Course Content Related to Chronic Wounds in Nursing Degree Programs in Spain Angel Romero-Collado, PhD, MSc, RN1, Marta Raurell-Torreda, PhD, MSc, RN2, Edurne Zabaleta-del-Olmo, MSc, RN3, Erica Homs-Romero, RN4, & Carme Bertran-Noguer, PhD, MSc, RN5

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PROFESSION AND SOCIETY

1 Professor of Nursing, Nursing Department, University of Girona, Spain 2 Professor of Nursing, Nursing Department, University of Girona, Spain 3University Institute for Primary Care Research Jordi Gol (Institut Universitari d’Investigació en Atenció Primària (IDIAP) Jordi Gol), Barcelona, Spain and Researcher associated with the Universitat Autònoma de Barcelona, Bellaterra, Spain 4 Figueres Basic Healthcare Area (Àrea Bàsica de Salut de Figueres) Catalan Health Institute (Institut Català de la Salut), Girona, Spain 5Head of Nursing Department, University of Girona, Spain

Key words Curriculum, nursing education research,

nursing students, pressure ulcer, professional

competence, Spain, wound healing

Correspondence Dr. Angel Romero-Collado, Professor of

Nursing, Nursing Department, University of

Girona, C/ Emili Grahit, 77, 17071 Girona, Spain.

E-mail: angel.romero@udg.edu

Accepted: July 19, 2014

doi: 10.1111/jnu.12106

Abstract

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

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.

Background

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

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.

Methods

Design

A cross-sectional design was used to analyze the con- tent on chronic wounds in nursing degree programs in Spain.

Centers

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.

Data Collection

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

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.”

Ethical Considerations

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.

Data Analysis

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.

Results

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).

Discussion

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.

Pain Management

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,

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.

Course Content Related to Chronic Wounds Romero-Collado et al.

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Romero-Collado et al. Course Content Related to Chronic Wounds

These data show that the treatment of PUs and other chronic wounds is emphasized more than prevention in the degree programs (4.34% vs. 2.21% of courses and 61.8% vs. 36.9% of centers, respectively). Our finding is not consistent with other reports on the knowledge base of healthcare professionals, primarily nurses, which have found better results in the prevention than the treatment of PUs (Hinojosa-Caballero, 2012; Pancorbo- Hidalgo et al., 2007; Quesada Ramos & Garcı́a Dı́ez, 2008; Saleh et al., 2013). Our results highlight a problem in nursing education that can be addressed very directly when students are assigned to clinical training. In recent years, there have been more changes in PU treatment than in prevention strategies, and therefore prevention has taken a back seat in continuing professional educa- tion (Pancorbo-Hidalgo et al., 2007); however, we cannot allow this tendency to affect the preparation of new nurs- ing professionals. The clinical supervisor is a key player in ensuring that students acquire skills in both the pre- vention and treatment of PUs, not least because the stu- dent spends many more hours at the clinical site than in university courses on clinical practices. It is difficult to make changes in what students learn and to improve clin- ical practices if outdated (even nonrecommended) pro- cedures persist at clinical training sites. Therefore, it is essential that clinical supervisors teach evidence-based best practice and ensure that it is demonstrated by ex- ample at the clinical site.

Acute Wounds

We included the term “wounds, acute processes” as a control indicator to assess whether this type of wound is given importance similar to the category of “treatment of pressure ulcers and other chronic wounds.” This term was more prevalent than “chronic wounds” in 30% of the courses (5.8% vs. 4.34%) and was at least present in some course at 16 more centers (75 vs. 59). These results concur with Ayello et al. (2005), who reported that 70% of nurses responded that they had not received sufficient education on chronic wounds in their basic nursing ed- ucation program. Although more courses and more cen- ters indicate content related to “wounds, acute processes” than to “treatment of pressure ulcers and other chronic wounds,” acute wound care remains an area of concern because all centers should be providing this instructional content, independently of the present study’s focus on chronic wounds.

Lower Extremity Wounds

We also considered it important to identify content related to assessing nursing care of patients with dia-

betic foot or venous and arterial disorders in the lower limb, which are the other large groups of chronic wounds and have great impact on patients’ quality of life (Fe- inglass et al., 2012). We found content on “venous and arterial disorders of the lower extremities” to be slightly more prevalent than “prevention of pressure ulcers” (55 vs. 50), and more centers offered at least one related course (47 vs. 35). We consider this a deficiency be- cause future nurses must know the characteristics, diag- nosis, progression, and treatment of ulcers with venous or arterial etiology. These deficiencies have also been re- ported in specialized training of internal medicine resi- dents (Schwarcz, Quijano, Olin, & Ostfeld, 2012; Wyatt et al., 2010). Researchers have recommended a greater emphasis on lower extremity wounds in medical school and residency programs (Georgakarakos et al., 2013; Wyatt et al., 2010).

Content on “diabetic foot” is almost anecdotal in the courses analyzed, and was found only in four courses in four different centers. Between 15% and 25% of diabetic patients present with a foot ulcer at some point, and 14% to 20% of them are amputated (Conferencia Nacional de Consenso sobre Úlceras de la Extremidad Inferior, 2009). The training of nursing professionals in foot care is one of the implementation objectives that support patient ed- ucation and the prevention of possible disorders (van Houtum, 2012); therefore, it is critical to include this con- tent in the curriculum.

Elective Courses

When we analyzed the presence of elective courses, we were surprised to find only one elective course in all of Spain that offered the possibility of consolidating and deepening students’ knowledge of chronic wounds, far below other fields such as complementary or alterna- tive therapies (1 vs. 36). It could be argued that there is no need to offer elective courses related to chronic wounds because sufficient content is provided in the de- gree courses. However, the same case could be made for elective courses about research methods (the second most frequent elective offering); urgent, emergency, or disaster care (the third most frequent elective); or dependency, disability, and chronic disease (sixth in frequency). All of these topics were represented in required courses, but electives offer an opportunity to gain a deeper understanding.

In Spain, opportunities for specialization exist in elec- tive courses and in 2-year graduate residency programs in one of seven specialty nursing areas (family and com- munity health, geriatrics, gynecology/obstetrics/midwife, medical-surgical care, mental health, occupational health, and pediatrics). Although caring for chronic

Course Content Related to Chronic Wounds Romero-Collado et al.

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66 (6 3. 5)

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85 (8 1. 7)

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1 3 (0 .4 )

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10 3 (9 9. 0)

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Romero-Collado et al. Course Content Related to Chronic Wounds

wounds is of obvious concern in the geriatric population and in medical-surgical hospital nursing, awareness of their preventability and of current best practices in the prevention and treatment is a competency that can contribute to quality patient care in any setting. This can be addressed by site protocols and continuing education workshops, but it is also key that universities adequately address the topic in their curricula. Unlike countries that offer a specialization in wound care or diabetes care, universities in Spain need to provide elective courses and units of required degree courses that make it possible for students in any program to acquire this important area of competency and be prepared to provide affected patients with the needed care.

Limitations

An important limitation of our data collection was the lack of a common set of official criteria governing nursing course content descriptions. Some centers provide exten- sive descriptions and others offer rather scant informa- tion about the content of their courses. We also did not have access to all courses in all programs because Spain has gradually implemented the university-level degree in nursing and not all centers have proceeded at the same pace. Nonetheless, we were able to review course con- tent from 83.3% of the centers, more than 80% of them through the second year, and had access to 65.72% of all listed courses. Therefore, our results are drawn from an extensive panorama of the undergraduate nursing degree programs in Spain.

Another limitation of this study is the lack of elec- tronic access to the course content taught at 16.7% of the centers that award the degree in nursing. However, we gained access to more than 80% of the relevant infor- mation through the second year of the degree program, at which point students have completed the bulk of their required and introductory courses.

The analysis was confined to nursing degree pro- grams in Spain. Although we found no studies with sim- ilar methodology, we located several reports of these same deficiencies in other countries: in Germany, us- ing content analysis of nursing textbooks (Wilborn et al., 2009); in England, where students in the fi- nal year of their nursing degree reported a perception that they did not know how to manage patients’ skin integrity effectively (Ousey et al., 2013); and a U.S. study of faculty perceptions and documentation of PU content in all 50 states and the District of Columbia (Ayello et al., 2010).

Conclusions

In this study, we observed differences in the presence of the four top educational priorities in wound manage- ment and tissue repair (Cowman et al., 2012) in courses that comprise the degree in nursing in Spain. Content on pain management in patients with chronic wounds (top priority) is nonexistent and about PU prevention (second priority) is deficient, compared to content about PU treat- ment (third and fourth priorities).

The course content related to chronic wounds that is offered to future nurses in Spain appears to be deficient. This situation must improve in order to phase out the use of nursing interventions not recommended for PU prevention. In the 21st century, we simply cannot allow more than half of the teaching centers that offer a degree in nursing to ignore the prevention of PUs in their course content. This change must be implemented in required courses, because there are almost no elective courses re- lated to the prevention and treatment of chronic wounds.

Degree programs responsible for preparing future nurses must guarantee the acquisition of minimum basic skills in the prevention and treatment of chronic wounds. University programs in all countries should review their curricular offerings and take steps to reduce the theory– practice gap in this field.

Acknowledgments

We appreciate the translation and manuscript editing provided by Elaine Lilly, PhD. Preliminary results of this study were presented at a GNEAUPP Symposium (IX Simposio Nacional GNEAUPP. Ciencia, Arte y Compro- miso) held in Sevilla November 14–16, 2012.

Clinical Resources � European Pressure Ulcer Advisory Panel: http://

www.epuap.org � European Wound Management Association: http://

ewma.org/english.html � Spain’s official database of universities, centers,

and diplomas [Registro de Universidades, Cen- tros y Tı́tulos (RUCT)]: https://www.educacion. gob.es/ruct/home#

� Spanish Pressure Ulcer and Chronic Wounds Advi- sory Panel: http://www.gneaupp.org

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Course Content Related to Chronic Wounds in Nursing Degree Programs in Spain Angel Romero-Collado, PhD, MSc, RN1, Marta Raurell-Torreda, PhD, MSc, RN2, Edurne Zabaleta-del-Olmo, MSc, RN3, Erica Homs-Romero, RN4, & Carme Bertran-Noguer, PhD, MSc, RN5

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