Nursing students' skills in applying short-stretch compression bandages using the control of compression bandaging score

Venous leg ulcers (VLU) are defined as open skin lesions on the leg or foot resulting from venous hypertension (O'Donnell et al, 2014), and are the most frequent of all leg ulcers (Poskitt and Gohel, 2016; Guest et al, 2020). According to the CEAP clinical classification (where C stands for clinical, E for etiological, A for anatomical, and P for pathophysiological), VLUs are a symptom of the highest grade of chronic venous insufficiency (CVI) (Eklöf et al, 2004), which sometimes result from a non-healed trauma of the leg (Probst et al, 2020). The mean healing time of VLUs is estimated at 13 months in European countries (Gethin et al, 2021). Once healed, a recurrence rate of 57 % at 1 year and up to 80 % at 3 years have been reported (Finlayson et al, 2015). This chronic and recurrent condition imposes a financial burden of £941 million per year on the UK healthcare system (Guest et al, 2017). More specifically, unhealed VLUs are 4.5 times more expensive to treat than healed ones (Guest et al, 2018).

Living with a VLU, which are regularly associated with pain, insomnia, mobility restriction, leg swelling, exudate and/or odour (Persoon et al, 2004; Heinen et al, 2007; Phillips et al, 2018), has a considerable impacts on a patient's quality of life (González-Consuegra and Verdú, 2011). Best practice guidelines recommend a multifaceted approach, including compression therapy (Tan et al, 2019). The use of compression therapy improves blood circulation in the lower leg and is considered to be the gold standard for the treatment and prevention of recurrence of VLU (Fletcher et al, 1997; O'Meara et al, 2012; Nelson and Bell-Syer, 2014; Shi et al, 2021). Evidence has demonstrated that, in clinical practice, up to 87% of individuals with a VLU receive a prescription for a compression therapy system (Guest et al, 2018), but adherence is challenging for those concerned (Van Hecke et al, 2009; Weller et al, 2021).

The application of compression therapy varies across settings. For example, it is widespread in leg ulcer clinics (96% of VLU cases); however, in some homecare services, it is probably underused (15% of cases) (Hopkins and Samuriwo, 2022). Similar results have been reported by Heyer et al (2017a), showing that compression therapy is frequently underprescribed and awareness of its benefits should be increased among healthcare providers.

Nurses perform most wound-care interventions for individuals with VLUs in the community (Guest et al, 2017; Guest et al, 2018). Therefore, they should be equipped with sufficient skills and knowledge about the indication and contraindication, for compression therapy as well as how to apply it. Incorrect application contributes to ineffective treatment and results in negative side-effects (Dissemond et al, 2016; Rabe et al, 2020).

Background

Nurses' knowledge of VLUs and familiarity with compression therapy devices appears to be low (Heyer et al, 2017b; Duran-Saenz et al, 2022). In 2014, Ylönen et al (2014) conducted a systematic review of 16 research projects, highlighting a gap in nursing knowledge regarding compression therapy based on questionnaires, interviews or observations. Ylönen et al (2014) reported that nurses did not know when to use compression therapy, and were not aware of the effectiveness of compression therapy or graduated compression principles.

In clinical practice, a vast amount of different bandages (short stretch, four-layer compression, Unna boots etc) (Shi et al, 2021) are available, all of which require different application techniques (Dissemond et al, 2016) and deliver different pressures (Coull et al, 2006). The theoretical aspects, as well as the recommendations of guidelines on compression therapy, indicate that the technique needs to be adapted to individual patient tolerance and shape of the leg (Franks et al, 2016), which can be a challenge for nurses in clinical practice.

Evidence has demonstrated (Clarke-Moloney et al, 2008) that specific training for community nurses to develop skills and knowledge on caring for people living with VLUs increased the use of compression therapy devices. However, the appropriate application of compression remains an ‘art’. International studies have reported that nurses frequently apply suboptimal pressure (Taylor et al, 1998; Tidhar et al, 2017; Protz et al, 2021), which is likely due to the fact that this is group of health professionals do not generally receive specific training in the procedure (Barrett et al, 2009). It is therefore imperative that nurses receive appropriate education on both theory and the practical skills of applying compression bandages during their undergraduate education.

There is evidence of specific training developed for nurses led by both specialist nurses (Taylor et al, 1998; Protz et al, 2021) and specialised physiotherapists (Tidhar et al, 2017). The studies showed that after this targeted training, application of compression therapy at the targeted pressure increased (Taylor et al, 1998; Tidhar et al, 2017; Protz et al, 2021). However, pressure alone is not sufficient to appraise the quality of a student's bandage application technique. To address this, Protz et al (2021) developed the Control of Compression Bandaging score (CCB), which includes absolute pressure measurements and other criteria for applying short-stretch compression therapy, such as using underpadding or including the heel. The score was used in trials, which highlighted that one-time training increases overall skills immediately after training and over the following period of 3 months (Protz et al, 2021; 2022). However, ensuring the application of adequate pressure remains challenging (Protz et al, 2021).

It has been recommended that, within undergraduate nursing curricula, education on wound care should include compression therapy (Lindhal et al, 2021). However, to the authors' knowledge, there are no specific recommendations on pedagogical interventions and no undergraduate nursing education course that delivers education on pressure-measuring devices to monitor the effectiveness of compression therapy.

This pilot study, therefore, aimed to assess the feasibility of the use of the CCB score during a workshop on compression therapy for BSc Nursing students.

Materials and method

Design

A quasi-experimental pilot study using a one group pre-post-test design was used. The students' skills were assessed before (T1) and after (T2) a compression therapy workshop.

Setting and population

The study took place at the University of Applied Sciences and Arts in Western Switzerland during March 2022. The participants were students recruited from the second year of a BSc Nursing course.

Description of the pedagogical intervention

For this pilot study, the chair of wound care of the University of Applied Sciences adapted a previously implemented (Bobbink et al, 2022a) blended learning unit, combining e-learning and a workshop on leg ulcers and compression therapy. The three sessions e-learning unit uses the learning outcomes defined by the European Wound Management Association (EWMA) (Pokorná et al, 2017). Additional content was developed in consultation with the chair of wound care at the university, clinical nurse specialists (CNSs) in wound care, and an extensive literature review. The unit content included definition of VLUs, their impact on individuals and healthcare systems, interprofessional recommendations for best practices and highlighting the indication and contraindication of compression therapy. To illustrate best practice application of short-stretch bandages the e-learning includes three newly recorded videos by the educational innovation team in collaboration with three CNSs.

After the e-learning, six simultaneous hands-on workshops were carried out in six different rooms and repeated four times. The workshops, each led by a CNS, included for each student:

• Two sessions discussing a clinical case using recent literature, and highlighting the challenges and risks of compression therapy
• Two sessions of practical exercises, during which students applied compression bandages using peers as models.

Table 1 provides an overview of the time frame and learning outcomes.

The university's wound curricula (Bobbink et al, 2022b) within the undergraduate nursing programme ensured that students were familiar with the use of blended learning design, which combines e-learning and workshops led by a CNS with a certificate of advanced studies in wound care. In previous courses, pressure ulcers and diabetic foot ulcer were covered as part of wound care education. As students were in their second year of nursing education, they followed three clinical practice training sessions.

Recruitment

Four sets of six hands-on workshops were run over 2 days. However, only four Picopress pressure-measuring devices were available during the study, so data were collected for four out of the six workshops from each set, or for 16 students. Four CNSs in wound care consequently collected data over the two days for the participating workshops (Figure 1). At the beginning of each workshop students received oral and written information from the CNSs that outlined the project's aim and data collection process. In each group, one student was invited on a voluntary basis to apply a compression bandage to the leg of a peer at the beginning and then at the end of the workshop. They were informed that, during the exercise, the students and the CNS were not allowed to interact among themselves or offer the practising student advice, who in turn was also not permitted to interact with the model.

To enable a pre/post design, the groups taking part in data collection were allocated less time for the theoretical component of the workshop. This was to allocate students time to undertake an initial application of a short-stretch compression bandage without having to extend the time allocated to the workshop overall (Figure 2).

Data collection

Data were collected by the CNSs who tutored the different groups before and after the workshops. Prior to data collection all CNSs received a brief tutorial explaining how to use the CCB score and how to apply the Picopress devices, as well as a handout describing the learning outcomes and time frame of the workshop (Table 1). During the workshop, the CNSs collected data using a paper questionnaire. Data collection included:

• Measurement of absolute pressures in mmHg at the forefoot (A) and calf base (B1), which were measured with a Picopress device. This pneumatic pressure device has a high degree of accuracy (Partsch and Mosti, 2010; Nandasiri et al, 2020) and consists of a 5 cm flat air-filled sensor. Guided by a clinical picture, the study nurse fixed the cables with a strip
• The CCB score (Protz et al, 2021) was used to assess students' skills in applying short-stretch compression therapy. To the research team's knowledge, this recently developed score is the only available measure that does not focus solely on the pressure under compression therapy device. It consists of six indicators to assess how well short-stretch compression therapy has been applied:
• Underpadding included
• Starting point of bandages
• Application of compression bandages that resulted in a pressure of between 22 mmHg and 27 mmHg at the forefoot (A), directly below the space between the big and second toe
• The heel is included
• The bandages are unrolled exclusively in the direction of the heart
• Application of compression bandages that resulted in a pressure of between 50 mmHg and 60 mmHg at the calf base, the junction between the tendon and the calf muscle, situated about 10 cm above the inner ankle.
• NB A total score of between 0 and 7 could be obtained (apart from item (f), which scored 2 points if it was achieved, all items scored 1; not addressing an item was scored 0). The score items were subtitled in French translation.
• The time to complete the exercise.

Other information recorded included assessment by the CNSs on, for example, the ability to use a pressure device, understanding the score, as well as additional comments.

Other information recorded included the viewpoint of the CNSs on, for example, students' proficiency in using a pressure-measuring device, understanding the score, as well as additional comments.

Data analysis

Each item on the CCB score was analysed as dichotomous data. Pressures measured by the Picopress device and the total score, as well as the time to undertake the exercise and obtain the score were interpreted as continuous data. The Wilcoxon signed-rank test was used to compare the groups before and after the workshop. The statistical software, STATA 16^©, was used for data analysis. Because this was a pilot study, no sample size was calculated.

Ethics and informed consent

Participation was voluntary. Students provided oral consent to participate. All data were anonymised before being transferred to the research team. According to the Swiss Human Research Act (HRA), ethical approval was not required, because no health-related or personal-related data were collected.

Results

The participation rate was 100% and, out of the 16 workshops, 16 participants were included into the pilot study and six CNSs were involved in data collection. The mean time for data collection was 8.02 minutes (min=3, max=20, SD=5.19) before the workshop and 9.25 (min=5, max=17, SD=4.03) afterwards.

The results show that mean pressure applied to the forefoot (A) increased from 13.06 mmHg (CI 95%: 7.45-18.67; SD=10.53) to 42 mmHg (CI 95%: 24.85-9.15; SD=32.19), which was statistically significant (z=-2.69; P=0.01). The obtained pressure was higher than the expected target (Figure 3). Before the workshop, 14 participants had applied the therapy below the expected pressure and two above. No students reached the target range of 22–27 mmHg. After the workshop, five participants' application fell below the expected pressure, nine achieved pressure above and two attained pressure within the target range.

The results for mean pressure on the calf base (B1), 10 cm above the inner ankle, increased with a statistical difference (z=-2.12; P=0.03) increased from 33.38 mmHg (CI 95%: 23.15-43.60; SD=19.18) before the workshop to 57.19 mmHg (CI 95%: 35.0-79.30; SD=41.5) after the workshop (Figure 4). Before the workshop, 13 participants applied the therapy under the targeted pressure, two above and one reached the targeted range of 50–60 mmHg. After the workshop, nine participants applied the compression therapy under the targeted pressure, four above and three attained the target value. One participant achieved a high score, with 108 mmHg at the forefoot and 180 mmHg at the calf-muscle base.

The mean CCB score increased from 3.57 (CI 95%: 3.08-4.06; SD=0.85) before the workshop to 4.47 (CI 95%: 3.81-5.12; SD=1.19) after participation. The Wilcoxon signed rank test showed no statistical difference (z=-1.41; P=0.16) between pre and post-measures. Two items of data were missing from the pre-workshop questionnaires, resulting in two incomplete scores, and four items were missing from the post-workshop questionnaires, resulting in one incomplete score. Table 2 presents the results obtained per item, including the missing data.

It was the opinion of the six CNSs that the CCB score and the Picopress device were easy to apply and to understand. In addition, they acknowledged the importance of using pressure devices and suggested adding criteria, such as ‘the foot position should be at a right angle to the lower leg’ or ‘use of at least two bandages’.

Discussion

This pilot study aimed to assess the feasibility of using the CCB score before and after a workshop on the application of short-stretch compression bandages with a cohort of BSc Nursing students. The participation rate was 100%, which was satisfactory. Providing students with the opportunity to participate in a study within a regular workshop showed that they had confidence in their own abilities, and so were comfortable in undertaking the exercise in front of their peers and the CNSs. However, the approach used could result in selection bias because the students involved were self-selected and so more likely have confidence in their own skills.

In this pilot study, before the workshops, the pressures attained by students when applying a short-stretch bandage the first time were low, showing an increase directly after the workshop in alignment with previous studies (Taylor et al, 1998; Tidhar et al, 2017). This study obtained pressure values above the expected range, which were also the findings of Tidhar et al (2017) and Keller et al (2009) in their studies. Incorrect handling of the device may have resulted in erroneous measurements, recording extreme outliers, an area that should be investigated in larger scale study. However, these similarities with the literature should be discussed with caution, because the different types of available bandages (inelastic or elastic bandages) may require different targeted pressures. In addition, as discussed in the literature (Taylor et al, 1998; Tidhar et al, 2017, Protz et al, 2021), it is important to take into consideration the fact that in these studies students are applying compression therapy on healthy legs without considering the challenges of difficult-shaped legs.

The overall CCB score, which in this study was 3.57 at T1 (before the workshop), was higher than Protz et al (2021), who reported a CCB score of 2.76. This could be because of the effectiveness of flipped classroom methodology (Banks and Kay, 2022) used in this study, which included specific videos (Coyne et al, 2018) to ensure that students were well prepared to perform technical skills during the workshop. The global CCB score at timepoint T2 (after the workshop) increased from 3.57 to 4.47. This is lower than that of Protz et al (2021), who reported a score of 4.88. A higher score may be influenced by variations in the skills of the study population, as Protz et al's (2021) study included registered nurses, who have experience of applying compression therapy in clinical practice.

The mean and minimum time required to apply short-stretch compression therapy increased after the workshop. This increase in time is likely to be related to the increased use of underpadding, the inclusion of the heel and the concentration required to apply to the target pressure. According to these results, a time frame of 20 minutes per participant should be planned to assess application of short-stretch compression therapy.

There is evidence (Zarchi and Jemec, 2014) to demonstrate that patients who have VLUs frequently receive inadequate compression therapy. It is therefore important that skills in applying pressure bandages should be acquired during nurses' undergraduate education (Lindhal et al, 2021), followed by continuing professional development, as these initially acquired skills have been described as ‘short term’ (Duran-Saenz et al, 2022).

Following data collection, and in alignment with other reported educational projects (Taylor et al, 1998; Tidhar et al, 2017), all the specialist wound care nurses who participated in the authors' study emphasised the importance of pressure monitoring to support the learning of compression therapy and were themselves able to use pressure-monitoring devices following a short tutorial. The CCB score was well understood by all the CNSs and small amendments were suggested by the participating CNSs to refine the score to better fit the context.

In total, three CCB scores were incomplete in our data collection – to minimise the risk of missing data when we undertake a full study the data will be collected electronically.

Strengths and limitations

To our knowledge, this pilot study is the first that has used absolute pressure measures and an objective score to evaluate students' application of compression therapy, to teach and then provide a formative assessment of nursing students' skills on an undergraduate BSc Nursing programme. Obtaining feasibility data, such as student participation rate or the time necessary to apply a compression bandage and assess a student's CCB score, will allow the authors to reuse the CCB score in standard pedagogical scenarios or further large-scale research projects. Nevertheless, if the CBB score is used for formal evaluation, a pass score would need to be defined when designing the course. However, due to selection bias (one student per group) and the small sample size, and because the study was conducted in one university, the results on the CCB score and absolute pressure reported from this study should be interpreted with caution and should not be generalised.

Conclusion

This pilot study demonstrated the feasibility of using the CCB score for educational purposes as part of a workshop with BSc Nursing students. The recruitment procedure worked as expected in terms of access to participants and participation rate. The use of Picopress and the CCB score may be valuable tools for data collection in a nurse education context and provide criteria for student feedback. This score and tools will be used in a larger study to determine the evolution of skills and their consolidation over time before and after students have received teaching on applying compression therapy via a blended learning module.

KEY POINTS

• The recruitment strategy worked and will be retained for the larger study
• Data collection using the CCB score was satisfactory
• A structured score helps to assess skills evolution
• Efficacy of blended-learning designs on compression therapy skills should be investigated

CPD reflective questions

• According to the variety of compression therapy devices, how would you support undergraduate nurses to be prepared for clinical practice?
• Which pedagogical scenario could fit existing nursing curricula to ensure skills maintenance in compression therapy over time?
• In your practice, do you apply compression therapy using pressure measurement devices?
• Regarding the effectiveness of compression therapy, consider why there is a lack of emphasis on educational projects?