Purpose: To analyze content related to chronic wounds in nursing degree programs in Spain. Design: Cross-sectional descriptive study. Methods: Course descriptions available for online access during June and July of 2012 were reviewed for the 114 centers in Spain that offer a nursing degree, according to the official Registry of Universities, Centers, and Titles. Findings: Of the 114 centers with degree programs, 95 (83.3%) post course content online, which make it possible to analyze 2,258 courses. In 60 (63.1%) of these centers, none of the courses included the concept of pressure ulcer prevention, and the course content posted by 36 (37.9%) centers made no mention of their treatment. None of the course descriptions contained any reference to pain management in patients with chronic wounds. Of the 728 elective courses analyzed, only one was related to chronic wounds. Conclusions: This review of available information about nursing degree programs in Spain indicates that pain management in patients with chronic wounds is not addressed in any course, and more courses consider the treat- ment of pressure ulcers than their prevention. Clinical Relevance: Degree programs responsible for the training of future nurses should be reviewed and revised as needed to ensure that graduates have acquired minimum basic competencies in the prevention and treatment of chronic wounds that help to decrease the theory–practice gap in this field.
Chronic wounds are a major factor in morbidity, mortal- ity, and healthcare costs (Augustin, Brocatti, Rustenbach, Schäfer & Herberger, 2014; Sen et al., 2009). On health- care teams, nurses typically have the responsibility of car- ing for patients who have these wounds or are at risk for them (Caron-Mazet, Roth, & Guillaume, 2007; Romero- Collado, Homs-Romero, & Zabaleta-del-Olmo, 2013).
Despite increased knowledge about chronic wound prevention and treatment, scientific evidence is not always translated into clinical practice to the extent that
would be desirable. The knowledge possessed by health- care professionals is one of the key factors most fre- quently identified in efforts to explain the existence of this theory–practice gap, although organizational and environmental factors also have an impact (Moore, 2010). Cowman et al. (2012) conducted an international, multidisciplinary eDelphi study to identify the research and education priorities in wound management and tis- sue repair. This study offers a point of reference to con- sider where we are in this field and what should be
Journal of Nursing Scholarship, 2015; 47:1, 51–61. 51 C© 2014 Sigma Theta Tau International
Course Content Related to Chronic Wounds Romero-Collado et al.
done to improve the preparation of healthcare profes- sionals, thereby improving the prevention and treatment of chronic wounds.
The Bologna Declaration (European Ministers of Ed- ucation, 1999) establishes a new framework for Eu- ropean universities and a convergence of university degrees to facilitate mobility in the European job market (Davies, 2008). It also encourages study of the major Eu- ropean Union languages and discipline-specific study in those languages.
For the nursing profession in Spain, the new frame- work has led to the progressive disappearance of the 3-year nursing programs in universities (Zabalegui & Cabrera, 2009), which are being expanded to 4 years, 240 European Credit Transfer System (ECTS) units, and foreign language competency (level B2.1) in English, French, German, or Italian. In contrast, nursing degrees are completed in 3½ years and 210 ECTS in Denmark and Finland, and 3 years and 180 ECTS in Norway and Swe- den (Råholm, Hedegaard, Löfmark & Slettebø, 2010). Full implementation of the new degree program in Spain will give the nursing profession equivalency with other de- grees with respect to future options and opportunities. This includes access to higher academic degrees (mas- ter’s and doctoral degrees) by way of their own disci- pline rather than by way of disciplines such as biology or psychology.
Another substantial impact of the Bologna process is a change in the concept of learning. The previous model was that learning was based on the knowledge consid- ered necessary to obtain the diploma. This could concur— or not—with what the future professional would need to know for success in the workforce, but there sometimes appeared to be a large gap between the academic and working worlds. Under the Bologna process, learning is oriented toward skills and competencies and is student centered (Zabalegui & Cabrera, 2009). To address the theory–practice gap, courses must be designed to achieve essential competencies, along with knowledge of theory. This aligns with the white paper on the degree in nurs- ing published by Spain’s national accreditation agency, which indicated that the cross-cutting competency most valued by practicing nurses, university professors of nurs- ing, and nursing administrators is “the ability to apply knowledge to practice” (Agencia Nacional de Evaluación de la Calidad y Acreditación, 2004).
The theory–practice gap, defined as the lack of match- ing textbook descriptions of clinical situations with the reality of practice, is a vitally important topic for
nursing education (Scully, 2011). For example, the lack of education about the prevention of pressure ulcers (PUs) is cited as a cause of their high prevalence and incidence (Moore, 2010) and of the persistence of care interventions that are not recommended, such as the use of “doughnut”-type devices or massaging areas of redness (Iranmanesh, Rafiei, & Foroogh Ameri, 2011; Panagiotopoulou & Kerr, 2002; Pancorbo-Hidalgo, Garcı́a-Fernández, López-Medina, & López-Ortega, 2007; Saleh, Al-Hussami, & Anthony, 2013). In other studies, the majority of nurses in an intensive care unit had the perception that their unit could improve its attention to patients who had or were at risk for developing PUs (Quesada Ramos & Garcı́a Dı́ez, 2008), and slightly more than half of the nurses in 14 long-term care units consid- ered their knowledge of chronic wound management to be “average” (Caron-Mazet et al., 2007).
The prevalence of PUs in Spain ranges from 5.9% to 13.5%, depending on whether the population is being treated as part of a primary care home-health program or in a hospital or long-term care center (Leyva-Moral & Caixal-Mata, 2009; Soldevilla Agreda, Torra Bou, Verdú Soriano, & López Casanova, 2011). These values are similar to those of other European countries, such as Sweden’s 14.5% prevalence in nursing homes and 16.6% in hospitals (Gunningberg, Hommel, Bååth, & Idvall, 2014), the 6.4% reported in a long-term care study in France (Caron-Mazet et al., 2007), and the 9% observed in a long-term care setting in the Republic of Ireland (Moore & Cowman, 2012).
Training nurses in the prevention and treatment of PUs is of fundamental importance. Nonetheless, there are ma- jor deficiencies in undergraduate course content related to this type of wounds (Ayello, Zulkowski, Capezuti, & Sibbald, 2010). In a study of emergency care profession- als in Spain (Hinojosa-Caballero, 2012), just 23% consid- ered their university education about PU prevention to be “good,” and the rate decreased to 19% when asked about aspects of PU treatment. Other studies have reported that 25% of nurses reported never having received any spe- cific information about PUs in their professional program (Zamora Sánchez, 2006), 53.1% received no training spe- cific to PU wound care (Romero-Collado et al., 2013), and 70% indicated they did not receive sufficient education about chronic wounds in their basic nursing education program (Ayello, Baranoski & Salati, 2005). These defi- ciencies were also observed in textbooks recommended by nursing educators (Wilborn, Halfens & Dassen, 2009), and wide variation in PU-related textbook content has been reported (Ayello & Meaney, 2003). However, nurs- ing textbooks are not the only element that requires improvement to develop the needed skills. Educational programs must combine textbook content with a variety
52 Journal of Nursing Scholarship, 2015; 47:1, 51–61. C© 2014 Sigma Theta Tau International
Romero-Collado et al. Course Content Related to Chronic Wounds
of learning methods, including hands-on experience in the laboratory.
An analysis of what undergraduate nursing students know about PUs reported a low general level of knowl- edge (Larcher Carili, Miyazaki, & Pieper, 2003), despite evidence that even a small educational intervention (2- hr lecture-laboratory session) is effective in the short term (2-month follow-up) in improving students’ knowl- edge about chronic wounds (Huff, 2011). Nursing stu- dents also believe that the more time dedicated to guided practice and clinical teaching, the greater will be the im- provement in their skills and knowledge about main- taining skin integrity (Ousey, Stephenson, Cook, Kinsey, & Batt, 2013).
Given the impact of chronic wounds in the gen- eral population, a multidisciplinary, international eDel- phi study (Cowman et al., 2012) was conducted to identify research and education priorities to improve wound management and tissue repair. The purpose of the present study was to analyze the content specified in de- scriptions of the basic courses taught in the 114 degree in nursing programs in Spain to identify instruction re- lated to the four priorities identified by Cowman et al. (2012): pain management, PU prevention, wound bed as- sessment, and selection of dressings.
A cross-sectional design was used to analyze the con- tent on chronic wounds in nursing degree programs in Spain.
We analyzed the degree programs offered by the 114 teaching centers that award the degree in nursing in Spain, as indicated by Spain’s official database of uni- versities, centers, and diplomas offered, the Registro de Universidades, Centros y Tı́tulos (RUCT; Gobierno de España, 2008). Search terms included degree titles con- taining “Nursing,” academic level of “Degree program,” and discipline of “Health Sciences.” For each center, we obtained the names of courses and number of credits for each course in the nursing degree program.
From June 11 to July 6, 2012, we analyzed the degree in nursing program information included in the RUCT, accessed the web page for each center, and assessed the program and course content that was available online. No
centers were excluded from the study. We would note, however, that Spain has gradually implemented the un- dergraduate nursing degree and not all universities have proceeded at the same pace. Therefore, not all programs have published course descriptions for the full 4-year de- gree in nursing program.
Two researchers independently analyzed the content of each course description or syllabus and reached a consen- sus agreement. A third researcher was available to review the course information in the event of any discrepancy. A data collection form was designed ad hoc to record the data obtained about each degree program and course. The following variables were recorded for each program: � Access: The number of years of the 4-year undergradu-
ate degree in nursing for which online access to courses was available.
� Number of Required Courses: Total numbers of re- quired courses, basic courses, guided practice, and fi- nal project (recorded to determine the nursing degree requirements, excepting elective courses).
� Courses Entirely Related to Chronic Wounds: Number of required courses with a title explicitly containing the words “chronic wound.”
� Courses With Content Related to Wounds: Number of required courses, basic courses, guided practice, and fi- nal projects that included any of the following content in the available description: Pain and chronic wounds, Pain control or management (to capture any content related to controlling pain in general), Prevention of pressure ulcers, adults (assigned to a related “pressure ulcer” variable because there could be courses with only this content), Wound bed assessment, selection of dressings, or the mention of any product related to moist wound healing. These were later assigned to a related variable covering a broader concept, “Treat- ment of PU or other chronic wound (venous, arterial or neuropathic/diabetic etiology).” Other variables related to chronic wounds were
recorded to explore the availability of any content about other aspects of chronic wound care, in ad- dition to the four educational priorities defined by Cowman et al. (2012). At the same time, this approach provided control variables to decrease the risk of in- formation bias in the primary variables studied: Nurs- ing or physiology—attention to patients with venous and arterial disorders in the lower extremities or with “diabetic foot”; Burns (adults, children, adolescents), ex- tensive burns; Wounds related to acute processes; Con- tent related to acute or chronic wound healing; Antisepsis or antiseptics.
If the same content appeared two or more times in the description of the same course, the content was recorded only once; if two or more different content variables were
Journal of Nursing Scholarship, 2015; 47:1, 51–61. 53 C© 2014 Sigma Theta Tau International
Course Content Related to Chronic Wounds Romero-Collado et al.
identified in the same course, each one was counted as “a course” containing that information.
Electives. All elective course options were recorded and placed into the following categories: “chronic wounds,” “language courses,” “palliative care,” “oc- cupational health,” “health promotion,” “Catholicism,” “dependency and chronic illness,” “urgent, emergency and/or catastrophic patient care,” “research,” “com- plementary/alternative therapies,” “cooperation,” and “school health.”
All of the information recorded (degree programs, course content) was found online, in the RUCT database, and on the official web site of each university; therefore, all data were publicly available. No personal data were accessed (e.g., related to any individual who designed a degree program or course) for this study.
Univariate descriptive methods (i.e., frequencies, per- centages, means, and standard deviations [SD]) were used to analyze the data. IBM SPSS Statistics 19 (IBM Corporation, Armonk, NY, USA) was used for the analysis.
The assessments completed by the two designated eval- uators were in consensus, eliminating the need for the intervention of a third evaluator and for inter-rater reli- ability analysis. The study included the 114 degree pro- grams available online, although detailed course analysis was limited to the 95 (83.3%) centers that provided on- line access to course content, of which 37 (32.5%) centers had implemented 2 full years of the new degree require- ments, 34 (29.8%) provided 3 years, and 24 (21.1%) provided detailed information for the full content of the 4-year degree in nursing program.
Of the 3,436 required, basic, guided practice, and fi- nal project course descriptions reviewed, representing all of the nursing degree programs in Spain, 2,258 (65.7%) courses were analyzed in detail. The mean num- ber of courses required for degree completion was 30.1 (SD 3.56) required and 6.7 (SD 4.56) elective courses. Ta- ble 1 contains a descriptive analysis of the number and type of courses.
The highest number of nursing degree programs are lo- cated in 3 of Spain’s 17 autonomous communities, with 18 (15.8%) in Andalucia, and 15 (13.2%) in Catalunya
and in Madrid. Only 1 (0.9%) program is offered in 4 communities: Cantabria, Ceuta, La Rioja, and Melilla. The remaining 62 (54.2%) programs are distributed across 10 autonomous communities.
Our analysis identified no course offered at any center that was dedicated to chronic wounds or included con- tent on pain management specific to chronic wounds; however, 94 (98.9%) centers offered at least one course related to general pain control. Only 40 (46.9%) cen- ters offered a course with specific content on prevention of PUs in adults, although some type of content specif- ically related to PUs was offered at 62 (65.3%) centers (Table 2). Only 10 (10.5%) centers indicated both of these content areas in their courses and 37 (38.9%) cen- ters offered neither of them. “Wound bed assessment” was identified in one course in 1 (1.1%) center, and “How to select dressings” was found in 23 courses in 21 (22.1%) centers. “Treatment of pressure ulcers or other chronic wounds” was contained in 98 courses distributed across 59 (62.1%) centers (see Table 2).
Half of the centers offered no courses related to ve- nous or arterial disorders in the lower extremities, and 91 (95.8%) centers offered no course description with the term “diabetic foot.” We included 131 courses offered by 75 (78.9%) centers in a “wounds, acute processes” cate- gory (Table 3).
The analysis of elective courses showed 50 courses re- lated to the Bologna requirement for instruction in other European Union languages in 42 (40.4%) centers, 44 courses related to instruction in research methods in 34 (32.7%) centers, and 36 courses related to complemen- tary or alternative therapies in 31 (29.8%) centers. In all of Spain, only one center (1.0%) offered one elec- tive course that included the term “chronic wounds” (Table 4).
Analysis of course content in degree in nursing courses at Spanish universities revealed that the education of- fered future nurses about chronic wounds is insufficient and largely fails to meet the four educational priorities identified by Cowman et al. (2012). We considered our results in the context of each of these priorities.
The first of the four education priorities in wound man- agement and tissue repair, pain management in chronic wounds (Cowman et al., 2012), was not mentioned in any of the nursing courses offering some content related to chronic wounds. Although PUs produce “end- less pain and a restricted life” (Hopkins, Dealey, Bale,
54 Journal of Nursing Scholarship, 2015; 47:1, 51–61. C© 2014 Sigma Theta Tau International
Romero-Collado et al. Course Content Related to Chronic Wounds
Table 1. Number of Courses in Nursing Degree Programs in Spain
Courses in the degree program
(n = number of centers) Minimum Maximum Total Mean SD
Number of required courses offered
(nonelective) (n = 114) 20 41 3436 30.14 3.55
Number of required courses
reviewed (n = 95) 0 40 2258 19.81 10.46
Number of elective courses offered
(n = 107) 0 23 728 6.68 4.56
Number of elective credits, ECTS
(n = 114) 0 30 1157.5 10.15 7.05
Note. ECTS = European Credit Transfer System.
Defloor, & Worboys, 2006), deficiencies exist in the im- portance assigned to them in clinical practice (Caron- Mazet et al., 2007) despite recommendations that wound care should be incorporated into all patient care plans (Günes, 2008). We must be aware that all PUs cause pain and that wound care treatments (e.g., dressing changes) also can cause pain. Inadequate knowledge of pain man- agement is a barrier to proper treatment. This deficiency must be addressed by including content about pain as- sessment and management in training related to chronic wounds (Pieper, Langemo & Cuddigan, 2009). In Spain, for example, the needed change could readily be accom- modated by incorporating a unit on “pain management and chronic wounds” into the appropriate courses as, in response to the mandates of the Bologna Plan, the 3-year diploma program is converted to a 4-year university de- gree and credit hours in pharmacology are increased.
How to Prevent Pressure Ulcers
In the courses we reviewed, this second priority was absent from the content of the degree courses offered at nearly two thirds of the centers that award the degree of nursing in Spain. We consider this lack of training in PU prevention alarming because this is a cross-cutting problem that can affect patients of any age—children, adults, the elderly—in any healthcare setting (primary care, hospitals, long-term care). This limited presence of the topic in nursing studies could be related to the finding by Zamora Sánchez (2006) that 25% of Spanish nurses reported receiving no specific PU training during their of- ficial program of study, or to the 23% of health profes- sionals on the other end of the spectrum who indicated that they had received “good” training in PU prevention (Hinojosa-Caballero, 2012). We must add that, despite clinical guidelines that recommend against particular care interventions (such as massaging reddened skin or using doughnut cushions), many nurses in different countries and of different professional generations continue to use
them (Iranmanesh et al., 2011; Panagiotopoulou & Kerr, 2002; Pancorbo-Hidalgo et al., 2007).
Basic theory taught in nursing programs should explain what is and is not recommended by clinical guidelines for the prevention of PUs. This should be complemented by guided practice and the involvement of clinical instruc- tors in practical training to ensure that traditional inter- ventions give way to current, evidence-based standards of practice (Saleh et al., 2013; Zamora Sánchez, 2006). Other researchers have reported a lack of course offer- ings on certain related topics in other university degree programs (e.g., medicine, physical therapy). For exam- ple, required courses related to aging are needed in Spain (Jiménez Dı́az, Pulido Jiménez, Villanueva Lupión, Villar Dávila, & Calero Garcı́a, 2011), and gerontological care is not adequately addressed in nursing education programs in Flanders, Belgium (Deschodt, de Casterlé, & Milisen, 2010). Although PU prevention tends to be considered a nursing task, some researchers have advocated that it should be the responsibility of the entire medical team and therefore should also be incorporated into physician education (Levine, Ayello, Zulkowski, & Fogel, 2012).
Wound Bed Assessment and How to Select Dressings
The third priority, wound bed assessment, was present in just one course at only one center. On the other hand, 23 courses at 21 (22.1%) centers included con- tent on the selection of dressings, the fourth priority in the eDelphi study and an area in which another re- cent study (Ousey et al., 2013) also found that students are underprepared. The inclusion of “Treatment of PU and other chronic wounds” (a more general term that could potentially incorporate the third and fourth edu- cation priorities, “wound bed assessment” and “selection of dressings,” respectively) added 98 courses (4.34%) at 59 (61.8%) centers to the analysis.
Journal of Nursing Scholarship, 2015; 47:1, 51–61. 55 C© 2014 Sigma Theta Tau International
Course Content Related to Chronic Wounds Romero-Collado et al.