Peer-to-peer learning/teaching: An effective strategy for changing practice and preventing pressure ulcers in the surgical patient

International Journal of Orthopaedic and Trauma Nursing (2014) xxx, xxx–xxx

www.elsevier.com/locate/ijotn

Peer-to-peer learning/teaching: An effectivestrategy for changing practice and preventingpressure ulcers in the surgical patient

Anita Meehan MSN, RN-BC, CNS, ONC (Clinical NurseSpecialist Gerontology) *, Nancy Beinlich MSN, RN,CWON (Director, Wound Center) 1

Akron General Medical Center, 1 Akron General Way, Akron, OH 44307, United States

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KEYWORDSPressure ulcer;Peer-to-peer learning/teaching;Resource nurse program

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* Corresponding author. Tel.E-mail addresses: anita.meTel.: +1 330 603 6488; fax

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Abstract Hospitals are increasingly focused on finding cost effective ways toensure patient safety and enhance quality outcomes. Hospitalized patients are atincreased risk for a variety of complications, one of the most common is the devel-opment of pressure ulcers. In 2008, the Center for Medicare and Medicaid services,the largest payer source for older adults in the US, began to withhold reimburse-ment to care facilities for pressure ulcers (Stage 3 or 4) that develop as a resultof hospitalization. Staff nurses are ideally positioned to prevent the developmentof hospital acquired pressure ulcers (HAPUs); however, studies reveal several barri-ers including a knowledge deficit of causative factors, incorrect identification andstaging of wounds, inaccurate use of risk assessment tools and an under utilizationof evidence-supported prevention intervention strategies (Ilesanmi et al., 2012; Sie-vers et al., 2012). This paper examines a cost effective, innovate approach toaddress these barriers and reduce hospital acquired pressure ulcers using peer-to-peer learning/teaching with staff nurses.

�c 2014 Elsevier Ltd. All rights reserved.

4 Elsevier Ltd. All rights reserved.3.12.004

671 7270.krongeneral.org (A. Meehan), [email protected] (N. Beinlich).996 2992.

, A., Beinlich, N., Peer-to-peer learning/teaching: An effective strategy for changing practice and pre-tient, International Journal of Orthopaedic and Trauma Nursing (2014), http://dx.doi.org/10.1016/

http://dx.doi.org/10.1016/j.ijotn.2013.12.004

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mailto:[email protected]

http://dx.doi.org/016/j.ijotn.2013.12.004



2 A. Meehan, N. Beinlich

Editor comments

There are few individuals more at risk of developing pressure ulcers than patients with a hip fracture.Many health care providers and nurses around the world have developed education and practicedevelopment systems designed to enhance pressure ulcer prevention care. These are driven by adesire to prevent suffering and to reduce both human and financial costs. This paper describes justsuch a model that is specifically focussed on peer education and which is worthy of consideration byorthopaedic and trauma nurses. The authors clearly demonstrate the potential value of such anapproach in preventing these devastating and costly complications of care.

JS-T

Introduction

Health care systems around the world are chal-lenged to maintain quality outcomes in the wakeof decreasing resources. This challenge comes at atime when the global population is aging and therates of hip fractures are rising. World wide projec-tions of hip fractures, while declining since predic-tions made in the early 90’s, still represent asignificant health imperative withmore recent anal-ysis of trends suggesting that by the year 2050 num-bers could reach as high as 1.04 million hip fracturesannually in the U.S. alone (Brown et al., 2012). A na-tional survey revealed a pressure ulcer rate of 20.6%for those older adults undergoing orthopedic surgery(Chen et al., 2012). A Pan European study of olderpatients hospitalized with hip fracture reportedpressure ulcer prevalence at 10% on admission and22% at discharge (Lindholm et al., 2008). Every yearin the US approximately 2.5 million patients aretreated for pressure ulcers in acute care settings.

Thedevelopment of thesewounds is considered anindicator of the quality of nursing care delivered.Pressure ulcers are both painful and costly and nega-tively impact quality of life (Casey, 2013). Each yearapproximately 600,000 patients die as a result ofpressure ulcer related complications; most com-monly sepsis, osteomyelitis and infection (Fleck,2012; Institute for Healthcare Improvement, 2011).Factors that contribute to increasing risk for pressureulcer development in the older population includepre-existing co-morbidities such as diabetes, alteredmental status, low hemoglobin, poor nutritional sta-tus and cardiovascular instability (Campbell et al.,2010; Lindholm et al., 2008; Moore and Cowman,2008). Nurses are ideally positioned to prevent thesewounds. Studies have shown, however, that thereare barriers to preventing HAPUs. These includeknowledge deficit of causative factors, incorrect

Please cite this article in press as: Meehan, A., Beinlich, N., Peer-to-peer lventing pressure ulcers in the surgical patient, International Journal of Oj.ijotn.2013.12.004

identification and staging of wounds, inaccurateuse of risk assessment tools and an under apprecia-tion of evidence-supported prevention interven-tions (Ilesanmi et al., 2012; Sievers et al., 2012).

Development of the resource nurseprogram

The Wound Center of a 500 bed, community, teach-ing hospital in Midwest USA, is responsible for con-ducting quarterly pressure ulcer prevalencestudies (PUPS) and completing consultation for hos-pital-associated pressure ulcers and other chronicwounds as well as developing wound treatmentplans for hospitalized patients. Certified woundand ostomy nurses and advanced practice nursesare responsible for developing and guiding standardsof practice for prevention and treatment of pressureulcers. Each quarter the wound center nurses con-duct a pressure ulcer prevalence study (PUPs), aone-day survey of all patients to determine the num-ber of pressure ulcers. The data from these surveysfrom 2006 to 2009 demonstrated an increasing trendin hospital acquired pressure ulcers (HAPUs) (seeFig. 1) with approximately 22% of these woundsoccurring on units caring for surgical patients (seeFig. 2). In 2008 the Centers for Medicare and Medic-aid Services (CMS), the largest U.S. payer of medicalcare for the elderly, issued a ruling denying hospitalsreimbursement for care for Stage 3 and 4 pressureulcers that developed during hospitalization. Ourdata coupled with the CMS ruling provided the impe-tus for the development of an action plan to reversethis trend. While wound and ostomy nurses possessadvanced knowledge in the assessment, treatmentand prevention of pressure ulcers and serve as animportant resource for staff nurses, there is insuffi-cient time for the limited number of these nurses toeducate an adequate number of staff to effectively

earning/teaching: An effective strategy for changing practice and pre-rthopaedic and Trauma Nursing (2014), http://dx.doi.org/10.1016/



Fig. 1 Number of hospital-acquired pressure ulcers �prevalence.

Fig. 2 Number of surgical-related hospital-acquiredpressure ulcers � prevalence.

Peer-to-peer learning/teaching 3

prevent these wounds (Wound Ostomy and Conti-nence Nurses Society, 2010). The Director of theWound Center, with support from the Gerontologi-cal Clinical Nurse Specialist, used the IOWA model(Titler et al., 2001) for integrating evidence intopractice as a guide to address this growing concern.An interdisciplinary team was formed, literaturewas reviewed and an action strategy was developed.A peer-to-peer learning/teachingmodel was used todevelop the Resource Nurse program. Peer to peerlearning teaching is a proven strategy to fosterteamwork/collaboration, encourage critical inquiryand reflection and enhance communication skillsand self-confidence of both the learner and teacher(McKenna and French, 2011). The program was de-signed to educate staff nurses to serve as a resourcefor their colleagues on issues related to pressure ul-cer assessment, identification and prevention. With


the support of nursing administration, nurses fromsix clinical units were selected based on the follow-ing guidelines: one-year employment as a staff RN inthe hospital, recommendation from their unit direc-tor and an interest in pressure ulcer prevention andlife-long learning. Preparatory education includedparticipation in a 12-h educational curriculumdeveloped by the master’s prepared Wound Cen-ter’s program director in collaboration with thegerontological Clinical Nurse Specialist. The coursefocused on the deficiencies identified in the litera-ture and includes evidence-supported risk assess-ment modalities, identification and staging/documentation of wounds and pressure ulcers, pre-vention/intervention strategies for pressure-re-lated ulcers, etiology and treatment of moistureassociated skin damage and age related pressure ul-cer risk factors. In addition, the hospital librarianprovided a course on the use of software programsto enhance the Resource Nurses’ access to sourcesof information in the literature.

After completing the education curriculum,these Resource Nurses are responsible for 12-h ofpeer-to-peer learning activities (see Table 1) serv-ing as a resource on their respective units for theircolleagues. These teaching hours are above and be-yond their work schedule and they are paid for theirtime to serve in this role. Armed with evidence-sup-ported risk assessment and prevention strategies,the Resource Nurses serve as consultants for skin re-lated concerns, recommending prevention andtreatment interventions when indicated. They alsodevote 4 h per month doing clinical audits, assess-ing for accuracy of Braden Risk Assessment andtimely implementation of appropriate interven-tions. They also provide their unit colleagues withbi-yearly educational offering on topics identifiedby the Resource Nurses, such as appropriate useof barrier ointments and fungal/yeast treatmentand correct staging of pressure ulcers. These ses-sions are repeated several times on the unit, allow-ing all staff to attend on a rotating basis and mayinclude power point lecture with interactive discus-sion, hands on learning and demonstrations of vari-ous products available for prevention and/ortreatment. Unit based peer-to peer education as-sists the staff nurse to prioritize care and enhancescritical thinking skills when caring for at risk pa-tients (McKenna and French, 2011).

Program expansion

To date there are 15 nurses who serve as ResourceNurses. Initially the focus of the Resource Nurse




Table 2 Pressure mapping using heating blanket andgel overlay.

2’’ mattress 4’’ Viscoelasticmattress

HeadAverage (mm Hg) 15.73 7.59Maximum (mm Hg) 64.53 20.61

ScapulaAverage (mm Hg) 7.13 4.62Maximum (mm Hg) 20.72 10.46

SacrumAverage (mm Hg) 7.46 4.39Maximum (mm Hg) 34.93 13.52

HeelsAverage (mm Hg) 17.66 18.06Maximum (mm Hg) 40.95 40.24

Table 1 Resource nurse role responsibilities.

� Unit-based in-service programs related to IAD & pressure ulcer prevention� Braden checks/rounding on units, reviewing results/interventions with individual staff at bedside� Quarterly participation in NDNQI pressure ulcer prevalence study (PUPS)� Participation in root cause analysis for hospital acquired pressure ulcers� Monthly meeting with CWON/program director and geriatric CNS; education and review of activities,program planning/goals, process improvement initiatives� Facilitating quarterly unit journal club meetings� Individualized unit educational bulletin boards and CE offerings� Participation in annual nursing grand rounds� Involvement in lean/six sigma processes pertaining to maintaining patient function� Participation in ongoing quality improvement programs/studies in preventing pressure ulcers


program was on risk assessment, wound type iden-tification and staging, however as the program ma-tured the focus broadened to include participationin quality improvement initiatives throughout thehospital system. One project focused on the identi-fication, prevention and treatment of inconti-nence-associated dermatitis (IAD). Observing thattheir peers were frequently misidentifying IAD asa Stage 2 pressure ulcer, the Resource Nurses pro-vided additional education on differentiating IADfrom a pressure ulcer. They also consulted the lit-erature and conducted a chart audit that revealedthat the method of making beds was contributingto the occurrence of IAD.

The evidence was brought to the attention ofthe Nursing Evidence Based Practice and Researchcouncil, which approved the development of anursing policy establishing a standard for bed mak-ing. The policy included a reduction of linen layersand the replacement of incontinence briefs with apolymer-based, ultra absorbent pad for incontinentbed-bound patients (Williamson, 2009). Thesechanges resulted in the reduction of the incidenceof hospital-associated IAD, going from 56 consultsin 2009 to 1 consult in 2011 (data gleaned fromthe Wound Center electronic medical record).

To investigate key factors contributing to thedevelopment of HAPUs, Resource Nurses also partic-ipate in root cause analysis (RCA). This strategy pro-vides a better understanding of the how and why anevent occurs and is essential for preventing reoccur-rence (Rooney and VandenHeuvel, 2004). The anal-ysis was conducted on charts of patients whodevelop pressure-related wounds using a data col-lection tool created to identify common risk factors.Findings revealed that in our hospital, HAPUs tend tooccur in patients who: are older, have diabetes andremain immobile for greater than three hours in suc-cession, either in the emergency department or per-ioperative setting. This information provided theimpetus for the Resource Nurses to develop a perfor-mance improvement project during the summer of


2010. A published reviewof clinical evidence reportsthat procedures lasting greater than three hours areassociated with increased rates of pressure ulcerformation in surgical patients. Incidence continuesto increase with extended duration thereafter (Ge-fen, 2008). A randomized controlled trial conductedby Nixon et al. (1998) found that using a 4 ‘‘ visco-elastic operating room (OR) mattress resulted in sig-nificantly fewer pressure ulcers when compared to astandard foam surgical mattress. The ResourceNurses validated this finding by initiating a limitedpressure-mapping study. The 4’’ mattress was com-pared to the current 2’’ foammattress. The compar-ison data demonstrated the 4-inch Viscoelasticmattress outperformed the hospital-owned mat-tress (see Table 2) in all areas except the heel wherethe findings were essentially equal. It is important tonote that the standard of care in our hospital is tooff-load heels in the operating room. The data ob-tained from this project encouraged administrationto purchase two new OR mattresses for patients




Fig. 3 Number of surgical-related hospital-acquiredpressure ulcers � incidence.


undergoing extended surgical procedures. This pro-ject led to a more formal pressure mapping study,which provided evidence used to support replace-ment of all OR table surfaces with 4-inch Viscoelas-tic mattresses.

Data collected to evaluate the effect of thesechanges on units caring for patients who had sur-gery revealed a decrease in incidence of HAPUsfrom 2010 to 2012 of 27% in the ICU, 60% on theorthopaedic unit, and a 100% decrease in the gen-eral surgery unit. (see Fig. 3).

Surgical focus

The change in OR mattresses reduced the incidenceof pressure ulcers in surgical paitents but a chartaudit of HAPUs showed that the vast majority ofthese wounds were still occurring in patients

Fig. 4 Number of hospital-acquired pressure ulcers percalendar year � prevalence.


following a surgical event. In early 2013, the Re-source Nurses from the Peri-operative and post-sur-gical units formed a small workgroup to review theliterature for suggestions of methods to help reducethe hospital’s incidence of these surgical-relatedpressure ulcers. They also conducted a retrospec-tive review of charts for surgical patients whodeveloped pressure ulcers in 2012 and found that70% of these patients were 60 or older, 37% had dia-betes and 90% had a Braden score of 18 or less. Pre-operative identification of those patients at-riskcan aid in the implementation of prevention inter-ventions before and during surgery, as well asimmediately after surgery (Lyder and Ayello,2008). Recognizing a need to raise awareness ofat-risk patients in the perioperative area and find-ing a paucity of information in the literature regard-ing surgical-specific risk assessment tools, theResource Nurses decided to develope and test a sur-gical specific risk assessment tool with correlatingprevention interventions. This tool is currently un-der investigation in the peri-operative area. A com-panion tool is also being evaluated which followsthe patient after surgery to both the post anesthe-sia care unit as well as to their nursing unit. Using ananatomical diagram, the tool alerts staff to at-riskareas related to patient positioning during surgeryand emphasizes the need for continued assessmentand intervention. Developing a consistently usedevidence-based standard of care which focuses onearly identification and prevention, coupled withsupportive documentation, is essential in prevent-ing these wounds (Tschannen et al., 2012).

Impact on pressure ulcer prevalence andincidence

Although inferential analysis was not performed, areview of information collected from our PUPs sug-gests that since its inception in 2009, the ResourceNurse program has effectively reduced HAPUs inour facility. Comparative prevelance data from2009 through 2012 reveals a 77% decrease in HAPUs(see Fig. 4). Data gleaned from the Nursing Data forNursing Quality Indicators (NDNQI) survey tool sug-gests that nurses are independently initiating pre-vention strategies earlier in the patient stay. TheResource Nurses also report that staff nurse inter-ventions are being instituted, as observed duringtheir monthly Braden Risk Assessment clinical auditrounds on their units. While the Braden Assessmentis performed on every patient on admission andevery shift, the Resource Nurses also do monthlyrounding. This is an opportune time for them to re-




Fig. 5 Numbers of hospital-acquired pressure ulcers �incidence.

Fig. 6 Actual variable cost savings.


view Braden assessment findings with their col-leagues as well as to evaluate the timeliness of ini-tiation of prevention interventions and answer anyquestions staff may have (Gadd, 2012; Magnan andMaklebust, 2009).

Incidence data is an equally important factor indetermining overall occurrence of HAPUs anddefining quality and financial outcomes for hospi-tals. Incidence data is collected throughout thecalendar year whenever a hospital-associated pres-sure ulcer is discovered. This information providesa longitudinal view rather than, as in the PUPS, aone-day snapshot in time. Incidence data prior toand after the initiation of the Resource Nurse pro-gram reveals a reduction in HAPUs of 44% from2009 to 2012 (see Fig. 5). A specific pressure ulcerincidence reporting form was developed in 2010 tobe used by the staff nurses to identify HAPUs with arobust educational roll out associated with this newform. The rise in reported incidence of HAPUs from2009 to 2010 is thought to reflect the educationalinitiative resulting in heightened staff awarenessand utilization of this standardized reporting form.

Cost savings

The primary goals of reducing pressure ulcers is toavoid unnecessary pain and suffering for the pa-tient by providing evidence supported care. In to-day’s health care environment, however, it is alsonecessary to demonstrate the cost effectivenessof any program. Actual cost savings were computedwith data provided by the finance department usingthe decrease in total numbers of HAPUs based onprevalence and incidence data. Using 2009 as abenchmark the associated costs of caring forpatients with HAPUs in that year were over $160


thousand dollars (prevalence and incidence). Com-bining the dollars saved by decreasing thesewounds from 2009 to 2012 and then subtractingthe costs of the Resource Nurse program, the hos-pital realized over $95 thousand dollars in savingsover the course of three years (see Fig. 6). Theseoutcomes demonstrate the cost-effectiveness ofthis evidence-based program.

Conclusion

Hospital acquired pressure ulcers (HAPUs) are con-sidered a nurse sensitive quality care indicator,implying that good nursing care may prevent theirdevelopment (Centers for Medicare and MedicaidServices, 2010). This nurse-driven quality improve-ment initiative demonstrates that a peer-to-peerlearning teaching initiative such as the ResourceNurse program is a cost effective way to addressthe issue of pressure ulcers in an acute care set-ting. This model is an effective way to change prac-tice by supporting an interdependence of peerslearning from and teaching each other in pursuitof a common goal of improving patient outcomesby using evidence supported interventions(McKeachie and Svinicki, 2006).

Conflict of interest statement

The authors have no conflict of interest to declare.

Ethical approval

The program outlined in this manuscript is notresearch but rather a quality improvement project.





Funding source

No funding source to declare.

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Peer-to-peer learning/teaching: An effective strategy for changing practice and preventing pressure ulcers in the surgical patient