The Journal of Continuing Education in Nursing

Original Article 

Developing Competencies of Nurses in Wound Care: The Impact of a New Service Delivery Model Including Teleassistance

Genevieve Corriveau, MSc; Yves Couturier, PhD; Chantal Camden, PhD

Abstract

Background:

The implementation of a new wound care model of service delivery, including training and teleassistance, provided us with the opportunity to study nursing competencies in a primary health care context.

Method:

A mixed-methods study was chosen to address the complexity related to the development of competencies from two complementary perspectives.

Results:

Nurses' self-perceived knowledge and skills improved immediately after training. Factors identified as influencing the development process were grouped into three themes: Acquired Skills and Knowledge, Personal Factors, and Work Organization Factors.

Conclusion:

Our study demonstrates that the skills and knowledge can be enhanced through integrated continuing education efforts, and brings a deeper understanding of factors that influence the competency development. Finally, the research team highlighted the potential of telehealth technologies. [J Contin Educ Nurs. 2020;51(12):547–555.]

Abstract

Background:

The implementation of a new wound care model of service delivery, including training and teleassistance, provided us with the opportunity to study nursing competencies in a primary health care context.

Method:

A mixed-methods study was chosen to address the complexity related to the development of competencies from two complementary perspectives.

Results:

Nurses' self-perceived knowledge and skills improved immediately after training. Factors identified as influencing the development process were grouped into three themes: Acquired Skills and Knowledge, Personal Factors, and Work Organization Factors.

Conclusion:

Our study demonstrates that the skills and knowledge can be enhanced through integrated continuing education efforts, and brings a deeper understanding of factors that influence the competency development. Finally, the research team highlighted the potential of telehealth technologies. [J Contin Educ Nurs. 2020;51(12):547–555.]

Chronic and complex wounds may represent a significant burden for patients and for health care systems (Gray et al., 2018). Ongoing efforts have been made to increase the quality of care, patient and system outcomes, and nursing skills since nurses first learned about wound care in the late 1950s (Corbett, 2012). More than five decades later, nurses still strive to use best practices to cure and limit wound complications as quickly as possible and in the least invasive way for the patient. The impact of care on the wound is influenced by the patient's condition, the wound type, the treatment used, and by the nurses' skills and knowledge (European Wound Care Management Association, 2014). The skills and knowledge required by nurses to treat wounds are known to be diverse and numerous (Anderson, 2015). Although basic nursing education programs prepare graduates for wound care, continuing education is required for nurses to remain current with best practices. To do so, training is generally the most commonly used method in nursing (Fukada, 2018) and in health care (ten Cate & Scheele, 2007). Multiple studies have demonstrated that training fosters improvement in nurses' wound care knowledge (Dowsett, 2009; Khomeiran et al., 2006; Moran et al., 2018). However, training alone does not lead to change in practice (Epstein & Hundert, 2002; Légaré et al., 2015).

After initial training, in-practice support, such as mentoring (Lamb & Norton, 2018) and knowledge brokering (Glegg & Hoens, 2016), can further enhance the development of knowledge and skills. In the past decade, technology has also created new opportunities to implement on-the-job and after-training forms of peer support (Bogossian, 2015). In nursing care specifically, the use of teleassistance is perceived to be useful to improve knowledge sharing between nurses (Gagnon et al., 2014). Moreover, the use of teleassistance in wound care improves nurses' ability to clinically assess the wound (Lister et al., 2018).

Several authors have stated that knowledge and skills constitute key elements of competencies (Epstein & Hundert, 2002; Evans & Donnelly, 2006; Fernandez et al., 2012). In the field of nursing, competencies consist of knowledge (Kielo et al., 2018; O'Shea, 2002), skills (Kielo et al., 2018; O'Shea, 2002), and attitudes (Kielo et al., 2018). As nurses' competencies ensure quality of care and patient safety (Axley, 2008), seeking a clearer understanding of how these competencies developed is vital, specifically its main components—skills and knowledge. Advances in clinical practice and education have led to a clearer description of competency, but little is known about the factors influencing its development (Mccluskey & McCarthy, 2012). Most studies on nursing skills development are quantitative studies and do not offer an in-depth understanding of the development process or the factors that may influence this process (Welsh, 2018).

The implementation of a new wound care model of service delivery, including training and virtual clinics delivered through teleassistance, provided us with the opportunity to study nursing competencies in a primary health care setting. The primary objective was to determine whether the new model supports the development of competencies among nurses. We also explored the factors influencing the development of nursing competencies.

Method

Design

A mixed-methods study was chosen to investigate the development of competencies and to address the complexity of the phenomenon from two complementary perspectives. We opted for a concurrent design (Creswell, 2015).

Wittorski's (1998) competency development process has underpinned the current study, given that it proposes a functional and modern concept of competencies, where competency is achieved by an individual in a given situation and is recognized socially. It is the use through action of various skills and knowledge combined in a specific way (Wittorski, 1998). The framework developed by Wittorski helped to define the theoretical foundations necessary to inspire the research project (objectives), supported the development of collection tools, and guided the interpretation of the data. For example, given that the author maintains the influence of the knowledge and skills acquired in training on competency development, the research team chose to focus specifically and independently on each of these elements in the study. Also, Wittorski identified possible influences on the competency development process that were incorporated to the interview guide: personal motivation, perceived recognition, and witnessing the results. Wittorski's work is extensive; not only has it led to the identification of possible influences on competencies development but also to the creation of a typology of competencies development paths. Finally, the choice was made on Wittorski's work for a more open perspective. Indeed, this framework can be transposed to various professionals in the health and social services system.

The study was approved by the Research Centre's Ethics Committee of the Integrated University Health and Social Services Centres of Estrie–University Hospital of Sherbrooke.

Context

In three regional health care organizations (in a Canadian province), community nurses self-manage their case-load, comprising patients with various health care conditions, including wounds. Traditionally, when nurses did not feel they had the competencies to respond to their wound care patients' needs, they needed to seek help from experts in hospital centers. However, they struggled to obtain the required coaching because no formal procedure existed. Health care managers thus decided to implement a new service delivery model including teleassistance. Teleassistance is defined as a clinical act performed by a doctor or a health professional intervening with a patient or his or her family under the assistance of an expert, via video-conference (Centre de Coordination en Télésanté–Centre Hospitalier Universitaire de Québec, n.d.). In the current project, teleassistance was provided by virtual clinics.

The implementation of the teleassistance service began in spring 2017 with the recruitment of community nurses who would become resource nurses. These nurses attended a training session including theoretical teaching and practical exercises on wound care provided by enterostomal therapists, and a technology session by a telehealth technology expert to manage the virtual clinics. The training session was based on a wound care best practice guide developed by wound care expert nurses practicing in the Canadian province (Bouchard & Morin, 2009). It should be noted that during the training, updates or corrections were presented to nurses when needed (e.g., if a new treatment has been suggested in recent literature).

Following the training, each resource nurse returned to his or her job as a community nurse, but with new responsibilities related to providing support, advice, and information to other community nurses who had not taken part in the training. All community nurses were asked to refer to resource nurses when there was no sign of progress after 2 weeks of wound treatment. When consulted by a colleague, resource nurses could provide advice (no home visit required), make a home visit, and provide care, or they could ask an expert nurse for advice and coaching. This third option was made possible through virtual clinics, which allowed the resource nurse to interact directly from the client's home with an expert nurse based in a hospital center. When the latter option was preferred, the resource nurse had to schedule a meeting with the expert nurse and manage the technology at the patient's home to enable the expert nurse to see the wound and the home environment.

Population

The study population consisted of resource nurses, working in a primary care unit, recruited from 20 nursing teams across the three regional health care organizations.

Study Procedures

Questionnaire

Resource nurses were asked to complete a self-assessment questionnaire at three strategic moments: before the training session, immediately after, and 4 months after the training session. The questionnaire included 25 questions using a 9-point Likert scale. The questionnaire was developed jointly by the research and training teams, using the wound care best practice guide developed by Bouchard and Morin (2009) to ensure that it covered all the skills and knowledge involved in wound care. Two scores were calculated from the questionnaire: one for skills, and the other for knowledge.

Additional questions were included at each data collection time point. The prequestionnaire included five sociodemographic questions and one about the nurses' comfort level when using technology. The questionnaire distributed immediately after the training session included five questions (9-point Likert scale questions) about the intention to change practice based on behavioral change theories (Lauzier & Denis, 2016). These questions were used to describe participants in our study.

Interviews

Eight months after the beginning of the implementation, individual semistructured interviews were conducted with all participants (n = 11). The interview guide was developed with the implementation team using Wittorski's framework. Interview themes included the nurses' experience with the implementation process and factors influencing the development of their competencies according to Wittorski's work (i.e., motivation, perceived recognition, acquired skills and knowledge). Interviews were conducted over the telephone and lasted between 20 and 30 minutes. Interviews were recorded and transcribed.

Analysis

Questionnaire

Scores were computed for knowledge and skills, as well as converted to generate a percentage, enabling easier representation and comparison between categories not having the same number of questions. The Wilcoxon test was performed on each category's scores to assess whether self-perceived knowledge and skills in wound care changed over time: first, to measure whether training improved scores (posttraining score – pretraining score); second, to measure whether knowledge and skills were maintained over a 4-month period (4-month score – posttraining score).

Interviews

Data from the interviews were analyzed with NVivo using a mixed deductive-inductive approach. A content analysis was performed to identify themes relating to Wittorski's factors known to influence the competency development process, and emerging factors were added. To ensure the quality of the codification process, one team member did the first round and a second member reviewed half of the interviews.

Results

Participants

A total of 29 participants completed the prequestionnaire and the questionnaire following the training session, and 14 completed the 4-month posttraining questionnaire. Analysis showed there was no significant difference between the 14 participants who participated in every data collection and those who only completed the pre- and the posttraining questionnaire. Most of the resource nurses had more than 10 years of experience (n = 24; 82.8%) and more than 5 years of experience in wound care (n = 21, 72.5%). One in four participants did not feel comfortable using the technology before the training (1, 2, or 3 on a 10-level scale), and half of the participants felt only partially at ease (5, 6, or 7). Regarding the participants' intention to change, motivation to change practice, and the perceived usefulness of the content taught at the training session, the scores were higher than anticipated scores, which were already high. Table 1 presents these participants' characteristics.

Characteristics of Resource NursesCharacteristics of Resource Nurses

Table 1:

Characteristics of Resource Nurses

Changes in Self-Perceived Wound Care Skills and Knowledge

The nurses' self-perceived knowledge and skills improved immediately after training (p < .05), which demonstrates the impact of training on the two key elements of competencies. The same analysis conducted on post-training and 4-month posttraining scores showed no significant difference for either knowledge or skills. These results indicate that nurses had maintained their knowledge and skills 4 months after the training. Table 2 presents descriptive statistics of the knowledge and skill scores.

Descriptive Statistics of Total Scores for Knowledge and Skills at Each Measure Time (Pretraining, Posttraining, and 4-Month Posttraining)

Table 2:

Descriptive Statistics of Total Scores for Knowledge and Skills at Each Measure Time (Pretraining, Posttraining, and 4-Month Posttraining)

Factors Influencing the Competency Development Process

Factors identified as influencing the development of competencies were grouped under three themes: Acquired Skills and Knowledge, Personal Factors, and Work Organization Factors. Table 3 presents these themes and factors.

List of Themes and Factors Influencing the Development of Competencies

Table 3:

List of Themes and Factors Influencing the Development of Competencies

Acquired Skills and Knowledge. Acquired skills and knowledge were mentioned repeatedly by nurses as important factors influencing the development of their competencies. In fact, every nurse instinctively named skills and knowledge acquired by two different but complementary methods, training and virtual clinics, as essential means to developing their competencies. Comments from the resource nurses included:

  • My competencies did improve [after the training] because I gained knowledge in wound care.
  • She [the expert nurse] tells us what to look at [during virtual clinics] so I have direct support as I perform an action, which, in turn, supports the development of my competencies.

Complementarity between the training and virtual clinics was illustrated by the following quotes:

  • Both ways are different but equally valuable.
  • One does not come without the other, they complement each other.

Personal Factors. Five personal factors were identified as influencing the development of competencies: personal motivation, witnessing the results, perceived recognition, practice and experience, and attitude toward technology.

Nurses stated that personal motivation was a positive factor that influenced the development of their competencies because it enabled them to engage in care and improved their skills and knowledge. On the other hand, lack of motivation had a negative influence on the development of competencies. One resource nurse stated, “My personal motivation for wound care certainly influences my competency development.”

Witnessing the results among their patients, especially positive treatment outcomes (or stability when in the presence of a chronic wound) helped to build confidence and facilitated the integration of new learning. Witnessing the results enabled nurses to replicate in other patients what had worked for a certain wound type. This type of experiential learning was only possible in real-life clinical activity. Nurses stated that they learned from obstacles and negative outcomes:

  • It is positive because what I did, what I learned, what worked for my patient can be applied more easily than theoretical information.
  • Of course, it contributes to the development process because even when outcomes are not so positive, it forces us to look further.

Perceived recognition (e.g., from an immediate superior) was sought by nurses because it gave them confidence in their role and facilitated their competency development. The opposite was also observed; lack of recognition diminished their motivation and interest. Several nurses indicated they did not perceive any recognition, or even worse, they felt they received only negative comments regarding their roles. Recognition from peers was also seen as influential, as it meant more referred cases and a higher level of motivation and confidence. Lack of recognition from peers had a negative influence on their self-perceived competencies because it undermined their self-confidence and motivation. Several nurses commented:

  • I do not feel any recognition from my immediate superiors and it negatively influences the development of my competencies.
  • Negative comments or doubts about my capabilities definitely affect the development of my competencies.

Practice and experience were perceived as crucial for the development of competencies because practice consolidated acquired skills and knowledge, and experience strengthened and facilitated subsequent practice. According to one resource nurse, “I am 100% confident that practice and experience contributed to improving my competencies. Also, practice and experience boosted my confidence.”

Attitude toward technology was important for developing competencies in this context. Results showed that a positive and confident attitude toward technology had a positive influence on the development of competencies. In contrast, negative sentiment or technological distrust limited development. A resource nurse stated, “It certainly slowed down my development, at least at the beginning of the implementation phase…. I was afraid of not being able to do it, that something might go wrong.”

Organizational Factors. Identified organizational factors that affected the development of competencies were available time and technological issues.

Availability of time for care was a recurrent factor for most nurses. Planning and duration of clinics was organized to limit the impact on others. A nurse explained that she had to cancel a virtual clinic once because she had to cover for a staff shortage that day. Strategies that could potentially maximize time for care were the exchange of patients among nurses or asking immediate superiors for caseload rearrangements. Only a few tried these strategies because they did not want to overload their colleagues. In contrast, some nurses considered time as a positive influence for competency development for the following reasons:

  • They were exclusively dedicated to their resource mandate,
  • They had a combination of different responsibilities, or
  • They had a decreased caseload. As a result, they did not feel the same pressure as their colleagues who had a traditional community nurse caseload.

One nurse stated:

When we manage a virtual clinic, we are very anxious about the duration of the clinic because we do not want to neglect our other patients. We run like crazy, so it is not optimal for our practice.

Technological issues were generally perceived as a negative influence for the development of competencies, especially because after the training, some nurses waited up to 5 months before receiving their equipment for the virtual clinic and having a working internet connection. These delays forced the nurses to wait a long time before operating virtual clinics and using the technology. Delays before the practical application of knowledge presented a real challenge and had a negative influence, especially in terms of maintaining the nurses' newly acquired technology skills. Beyond delays and technological operability running, other issues were reported, such as the information technology (IT) support team's inability to solve problems rapidly during virtual clinics. The main consequences were as follows:

  • Nurses had to cancel virtual clinics.
  • The level of motivation decreased.
  • The nurses' feelings of anxiety rose sharply, especially among those who did not feel confident with the technology.

Ultimately, nurses stated that these technology-related issues had a negative impact on the development of their competencies. One nurse said:

The IT support team does not offer adequate support for my situation. Let's say I am at my patient's house and I have a problem: Their response is not appropriate. The IT guy asked me when he could call me back… I am at my patient's house right now, waiting for this technology to work! I am a community nurse. I visit patients all day. You can't call me back later!

Discussion

The study assessed whether the new model of service delivery, including training and virtual clinics, could support the development of competencies in wound care for nurses. Two key findings emerged from this study:

  • The new model of service delivery supports the development of competencies.
  • Multiple factors relating to acquired skills and knowledge, personal and organizational factors interact, either positively or negatively, with the development of competencies.

Our results showed that posttraining scores were significantly higher than pretraining scores. These results demonstrate that the training had a positive impact on the development of knowledge and skills. As the latter are the two unanimously recognized components of competencies (Fernandez et al., 2012), we conclude that the training therefore contributed to improving the nurses' competencies in wound care. Also, our results showed no significant difference between the posttraining and the 4-month posttraining measures for neither knowledge nor skills. This is important because it demonstrates that nurses maintained their skills and knowledge over this period. A previous research among nurses concluded that the forgetting curve can stretch from a few hours to a few months depending on the educational strategies used during training (Becker, 2017). Therefore, our finding is important because it demonstrates the preservation of the nurses' skills and knowledge over a period of 4 months.

Categories of factors identified as influencing competencies development (i.e., acquired skills and knowledge, personal factors, and organizational factors) are comparable to the results from other studies in nursing competency development (Khomeiran et al., 2006; Rizany et al., 2018; Yekta et al., 2002). However, some of our results relate specifically to the use of virtual clinics in the new service delivery model: Theoretical training allowed nurses to increase their wound care knowledge (Khomeiran et al., 2006) but it is only through active learning that skills can be learned and implemented (Arbon, 2004). Personalized support and coaching were valued by our study participants and were echoed by others who highlighted that an integrated approach, with active construction of competencies, has a higher potential for developing competencies (Field, 2004). We concluded that motivation significantly influences the development of competencies, as previously documented in multiple studies (Hassankhani et al., 2015; Khomeiran et al., 2006; Yekta et al., 2002). Perceived recognition was also identified as influential in our study and previous studies (Khomeiran et al., 2006).

Practice and experience were also reported as factors influencing the development of competencies, as echoed by others (Khomeiran et al., 2006). It is important to note that in the new model of service delivery, resource nurses would practice wound care more frequently due to their peer support role, multiplying opportunities to gain experience and thus increase their level of competency. Landmark et al. (2003) identified that repetition improves both technical and nontechnical skills and influences the development of competencies.

In the process of successfully implementing a new technology, new users may experience anxiety (Lee, 2004) and so they must be given technical support (Lister et al., 2018) and time to learn the technology (Barnard, 1997). Unfortunately, in our study, nurses stated that they did not have enough technical support and time to learn, and this may explain why attitude toward technology was considered a negative influence.

Organizational factors, such as technological issues and lack of time, are factors that influence the competency development process. In our study, nurses experienced significant delays and it is well documented that to facilitate the development of competencies, users must be able to practice immediately after the training session (Lee, 2004). As for lack of support, this can result in a negative experience when adopting technology and can have a significant influence on the development of competencies. Additionally, users are much more likely to develop a negative attitude toward a new technology when their experience is negative from the onset (Kolltveit et al., 2017).

Strengths and Limitations

First, the nature of the study generated more comprehensive results than a purely quantitative study. This was beneficial for research and clinical settings. Second, the fact that after the training most nurses in our sample felt committed to changing their practice demonstrated that implementing evidence-based practice created an appropriate setting for the study.

Inversely, it is possible that the population in our study was more committed to change or felt more comfortable using technology than the average community nurse and that the same implementation with a different population might lead to different observations.

One of the limitations of our study is the difficulty of assessing the effects of the frequent use of teleassistance on the development of competencies, as most of the resource nurses (n = 9) completed only two or fewer virtual clinics. A second limitation of this study is that, in the absence of a validated instrument to measure the development of wound care skills and knowledge, the research team opted to use a newly developed questionnaire for which additional experimentation and validation would be beneficial. Also, because our study is founded on a questionnaire that relies on self-perception, it is possible that results would have been different if experts had used a checklist to assess each nurse's skills. Further, the use of a wound care guide that dates from 2009 can pose a problem when it comes to its scientific relevance, given the rapid changes in knowledge in the evidence in wound assessment and treatment. Using more recent guidelines would certainly have guaranteed more up-to-date training. Finally, given that the research team focused on the two main components of competency and set aside other components, it is possible that other issues and influences were overlooked.

Implications and Future Opportunities for Nursing

This study highlights the importance for organization to better support nurses when a model of service delivery is implemented. For example, special consideration should be taken to ensure nurses have adequate support from their superiors to facilitate competency development and that technological support is available and based on the reality of home care. Finally, our research team recommends that studies should be conducted with more participants and over a longer period to assess whether frequent use of virtual clinics influences the development of competencies.

Conclusion

Competency is a complex concept and it remains difficult to grasp in research (Wittorski, 1998). Fortunately, Wittorski's work helps shape our data collection tools based on sound existing research on the competency development process, straightforwardly focusing on its influencing factors.

Our study offers a deeper understanding of the different factors that influence competency development. Furthermore, it demonstrates that skill and knowledge can be enhanced through integrated continuing education efforts. Finally, the research team highlighted the potential of telehealth technology and recommends further development of this component.

Following this study, our research team strongly emphasized the importance of performing a readiness assessment with future users and stakeholders to identify facilitating factors and challenges before implementing new technology.

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Characteristics of Resource Nurses

Variablen%
Sex
  Women2793
  Men27
Years of experience as a nurse
  5–10517.2
  11–201241.4
  >201241.4
Years of experience in wound care
  <113.4
  1–4724.1
  5–10931.1
  11–20931.1
  >20310.3
Professional status
  Full time2483
  Part time310
  Unknown27
Ease in using technology from 1 (veryuneasy) to 10 (very at ease)
  127.1
  213.6
  3414.3
  400
  5621.5
  613.6
  7725
  8414.3
  913.6
  1027.1
Intention to change—Motivation
  8724.1
  91965.5
  10310.4
Intention to change—Perceived usefulness
  8620.7
  91965.5
  10413.8
Intention to change—Anticipated support
  526.9
  6413.8
  7827.6
  8931
  9517.2
  1013.5

Descriptive Statistics of Total Scores for Knowledge and Skills at Each Measure Time (Pretraining, Posttraining, and 4-Month Posttraining)

Improvement Statistical Analysis Just After the Training (Posttraining – Pretraining)aImprovement Statistical Analysis 4 Months After theTraining (4 Months Posttraining – Posttraining)a


PretrainingPosttrainingPosttraining4-Month Posttraining
Knowledgen= 29Min: 32%n= 29Min: 69%n= 14Min: 73%n= 14Min: 68%
Max: 94%Max: 97%Max: 97%Max: 96%
Mdn: 69%Mdn: 87%Mdn: 87%Mdn: 85%
Skillsn= 29Min: 46%n= 29Min: 75%n= 14Min: 73%n= 14Min: 73%
Max: 92%Max: 100%Max: 100%Max: 97%
Mdn: 76%Mdn: 89%Mdn: 89%Mdn: 92%

List of Themes and Factors Influencing the Development of Competencies

Acquired skills and knowledge
  Training sessions
  Virtual clinics
Personal factors
  Motivation
  Witnessing the results
  Perceived recognition
  Practice and experience
  Attitude toward technology
Organizational factors
  Time management
  Technology issues
Authors

Ms. Corriveau is Graduate Student, Health Sciences Research, Dr. Couturier is Professor, and Dr. Camden is Assistant Professor, University of Sherbrooke, Sherbrooke, Quebec, Canada.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank the Telehealth Expertise and Coordination Centre from the Integrated University Health and Social Services Centres of Estrie–University Hospital of Sherbrooke for their collaborative and helpful engagement throughout this entire research project, and Canada Health Infoway for the grant they received (Canada Health Infoway was not involved in any decision concerning the study design, collection, analysis, interpretation of data, or the writing of this report).

Address correspondence to Genevieve Corriveau, MSc, Graduate Student, Health Sciences Research, University of Sherbrooke, 1036 Rue Belvedere, Sherbrooke, QC J1C 4C4, Canada; email: genevieve.corriveau@usherbrooke.ca.

Received: April 12, 2019
Accepted: June 08, 2020

10.3928/00220124-20201113-05

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