Tissue viability education has been an important feature of preregistration nursing programmes at the University of Salford since 2011. Historically, students could take two optional modules in their second year, one of which was tissue viability. This module was always oversubscribed, which meant that not all students could develop fundamental knowledge and skills needed for wound care practice. With the advent of the Nursing and Midwifery Council's (NMC, 2018) Future Nurse standards and the development of a future nurse curricula, an opportunity to integrate tissue viability practice arose so that all second-year students, regardless of their field of practice, would have access to a structured wound care educational programme.
Using a case series approach, the purpose of this article is to evaluate the week of intensive teaching on wound care for undergraduate nursing students and make recommendations for future iterations.
Background
It is widely recognised that wound care spans not only the life course of the population, but also the health and social care settings in which people may live, work and access. With rising numbers of people living with a wound or wounds and the resulting increasing burden on health and social care resources, research has focused on initiatives that lead to better patient management and product selection to improve outcomes and clinical effectiveness (Guest et al, 2015).
Inadequate wound care, variations in practice and overuse/underuse of evidence-based wound management has meant that people with wounds experience delayed healing, pain and a poor quality of life (Gray et al, 2018). To address these issues and improve tissue viability practice, the knowledge and skills of the practitioners who deliver wound care should be developed.
Preregistration programmes provide opportunities to improve the quality of wound care through innovative curriculum design, allowing academics ‘to embed skin integrity and wound management across the theoretical and clinical of the preregistration curriculum’ (Holloway, 2022: 10). However, a semi-systematic literature review by Welsh (2018) found that tissue viability education in undergraduate programmes was insufficient and recommended the development of more structured wound care education at preregistration level.
To address these issues and the NMC (2018) Future Nurse curriculum proficiencies related to wound care, a small team of nursing academics at the University of Salford developed a themed week as part of the second-year Future Nurse curriculum called Getting Wound Care Right (GWCR) week. This was part of the fundamentals of integrated nursing practice module, which provides intensive training to second-year students in all fields of practice on a range of wound-care-related topics and clinical skills. As new guidance on wound care educational programmes was developed, the week was found to align with the European Wound Management Association's (Lindahl et al, 2021) curriculum for student nurses at level 4 and the National Wound Care Core Capabilities Framework for England (Beasley et al, 2021).
Historically, the optional tissue viability module had been delivered face-to-face with seminars and lectures, and linked to a practice assessment called principles of asepsis. However, because of the COVID-19 pandemic, GWCR week was initially developed for an online audience. The literature shows undergraduate wound care courses have been developed for delivery digitally (Carr, 2019), face-to-face (Parker et al, 2022) and in laboratories (Huff, 2011). Despite this, the team felt that a combination of lectures and self-directed online activities would be required to promote engagement in the week. This would create COVID-19-safe spaces for learning and various opportunities for student engagement. Students would learn theory remotely then attend university to practise what they had learnt during in-person skills sessions with lecturers, then have opportunities for discussions with wound-care companies at an exhibition. The face-to-face part of blended learning is spent actively practising skills, getting hands-on experience and asking questions regarding their new knowledge (Li, 2019). This included teaching on the theoretical and clinical aspects of wound care (Table 1).
Table 1. Getting Wound Care Right Week teaching contents
| Lectures | Clinical teaching |
|---|---|
| History of tissue viability | Holistic wound assessment |
| Epidemiology and economics of wound care (UK) | Dressing choice and application |
| Physiology of wound healing across the life span | Removal of sutures and clips |
| Factors affecting wound healing | Bandaging |
| Aetiology of pressure ulcers | Wound cleansing |
| Aetiology of leg ulcers | Additional self-directed work was encouraged focusing on the following areas for exposure to other fields of practice:
|
| Aetiology of dermatology-related wounds | |
| Aetiology of the diabetic foot | |
| Aetiology of acute and surgical wounds (including surgical site infection) | |
| Aetiology of burns | |
| Advanced wound therapies | |
| Research challenges in wound care |
The week begins online with a 30-minute introduction to the NMC (2018) standards related to tissue viability practice. The students are asked to self-assess their current knowledge, skills and attitudes against the standards to develop a SWOT (strengths, weaknesses, opportunities and threats) analysis.
From the weaknesses, the students then set SMART goals (specific, measurable, achievable, realistic and time bound) (Cottrell, 2019) for future placements to gain wound-care skills supported by theoretical knowledge delivered during the week. The purpose of this is to integrate practice competencies with theoretical knowledge—an essential component to improve outcomes and clinical effectiveness (Guest et al, 2015).
The team deliver online a series of six 50-minute lectures on day 1 and, on day 2, another six 50-minute lectures plus one 30-minute lecture on a variety of topics (Table 1). On days 3 and 4, because of large cohort numbers, the nursing students attend face-to-face clinical skills sessions lasting 3 hours and are also directed to online learning materials and skills videos to engage with. These include exposure to wounds seen in other fields of practice (mental health, children and young people, learning disabilities and midwifery).
The week culminates with a wound care exhibition and the students submitting a poster they have created from a list of case studies to a Padlet online bulletin board. The poster includes a wound assessment, care plan and consideration of other members of the multidisciplinary team who would be involved. The students can be creative and must support their poster with literature.
Methods
To evaluate the week, students who had participated in all the activities were approached via email 6 months afterwards and asked if they wished to contribute a 250-word reflection to develop a case series paper.
The aim of a case series is to provide a description of the characteristics and outcomes among a group of individuals who have been exposed to an intervention over a period of time, without a control group or randomisation (Murad et al, 2018).
The aim of the reflections was to understand the impact of the week on students' knowledge, skills and confidence in caring for patients with wounds and whether it sparked their interest in further learning. As students who submitted reflections would also be asked to co-author this paper, we did not require ethics review.
Results
From a cohort of 554 students who attended the study week, 250 completed all learning activities.
Of this group, only four students responded to the request of a reflection, all of whom were from the adult field of practice.
The module evaluation identified that one children and young people's nursing student suggested a greater emphasis should be placed on the relevance of wound care teaching to this field of practice.
The reflections below explore the self-reported impact on knowledge, skills and patient care.
Student Nurse 1 (BSc Adult)
The week educated students on wound care, treatment options, the physiology of wounds and the processes involved in healing, as well as factors that can impact healing rates and skin integrity. A convention was set up for students on campus, which facilitated further learning on the more common approaches and treatments for wounds, including pressure relief systems, topical treatments and nursing interventions available. Furthermore, the classes and simulated sessions were invaluable in showcasing how intricate and precise we need to be as professionals in supporting healing, how to grade wounds and what to look for to assess if the wound is deteriorating.
In practice, registered staff are unaware of how to care for or grade wounds. This comes at a cost to patients and the NHS due to costs of misusing interventions and hospital readmissions. I can troubleshoot with the multidisciplinary team to understand why a wound is not healing now, for example, a lack of zinc in the diet. It ignited a passion in me to get wound care right, as there is a huge lack of education on the subject. Annually, the NHS spends £5.3 billion on wound care, compared with obesity at £5 billion (Guest et al, 2020). This is a crisis for the NHS and its patients. Getting wound care right will save lives, and could prevent disability, while helping to save our overstretched NHS. All registered staff should have this knowledge so they can act fast for treatment, opposed to having to delay treatment waiting for a specialist.
Student Nurse 2 (BSc Adult)
I thoroughly enjoyed the wound care week, and I was amazed to find out how few universities provide wound care education. The week opened my eyes to the importance of wound care, and the negative effects it can have on quality of life for people when not performed properly. I have an interest in pressure area management, so the education provided by the seating company on how to maintain good posture while being seated was crucial.
The specialist seating they provide tilts in a way to redistribute pressure while maintaining correct posture and, although I feel this should be the gold standard in practice, this kind of seating isn't always available on a ward environment. Since meeting them, I've found myself having more awareness around how my patients are seated while out in practice, encouraging them to sit in better-designed chairs and change their position more frequently in order to reduce the chance of pressure-related injuries. While on placement, I've now realised there is a lack of suitable seating in hospitals and would love to see this improved in future. I also feel more confident in assessing wounds, noticing the different stages in wound progression and I have a better idea of what dressings should be used at each stage. Overall, I believe that wound care education is key to seeing more evidence-based practice in the future, and it should be provided to all nursing students in order to create better outcomes for patients.
Student Nurse 3 (BSc Adult)
The online lectures included in this week were really informative and went into depth about the anatomy of wounds and the physiology of wound healing. I already had basic knowledge and understanding of wounds, as I have completed a placement with district nurses where I was able to observe and contribute to the management and care of various wounds.
The enrichment week enabled me to further understand why we care differently for wounds depending on what grade they are, where they are or what they have been caused by. I now know the factors that affect wound healing and the optimum environment needed for wounds to heal. Out on my community placement, I observed pressure dressings and Doppler tests on patients with venous legs ulcers and understood to an extent why these were required for this type of wound but, after the enrichment week, I now know the anatomical reasons and the evidence base behind this practice. On the last day of the enrichment week, I attended the wound care exhibition, where representatives from different wound care companies came in to demonstrate and inform us about their products. I found the wound care company representatives particularly helpful as they fully explained and demonstrated how their different wound dressings worked with the wound to aid in the healing process.
I have experienced nurses on various placements who did not know how to adequately manage wounds and how to select the correct dressings and believe that, if all universities offered the teaching included in this module and the wound care exhibition to all preregistration nurses, the wound care and management on wards would be a lot better than it currently is.
Student Nurse 4 (BSc Adult)
The Getting Wound Care Right week was very interactive and engaging, and had a perfect balance of theoretical knowledge and practical skills. From the epidemiology and economics of wounds to their physiology and aetiology, we had the opportunity to cover a lot of key skills and knowledge that I believe are a vital part of nursing care. Anywhere you work, any set of patients you may be looking after, at one point or another, as a nurse, you will encounter wounds.
I find leg ulcers in particular very fascinating! I was thrilled when this was covered in a lecture during this week, I was able to learn so much more about them that I otherwise would not have known until I was already faced with one in practice. I do feel more prepared for my next placement; this week has given me the confidence and curiosity to perform wound care as well as to continue developing my clinical knowledge and skills.
It was also very exciting to be able to attend an exhibition – speaking to representatives from various wound care manufacturers was very beneficial. Some products I have used numerous times in practice I did not realise the extent of their purpose, or even exactly how they worked. Knowing this information now helps me to understand optimal treatments and be able to use their full potential. The experience overall made me feel like a true professional and it was great to be able to network with other members of the multidisciplinary team.
Discussion
The reflections of four students who responded on the introduction of the week into their preregistration studies were overwhelmingly positive. They describe the knowledge gained, which included that on anatomy and physiology of the skin and wound healing, evidence-based assessment, treatment and management of wounds, and the impact of wounds on patients' quality of life. Skills that developed from participating in the week included the categorisation of wounds, wound assessment and pressure redistribution when seated.
Reflections on the impact on clinical practice focused on the importance of multidisciplinary working within wound care, seating provision for pressure ulcer prevention and management, and appropriate dressing selection. Negative comments related to students realising that existing clinical practice could be improved, rather than indications that the GWCR week format was ineffective or inappropriate.
This suggests that a week-long intensive teaching approach to deliver wound care education to undergraduate nurses is a viable option for wound care pedagogy in this professional group. Collecting reflections 6 months after delivery allowed the lecturers who deliver the week to examine the impact of the week beyond the teaching period.
The outcomes indicated by the students' reflections on GWCR week are particularly relevant in the UK as nurses are the primary providers of wound care (Guest et al, 2020). However as wound care education is recognised as being a global concern, the findings may be of use to other countries. To improve poor clinical outcomes associated with wound care, as indicated by recent epidemiological studies in relation to low rates of accurate diagnosis and inconsistent management approaches (Guest et al, 2020), more emphasis is required on developing nurses' skills, knowledge and confidence.
The GWCR week appears to be an effective approach to developing these attributes in undergraduate student nurses and should be explored further to support the development of the professional nurse workforce to address the growing burden of wounds in the UK.
This is supported by recent enquiry into the use of intense block approaches to pedagogy in higher education, which consistently indicate positive student outcomes in relation to attainment and student satisfaction (Klein et al, 2020; Buck and Tyrrell, 2022). These studies report that intense blocks of teaching allow both students and faculty to focus on one area at a time and students are consequently more likely to approach learning with a greater degree of enquiry rather than dividing their focus on multiple areas of study simultaneously.
Further enquiry is needed to evaluate block approaches to teaching in the context of wound care within undergraduate nurse education, such as GWCR week. This may help determine the longer-term impacts of this approach on relevant metrics such as theoretical knowledge acquisition and clinical competence.
Limitations
This teaching evaluation using a case series approach is limited by a low rate of responses not only from students overall but also from all fields of practice; there were no reflections from those studying children and young people's and mental health nursing.
The GWCR week approach was also evaluated in only one university and with only one cohort of student nurses and participants were from one field of practice. It is therefore unclear how generalisable the findings of this case series may be to other higher education settings, which means only weak inferences can be drawn and there is high likelihood of bias.
In addition, because of the nature of COVID-19 restrictions in place during the delivery of the week it is unclear what the true impact of this approach would be in normal circumstances where face-to-face teaching can be provided.
Conclusion
Overall, the results from this initial evaluation of the GWCR week indicated that the format is a viable approach to meeting the current Future Nurse curriculum requirements.
The lack of response from across different fields of practice limits findings on the impact of the week on children and young people's and mental health nursing students.
Attitudes towards the GWCR week were overwhelmingly positive indicating that the teaching improved students' clinical confidence on placements when caring for patients with wounds. Robust evaluation of GWCR week is needed; other higher education organisations should consider implementing the format to meet NMC curriculum requirements and to allow for wider evaluation of its impact.
KEY POINTS
- Although all nurses have to deal with wounds, education on wound care in preregistration programmes can be insufficient
- The Nursing and Midwifery Council's Future Nurse standards provides an opportunity to integrate tissue viability practice into preregistration nursing programmes
- An intensive week of education exposes preregistration students, regardless of their field of practice, to the fundamental knowledge, skills and confidence required to care for patients at risk or with tissue viability issues.
- A blended pedagogical approach allows students to apply theoretical knowledge developed from attending online lectures in a safe simulated learning environment
- An interactive wound care exhibition at the end of the week allows students to discuss products used to facilitate core skills and inspire better wound care practice
CPD reflective questions
- Which Nursing and Midwifery Council proficiencies relate to wound care knowledge and skill development?
- What methods have already been used to teach undergraduate nursing students about wound care?
- How can teaching allow both students and faculty to focus on one area at a time and lead to students developing a greater degree of enquiry?