Education and process change to improve skin health in a residential aged care facility

Abstract

We report on an intervention and evaluation in relation to changes in staff knowledge, time spent on healing and wound prevention and proportion of wounds in the facilities before and after. A rapid review of recent peer‐reviewed literature (2006–2016) found 14 education‐based intervention articles and provided the background and context for this intervention. A cohort of 164 nurses and personal care workers and 261 residents at two aged care‐approved facilities contributed to this intervention on the effect of education, mentoring and practice change on staff knowledge and wound prevalence between 2015 and 2016. There was a significant decrease in pressure injury prevalence and an increase in the early identification of potential wounds between phase 1 and 3 across the two facilities. Overall, registered nurses and enrolled nurses showed significant increase in mean knowledge scores. There was a reorganisation of time spent on various wound care and prevention strategies that better represented education and knowledge. Wound management or prevention education alone is not enough; this study, using an educational intervention in conjunction with resident engagement, practice change, mentorship, onsite champions for healthy skin and product choice suggestions, supported by an organisation that focuses on a healthy ageing approach, showed improvement across two residential sites.

Introduction

In Australia alone, it is estimated that more than 433 000 people suffer from chronic wounds such as leg ulcers, pressure injuries or non‐healing surgical wounds at any one time (1). The financial and personal costs associated with chronic wound management are argued to pose a significant burden to Australia's health care system 2. It is conservatively estimated that the incidence of chronic wounds cost the Australian health care system more than $2·85 billion a year, equating to almost 2% of the Australian national health care budget 1. These figures exist in the face of Standard 8 of the National Safety and Quality Health Service (NSQHS) Standards developed by the Australian Commission for Safety and Quality in Health Care 3. The NSQHS Standard 8 aims to prevent people admitted to hospitals developing preventable wounds and effectively managing a wound when they do occur. The standard is relevant to all clinical settings, including residential aged care facilities (RACF) 3.

Ensuring appropriate evidenced‐based decision making around wound prevention and healthy wound healing for people living in RACF is a critical indicator of quality service and resident satisfaction 4. The premise underpinning the evaluation of an education intervention reported in this article was an acknowledgement that enabling residents and staff to make better decisions around wound prevention or healthy wound healing requires a focus on how and why people make decisions, how any situation is assessed and what course of action may be taken.

The education intervention was implemented by experts from the Wound Management Innovation CRC in conjunction with the University of South Australia, School of Nursing & Midwifery and the Executive, Southern Cross Care SA&NT (SCC) – a large aged care‐approved provider with multiple facilities. The aim was to enable targeted RACF staff to ensure a systematic healthy healing and wound prevention approach for residents to improve resident outcomes 5.

This study reports on the specifics of the education intervention and findings of the evaluation in relation to resultant changes in staff knowledge and time spent on healthy healing and wound prevention and on the proportion of wounds in the RACF before and after the education intervention. To begin, findings from a rapid review of peer‐reviewed literature on wound care, wound prevention or skin management education interventions in RACF published in the last 10 years are presented to provide context to the elements of the educational intervention implemented.

Rapid review of published research articles

Methods

The purpose of this rapid review was to provide a synthesis of peer‐reviewed primary research studies on wound care, wound prevention or skin management education interventions for staff and/or residents for the treatment or prevention of chronic wounds of residents living in RACF. The search strategy is available in Appendix. This rapid review was based on the PICO framework (Population, Intervention, Comparison and Outcome): the Population of interest were staff and residents in RACF; Intervention was education or training that aims to treat chronic wounds or prevent wound occurrence in residents of RACF; any type of Comparison groups or interventions were included. Outcomes included but were not limited to staff/resident wound care, wound prevention or healthy skin care knowledge; prevalence of wounds; economics; and choice and control to residents. This review was restricted to English language peer‐reviewed primary research studies published in the last 10 years (2006–August 2016).

Results

The search found 14 articles discussing 13 studies relevant to education interventions in RACF, which were assessed for quality by a single author (K.K.) using the Critical Appraisal Skills Programme (CASP) critical appraisal tool appropriate to the study design. One included article scored low 6, three scored moderately 7, 8, 9, and the others all scored high on the range of CASP tools 10, 11, 12, 13, 14, 15, 16, 17, 18, 19. While there was a plethora of published research articles investigating prevalence rates of skin tears and PIs, all but one of the articles found 6 focused exclusively on pressure injury education and/or practice change for pressure injury prevention.

Two articles implemented an intervention based on an educational programme only 7, 11. Brownhill 7 worked in conjunction with community matrons to deliver training to personal care staff without formal qualifications to increase knowledge of prevention and care for falls, continence promotion and pressure injuries. The pressure injury prevention education reduced stage 2 pressure injuries by 63% and stages 3 and 4 pressure injuries by 88%. Interestingly, they focussed on stage 2 pressure injuries and higher, a stage at which it is too late for prevention activities. There was no education around identifying stage 1 or early indicators of pressure injuries. Keen and Gaudario 11 used the SKIN bundle (Surface/skin inspection; Keep moving; Incontinence; Nutrition). They found an increase in staff knowledge, an increase in communication between health care support staff and nurses regarding resident well‐being and an unanticipated improvement in documentation related to pressure injury prevention. Even though they did not intend to implement practice change, this occurred naturally as a by‐product of the increase in staff knowledge and communication.

Three studies implemented an educational intervention with a specific set of wound care and management products, supplied by the company funding the research 6, 9, 13. All three studies provided education covering basic anatomy, wound assessment and documentation and product choice for either skin tears 6 or pressure damage 6, 9, 13. This was supported by tailored wound care product packages (supplied by the product company), which aimed to reduce the multiple options for each wound treatment/dressing type to a selected few in order to reduce confusion over dressing use and ensure continuity of care between shifts and staff. Baines and McGuiness 6 found a more standardised approach to wound product usage after the intervention; however, they had no result with regards to knowledge change as no health staff participated in the follow‐up of the education and wound care package intervention. Large 9 audited pressure injury care pre‐ and post‐intervention, with a focus on stage 1 pressure injuries. The intervention resulted in a drop in pressure injury incidence rate from 14% to 1·3%. Norris et al. 13 found that the combination of education in risk assessment and early detection of pressure injuries, with easier access to skin care products tailored to each person, reduced incidence of pressure injuries and overall facility costs.

A further nine articles, discussing eight studies, investigated multi‐faceted interventions with a protocol or practice change in addition to wound prevention education 8, 10, 12, 14, 15, 16, 17, 18, 19.

Two of these studies introduced electronic support systems; Beeckman et al.8 combined education on pressure injury assessment and risk factors with a computerised clinical decision support system and found significant improvement in health care professional's attitudes and pressure injury prevention for seated residents in the intervention group but no difference in health professional pressure injury knowledge. Santamaria et al. 14 investigated the introduction of a pressure injury prediction and prevention system on pressure injury prevalence in 23 RACF with residents with high care needs in Australia. They introduced tools, risk assessments, practice guidelines and a new monitoring database in addition to pressure injury education. They found a significant increase in the number of residents with appropriate pressure injury prevention equipment (from 39% to 63%) and a decrease of 10% in pressure injury prevalence.

Kwong et al. 12 focussed on educating non‐licensed care staff to reduce the incidence of pressure injuries in a RACF and the implementation of a skin care protocol designed to ensure standard care across the facility, tailored to skill levels and care roles of the participant groups (registered and enrolled nurses and non‐regulated care workers). They found improvement in the early identification of pressure injuries (stage 1) by the care workers, an increase in knowledge of all participants and a decrease in pressure injury prevalence rates. Stern et al. 16 used mixed methods to test the economic value and clinical impact of enhanced multidisciplinary teams for pressure injury treatment. This was the most involved educational intervention described in the studies found in this search. A 3‐month education intervention involved the assessment of wounds, digital wound photography, completion of standardised assessment and treatment forms and liaising with an expert team following a referral rubric developed specifically for the study. This was followed by 11 months of remote support via email and telephone contact. No statistically significant changes in pressure injury treatment outcomes between pre‐ and post‐measurements were found.

Four of these studies developed or implemented bundles (education and process change with supporting tools and/or frameworks). A successful case study of education and practice change using an existing framework, supported by evidence‐based resources available on the developer's website, reduced pressure injuries by 19% and increased staff morale 10. Shannon et al. 15 introduced a Pressure Ulcer Prevention Program involving a formal face‐to‐face education approach with a product bundle and a decision‐making algorithm to prevent facility‐acquired pressure injuries. They found a decrease in pressure injuries of 67% over 6 months when compared to the control group. Thompson and Marks‐Maran 17 effected an educational strategy in conjunction with process change. They educated RACF staff, provided resources and developed documentation methods for reporting pressure injuries. They also implemented a Root Cause Analysis procedure to assess all facility‐acquired pressure injuries, allowing staff and carers to learn from previous mistakes. They found a reduction in pressure injuries, resulting in management making the training mandatory across the RACF. Finally, Van Gaal et al. 18, 19 trialled a programme specifically developed to reduce the incidence of three adverse events: falls, pressure injuries and incontinence. The ‘SAFE or SORRY?’ Program involved support and group education sessions on the intervention units, educational materials supplied via CD‐ROM and knowledge tests with feedback in the intervention groups. This was one of the only interventions found to include resident and carer education as part of the multi‐factorial approach. Nurses gave oral education and pamphlets relevant to each resident's risk factors. This study also did not consider pressure injuries until they were stage 2 or above.

In addition to the peer‐reviewed published literature found in the review, a study based in Queensland Australia 20 also informed the development of the intervention carried out in this study. They found that a Champions for Skin Integrity model, in addition to an evidence‐based resource tool kit made available to the RACF, resulted in increases in staff awareness of evidence‐based wound care, changes to wound management and prevention strategies and practices and decreases in the prevalence and severity of wounds. Edwards et al. 20 concluded that resources need to be brief, simple, tailored to the specific population group (resident, care workers or nurses) and easily accessible.

While varying designs were encountered in the review, the most common element was face‐to‐face education on basic skin anatomy, pressure injury identification and pressure injury prevention techniques. The more successful interventions appeared to be the combined knowledge and practice change interventions. Models that use pictorial reminders and handouts, staff education targeted to the workers training and care roles and models that included a specific/tailored product and/or guideline on usage were the most effective interventions. These last options cut costs of having multiple redundancies in skin care products, as well as standardising treatment across the facility.

The education intervention

Methods

The study consisted of four phases and was conducted in two sites of a large aged care‐approved provider located in metropolitan South Australia. Employees from two RACF involved in this project were invited to participate and included Registered Nurses (RNs), Enrolled Nurses (ENs) and personal care workers (PCWs). All participants were volunteers, and informed written consent was obtained from each before proceeding. Residents were informed of the study through a personal letter and a newsletter item. Participants (N = 164) were sub‐divided into two groups. Group 1 were the Healthy Healing Wound Prevention Champions: 12 RNs who volunteered to spearhead the project at their sites and who conducted the Wound Prevalence Surveys. Although they took on leadership roles in their locations, these RNs were included in all data collection as participants. Comprising group 2 were RNs (n = 25, including the 12 Champions), ENs (n = 41) and PCWs (n = 98) in a variety of service roles at the two RACF.

Phase 1, conducted in 2015, provided the baseline data and was a descriptive account of everyday activities collated through a Wound Prevalence Survey developed for this project. This was implemented by Group 1 with supervision from the Nurse Practitioner (NP) and Wound Healing Institute Australia (WHIA) expert staff. All RNs and ENs were invited to complete a knowledge assessment (scored out of 51, covering anatomy and physiology of the skin and wounds, and preventative and treatment strategies) that would contribute towards continuing professional development (CPD) requirements for RN/EN registration. A web link was provided and a CPD certificate given on completion. Both RNs/ENs and PCWs could participate in ongoing education and received expert advice in relation to decisions made as part of their situation assessment and course of action regarding healthy healing and wound prevention. All PCWs were invited to complete a knowledge assessment (scored out of 21, covering basic anatomy of the skin and causative/preventative factors for wound development). Data were collected from online and pen‐and‐paper forms. All data were entered into custom‐built MS Excel forms, and cross checking with the RACF icare database occurred via manual checks, MS Access 2016 and SAP Crystal Reports 2013. All data were checked independently by two researchers.

Phase 2, conducted in 2015 and 2016, involved implementing the education and face‐to‐face training, resident engagement through the provision of a resident letter combined with presentations at residents meetings, one‐on‐one discussions with residents and provision of NP services over a 6‐month time frame. During this time, all participating staff were invited to complete a diary of time spent on activities related to healthy healing and wound prevention.

Phase 3, conducted in 2016, was a repeat of the data collection in Phase 1.

Phase 4 involved analysis, reporting and sustainability of the approach.

Ethics approval was provided by the University of South Australia's Human Research Ethics Committee (Protocol no. 0000034285). Written consent forms were obtained from all volunteer staff participants, and information letters were provided to all residents of the RACF involved.

As part of their involvement in the study, SCC required a healthy ageing and wound prevention approach and inclusion of staff and residents in all education and prevention activities. This, combined with the evidence found in the literature, led to an educational intervention with many dimensions, including nursing and personal care staff access to the wound expert NP 16 for 5–6 hours a day, two days a week, over 6 months. All volunteer RNs and ENs received Back to Basics Wound Management Education Sessions (based on deficits from the baseline knowledge quiz) and a wound education book (210 pages). The PCWs (also part of Group 2) were offered sixteen 15–20‐minute sessions with the NP on healthy wound healing and prevention 7, 12, 18, 19; this involved an educational presentation, question and answer time, handouts and a healthy skin booklet. Additional education in the form of wound prevalence survey training, healthy healing wound prevention champion training and meetings were held for Group 1 RNs, and log on access to an online training module 10, 15 was also supplied to this group. The intent of implementing all these activities as part of the intervention was to support the process changes already occurring in SCC.

To support staff and resident learning and decision making, the NP provided both group and one‐on‐one staff education, experiential learning opportunities via bedside resident care reviews and staff mentorship, formal workshops, presentations at resident meetings and provision of brief and simple pressure injury prevention literature to residents. The NP also assisted with quality improvement projects for accreditation and provided guidance on making decisions related to wound prevention and management product usage 6, 9, 13. On other days of the week when not on site, the NP provided intermittent phone and email support to address questions usually related to wound prevention and management strategies and support on product usage. The education intervention included staff access to online education resources, a telehealth Wound Advisory Service and online educational modules hosted by WHIA (formerly Wounds West), which is now part of the Wound Management Innovation CRC. The content and interactive capacity of the online educational materials was provided for Group 1 as self‐directed learning and content revision and to any RNs or ENs in Group 2 who were unable to attend the Back to Basics Wound Management sessions. This allowed nurses in Group 2 who were unable to attend face‐to‐face education to complete the modules at a time convenient to them and provided Group 1 with ongoing learning, rather than it being a one‐off activity.

Student's t‐tests and descriptive statistics were conducted on pre‐ and post‐intervention variables.

Results

As the activity diaries were non‐identified, independent samples t‐tests were conducted. PCWs had a significant increase (P < 0·001) in overall time spent on wound prevention and care with residents after the educational intervention. A significant increase was noticed in time spent assisting the resident with orthotic footwear, applying or removing compression bandages, education for carers and residents, applying or changing dressings (all P < 0·01) and repositioning residents (P < 0·05). ENs had a significant (P < 0·01) increase in overall time spent on wound prevention and care of residents after the educational intervention. Most notably, this was in repositioning (mean 1·7 minutes per shift to mean 46 minutes, P = 0·001) and applying moisturiser (mean 5 minutes per shift, to mean 44·5 minutes, P = 0·004). RNs significantly decreased the time they spent on overall resident wound care (P < 0·01) but significantly increased time spent on wound risk assessment (P = 0·02). Overall, ENs and PCWs increased total time spent on wound care per staff member per shift after the intervention (ENs: 20–79 minutes; PCWs: 96–218 minutes), while RNs decreased their total time (36–18 minutes). Please see Table 1 for overview of changes.

Table 1.

Overview of changes in time spent on wound care per staff member per shift by activity and health care professional

Wound care activity	PCW	EN	RN
Repositioning (turning) resident	↑*	↑*	↓*
Apply moisturiser	↑	↑*	↓*
Apply or change dressings	↑*	↓	↓*
Wound assessment	not recorded at either time point	↓	→
Wound‐ and/or dressing‐related documentation in chart	not recorded at either time point	↑	↓*
Resident and/or carer education	↑*	↑*	↓
Risk assessment (e.g. Waterlow, Braden, etc.)	not recorded at either time point	not recorded at either time point	↑*
Wound tracing	not recorded at either time point	not recorded at either time point	not recorded at either time point
Apply or remove compression bandage or compression stocking	↑*	↓	→
Assist with orthotic footwear	↑*	not recorded at either time point	↓
Wound photography	not recorded at either time point	↓	↑
Other wound activity (please specify)	not recorded at either time point	not recorded at either time point	↑
Total time spent on resident wound care	↑*	↑*	↓*

Key: ↑, increase in time spent; ↓, decrease in time spent; →, no change in time spent; EN, enrolled nurse; PCW, primary care worker; RN, registered nurse.

^*Significant change.

Paired samples t‐tests were conducted on the participant groups that had both pre‐ and post‐interventions scores; independent samples t‐tests were conducted on all data for each care worker group. Overall, the PCWs showed a non‐significant increase in mean knowledge scores. The RNs and ENs both showed significant increases in mean knowledge scores. Please see Table 2 for results. One EN completed the post‐intervention test but had not participated in the pre‐intervention testing or the intervention. These data were excluded.

Table 2.

Knowledge change scores for health care workers at both RC sites (combined data)

	Number of participants Phase 1	Number of participants Phase 3	Knowledge scores Phase 1 (M, SD)	Knowledge scores Phase 3 (M, SD)	t‐stat, one‐tailed P‐value
All PCW	32	83	17·5, 3·7	17·9, 2·6	0·44, 0·3
PCW who completed both phases	17	17	18·2, 2·5	17·9, 2·5	−0·6, 0·3
All EN	28	13	11·8, 5·9	24·8, 7·2	6·11, <0·001
EN who completed both phases	10	10	13·5, 5·1	26·2, 10·1	5·5, <0·001
All RN	19	17	17·8, 4·9	38·7, 8·1	9·2, <0·001
RN who completed both phases	11	11	17·5, 5·5	41·9, 4·8	16·4, <0·001

EN, enrolled nurse; M, mean; PCW, primary care worker; RN, registered nurse; SD, standard deviation.

The nursing team who conducted the Wound Prevalence Survey approached 281 residents in phase 1, and 257 consented to skin inspections. In phase 3, the team approached 278 residents, and 261 agreed to skin inspections. There were no significant differences in the resident population at phase 1 and phase 3 (see Table 3).

Table 3.

Demographic data of residents who participated in the Wound Prevalence Survey

	2015	2016
Number of participants	257	261
Average age	87·2	86·8
% Female	69	72
Average years at SCC	2·7	3·3

SCC, Southern Cross Care.

Paired samples t‐tests were conducted on the pre‐ and post‐intervention data. The number of pressure injury prevention and management plans for residents with high to very high risk of pressure injury on the Waterlow risk assessment tool (the risk assessment tool used by the RACF) increased (from 92% of at risk residents to 95% of at risk residents), but it was not significant (M = 1·8, SD = 3·6, t(9) = −1·6, one‐tailed P = 0·07, 95% CI = −0·8, 4·4). There was a significant increase in risk assessment within 7 days of admission between pre‐ and post‐intervention (M = 1, SD = 1·6, t(9) = 2·0, one‐tailed P = 0·03, 95% CI = −0·1, 2·1) and within 30 days of admission between pre‐ and post‐intervention (M = 4·2, SD = 3·1, t(9) = 4·3, one‐tailed P = 0·0009, 95% CI = 2, 6·4). There was a significant decrease in pressure injury prevalence between phases 1 and 3 from 12·5% to 6·8% (M = 2·6, SD = 3·3, t(9) = 2·5, one‐tailed P = 0·02, 95% CI = 0·26, 4·9), a significant decrease in skin tear proportions across the RACF from 20·2% in 2015 to 10·3% in 2016 (M = 2·5, SD = 4·3, t(9) = 1·8, one‐tailed P = 0·05, 95% CI = −0·6, 5·58) and a decrease in all wound types from 33·9% to 28·7% (M = 1·2, SD = 3·1, t(9) = 1·2, one‐tailed P = 0·1, 95%CI = −1·1, 3·5) and reporting of pre‐wound skin conditions increased by 31% between time points.

Discussion

In developing the education intervention, it was identified that three articles collated in the rapid review did not consider pressure injuries until they were a stage 2 or above 7, 18, 19. This approach was considered too late within a healthy ageing approach aiming to reduce the prevalence and/or incidence of pressure injuries in RACF. It is noted that the other 11 articles either included the stage 1 pressure injury and pre‐pressure injury prevention strategies or did not specify either way.

None of the reviewed articles found negative results (i.e. they did not find implementing the strategies disadvantaged the facilities, staff or residents). However, three articles 6, 16, 19 found no difference between intervention and control groups, while one 8 found no difference in knowledge but a significant difference in staff attitudes towards pressure injury prevention, and chair‐bound residents were significantly more likely to receive pressure injury prevention in the intervention group. The remaining 10 articles 7, 9, 10, 11, 12, 13, 14, 15, 17, 18 all found significant positive outcomes from the interventions. These included an increase in care provider knowledge, reduction of pressure injury incidence, improvement of morale in both staff and residents, improved documentation and communication and reductions in costs. This matches the results of our multi‐faceted educational intervention, which resulted in a reorganisation of staffing time allocation that was more in line with knowledge and qualifications and an overall increase in nurse's knowledge of wound care and prevention.

Regarding how the education intervention reported in this paper was implemented, ENs and PCWs increased time spent on actual wound care and prevention duties, while RNs reduced time spent on providing care, enabling them to increase time spent on risk, wound and critical skin incidence assessments. ENs and RNs all showed significant improvement in knowledge scores. While PCWs did not significantly improve their knowledge through the education intervention, they had a high starting point, from 83% average scores in the knowledge survey to 85%. Furthermore, it was clear through their wound care activity diaries that they took a much greater role in skin care and wound preventative behaviours, as well as taking on more in the way of wound prevention, treatment and education of residents and carers in management and prevention of wounds.

This study showed significant decreases in pressure injury prevalence and in the proportion of skin tears. In line with findings in Norris et al. 13, we also found an increase in the reporting of earlier signs of wounds and skin damage. This earlier identification and intervention will have an effect on reducing the number of skin issues that turn into full wounds, promoting the healthy ageing/healthy skin approach within SCC. Similar results in Norris et al. 13 lead to a reduction in pressure injuries and associated costs for the RACF.

The initial literature search showed that education in conjunction with a protocol intervention or facility management and process change were the most effective elements. Wound management or prevention education alone is not enough; there needs to be support from management for a holistic, organisation‐wide change 8, 10, 12, 14, 15, 16, 17, 18, 19 that addresses environmental issues such as adequate staffing 9, 10, staff mentorship 16 and time to enact the introduced protocols 12, 13 as well as access to facility and resident‐tailored wound care and prevention products 11, 13, 14, 15. The RACF that volunteered in this study was already in the process of making management changes and saw the education intervention as a part of this process of improvement.

In conclusion, using an educational intervention in conjunction with resident engagement and practice change, namely mentorship, onsite champions for healthy skin and product choice suggestions—backed by upper management involvement—showed improvement across the RACF. The reporting of earlier signs of potential wounds and skin damage indicated an increase in staff ability to identify stage one and pre‐pressure injury damage; this enables the early intervention and/or management of the skin. We believe this, in conjunction with the management changes the RACF had already made, contributed to the significant decreases in pressure injury prevalence and skin tear proportions, significant increases in pressure injury prevention and management plans conducted within 7 days of admission and more judicious use of staff time. By increasing the time PCWs and ENs spend on hands‐on wound care, the much smaller number of RNs are enabled to focus on risk and wound assessment activities.

Limitations of the study

With regards to the data for the activity diaries, it was non‐identifiable data, so we were unable to pair diaries from pre‐ and post‐intervention. Furthermore, participation decreased by approximately 34% at the post‐intervention data collection for the activity diaries. The aged care provider who enabled access to two RACF sites had already commenced significant organisational change prior to engaging with the research team. Their participation in the project was, in part, because they saw this as an extension of their current policy and the practice improvement initiatives in being involved. This organisational change involved a focus on a healthy ageing approach to resident care rather than an illness or treatment‐based approach.

Databases searched: Medline, Embase, Ovid Nursing database, Ageline, CINAHL, Scopus, Health source: nursing/academic edition, Health Sciences: SAGE, Cochrane, Health collection, ProQuest nursing and allied health database and AMED. Reference lists of relevant review articles were assessed (pearled) for primary research relevant to the inclusion criteria. For PRISMA flow chart, see Figure A1.

Figure A1.

PRISMA flowchart of search results.

Search concepts: (i) residential care facilities, (ii) wounds (healing, treatment or prevention) and skin (care, management or health) and (iii) CPD or continuing education.

Table A1.

Search terms for Medline.

Search #	Key word or search term	Hits (duplicates)
1	exp Residential Facilities/or residential care home.mp.	46 432
2	Nursing Homes.mp. or exp Nursing Homes/	38 296
3	Residential age* care and (facilit* or home*)	594
4	Old age* home or age* care home or care home	1544
5	OR/ 1‐4	51 026
6	Chronic AND (wound or sore or injury or ulcer)	78 892
7	exp Skin Ulcer/	38 836
8	Acute AND (wound or sore or injury or ulcer)	138 069
9	Pressure AND (wound or sore or injury or ulcer)	62 717
10	*‘wounds and injuries’/ or soft tissue injuries/	55 578
11	Wound AND (persistent or long term or ongoing)	11 264
12	Skin tear or skin ulcer	8164
13	Tissue damage	22 294
14	Bed AND (wound or sore or injury or ulcer)	6886
15	Wound AND (healing or prevention)	112 345
16	Healthy skin	1494
17	Skin care and (manag* or action or plan)	1674
18	Wound care product*	201
19	Skin care/	4636
20	Wound Healing/	80 486
21	((skin or wound) and assess*).mp	87 598
22	OR/ 6‐21	494 432
23	*education, continuing/ or education, nursing, continuing/ or education, professional, retraining/	26 135
24	(education* or train*) and strateg*	71 433
25	Continuing professional and (develop* or educat* or train* or skill*)	1756
26	(treat* or prevent*) and (interven* or program* or strateg* or effect*)	2 528 222
27	Staff AND (train* or educat* or upskill* or instruct* or program*)	78 100
28	exp Health Personnel/	427 143
29	Service and (change or modification or switch or alteration or shift)	18 903
30	OR/ 23‐29	3 022 559
31	AND/ 5, 22, 30	456
32	limit 31 to English language, 2006‐current	117 (4)