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Aseptic technique is a core competency for many nurses and is required for everyday procedures such as catheterisation and wound dressing. This first article in a two-part series outlines the principles of medial asepsis
Communication issues commonly feature in root-cause analyses of pressure ulcer incidents and patient complaints about care, but are an under-researched area. This final article in an eight-part series on a core education curriculum for pressure ulcer prevention and management, looks at how to ensure effective patient information and multidisciplinary team communication to help optimise the prevention and treatment of pressure ulcers.
Citation: Fletcher J (2020) Pressure ulcer education 8: giving information to patients. Nursing Times [online]; 116: 5, 31-33.
Author: Jacqui Fletcher is chair, Core Education Pressure Ulcer Curriculum Group, and senior clinical adviser, NHS Improvement/England.
- This article has been double-blind peer reviewed
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Communicating and transferring information about all elements of pressure ulcer prevention is an under-researched area, despite communication issues being one of the most common areas identified in root-cause analyses of pressure ulcer incidents and patient complaints about care (ACT Academy, 2018).
The importance of good communication is recognised in aSSKINg – the new educational framework for pressure ulcer prevention and management described in part 1 of this series. The framework includes a module on how to communicate effectively with patients, carers and the multidisciplinary team (MDT) through:
- Developing an awareness of a range of communication strategies;
- Selecting and implementing the most appropriate approach to increase awareness and help concordance and engagement with pressure ulcer prevention strategies;
- Good communication of the effective and safe use of interventions;
- Understanding and recognising when clinical concerns need to be escalated;
- Promoting effective pressure ulcer prevention approaches;
- Understanding effective resource allocation;
- Escalating concerns when resources are unavailable (NHS Improvement, 2018).
Guidance from ACT Academy (2018) states that: “Good patient information ensures patients are prepared and fully aware of the next steps in their pathway, so they are able to plan ahead. It helps to involve patients and carers in their care and improve their overall experience”. Patient information should also:
- Identify any risks that may occur during their episode of care;
- Discuss how patients may be involved both in delivery of care and amelioration of any risk.
Information may be given verbally when the opportunity arises, or in a more structured way using other media, such as through leaflets, apps, videos or communications via social media, reminder emails or texts.
Whatever the mode of delivery, information should:
- Be clear;
- Focus on the key messages;
- Be in everyday language without being patronising;
- Consider the recipient’s ability to learn;
- Be reinforced in more than one way, wherever possible.
In many cases, it should also be repeated, preferably at different points in time. Patients should also be asked to explain what they have been told to check that they have understood the information that has been passed on.
A study by Durrant et al (2019) found there was poor engagement and understanding of written information on pressure injury among patients in the community, and suggested the focus should be on improving the patient-health professional relationship and enhancing verbal dialogue. The researchers concluded that written patient materials should be subsidiary to, rather than a substitute for, verbal conversations and that conversations need to occur in a manner tailored to individual patients.
Patients’ ability to learn is not just about information being at the appropriate level (for example, jargon free, at an appropriate reading age, in clear English or other languages where required); it is also important to check whether a patient’s physical and/or psychological state may affect their ability to understand the information – for example, ask yourself if they are pain free, have recently been given bad news, are supported by a friend/relative/carer in attendance, are taking medication that may impair cognition, have their glasses and/or hearing aids in place. Learning age, reading ability and any learning disabilities should also be considered, and easy-read documents, pictures, audio or video used where appropriate (NHS England, 2018).
Most NHS trusts provide information leaflets, but information on pressure ulcer prevention should ideally be personalised, with examples of how to use the information. For example:
- If you find it difficult to check your own skin, a mirror may help;
- You need to drink [amount] of fluid a day – this is [number] of the cups you usually have.
When developing written materials there are many sources of good advice on how to present the information and what type of language to use; one example is the Department of Health and its advice on how to prepare a patient leaflet (Box 1).
Box 1. Advice to ensure clarity of patient information
To help patients understand the written information you give them:
- Keep sentences short – in general, use no more than 15-20 words
- Avoid unnecessary capital letters in written information – use lower-case letters as they are easier to read. Capital letters are only needed for proper nouns and at the beginning of sentences
- Use present, active tenses, where possible – for example, “moisturise your skin using…” rather than “skin can be moisturised using…”
- Use bulleted or numbered points or a question-and-answer format to break up text
- Avoid long paragraphs
- Use headings to break up the text – these will also guide the reader and help them to find the information they need
- Make use of white space as this makes information easier to read
- Avoid italics and underlining text – such formatting can make text more difficult to read
- Numbers from one to nine are easier to read if written in words; use numbers for 10 and upwards
- Use a font size of no less than 12 point
- Where appropriate, use diagrams and pictures to illustrate text – remember to label them and do not print over the top of them
Source: Adapted from Department of Health (2003)
Use of the Simple Measure of Gobbledygook (SMOG) index (Box 2) should also be considered, as it identifies the reading level for which materials will be suitable; an online calculator is available here.
Communication within the MDT must be factual and should convey the relevant level of importance/urgency. Information should also be relayed in a clear, structured way, and meet the appropriate professional standards and guidance, and recognise that patients with, or at risk of, pressure ulcers often have complex comorbidities and may be cared for by many different, but linked, organisations and MDT members.
The NHS’s digital strategy is focused on improving access to, and use of, digital solutions, particularly better data interoperability. This will ensure patient information only needs to be collected once, rather than being collected every time a patient sees a different clinician or team (NHS Digital, 2016).
Information should include clinical assessment, test results, care delivered and any refusal of care or inability to comply with suggested care; this should be clearly documented and, if necessary, escalated to other MDT members. Team members should also develop networks with other specialities to ensure correct and appropriate referrals, and to promote knowledge development in their own speciality.
“Communication issues are one of the most common areas identified in root-cause analyses of pressure ulcer incidents and patient complaints about care”
Giving information is a complex process that requires giving consideration to who the recipient is and how that person may best receive that information. Communication within the MDT must adhere to professional standards and concisely convey all the relevant information. Digital technology is likely to play an increasing role in multidisciplinary communication and, if used correctly, should go some way to reducing the burden of documentation.
- Research shows there is poor patient engagement and understanding of written information on pressure ulcers
- Giving information is a complex process, requiring consideration of the recipient and how they may best receive that information
- Patient information on pressure ulcer prevention should, ideally, be personalised and include examples of how it should be used
- Written patient information should never be a substitute for face-to-face discussions
- Prevention and management of pressure ulcers depends on effective communication between different members of the multidisciplinary team
- Acknowledgements [online only] Core PU Curriculum Group membership: Ria Betteridge, nurse consultant in tissue viability, Oxford University Hospitals NHS Foundation Trust; Sue Burgis, head of practice development and innovation, Imperial College Healthcare NHS Trust; Fiona Butler, tissue viability nurse, Nuffield Health; Paul Chadwick, consultant podiatrist and clinical director, Society of Chiropodists and Podiatrists; Jacqui Fletcher (chair), senior clinical advisor, NHS Improvement/England; Jennie Hall, programme director/strategic nurse adviser, NHS Improvement/England; Karen Ousey (vice chair), professor of skin integrity, University of Huddersfield; Dawn Parkes, deputy director of nursing, Mid Yorkshire Hospitals NHS Trust, representing NHS England LCAV programme; Alison Schofield, tissue viability nurse, North Lincolnshire and Goole NHS Foundation Trust; Amy Verdon, tissue viability nurse, University Hospital of Coventry and Warwickshire; Jo-Anne Webb, senior lecturer occupational therapy, University of Salford; Deborah Wickens, tissue viability nurse, North East London Foundation Trust; Carole Young, lead tissue viability nurse specialist, Cambridge University Hospitals NHS Foundation Trust
ACT Academy (2018) Online Library of Quality, Service Improvement and Redesign Tools: Patient Information. NHS Improvement.
Department of Health (2003) Toolkit for Producing Patient Information. DH.
Durrant LJ et al (2019) Health literacy in pressure injury: findings from a mixed-methods study of community-based patients and carers. Nursing and Health Sciences; 21: 1, 37-43.
NHS Digital (2016) Data and Information Strategy. NHS Digital.
NHS England (2018) Guide to Making Information Accessible for People With a Learning Disability. NHS England.
NHS Improvement (2018) Pressure Ulcer Core Curriculum. NHS Improvement.
National Institute of Adult Continuing Education (2009) Readibility: How to Produce Clear Written Materials for a Range of Readers. NIACE.