.

4.2. Digital information, knowledge translation, and consumer involvement in care

The results from this study suggest a significant gap in translating PI prevention and management knowledge in pursuit of successful shared decision‐making in a modern acute care setting. Defined as “ensuring that stakeholders are aware of and use research evidence to inform their health and healthcare decision making,”57 ^{(p e2)} knowledge translation requires considering patients and their families as major stakeholders. Therefore, research knowledge infrastructures developed by health care systems should address the needs of all stakeholders, including health professionals, policy makers, and patients.57 Clinical practice guidelines1 contain the latest evidence‐based knowledge on PI prevention and management, but this is seldom translated to patients in a clear way, nor is it based on a reciprocal exchange of information. Patient and public empowerment and self‐management provide critical support to the clinical practice guideline implementation in clinical practice in contrast to simple strategy of guideline dissemination.58

To address the gap in knowledge translation, a concentrated effort at every level is needed. The key elements of successful shared decision‐making interventions include the following: developing an organisational culture open to this approach and health professional skilled in the shared decision‐making conversations, using patient decision aids that provide information and facilitate engagement, and providing infrastructure and resources that support implementation of shared decision‐making in practice.59 Health services that plan to integrate shared decision‐making into routine clinical practice face various challenges.59 One such challenge is health professionals' perception of their role as health educators is not important/needed.60 For example, findings from relatively recent Australian study revealed nurses tend not to engage patients as partners in PI preventive practices.32 This lack of engagement may depend on health professionals' perception of their professional role as health educators and patient education.60

Given that patient safety is a shared responsibility, it is important that both parties be involved.61 The degree of patient involvement may vary and will depend on many factors, including the type of illness or trauma, comorbidities, life‐stage transition (eg, end‐of‐life), cultural aspects of care, personal preferences, and patient's knowledge.62 Poor health literacy is a further barrier to active patient participation and shared decision‐making.63 Patients' exposure to educational materials may improve their knowledge and increase their participation in prevention of PIs.43 Digital information seeking has been shown to be associated with improved patient professional communication64 and patient health outcomes.65, 66 However, this is dependent on the availability and accuracy of health information on the health service's website.

4.3. Study limitations and precautions

This study has several limitations. The first relates to how hospitals deliver health information upon admission. For example, some hospitals may provide patients and their families an authorised log in to their internal web page with the specially designed custom materials available to inpatients. Because we only searched publicly available information, we cannot exclude this possibility. We also cannot exclude the possibility that patients are given links to other reputable organisations upon admission, as a key assumption here is that patients would look to their hospital first (rather than other health information sources). However, patients would be encouraged to look at their own health service overall, as different hospitals would, for example, have different pressure relieving equipment available and, therefore, the information and materials may be customised to that health service.

5. CONCLUSION AND SUGGESTIONS FOR POLICY, PRACTICE, AND RESEARCH

PIs present a substantial economic burden for the health care sector5 and reduce health‐related quality of life of patients.13, 16 Prevention of PIs is a cost‐effective approach for reducing HAPIs and improving patient outcomes.67 Prevention relies on patient engagement in care,32 which relies on their knowledge of PI risks and preventive strategies.33 This research suggests there is a deficit of uniform, high quality, patient education materials on prevention and management of PIs on hospital websites in Victoria, Australia. In the context of a patient‐centred model that requires self‐care,33 this lack of information likely translates to suboptimal outcomes, including higher rates of PIs and longer hospital stay. There is a need for evidence‐based consumer‐endorsed uniform materials on PI prevention and management to be available on all hospital websites. In Table 2, we provided a list of suggestions on how to improve the content and availability of PI educational materials and proposed further research in this field.

Table 2.

Patient education materials on pressure injury prevention in hospitals and health services in Victoria, Australia: Suggestions for quality improvement, dissemination, and research

Field of improvement	Suggestions for quality improvement, dissemination, and research
Content	More information on staying active and early mobilisation could be provided, along with more information on pressure relieving equipment
Design	More visual aids could be utilised, including images of various stages of pressure injuries, images of pressure points, and images of pressure relieving equipment
Recency of information	Content in health education materials should be regularly updated in line with the current guidelines and latest evidence and the date The links to other sources could be more regularly checked and updated if necessary
Endorsement by consumers group	Provide information on endorsement by community groups, if already enacted, or seek endorsement from a community group to ensure material suitability
Availability on community languages and referral to interpreting services	More information on translating services, and increasing the availability of materials in other community languages could be provided without having to request the information
Dissemination	Available materials should be more widely disseminated and available of hospital websites, subject to copyright permission A central repository of health education materials on pressure injury prevention and management on Wounds Australia website could be considered
Research	Research on readability of the available educational materials on pressure injuries Research on awareness and use of pressure injury education materials by consumers Research on awareness and use of pressure injury education materials by health professionals

Future studies on patients' awareness and the use of PI education information, as well as health professional awareness of PI health education materials would provide additional information on the topic. It would be useful if future research also focused on assessment of readability of the educational materials on PI prevention and management that patients are provided in care and consumer involvement in the production and dissemination of these materials. Findings from these research projects will provide directions for health promotion agencies and hospitals to improve the quality of patient‐centred care of the current health care model.

Finally, our findings confirm that there is a need for new approach to PI management, requiring a national reform in the wound care sector in Australia39 and other countries.68 Health care reform that aims to change a “resistant biomedical health service culture” to “a universal person and health literacy centred model of service delivery”69 ^{(p e2)} may also seek to change health professionals' perceptions of their roles in educating patients, using evidence‐based consumer‐endorsed uniform educational materials.

CONFLICT OF INTEREST

The authors declare no potential conflict of interest.

Team V, Bouguettaya A, Richards C, et al. Patient education materials on pressure injury prevention in hospitals and health services in Victoria, Australia: Availability and content analysis. Int Wound J. 2020;17:370–379. 10.1111/iwj.13281