Providing effective management of chronic wounds can be a major challenge for nurses practicing in health care systems. Alvarez et al. (2007) defined a chronic wound as one that exhibits no clinical signs of improvement (has not developed 60% to 70% healthy granulation tissue and/or has not positively responded to treatment) in 3 to 6 months. Types of chronic wounds include infectious wounds, ischemic wounds, radiation poisoning wounds, surgical wounds, and ulcers (arterial, venous, diabetic, and pressure; Wound Care Centers, n.d.). Pressure ulcers, although preventable, are one of the most common and often debilitating chronic wound types. Despite advances in technology, preventive measures, and increased costs of care, pressure ulcers remain a common concern to health care professionals and can potentially increase the morbidity and mortality rates in those individuals affected by them. There are approximately 2 million individuals in the United States who develop a pressure ulcer each year, and the average cost for care in an acute care facility for an acquired in-house stage three or four pressure ulcer is reported at approximately $43,180 per case (Thomas, 2012).
As the population of older adults increases worldwide, the complexity of treating chronic wounds and the subsequent need for chronic wound care management has become a significant challenge for health care providers. Older adults are at a higher risk for developing chronic, comorbid conditions such as diabetes and diabetes-related complications, peripheral arterial and venous diseases, coronary artery disease, and immobility. These conditions often contribute to the development of chronic wounds and, combined with the normal age-related changes of older adulthood, increase the complexity of chronic wound care treatment and management (Gould et al., 2015). For example, the cost for management and treatment of diabetic foot ulcers in the United States was estimated to be between $7,000 and $10,000. However, this estimation increased to as much as $65,000 when complications such as amputations were needed (Trueman, 2008).
According to the Wound Care Centers (n.d.) across the United States, general evidence-based practices and guidelines for preventing chronic wounds are to teach patients to avoid all known risk factors that can lead to the development of a wound and to maintain a healthy lifestyle with proper hygienic practices. Treating and removing the underlying causes of chronic wounds should be the primary focus of management, followed by keeping the wound clean, applying topical antibiotics with appropriate wound dressings, prescribing anti-inflammatory medications, and eating a healthy, high-protein diet. In some cases, surgical debridement to remove accumulated dead tissue may be necessary to improve blood flow and supply of nutrients to the wound.
Standardized criteria for staging wounds have been developed to assist practitioners in wound care treatment and management (Infolink, 2016). These stages are:
- Stage 1: Observable and palpable changes to the top layer of skin tissue. Symptoms include skin color that is slightly more red, blue, or purple than surrounding tissue, and slightly warmer and raised.
- Stage 2: Considered partial thickness wounds that involve tissue loss of epidermis and dermis levels. Common stage 2 wounds are abrasions and blisters.
- Stage 3: Characterized by full-thickness tissue loss extending to subcutaneous level. Necrotic tissue and tunneling may be present.
- Stage 4: Extreme loss or damage to tissue, muscles, and bones. Muscle and bone are often exposed. Necrotic tissue and tunneling are often present. Pain levels may not match the severity of the wound as they beyond nerve endings.
- Unstageable: Wounds that are unclassifiable due to tissue (eschar and slough) covering the wound.
The National Pressure Ulcer Advisory Panel has also identified deep tissue pressure injury for pressure ulcers only. These wounds have intact or nonintact skin with nonblanchable deep red, maroon, or purple discoloration, or epidermal separation revealing a dark wound bed or blister (Infolink, 2016).
Background and Significance
Since Florence Nightingale's (1992) landmark publication Notes on Nursing: What It Is, and What It Is Not, nurses have been educated to prevent and care for wounds. Nurses' knowledge and attitudes regarding chronic wound care management are critical to successful chronic wound care outcomes. The meta-analysis by Ubbink, Santema, and Stoekenbroek (2014) of the Cochrane systematic reviews found a large amount of evidence-based practices that should be used by all health care providers to ensure optimum quality of care for patients with chronic wounds. However, nurses have been found to lack adequate knowledge in evidence-based practices and guidelines in the adequate provision of chronic wound care management (Ayello, Baranoski, & Salata, 2005; Dunk & Taylor, 2011; Jergensen & Nygaard, 2010; Zulkowski & Ayello, 2005). Ayello et al. (2005) surveyed 692 nurses in the United States and found that nurses in general have a good understanding of wound care. However, younger nurses, less experienced nurses, and nurses working in hospitals were found to need more education regarding wound care. In Denmark, 80% of wounds were found to be treated by nurses in home care settings, yet nurses working in these sites lacked adequate evidence-based knowledge to recognize early signs of wound decline. The authors concluded from their findings that a systematic ongoing educational approach to teach nurses regarding evidence-base practices to improve chronic wound care outcomes is essential (Jergensen & Nygaard, 2010). A study of nurses in Australia (Dunk & Taylor, 2011) cited the rigors and time restraints of many nursing programs limit adequate preparation of graduates in chronic wound care and chronic wound care management. Limitations on the amount of time devoted to these topics in undergraduate curriculums were hypothesized to be the reason for this lack of knowledge. Zulkowski and Ayello (2005) surveyed a sample of 164 RNs and 63 licensed practical nurses in urban and rural areas and found thatafter completing the Pieper Pressure Ulcer Knowledge Test (Pieper & Mott, 1995), participants scored in the 70%, or grade of C, range. Zulkowski, Ayello, and Wexler (2010) surveyed 460 nurses and found that those who were certified as wound specialists from the Wound Ostomy Continence Nursing Certification Board and the Academy of Wound Care Management had significantly higher pressure ulcer knowledge scores than nurses who were not certified in wound care or any nursing specialty. Therefore, the need for continuing education for nurses regarding the assessment and management of chronic wounds, as well as the need to provide nurses with repeated educational sessions to retain knowledge and improve levels of understanding, is warranted (Thomas, 2012).
Research on evidence-based chronic wound care and chronic wound management has been studied by nursing scholars, with emphasis on education and training in wound healing. Most studies have been quantitative with emphasis on investigating the need for further nursing education and training in chronic wound care management and thus increasing nursing's knowledge and practice skills regarding chronic wound care management. Nursing has a crucial role in improving chronic wound care outcomes and subsequently reducing the rising health care cost expenditures. Therefore, the purpose of this pretest–posttest study was to determine whether nurses' knowledge regarding current chronic wound care and chronic wound management practices would differ after attending an educational workshop that emphasized the use of evidence-based practice guidelines in chronic wound care and chronic wound management. The following research question was addressed in this study: “Will nurses who attend an educational workshop emphasizing the use of evidence-based practice guidelines demonstrate an increase in knowledge regarding evidence-based chronic wound assessments and chronic wound management?”
Participants were recruited from long-term–care facilities and home care agencies in one metropolitan area in the midwestern United States. Directors of nursing were contacted to arrange for an informal meeting to present information regarding the study, answer any questions about the study, and obtain permission to post flyers on staff communication boards. Potential participants were prompted on the posted flyers to contact the principal investigator (PI; L.G.-E.) and register for the educational workshop. Individuals were eligible to participate if they were RNs, licensed practical nurses, or advanced practice registered nurses who were working directly, working indirectly, or not working at all with chronic wounds but had an interest in gaining knowledge and information regarding current evidence-based chronic wound care and chronic wound management practices.
Participants were asked to fill out a demographic survey that asked questions regarding the participants' age, gender, race, ethnicity, educational level, and years of practice as a nurse. Participants were then asked whether they believed wound care was important, whether they cared for patients with wounds, and whether they used evidence-based practice guidelines. The demographic survey ended with a self-reported assessment of adequacy regarding preparedness to treat chronic wounds and/or sought independent learning activities or consulted experts regarding chronic wound care and chronic wound management. A pretest and duplicate posttest consisting of 20 questions (multiple choice and true or false) was developed by the PI derived from the content that was presented in the 8-hour workshop. The tests measured the nurses' knowledge of chronic wounds and chronic wound care management prior to attending the workshop and then postworkshop. The number of correct answers to the questions were summed, resulting in a range of zero to 20. Content validity of the test questions was assessed by two PhD-prepared faculty members.
Institutional review board approval from a university in the Midwest was obtained prior to implementation of the study. On the day of the educational workshop, an information sheet highlighting the purpose, procedures, risks, and benefits of the study was distributed and reviewed with each participant. A demographic survey and pretest was then distributed for completion prior to onset of the educational workshop. Once the pretests were collected, the educational workshop was conducted. Total time for the educational workshop was approximately 8 hours. After the workshop, participants were asked to complete the posttest. Participants were then provided 7.0 continuing education contact hours if they attended the entire educational workshop.
The educational workshop was conducted as an interactive, PowerPoint® presentation designed to engage participants in active discussions, brainstorming, and debates regarding evidence-based chronic wound care practice guidelines and wound management concepts and principles. The educational workshop began with a brief discussion of the structure and function of the skin and how the skin changes with aging. Differences between acute and chronic wounds were then presented, followed by the phases of wound healing. Wounds with necrotic tissue, exudate, and infection were discussed, ending with wound bed preparation. Common chronic wounds were then reviewed in detail by the PI, and this included diabetic foot ulcers (Wounds International, 2013), pressure ulcers (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, & Pan Pacific Pressure Injury Alliance, 2014), venous leg ulcers (O'Donnell et al., 2014), and arterial ulcers (The Wound Healing Society, 2006). Evidence-based assessment skills were presented to assist in determining what type of chronic wound the patient had (diabetic foot ulcers, pressure ulcers, venous leg ulcers, and arterial ulcers), followed by the appropriate practice guidelines to treat and manage them. Participants were also instructed on how to effectively evaluate wound healing progression. Workshop objectives are presented in Table 1.
Learning Objectives for the Educational Workshop
Data analyses using SPSS® 21.0 software were used in this study. Descriptive statistics were computed that included frequency distributions and percentages, means, and standard deviations (Tables 2–3). Paired-samples t tests were used to address the research question. The level of significance for each test was preset at alpha = .05.
Sample Characteristics (N = 31)
Adequacy of the Preparation and Continued Education of the Participants (N = 31)
Thirty-one RNs consented to participate in the study. On average, the nurses were approximately 51 years old (SD = 12.2), female (n = 28, 90.3%), African American (n = 15, 48.4%), had an Associate Degree in Nursing (n = 11, 37.9%), and were actively practicing for 22.5 years (SD = 15.5). Twenty-nine participants reported that chronic wound care management was an important health concern for RNs (Table 2). Most of the participants reported managing (n = 26, 83.9%) and treating (n = 23, 74.2%) chronic wounds, whereas only 10 (32.4%) could make diagnoses. Almost all participants (n = 29, 93.5%) did patient teaching regarding self-management of chronic wound care. Of interest, 25 RNs (80.6%) reported referring patients to wound care specialists and 20 (71.4%) felt inadequately prepared to care for patients with chronic wounds. In addition, only 18 (58.1%) cited using specific chronic wound care management guidelines. Finally, the most common modes of continuing education on chronic wound care management reported by the participants in descending order were from conferences (n = 20, 64.5%), journals (n = 16, 51.6%), textbooks (n = 13. 41.9%), and experts (n = 13, 41.9%; Table 3).
Educational Workshop Effectiveness
After attending the educational workshop, a statistically significant increase in the participants' knowledge regarding chronic wound care management was found from pretest (M = 13.48, SD = 2.49) to posttest (M = 16.03, SD = 2.21; t = −4.50, p < .05). Nurses in this study demonstrated an increase in knowledge regarding evidence-based chronic wound assessments and chronic wound care management for a variety of chronic wound types.
Nurses who attended this educational workshop and participated in this study reported a statistically significant increase in knowledge regarding chronic wound care management. More than half of the nurses in this study reported being inadequately prepared to treat chronic wounds and sought further assistance in managing them. This study adds to the existing body of evidence that supports the need for nurses to receive additional education and/or continuing education in chronic wound care management to achieve positive health outcomes within this population (Ayello et al., 2005; Jergensen & Nygaard, 2010; Zulkowski et al., 2010). Findings from this study also support those in the study by Dunk and Taylor (2011) that suggested the need for nursing programs to increase didactic and theoretical content within curricula on evidence-based chronic wound care management and within clinical practice settings. In addition, this study found that little more than half of the nurses reported using evidence-based clinical practice guidelines when treating chronic wounds; therefore, further education on the importance of using evidence-based clinical practice guidelines when managing chronic wounds is crucial to achieve more positive health outcomes.
Despite these interesting findings, there were several limitations. The first limitation was the small sample size (N = 31) that decreased the generalizability of the findings.
The second limitation of the study was that the nursing knowledge was only tested on paper and not in clinical practice. An assumption in this study was that an increase in knowledge would carry over into the care and management of chronic wounds; however, this assumption was not tested in practice. Finally, there was no time lapse between the end of the workshop and the posttest to determine whether the knowledge gained from the workshop persisted overtime. Further research is needed in larger sample sizes and within practice settings through measurable chronic wound care outcomes over time.
Implications for Nursing Education and Practice
As the population of older adults with multiple comorbid conditions continues to increase, the need for continued education on the use of practice guidelines and chronic wound care management is crucial. This study suggests the need to increase nursing education in chronic wound care management across nursing curriculums and health care systems. Nursing education must address current chronic wound care evidence-based practice guidelines to improve clinical outcomes. Advanced registered practice nurses, especially those who are board certified wound specialists, are authorized to educate practicing nurses through continued educational programs and/or hands-on opportunities within health care systems. Policies within health care systems can also be developed to mandate continued education on chronic wound care management. Nurses have been managing chronic wounds since the time of Florence Nightingale; however, the complexity of caring for older adults with comorbid conditions requires nurses to be knowledgeable when there are changes in standards, in science, and technology regarding current evidence-based wound care management protocols and guidelines.
- Alvarez, O.M., Kalinski, C., Nusbaum, J., Hernandez, L., Pappous, E., Kyriannis, C. & Comfort, C.P. (2007). Incorporating wound healing strategies to improve palliation (symptom management) in patients with chronic wounds. Journal of Palliative Medicine, 10, 1161–1189. doi:10.1089/jpm.2007.9909 [CrossRef]
- Ayello, E.A., Baranoski, S. & Salati, D.S. (2005). A survey of nurses' wound care knowledge. Advances in Skin and Wound Care, 18, 268–275. doi:10.1097/00129334-200506000-00013 [CrossRef]
- Dunk, A.M. & Taylor, J. (2011). Understanding and closing the knowledge gaps for graduate nurses. Australian Nursing Journal, 19(2), 39.
- Gould, L., Abadir, P., Brem, H., Carter, M., Conner-Kerr, T., Davidson, J. & Schmader, K. (2015). Chronic wound repair and healing in older adults: Current status and future research. Journal of the American Geriatrics Society, 63, 427–438. doi:10.1111/jgs.13332 [CrossRef]
- Infolink. (2016). Association news: National Pressure Ulcer Advisory Panel. Advances in Skin Wound Care, 29, 248.
- Jergensen, S.F. & Nygaard, R. (2010). Evidence based guidelines: How to channel relevant knowledge into the hands of nurses and cares who are treating patients in daily life. EWMA Journal, 10(2), 23–26.
- National Pressure Ulcer Advisory PanelEuropean Pressure Ulcer Advisory PanelPan Pacific Pressure Injury Alliance. (2014). Prevention and treatment of pressure ulcers: Clinical practice guideline. Osborne Park, Australia: Cambridge Media.
- Nightingale, F. (1992). Notes on nursing: What it is, what it is not. Philadelphia, PA: Lippincott Williams & Wilkins.
- O'Donnell, T.F., Passman, M.A., Marston, W.A., Ennis, W.J., Dalsing, M., Kistner, R.L. & Gloviczki, P. (2014). Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum [Supplemental material]. Journal of Vascular Surgery, 60(2), 3S–59S. doi:10.1016/j.jvs.2014.04.049 [CrossRef]
- Pieper, B. & Mott, M. (1995). Nurses' knowledge of pressure ulcer prevention, staging, and description. Advances in Wound Care, 8(3), 34–48.
- Thomas, A. (2012). Assessment of nursing knowledge and wound documentation following a pressure ulcer educational program in a long-term care facility: A capstone project. Wound Practice and Research, 20, 142–158.
- Trueman, P. (2008). Cost effectiveness considerations for home health V.A.C. therapy in the United States of America and its potential for international application [Supplemental material]. International Wound Journal, 5(Suppl. 2), 23–26. doi:10.1111/j.1742-481X.2008.00468.x [CrossRef]
- Ubbink, D.T., Santema, T.B. & Stoekenbroek, R.M. (2014). Systematic wound care: A meta-review of Cochrane systematic reviews. Surgical Technology International, 24, 99–111.
- Wound Care Centers. (n.d.) Types of chronic wounds. Retrieved from http://www.woundcarecenters.org/article/wound-types/chronic-wounds
- The Wound Healing Society. (2006). Chronic wound care guidelines. Retrieved from http://woundheal.org/files/2017/final_pocket_guide_treatment.pdf
- Wounds International. (2013). Best practice guidelines: Wound management in diabetic foot ulcers. London, United Kingdom: Author. Retrieved from http://www.woundsinternational.com/media/issues/673/files/content_10803.pdf
- Zulkowski, K. & Ayello, E.A. (2005). Rural and urban nurses' knowledge of pressure ulcers. World Council of Enterostomal Therapists Journal, 25(3), 24–30.
- Zulkowski, K., Ayello, E.A. & Wexler, S. (2010). Certification and education: Do they affect pressure ulcer knowledge in nursing? [Supplemental material]. Journal of Nursing Administration, 40, S34–S38. doi:10.1097/NNA.0b013e3181f37e56 [CrossRef]
Learning Objectives for the Educational Workshop
|After Attending This Workshop, Participants Will Be Able to:|
Identify the basic structures and function of the skin.
Identify the differences between acute and chronic wounds.
Identify age-related changes to the skin.
Identify the phases of wound healing.
Describe primary/secondary intention wound healing.
Describe characteristics of healthy/unhealthy granulation tissue.
Identify types of exudate.
Describe the principles of wound bed preparation.
Describe how wounds are staged/classified.
Describe incontinent associated dermatitis and moisture associated skin damage.
Identify several types of wound care products.
Describe etiology, risk factors, assessment, and treatment of pressure ulcers.
Describe etiology, risk factors, assessment, and treatment of venous ulcers.
Describe etiology, risk factors, assessment, and treatment of arterial ulcers.
Describe etiology, risk factors, assessment, and treatment of diabetic foot leg ulcers.
Sample Characteristics (N = 31)
|Characteristic||n (%)||Mean (SD)||Range|
|Age (years)||51.1 (12.2)||27 to 72|
|Years in practice||22.5 (15.5)||1 to 53|
| Female||28 (90.3)|
| Male||3 (9.7)|
| Asian||9 (29)|
| African American||15 (48.4)|
| Pacific Islander||1 (3.2)|
| Hispanic or Latino||1 (3.2)|
| Caucasian||5 (16.1)|
|Highest degree achieved|
| Diploma||4 (13.8)|
| Associate Degree in Nursing||11 (37.9)|
| Bachelor of Science in Nursing||9 (31)|
| Master of Science in Nursing||4 (13.8)|
| PhD in Nursing||1 (3.4)|
|Chronic wound care is an important health concern.|
| Yes||29 (100)|
| Missing||2 (6.5)|
Adequacy of the Preparation and Continued Education of the Participants (N = 31)
|Felt adequately prepared to care for chronic wounds|
| Yes||8 (28.6)|
| No||20 (71.4)|
|Additional continued education:|
| Used textbook||13 (14.9)|
| Took a course||10 (32.3)|
| Attended conferences||20 (64.5)|
| Read journal articles||16 (51.6)|
| Sought experts||13 (41.9)|
| Joined wound organization||4 (12.9)|
| Attended work meetings||10 (32.3)|
| Attended workshops||9 (29)|