Wound Care Self-Efficacy Assessment of Italian Registered Nurses and Wound Care Education in Italian Nursing Education System: A Cross-Sectional Study

Wounds are a major public health challenge for nurses, and poor wound care has important implications for patients and health care systems. The aim of this study is to assess the Italian registered nurses’ (RNs) perception in the area of wound care, regarding their knowledge, tasks of care delivery, wound management, values, and attitudes, exploring also the previous specific education received during nursing education. An observational online web-based survey was used to assess learning goals and content for wound care education in undergraduate nursing education and the skills and level of self-efficacy in this area during clinical practice. The data were collected between April and May 2022. A total of 210 RNs were interviewed and divided into five national geographic areas. Northwestern RNs showed a better education about the wound care area during university courses: the rate of RNs that did not receive any training in the wound care area was lower than in other Italian geographical areas. Southern RNs presented a better knowledge about factors that expose the wound to becoming chronic, wound drains care, and the ability to assess diabetic foot. This study showed that, in Italy, education in wound care among nursing students is relatively poor, and many skills are achieved during an RN’s career in an empirical way.


Introduction
Wounds (acute or chronic) are a major public health challenge for nurses, because of their high prevalence in the general population. Vascular (arterial, venous, and lymphatic) ulcers, diabetic foot, ulcers, pressure ulcers, and skin tears are the most common types of chronic wounds [1][2][3][4][5][6]. In addition to chronic wounds, nurses deal also with acute wounds such as surgical incisions, as they play a crucial role in wound healing during the recovery and rehabilitation of operated patients to avoid surgical site infections, wound dehiscence, and delayed wound healing of the surgical site [7][8][9]. Moreover, among acute wounds, we have traumatic wounds, burns, and frostbite injuries [10][11][12]. Therefore, wound care is an essential activity of registered nurses' (RNs) daily practice, and nursing education and training are pivotal for the acquisition of specific wound care skills [13]. Several studies focused on the issue of competence in the wound care area, and they found quite limited competence among RNs and even among graduating nursing students that blame having not received enough education in this area, and undergraduate nursing education is not standardized [14][15][16][17][18]. A recent study [14] assessed learning goals and content for wound care education in a nursing academic program in Finland and showed how the skills related to wound care competence are gained during undergraduate nursing training.
In Italy, following the Bologna process, RNs are educated at universities with a Bachelor's degree encompassing a three-cycle education (from Bachelor's to Doctorate degrees). In particular, this includes 3 years of full-time studies (Bachelor's degree, which is the required step to practice as an RN after the regulative board registration) and, possibly, in addition, 2 years of full-time studies for a Master's degree in Nursing and Midwifery Sciences (required managerial career), and a further 3 years for a Doctorate course for an academic career. For wound care specialistic education, a postgraduate diploma in wound care (1 year of full-time studies) can be attended after completion of the bachelor's degree [19,20]. Supplementary Material S1 shows the list of Italian universities providing Bachelor's degrees in Nursing, Supplementary Material S2 shows the list of Italian universities providing Master's degrees in nursing and midwifery sciences, and Supplementary Material S3 shows the list of the universities that provide postgraduate diploma in wound care.
In Italy, out of 98 universities (https://www.universitaly.it/index.php/cercacorsi/ universita) (accessed on 20 May 2022) [21], 42 universities provide Bachelor's degrees in nursing, while 34 universities provide Master's degrees in nursing and midwifery sciences. For both types of degree, therefore, it is possible to observe a sufficient distribution throughout the Italian territory from north to south. As regards, however, specialist wound care training, to date, this accounts for only four universities: two in the northern part and two in the southern part of the Italian territory (Supplementary Material S3). (https://www.almalaurea.it/lau/postlaurea/aa2019-2020) (accessed on 20 May 2022) [22].
The aim of this study is to assess the Italian registered nurses' (RNs) perception in the area of wound care, regarding their knowledge, tasks of care delivery, wound management, values, and attitudes, referencing also the previous specific education received during nursing education.

Design
We performed an observational online web-based survey that was used to assess learning goals and content for wound care education in undergraduate nursing education.

Setting
The observational online web-based survey used in this study was conducted using Google Modules, structured as in previous works [24,25].

Survey Online Structure
The survey was built based on learning objectives and content for wound care based on areas of expertise as indicated in the papers of Kielo-Viljamaa [13,14,17]. Specifically, we used four competence areas: (1) Anatomy and physiology, (2) Care of chronic and acute wounds, (3) Wound management and assessment, and (4) Values and attitudes. Each learning goal and piece of content was assessed for its clarity, relevance, and importance using a seven-point scale (Likert scales): -strongly disagree 1-2-3-4-5-6-7 strongly agree-. The full questionnaire is included in Supplementary Material S4. The questionnaire was pilot tested with 15 nurses before the onset of the study.

Procedures in Place to Check against Bots Completing the Survey
Although the risk of bots completing the survey was low, as this survey provided no compensation for participants, three open-ended questions (age; educational qualification-"Other Master's degree" option; actual work-"other" option), located at the beginning of the survey, were used to detect bots and enabled us to check the answers for consistency.

Participants
The participants of the survey had a Bachelor's degree in Nursing, a Master's degree in Nursing and Midwifery Sciences, a Postgraduate diploma in wound care, or a combination of the various titles. The current work positions were different: ward nurses, home nurses, private nurses, or other. The selection criterion for the survey was only to be a nurse.

Data Collection
The data were collected between April 2022 and May 2022 using Google Modules, and RNs were interviewed and divided into five different geographic areas, according to the Nomenclature of Statistical Territorial Units of Italy (NUTS: IT, level 1) (https://ec.europa. eu/eurostat/web/nuts/nuts-maps) (accessed on 20 May 2022) [26]. Participants were recruited using different networks in organizations, such as hospitals, via email, telephone, and social networks. Participants were also recruited using social media nursing groups. The open link to the online questionnaire was invited. The recruited participants were invited to use their own social networks to share the link with their colleagues to improve the representativeness of the sample.

Data Analysis
The data from the survey were analyzed using Stata version 16 (StataCorp, College Station, TX, USA). Continuous variables ("age", "competence area in wound care", "wound management and care of a patient with a wound", "values and attitudes") were analyzed by one way-ANOVA test, after verifying their normal distribution and homoscedasticity using the Shapiro-Wilk normality test and F test, respectively. All continuous variables were also subjected to post hoc analysis using the Tuckey test to show any significant comparison. Categorical variables ("females", "educational qualification", "current work", "educational wound care area") were analyzed with a five-sample test for the equality of proportions without continuity correction.

Results
No bots completing the survey were detected and all the answers were considered eligible for analysis.
No other differences were found in the four competences examined areas (Tables 3-7).  Table 4. Competence area in wound care: anatomy and physiology area. Each query expects a score value as an answer, based on a seven-point scale (Likert scale) ranging from 1 (strongly disagree) to 7 (strongly agree). Results are shown as mean ± standard deviation (mean ± sd).

Anatomy and Physiology area
Answers: strongly disagree 1-2-3-4-5-6-7-strongly agree   Table 6. Competence area in wound care: wound management and care of a patent with a wound. Each query expects a score value as an answer, based on a seven-point scale (Likert scale) ranging from 1 (strongly disagree) to 7 (strongly agree). Results are shown as mean ± standard deviation (mean ± sd).   Table 7. Values and attitudes. Each query expects a score value as an answer, based on a seven-point scale (Likert scale) ranging from 1 (strongly disagree) to 7 (strongly agree). Results are shown as mean ± standard deviation (mean ± sd).

Values and attitudes
Answers: strongly disagree 1-2-3-4-5-6-7-strongly agree 4.1 I understand the importance of multi-professional working and consultations when caring for a patient with a wound (mean ± sd) 6

Discussion
Wound care is a specific clinical area that involves multidisciplinary teamwork in which RNs play a pivotal role. Wounds are usually classified as either acute or chronic, and especially the latter is a significant concern for healthcare services and affected individuals and are also responsible for elevated costs for health systems and society and for decreased quality of life [16,17]. Therefore, wound care is an important area of clinical practice for nursing and, as so, academic education and teaching on wound care, both in basic nursing and in postgraduate knowledge, are fundamental in developing adequate and satisfactory competence and specific skills that are directly related to improving professional standards, patient safety, and more in general, quality of care in this area [7,13,16,17].
The aim of this study was to explore, among Italian RNs, wound care education received during basic or postgraduate nursing academic education, and several competence areas and specific wound care knowledge required to have adequate wound care nursing competence.
The hours of training received during academic training were adequate (≥9 h of specific training) in 33% of cases, whereas in 47.6% it is considered suboptimal (≤8 h), and it is totally inadequate in 19% of cases (lack of training) ( Table 3).
Although 43.3% of participants achieved only a Bachelor's degree, and only 5.7% achieved a Master's degree (Table 1), the general self-perception in terms of the knowledge of the wound care area is quite sufficient, oscillating around the values of at least 4, considering the Likert values used with a scale from 1 to 7. Nevertheless, one must consider the possibility that there have been phenomena of social desirability and socially desirable responding (SDR) [27] that have led to the overestimation of the perceived training. This hypothesis is supported by the data available, since 47.6% of respondents received almost scarce training in wound care (between 1-8 h), and even 19% of respondents did not receive any university training in this regard (Table 3).
Moreover, with regard to the correlation between training time effectively carried out and perceived competence, it is possible to detect how, in the areas of more advanced competence in wound care, the respondents were found to be below the general trend, and in particular, in recipient and donor skin transplantation (on average 3.3 ± 2.2), in the first aid of frostbite ulcers (3.3 ± 1.9), and in the assistance of atypical wounds (3.6 ± 2.1) ( Table 5). In fact, analyzing skills in these more specialized areas, the lack of adequate training time, with consequently less professional expertise, is more explicit.
Competence areas in wound care are strongly related to theoretical issues and practical training, during the academic attendance of nursing students, to develop and achieve appropriate skills to deliver optimal wound care to patients [16,17].
This study clearly showed that caring for patients with wounds requires several skills and attitudes from RNs. Moreover, wound care education in undergraduate nursing students is not always adequate and lacks consistent learning goals, content, and duration of academic training.
This study has some limitations: the findings are observational due to the crosssectional structure of the study design; the online web-based survey may lead to selection bias and limit the generalizability of the study; the assessment of competence areas was based on self-reporting, and the participants may perceive in different ways the items that were investigated. Moreover, we were able only to assess Italian nurses' perception of self-efficacy and of their own capacity to deal with the wound care area. Probably further studies with psychometric testing [28] may validate our results in terms of comprehensive competence assessments in the wound care area.

Conclusions
This study shows that in Italy, education in wound care in nursing students is relatively poor and, probably, many skills are achieved during RNs' careers in an empirical way. Further research is needed to find out what educational interventions are needed for nursing students and for those RNs that already work in an area where wound care management is required in clinical practice.  Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Data Availability Statement:
Datasets are available on request from the corresponding author only as the data are sensitive, and participants may be potentially identifiable.