R.I.S.E for the prevention of
pressure ulcers
Reposition, Inspection, Skin care, Eat well (R.I.S.E.)
– Information leaﬂet for carers for pressure ulcer prevention
Georgina Gethin,
Member of the
EWMA Council
PhD, RGN, PG Dip
Wound Healing, FFNM
RCSI, Dip Anatomy, Dip
Applied Physiology, MSc
(c) Clinical Research.
Senior Lecturer, School of
Nursing and Midwifery,
National University of
Ireland, Galway, Ireland
Professor Caroline McIntosh, PhD, BSc (Hons),
MSc, MChS. Head of podiatry, School of Health
Sciences, National University of Ireland, Galway,
Ireland
Correspondence:
georgina.gethin@
nuigalway.ie
Acknowledgements
We are grateful for
the funding from the
EXPLORE team at NUI
Galway (Wound Management Association of
Ireland [Western branch])
and the valuable feedback
and contributions from
many colleagues.
Conﬂits of interest: None
52
INTRODUCTION
Pressure ulcers are a signiﬁcant health care issue
that affect up to 18% of hospitalised patients and
3-10% in the home care setting. They also represent 4% of the caseload of community nurses1,
2. These ulcers are a major source of morbidity,
and they cause pain, depression, and the reduced
quality of life in the individual. In some cases,
death may occur. In addition, they constitute a
signiﬁcant cost to the health service, the patients,
and their families3.
Pressure ulcers are deﬁned as a localized injury to
the skin and/or underlying tissue. They usually
develop over a bony prominence as a result of
pressure itself or in combination with shear and/
or friction4. Attempts to prevent pressure ulcers
are varied and include approaches, such as risk
assessment, pressure re-distributing devices, and
local and regional health care initiatives, including education programmes for staff and patients
and the introduction of clinical care pathways.
Although all health care professionals have a role
and responsibility in pressure ulcer prevention, the
current situation of more people receiving health
care in the home care setting means that informal
carers are increasingly in the front line for prevention strategies.
HOME CARE SETTING
The shift in health care provisions from a hospitalbased system to the home care setting throughout
Europe has been reported in the European Wound
Management Association (EWMA) document entitled “Home Care Wound Care” (Probst et al.
2014) . The aim of this shift in care has been to
promote community and health care delivery in
the home care setting while simultaneously delivering better services, improving productivity,
increasing patient safety, and improving the quality of care5. A key challenge is that there is an increasing trend for patients in the home care setting
to be older with multiple co-morbidities, more
disabilities, and more complex health needs6, 7.
Such individuals rely not only on resources of the
healthcare system but also on informal carers to
help meet their needs.
Informal carers may include spouses, children,
neighbours, or friends. There is a large range of
possible relationships. For example, a young informal carer could provide support to a parent or
sibling, or younger parents could care for children.
Informal carers often gain satisfaction from their
caring role, as they are willing to take over the
responsibility of caring for a family member at
home8, 9. This underscores the need for the informal carer to receive appropriate support to be able
to undertake practical health care tasks, such as
the application of a wound dressing. Furthermore,
the onus is on health care providers to ensure that
appropriate information is available for informal
carers and that they can access support for their
decision-making role9.
The aims of education for patients and carers are
to optimize their input in the decision-making
process, improve understanding, recall, and
compliance, and reduce stress and anxiety. Effective education strategies for lay persons require
an understanding of factors that inﬂuence them
in decision making: knowledge, attitudes, skills,
and understanding. These strategies should also
consider literacy and language barriers and how
people may access information. The latter elements of language and literacy should be a major
consideration in designing information strategies,
due to the multicultural societies we now live in
and the low levels of literacy that are seen in some
countries.
Using data from Ireland as an example, the 2011
census ﬁgures showed that over half a million
(514,068) Irish residents spoke a foreign language
EWMA JOURNAL
2014 VOL 14 NO 2
Scientiﬁc Communication
Samples of the leaﬂet were distributed
by team members at the EWMA
conference in Madrid in May 2014.
PROJECT AIMS
This project was established, due to (1) the
important role of the informal carer in health
care provisions and the promotion of health
and wellbeing, (2) increases in the number of
people who are receiving health care in the
home care setting, and (3) challenges that are
involved in increasing the awareness of pressure ulcers and their prevention. Funding was
successfully obtained from EXPLORE at the National
University of Ireland, Galway (NUI Galway). This scheme
was intended to support initiatives in which students and
staff collaborate as equal partners in projects. Therefore,
this project aimed not only to promote the awareness of
pressure ulcer prevention among informal carers but also
to engage undergraduate nursing and podiatry students
in wound care innovations and to foster a lifelong interest
in the subject area. Further collaboration was gained from
the Carers Association of Ireland and the Irish Practice
䊳
Nurses Association (IPNA).
at home. Of these languages, Polish was by far the most
common, followed by French, Lithuanian, and German10.
Foreign languages are not the only consideration in the
provision of information. The International Survey of
Adult Literacy has shown that one in four Irish adults
have literacy difﬁculties11. Another 30% of Irish adults
were demonstrated to be at level 2, which signiﬁes that
they can only cope with very simple materials. Individuals
with literacy difﬁculties struggle to understand discharge
instructions, consent forms, handouts, and labels on prescriptions and over-the-counter medications. Many of
them cannot understand important health-related letters
or medical forms.
Ulcers
nt Pressure
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in
wash the skin
in Care • Eat
Well
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What do pressure ulcers look like?
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A pressure ulcer can look like redness of the skin
that does not go away to an open sore that goes
through to bone.
Preventing
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people wit
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This leaflet is intended as a guide only. If you are
concerned about anything in this leaflet please
discuss this with your healthcare professional.
Shoulder
Elbow Buttocks
Shoulder
Elbow
Hip
Ankle
Heel
Thigh
(external)
Shoulder
top
d at the
Reposition • Inspect • Skinban
Care
• Eat
Well
the legs.
To download this leaflet or for further
information on pressure ulcers please visit :
Sacrum
Funded by:
Heel
Care Giver Tip
Don’t forget to check places like the ears and tips
of toes. These are common areas where pressure
ulcers develop and are often forgotten.
EWMA JOURNAL
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If concerned
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Remember
ional.
care profess
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Further Information:
• www.wmai.ie
• www.carersassociation.ie
• www.irishpracticenurses.ie
Head
Ischion
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(internal)
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healthy
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We need goo ling. It is important
nutrition.
hea
are high in
and to help
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alw
so
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RISE
Where on the body can you get
Pressure Ulcers?
Eat well
Inspect
Pressure Ulcers
Reposition • Inspect • Skin Care • Eat Well
Contact Details:
for to move
are caring
person you
ld involve
y to help the more often. This cou
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2014 VOL 14 NO 2
Endorsed by:
Information
for Carers
Project team
Dr. Georgina Gethin, Professor Caroline McIntosh,
Brid McGing, Fiona Mullins, Lauren Brennan,
Sally Glynn, Orla Carey, Jacqui Hartigan,
Ann Gardiner, and Moira GunningNoone.
53
Scientiﬁc Communication
STEPS OF THE PROJECT
Step 1: Search and appraisal
To look for leaﬂets and information that are speciﬁcally
aimed at carers for pressure ulcer prevention, we searched
international wound care organizations’ websites and researched health information. We found only six examples
of information leaﬂets. However, these were all produced
for patients and not for carers. No other forms of information, such as videos or interactive education portals,
were found.
The six leaﬂets were appraised by the team for readability, clarity of expression, language use, use of illustrations
to convey messages, and general appeal. Of those identiﬁed, only one from the United States was sponsored by a
commercial organization and of high quality. This leaﬂet
was twelve pages long, A5 sized, and well-illustrated with
colour images. The language was also clear and easily understood. However, the ﬁnal four pages of the leaﬂet contained commercial advertising, along with product placements. One other leaﬂet contained excellent information
but was of low readability. It was only available in text,
used a font that was too small for the ease of reading, and
had no illustrations. The remaining four leaﬂets were of
even less quality, with technical language, small font sizes,
and a lack of illustrations.
Having failed to ﬁnd any available leaﬂets, the process of
designing content and presentation style commenced. A
key driver of the project was the readability of the ﬁnal
product and the ease with which it could be translated
into other languages.
Step 2: R.I.S.E.
The acronym, R.I.S.E., was devised to promote the basic
principles of pressure ulcer prevention among carers.
Reposition – regular repositioning can help prevent
tissue damage.
Inspect – daily inspection of the skin can identify
areas that are at risk of ulceration.
Skin care – washing and drying the skin can prevent
tissue damage.
Eat well – good nutrition and hydration are essential
for health and wellbeing.
We were mindful that this acronym could not be translated
verbatim into other languages but recognized that it could
be easily adapted by others. Although other acronyms have
been suggested within the literature, none were targeted at
carers. In addition, we wanted to keep the message simple
and direct. Therefore, fewer letters would help in recall
and understanding.
54
Step 3: Design and review
Over six months, the leaﬂet went through numerous iterations, and a ﬁnal design was chosen. Consultations with
graphic designers, carers, and practice nurses took place,
and further support, including project management and
project promotion, was gained from the Explore team.
Awareness and feedback on the project was also promoted
at the Stop Pressure Ulcer Day at NUI Galway in November 2013. The readability was appraised and deemed to be
appropriate to the reading ability of a 10-year-old person.
This was important, as some carers may have low literacy
levels when reading in their non-native language.
FINAL LEAFLET
The ﬁnal leaﬂet was launched at the Explore event in May
2014. In addition, samples of the leaﬂet were distributed
by team members at the EWMA conference in Madrid
in May 2014.
AVAILABILITY
The leaﬂet is freely available and has been uploaded on
the websites of the Wound Management Association of
Ireland (www.wmai.ie), IPNA (www.irishpracticenurses.
ie), and Carers Association (www.carersireland.com). Plans
are under way to have this available on other sites. As the
aim was to increase awareness and promote pressure ulcer
prevention, we agree that the leaﬂet can be downloaded
by any wound care organization, health care provider, or
patient support network. Furthermore, it can be translated into other languages, as long as the original source
䡵
is acknowledged.
References
1. Gallagher, P., Barry, P., Hartigan, I., McCluskey, P., O’Connor, K. & O’Connor, M.
Prevalence of pressure ulcers in three university teaching hospitals in Ireland.
J Tissue Viabil. 2008;17(4):103-9.
2. McDermott-Scales, L., Cowman, S. & Gethin, G. Prevalence of wounds in a
community care setting in Ireland. J Wound Care. 2009;18(10):405-6, 408,
410 passim.
3. Gethin, G., Jordan O-Brien, J. & Moore, Z. Estimating the costs of pressure area
management based on a survey of ulcer care in one Irish hospital. J Wound Care.
2005;14(4):162-5.
4. EPUAP (2009) Guide to pressure ulcer grading. EPUAP review 3 (on-line),
www.epuap.org/newsletter/epuap-reviews/vol10-issue1-2009/.
5. Vowden, K., Vowden, P. & Posnett, J. The resource costs of wound care in Bradford
and Airedale primary care trust in the UK. J Wound Care. 2009; 18(3):93-4, 96-8,
100 passim.
6. Probst, S., Seppanen, S., Gethin, G., Gerber, V., Hopkins, A. & Rimdeika, R.
EWMA Document Homecare WoundCare. J Wound Care. 2014;23(5):1-44.
7. Barry, U. Elderly care in Ireland-Provisions and Providers. In UCD School of Social
Justice Working Papers Series (U, B. ed. University College Dublin, Dublin)
2010:10:1-34.
8. Bee, P.E., Barnes, P. & Luker, K.A. A systematic review of informal caregivers’
needs in providing home-based end-of-life care to people with cancer. J Clin Nurs,
2009;18(10):1379-93.
9. McConigley, R., Halkett, G., Lobb, E. & Nowak, A. Caring for someone with
high-grade glioma: a time of rapid change for caregivers. Palliat Med.
2010;24(5):473-9.
10. CSO (2011) This is Ireland. Vol. www.cso.ie Central Statistics ofﬁce, Dublin.
11. OECD (2007) International Adult Literacy Survey: Results for Ireland. Vol.
www.nala.ie Department of Education and Science, Dublin.
EWMA JOURNAL
2014 VOL 14 NO 2