1. Introduction
Wounds are disruptions in the continuity of the skin caused by various factors, and their origins can be attributed to different pathologies [
1]. Wounds can be categorized as either acute or chronic based on their healing process, evolution over time, and the presence of pathogenic anomalies that may impede the healing process.
Dependence-related skin lesions and pressure ulcers have a prevalence of 11.61% in Spain, with the majority being treated in primary care services and accounting for 35% to 65% of patient visits [
2,
3]. Essentially, lower limb ulcers and neuroischemic ulcers comprise the greatest workload in nursing, both in primary care and in multidisciplinary units specializing in wounds [
4,
5].
To achieve competence in wounding healing, European nurses require extensive knowledge and the adoption of new, evidence-based solutions to enhance their expertise, ensuring the delivery of quality care to patients with wounds [
6]. Although this competence is implied in the profession, the Resolution of 20 October 2020 of the General Direction of Public Health, which validates the “Guide for the indication, use and authorization of dispensing medicines subject to medical prescription by the nurses of: wounds”, is the one document where the role of the nurse in the care of skin injuries, ulcers, or wounds is indicated [
7].
Knowledge about wound treatment, academic training in skin integrity, and positive behavior towards patients should form the basis of an efficient understanding of how to assist patients with wounds [
8]. However, there is no standardized content regulation for wound care in the university curricula. It is often left to the individual discretion of professors whether to include this topic in their courses. In many universities, wound care training is typically integrated across various subjects during the degree program. In Spain, only three universities offer an optional course specifically dedicated to this topic [
9].
Several studies aim to understand the teaching load regarding wound care in nursing undergraduate programs, revealing significant variations [
10]. Generally, students begin to receive education in the first year, covering topics such as skin histology and its physiology, as well as potential problems. The remaining education (the assessment, care, and treatment of dermatological conditions, acute wounds, and chronic wounds) is distributed throughout the rest of the degree program across different subjects, which may pose a challenge for professionals during their university studies [
11].
Furthermore, in the European Credit Transfer and Accumulation System [ECTS], aspects focusing on impaired skin integrity are few, comprising two ECTS, corresponding to about 50 h of student work, but insufficient in the total balance of the degree [
12]. It is assumed that, as a result of this training during their undergraduate degree, students should possess knowledge regarding skin integrity impairments. They should also be able to apply this knowledge to their work in a professional manner. Nurses are not able to reach an appropriate knowledge level in wound care, have a lack of comprehension of wound care, and feel insecure in performing wound care due to educational deficiency focusing on this topic. Considering this educational context, it is not surprising that wound care based on traditional practices or the personal preferences of professors continues to be carried out today, ignoring the new scientific evidence that is available [
13].
Education on wound care beyond the nursing undergraduate degree in level Spain is based on continuing education courses, training provided by commercial laboratories, numerous university expert courses in wound care for patients, and a university Master’s degree [
14]. Some studies link the low level of knowledge about chronic wound management among postgraduate nurses in various care areas with the fragmentation and lack of objectives in the undergraduate curriculum [
15].
Educational interventions have taken place based on previously identified training needs after a process of deep reflection [
16]. Training interventions for nurse practitioners in wound assessment have been shown to help improve patient safety and benefit patients [
17,
18]. Interventions conducted on students have been shown to develop clinical skills about wound care [
19,
20].
The primary objective was to identify the barriers to the acquisition of knowledge about skin integrity impairment in nursing students from a university in Spain. The secondary objective was to analyze the effectiveness of an educational intervention about wound healing in nursing students.
2. Materials and Methods
2.1. Design
A quasi-experimental study was designed as a pre-test and post-test with an ad hoc questionnaire. The educational intervention was carried out over 10 hours, in which the knowledge about the assessment and treatment of damage to skin integrity was presented to pre-grade nurse students in a university located in the southeast of Spain. The study was completed between June and July of 2023.
2.2. Participants
The study population was 304 students, of which 165 made up the control group (CG) and made up 139 the intervention group (IG) during the period from June to July 2023.
2.3. Inclusion and Exclusion Criteria
The inclusion criteria for the control group were final year students of a Bachelor’s degree in Nursing who agreed to complete the questionnaire and signed an informed consent form.
The inclusion criteria for the intervention group were students of a Bachelor’s degree in Nursing who were not part of the control group, wished to participate in training on wound care, and agreed to complete the questionnaire and signed an informed consent form.
The exclusion criteria for both groups were students of other Bachelor’s degree programs than Nursing and students who did not complete the questionnaire in its entirety or did not sign the informed consent form.
2.4. Measures
Dependent variables were evaluated through 61 items with direct questions on these topics and 4 more items on the theoretical and practical training received. These variables each had three levels, corresponding to the three possible responses for each item: Yes, No, and Don’t know/Don’t answer.
These variables were dependence-related skin lesion prevention (items 1 to 15), chronic wound treatment (items 16 to 28), and pressure ulcer assessment/diagnosis (items 29 to 39). Knowledge about lower limb ulcers was evaluated in items 40 to 49, and specific aspects about wound bed preparation were assessed in items 50 to 61.
The independent variables were the following:
Demographics included age (a continuous variable that adopted values between 22 and 54); sex (dichotomous nominal variable); studies prior to the Degree in Nursing (nominal variable with 5 levels); and the course in which they are enrolled (nominal variable with 4 levels).
Training intervention was a nominal variable that adopted 2 values (intervention group and control group). The intervention group received 10 hours of training on the prevention, assessment/diagnosis, and treatment of wounds, lower limb ulcers, and wound management/wound healing (described below).
2.5. Procedure
An ad hoc questionnaire was developed for data collection, consisting of 61 closed-ended questions with 3 response options, of which only one was valid (ANNEX I). The creation of the questionnaire consisted of two phases.
In the first phase, after a review of the literature, 61 questions were selected in relation to wound assessment and care. This was complemented by a second questionnaire composed of 4 items. The initial questionnaire was sent as a pilot test to 5 professional nurses. In the pilot test, considerations were made regarding the language used, the format of the answers, and the relevant characteristics of the study population. The questionnaire was composed of questions with the answers “Yes, No, Don’t Know/Don’t Answer”.
Breaking down the questionnaire, the sources of the questions are as follows:
Items 1–39: Extracted and adapted from the evidence recommendations of the Practical Guide for Pressure Ulcers and the Practical Guide for Moisture Associated Skin Damages from the Collection of Practical Guides of Wounds of the Servizo Galego de Saúde [
21,
22], which aggregates several evidence-based clinical practice guidelines [
23,
24].
Items 40–49: Extracted and adapted from the evidence recommendations of the Practical Guide for Ulcers of the Lower Limb from the Collection of Practical Guides of Wounds of the Servizo Galego de Saúde [
25], which aggregates several evidence-based clinical practice guidelines [
26,
27,
28]
Items 50–61: Extracted and adapted from the study “Degree of knowledge of nursing in primary health care on the cure in wet environment and the use of dressings” [
29].
Regarding the thematic content of the questionnaire, it is divided into seven sections:
Initial questions (4): Personal and professional sociodemographic data of the participants (age, sex, studies prior to the Degree in Nursing, course in which they are enrolled);
Items 1 to 15: Dependence-related skin lesion (DRSL) prevention;
Items 16 to 28: Chronic wound treatment;
Items 29 to 39: Pressure ulcer assessment/diagnosis;
Items 40 to 49: Lower limb ulcer assessment/diagnosis;
Items 50 to 61: Wound bed preparation;
Items 62–65: Questions about wound training (theoretical and practical) received prior to completing the questionnaire.
The final test score was calculated as the sum of correct answers (from item 1 to item 61). A low level of knowledge was considered when between 1 and 20 correct answers were obtained, a medium level was considered when between 21 and 40 correct answers were obtained, and a high level was considered when between 41 and 61 correct answers were obtained.
Second phase: Based on the responses and suggestions received, the final questionnaire was prepared. The dissemination of the questionnaire to the participants was anonymous and voluntary, self-completed, and in online format (Google Form®). The questionnaire was distributed through the internal lists of the Faculty of Nursing, with a collection period of one month. Fifteen days were allocated as an ordinary period, followed by an additional fifteen days of reinforcement (reminder) in case the necessary sample size was not reached by the end of the first period.
Simultaneously, the intervention group was formed by offering an elective course to nursing degree students who voluntarily enrolled in the course. This was structured into 5 theoretical online sessions, each lasting 2 hours, where the topics were presented through lectures with visual support, including explanatory images, photographs, and videos. During and after each session, there were discussions regarding the practical application of the theoretical content, the clinical experiences of the students, and related questions. Students were evaluated through the resolution of a practical case.
The theoretical content was distributed as follows:
Session 1: The skin: structure, function, and healing process; skin integrity impairment; classification of wounds; moist wound healing; products and treatments.
Session 2: Wound management: dependence-related skin lesions; pressure ulcers; etiology, assessment, classification, treatment, and prevention.
Session 3: Lower limb ulcers: etiology, assessment, classification, differential diagnosis, treatment, and prevention.
Session 4: Surgical wounds, incised–contused wounds, and burns: etiology, assessment, classification, treatment and referral criteria.
Session 5: Periwound skin: physiology, assessment, classification, and treatment; periwound skin as a predictor of healing.
The aim of this educational intervention was to equip students with the following competencies:
Demonstrate possession and comprehension of knowledge regarding skin integrity impairment and relate this to the knowledge acquired during their undergraduate education.
Apply this knowledge to their work in a professional manner and obtain the necessary competencies to do so.
Gather and interpret relevant data to make judgments including reflection on the care of patients with ulcers or wounds.
They were invited to complete the same ad hoc questionnaire as an initial assessment and again 10 days after the end of the intervention to check whether the intervention had been effective.
2.6. Sample Size
The sample size calculation to compare two proportions of 17% (CG) to 43% (GI) and assuming an alpha of 0.01 indicated that 111participants per group would be necessary to have a statistical power of 95%.
2.7. Data Analysis
Data are presented as the total score of tests or as the percentage of students that answer correct, incorrect, or Don’t know/Don’t answer to the test’s questions. The significance level (p) was fixed at 0.05 (* p < 0.05; ** p < 0.01; *** p < 0.001).
The normality of the data regarding the total score of the tests was previously assessed using a Shapiro–Wilk test and the homogeneity of variance was also verified using the Levene test. For non-normally distributed data, a non-parametric Mann–Whitney U test was used to compare scores between the control group and the pre-test and post-test groups. Differences within the pre-test and post-test groups were assessed using the Wilcoxon signed-rank test.
To determine differences between the answers of the control and pre-test or post-test groups, respectively, χ2 tests were performed, while to assess differences between pre-test and post-test groups, the McNemar test was performed. Statistical analyses were conducted using SPSS 27.0 (SPSS, Chicago, IL, USA).
2.8. Ethics
The questionnaires were anonymous, and no information that could identify participants was collected. Each participant declared that the provided data were true by checking a box and gave their consent for the processing of their data and responses for the purpose of conducting the study and the subsequent dissemination of results.
This study was conducted in accordance with the Declaration of Helsinki and approved by the UCAM Research Ethics Committee with code CE062303.
4. Discussion
The main areas that revealed an educational gap were wound bed preparation and lower limb ulcers. Correct responses related to chronic wound assessment, diagnosis, and treatment were close to 50%, with only knowledge regarding the prevention of dependence-related skin lesions surpassing this threshold. The data for this student sample are similar to the data presented by the National Institute of Statistics (2022), which indicate that 84.1% of the nurses in Spain are female. This study has a higher percentage of female nurses (78%) than male nurses (22%) [
30]
The control group was composed of students that finished their nursing grade the same year. This characteristic allowed us to evaluate the final level of knowledge that was obtained by the students after finishing the grade. The final questions of the questionnaire provided us with a better understanding of the knowledge acquired beyond the students’ academic degree.
Despite the control group having finished their grade, our results suggest that they had a lower level of knowledge than the pre-test group, which could be due to the evaluation system only focusing on memorization and passing exams quickly, decreasing students’ reasoning and reflection about the subject they studied [
31,
32].
Other studies indicate that an effect of interventions is that students have greater certainty in answering questions [
33,
34]. The incorporation of web-supported education alongside conventional teaching positively enhanced the learning outcomes of nursing students [
35]. The result of our intervention showed that the students’ certainty was increased as the post-test group had a significantly reduced number of “Don´t know/Don´t answer” responses and an increased rate of the correct answers, suggesting a consolidation of their acquired knowledge [
36,
37,
38]. The certitude of the theoretical knowledge about skin integrity damage leads to better clinical practice, as patient assessments and the healing process will be carried out continuously, and this certitude is associated with increased decision-making for treatment [
39,
40,
41].
On the other hand, the theoretical content about other wounds, such as lower limb ulcers, is very little in this grade, comprising 6 h in the classroom, and could be increased via clinical simulations and external training in hospitals. Our intervention comprised 2 h on this topic, leading to improvements in the understanding about lower limb ulcers’ physiopathology and care, diminishing the number of “Don’t know/Don’t answer” responses in the post-test group. Improvements in the teaching strategy on this topic would allow students to overcome barriers to knowledge [
42].
When we observed the incorrect answers across all topics, the results showed that there were no significant differences in all three groups. However, the correct answers increased significantly because the number of “Don´t know/Don´t answer” responses was significantly reduced, suggesting an improvement in understanding due to a consolidation of the acquired knowledge.
The principal difficulties found regarding students´ ability to acquire knowledge about impaired skin integrity were as follows:
Cross-disciplinarity without critical assessment: During the four years of the grade, teaching about skin integrity damage is imparted across different subjects or forms of training without a consecutive or chronological order. This could lead to students facing difficulties in relating the concepts acquired in different subjects, such as microbiology, physiology, pharmacology, clinic subjects, etc., when they have to assist a patient with wounds. In the Nursing Degree program in Spain, the basic theoretical teaching about the assessment and management of wounds is between 0.5 and 2 ECTS, which is very light compared to the 6 ECTS recommended by the European Wound Management Association [
10,
43].
One suggestion to solve this problem of a shortage of hours is that a specific and obligatory subject about this topic is incorporated into grade studies, following the advice of the European Wound Management Association with a total of six ECTS, comprising four theoretical ECTS and two training ECTS (with small learning groups), with the objective of improving the care of people with wounds [
44].
Currently, the evaluation and teaching systems are focused on the student memorizing the topic in a short time without tools for relating or remembering. Different strategies have been attempted to innovate and improve teaching to solve these problems [
45]. The use of virtual reality [
46], flipped classrooms [
47], peer role-play, and clinic simulations could allow students to obtain cohesion in their knowledge of different subjects [
48,
49], although these strategies are underused in university training about skin integrity damage [
50].
Students´ learning could be negatively affected by disjointed teaching, according to different nursing professionals, especially regarding their knowledge of impaired skin integrity, at both the assistance level and educational level [
13]. The different criteria for these topics, excluding critical thinking, that are transmitted to students during their theoretical and training education lead to a negative impact on care, leading to longer recovery times, higher costs, and, finally, a reduced quality of life in patients due to appropriate wound healing being hindered [
51].
6. Conclusions
The main identified barriers to the acquisition of knowledge about wound care during undergraduate nursing studies are the cross-disciplinary nature of the education provided, the teaching and evaluation system, and the variability in the training of professionals and teachers responsible for students’ education.
This study demonstrates how the intervention group significantly improved their knowledge compared to the control group. Students’ access to information as a unit rather than as a cross-sectional contribution facilitates their learning and their ability to understand the relationship between concepts. The intervention facilitated the consolidation of knowledge, instilling self-confidence in students to make informed decisions in the care of patients with wounds.
There is a clear need to implement standardized undergraduate teaching and assessment of nursing students’ knowledge of skin integrity impairment. This would enable comparative studies between universities and the design of concrete training interventions.