Abstract
This article describes the collaborative process undertaken by the Canadian Association for Enterostomal Therapy and the Canadian Association of Wound Care in an effort to improve the quality of wound prevention and management education and programming. The end result of this process is the Wound CARE Instrument which promotes an interprofessional, collaborative appraisal process to support the development, adoption or adaption of wound management educational events and programs.
Keywords: Wound, Instrument, Standards, Education
INTRODUCTION
Over the last 15 years, the need for knowledgeable and skilled clinicians to deliver acute and chronic wound management has grown exponentially. This has created opportunity and demand for basic and advanced wound care education for and from health care professionals. Wound care education has become available through educational institutions, online services, certification programs, professional associations' conferences and educational events, corporate sponsored wound education programs and webcasts, and the list goes on. Comprehensive collaborative, patient‐centred and interprofessional education is part of a fundamental foundation towards the delivery of effective and efficient care to improve patient outcomes and the overall health of Canadians (1). However, how do we know health care professionals are receiving the quality wound management education they need to support career long learning that enables best practice for their patients?
The importance we place on effective, evidence‐informed and outcome‐driven health care requires health care professionals to be aware of the best available evidence for their clinical practice. Yet, with the amount of information and new research data doubling every 12–18 months (2), health care professionals are challenged to appraise, interpret and reconcile this information with their experiential knowledge and understanding of the clinical context while considering patient preferences. We know that investing in the education of health care professionals will enhance an evidence‐informed approach to wound management. Therefore, each year, Canadians invest significant human and financial resources into the provision of wound care by providing continuing education to health care professionals who help Canadians suffering from acute and chronic wounds. Health care professionals see learning as a career long process that lies at the heart of their discipline which must be planned, nurtured and managed in order to serve the needs of their patients (3). However, administrators in government, regional health authorities, hospitals, long‐term care and community care facilities determine where and when to make public investments in professional education or skills training and these decisions are often driven by the need for documented economic and patient health outcomes that show a positive result in response to their investment of public funds 3, 4.
Unfortunately, in an effort to meet the demand and pace for education, there has been little work to develop a set of comprehensive standards to ensure or evaluate the quality of the wound management education in the market place. How can we be assured that the knowledge is developed, delivered, evaluated and sustained by an educational event or programme that meets the highest standards as described in the Knowledge to Action Cycle? (5) (Figure 1).
Figure 1.
Knowledge to action cycle. (Reprinted with permission from reference 5.)
The Canadian Association of Wound Care (CAWC) and the Canadian Association for Enterostomal Therapy (CAET) agreed that there was sufficient evidence to support the development and publication of a standard for wound management education and programming that could be used worldwide by health care professionals and their employers to appraise existing and future investments in wound care education. In April 2010, CAET and CAWC created a development team, appointed a task force of wound care leaders and asked them to evaluate the available evidence and make comprehensive recommendations that would help to ensure a collaborative, evidence‐informed, unbiased, sustainable and patient‐centred approach to wound management education and programming (6).
BACKGROUND
Educational programmes for wound management should be structured, organised and comprehensive. They also need to be updated and revised on a regular basis to incorporate new evidence and new technologies to enhance health outcomes. While there is a wide range of wound care education and associated programmes available, the evidence shows professional educational programmes achieve maximum benefits when targeted to the appropriate health care providers, patients, family members and caregivers, maximising knowledge translation into practice and retention or sustainability [Registered Nurses Association of Ontario, 2006(7)]. The Royal College of Physicians and Surgeons of Canada have recognised the need for professionals to have knowledge, skills and attitudes beyond their subject or clinical expertise. Within the subject expertise we can define the health care professional as expert and scholar. Successful professionals also need to have skills in health care systems as communicator, collaborator and manager. And finally, each must consider their own personal growth to achieve a high level of performance in professionalism and health advocacy (8).
By developing an instrument that encourages organisations and individuals to provide a Collaborative Appraisal and Recommendation for Education, training and skills enhancement programs for health care professionals, the CAWC and CAET seek to influence the quality of wound management delivery and the overall health outcomes of patients across Canada and around the world. The standards that are identified in the Wound CARE Instrument will ensure that the benefits of wound management education and programming will be achieved if the Wound CARE Instrument is utilised for the planning, implementation and evaluation of wound management education and programming.
METHODOLOGY
Creating the Wound CARE Instrument
A Development Team and Task Force were appointed to develop the Wound CARE Instrument. Each Task Force member was involved in wound management education and programme development. The Development Team used four key documents to identify the standards: Health Canada Strategy “Interprofessional Education for Collaborative Patient‐Centred Practice”(9); Canadian Interprofessional Health Collaboration “Stronger Together: Collaborations for System‐Wide Change”(10); International Diabetes Federation “International Standards for Diabetes Education, 3rd edition”(11); and Registered Nurses' Association of Ontario “Toolkit – Nursing Best Practice Guidelines”(12). A literature search was then undertaken through CINAHL and MEDLINE using key words standards, education and health care to identify the evidence to identify and provide support for the proposed standards. Several drafts of the standards in the Wound CARE Instrument were developed and then reviewed and edited by the Task force. Eventually, a final draft of the Wound CARE Instrument was reviewed and approved in principle by the CAET and CAWC board of directors.
The Wound CARE Instrument was designed to address the key phases in the development of wound management education and programming (13). The standards were then located within each of the appropriate phases:
Phase 1: Preliminary planning – an often forgotten step that ensures the purpose and goal are considered beforehand. The standards in this phase need to be completed in a collaborative, comprehensive manner to successfully accomplish the remaining phases.
Phase 2: Preparation and development – identifies standards that ensure the components of the design and planning of the wound management education or programme are met.
Phase 3: Implementation – identifies standards that support the effective delivery of wound management education and programmes.
Phase 4: Outcomes – identifies the standards that support evaluation and measurement of the results post‐implementation of wound management education and programmes.
Phase 5: Sustainability and post–implementation planning – identifies standards that ensure short and long‐term strategies are in place to maintain the benefits of the wound management education or programme and provide ongoing support and evaluation.
Validating the Wound CARE Instrument
Once the Board of Directors of both the CAET and CAWC approved of the Instrument, the Delphi method was used to evaluate the Wound CARE Instrument. The results of the Delphi process guided the Task Force to make further revisions. Once the Instrument revisions were made a Pilot Test that included stakeholders from across Canada was initiated. The evaluation of the Pilot Test resulted in a positive response to the use of the Wound CARE Instrument.
Delphi process
Twelve expert wound care educators from across Canada were nominated by members of the task force and invited to participate as Delphi panel members. Nine expert educators accepted the invitation and participated in the Delphi process. In advance, it was determined that standards that received less than 80% endorsement required review by the development team to consider any potential rejections or modifications. The Delphi panel members were asked to implement the following steps of the Delphi process:
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Read the entire document carefully to fully understand the context of the Wound CARE Instrument, the standards listed within and the appraisal and recommendation process.
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Read each standard on the ‘Delphi Panel – Standards for Consideration’ evaluation form and indicate whether they would:
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agree with the standard
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modify the standard and if so, provide the reason, or
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reject the standard and if so, provide an explanation.
Delphi results
Round 1: No standards were rejected. All the participants agreed with the 30 standards; however, nine standards were identified as requiring modification related to sentence structure to improve clarity. These improvements were then forwarded to the Delphi panel members for a round 2 review.
Round 2: Some members still had concerns regarding the wording changes and further minor word changes occurred. The minor alterations were then sent to the Delphi panel members for final approval.
Round 3: The standards were accepted as written.
Pilot testing
A pilot testing of the Wound CARE Instrument was initiated to see how it performed ‘in action’ to assist in determining its usability. Sites that currently had wound care programmes were considered. Potential pilot sites were recommended by members of the Delphi panel and members of the task force, and invitations were sent to these individuals to participate in a pilot of the Wound CARE Instrument. Of the nine invited sites, six from across Canada agreed to participate in the pilot. No French‐speaking sites accepted the pilot opportunity. The pilot sites were reflective of different health care settings and included the following:
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Long‐Term Care (LTC), Ontario
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Acute Care, Ontario
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Academic Institution, Alberta
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Community Care Clinic, Alberta
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Health Care Centre, Newfoundland
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Community Home Care, Saskatchewan
Each pilot was led by a skilled wound care clinician and/or educator. Each site was asked to identify and evaluate an existing or proposed wound care educational event and/or programme in their organisation. Once the sites identified the wound care education or programming they wanted to appraise, they then:
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Identified the stakeholders to be involved [an evaluation team with a minimum of three stakeholders with diverse responsibilities in their organisation was required. Interprofessional collaboration for the appraisal and recommendations of wound care education and programming was to involve representation from administration, purchasing (if required), and a clinical expert with practice in wound management and/or wound management education].
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Had all stakeholders review the Wound CARE Instrument.
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Had stakeholders review the current or proposed wound education or programming to be appraised considering preliminary planning, planning and development, implementation, evaluation and sustainability of the wound care education and/or programme.
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Asked each stakeholder to appraise the event or programme independently using the Wound CARE Instrument.
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Had stakeholders meet to discuss their independent reviews and arrive collaboratively at a decision, achieve consensus and decide to endorse, adopt, adapt, purchase or reject the education or programme.
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Completed the Wound CARE Instrument Pilot Evaluation Form and returned it to the Development Team.
Pilot testing results
The following is a summary of the pilot sites' evaluations in response to the questions outlined on the pilot evaluation form.
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Was the Wound CARE Instrument easy to use? (Not at all easy to use = 1, Very easy = 5)
• 66·7% rated 4 (‘easy’)
• 16·7% rated 3·5
• 16·7% rated 1 (‘not at all easy’)
Comment: When further questioned regarding the low score, the responsible pilot site indicated a desire for a clarifying statement regarding each standard to ensure that everyone reviewing the standard was clear as to what the standard meant.
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Was the Wound CARE Instrument helpful in identifying gaps and strengths? (Not at all helpful = 1, Very helpful = 5)
• 50% rated 5 (‘very helpful’)
• 16·7% rated 4 (‘helpful’)
• 16·7% rated 3 (‘neutral’)
• 16·7% rated 2 (‘not helpful’)
Comment: The site that found the tool not helpful was an academic institution, as opposed to a clinical setting.
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Did the Wound CARE Instrument provide an environment for collaborative discussion? (Definitely NOT = 1, Definitely YES = 5)
• 66·7% rated 5 (‘definitely YES')
• 33·3% rated 4 (‘YES’)
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Did the activity using the Wound CARE Instrument result in a decision? (YES or NO)
• 66·7% rated ‘YES’
• 33·3% rated ‘NO’
Comment: Even though one site said no, in their narrative, they stated the Instrument did give them a score that helped them target improvements for a weak educational programme.
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Would you use the Wound CARE Instrument again? (YES or NO)
• 66·7% rated ‘YES’
• 33·3% rated ‘NO’
Comment: One site that rated no stated that if a user‐friendly statement was added after each standard they would use it.
Impact of the pilot
The Wound CARE Instrument was fully endorsed by four of the six sites. One of the two sites that did not fully endorse the Instrument felt the Instrument required further minor revisions to make it more ‘user‐friendly’. In response to this comment, a brief description called a ‘consideration’ statement was added under each standard to add clarity and aid in its interpretation. The professionals at the pilot site were pleased with the additional statements. The second site that did not fully endorse the Instrument was an academic institution. The professionals here thought that although the Instrument had potential to suit a clinical setting, it was not applicable to an academic setting where the linkage to the clinical environment is not always available.
Although there were only six pilot sites, these were enough to provide representative results from different types of health care facilities from provinces across Canada, with the exception of the province of Quebec or other French‐speaking area. Two French language pilot sites were invited to participate but declined.
THE WOUND CARE INSTRUMENT – THE FINAL DOCUMENT
The Wound CARE Instrument has been designed to provide a set of standards that support health care providers, wound management leaders, educators, purchasing managers, administrators, organisations and health authorities to undertake a comprehensive, collaborative and evidence‐informed appraisal process before developing or introducing a wound management education initiative. As a set of standards they offer a minimum acceptable level of performance in the developmental process of wound management education and programming (14). By providing a collaborative and evidence‐informed approach to the appraisal and recommendation process of wound management education and programming, the Wound CARE Instrument standards can support decision makers in their efforts to improve wound care knowledge, skills and attitude and improve the health of patients at risk for or suffering from wounds. In summary, the Wound CARE Instrument will:
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Provide a foundation to identify the components required to plan, develop, implement, evaluate and sustain evidence‐informed wound management education and programming.
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Provide a benchmark to appraise the quality of wound management education and programming.
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Support collaboration in the development and implementation of wound management education and programming.
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Inform decisions related to the endorsement, adoption, adaption, purchase or rejection of wound management education and programming.
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Improve patient care and health outcomes relating to the prevention and management of wounds.
WHO SHOULD USE THE WOUND CARE INSTRUMENT?
Anyone concerned with patient outcomes and cost‐effective use of health care resources and services will find the Wound CARE Instrument useful in ensuring the appropriate human and financial resources are supporting organisational objectives related to wound prevention and management effectively. Leaders in organisations and institutions including CEOs, directors, policy makers, managers, administrators or unit managers as well as reimbursement and funding agencies will benefit from using this Instrument. Procurement departments including the buyer or purchasing manager will find the Instrument helpful in ensuring that the requirements for evidence‐informed wound management education and programming are met in the consideration of any wound management related product or service. Educators and developers of wound management education and programming in organisations, health care and educational institutions and industry will be able to critically appraise education and programming that affects the training of their learners. Key wound care leaders, such as wound care specialists, enterostomal therapy nurses or clinical managers will be able to critically appraise education and programming that directly affects patient care. And finally, health professionals such as physicians, dietitians, nurses, podiatrists or chiropodists, social workers, occupational and physical therapists will also find value in the appraisal process as they review and determine the quality of wound management education they plan to attend or receive.
HOW TO USE THE WOUND CARE INSTRUMENT
To achieve optimal outcomes, the Wound CARE Instrument should be applied in an interprofessional/interdepartmental collaborative method. A minimum of three stakeholders with diverse responsibilities within the organisation or institution are required to appraise the wound care educational event or wound care programme under review. Interprofessional/interdepartmental collaboration for the appraisal and recommendations involves representation from administration, purchasing (if required), and a clinical expert with practice in wound management and/or wound management education. The following steps outline the process for using the Wound CARE Instrument:
Step 1: Select the educational event, initiative and/or programme to be appraised and identify the stakeholders to be involved.
Step 2: The stakeholders need to review the proposed or existing educational event or programme considering preliminary planning, planning and development, implementation, evaluation and sustainability.
Step 3: After reviewing the proposed or existing educational event or programme, each stakeholder appraises the event or programme independently using the Wound CARE Instrument.
Step 4: The stakeholders then meet to discuss their independent reviews and collaboratively arrive at a decision. The stakeholders work to achieve consensus and decide to endorse, adopt, adapt, purchase or reject the education or programme.
Step 5: The instrument is then signed by each of the stakeholders and dated to document the appraisal and final recommendation.
It is highly recommended that any conflict of interest is addressed and the person(s) or company delivering or developing the wound management education or programme should not be one of the appraisers. However, these individuals can use the Wound CARE Instrument as a guide for the comprehensive development of their education initiative or programme or for feedback on existing programmes.
CONCLUSION
Wound CARE Instrument is a valuable tool to aid in the appraisal and evaluation of wound management education and programming within a clinical setting and may not be applicable for academic settings. One particular comment from a pilot site sums up the value of the Wound CARE Instrument: The ‘Wound Care Instrument Tool provides us a better concept, a better connection, link and direct involvement across the continuum so that all health care professionals (learners) are able to adapt new and current wound care practices based on evidence and research. It also enabled our organisation and policy makers to better understand the importance of our wound care program and the need to change for a better well structured, comprehensive educational wound care management program.’
NEXT STEPS
External endorsements of the Wound CARE Instrument are being obtained. A dissemination strategy with outreach to the target audiences (e.g. private and public health care organisations, general purchasing organisations and endorsing bodies) is being determined. The impact of the Wound CARE Instrument on wound care education and programming with an independent evaluation and study is yet to be planned. A revision plan for the Wound CARE Instrument has been determined to take place every 3 years.
To access and download the Wound CARE Instrument please visit: www.caet.ca or www.cawc.net
REFERENCES
- 1. Borduas F, Frank B, Hall P, Handfield‐Jones R, Hardwick D, Ho K, Jarvis‐Selinger S, Lockyer J, Novak Lauscher H, MacLeod A, Robitaille MA, Rouleau M, Sinclair D, Wright B. Facilitating the integration of interprofessional education into quality health care: strategic roles of academic institutions. Ottawa, ON: Health Canada, 2006. [Google Scholar]
- 2. Virani T, Bajnok I. Knowledge in clinical practice guidelines. Senior Care Canada, 2004. URL http://www.seniorcarecanada.com/articles/2004/q1/knowledge.management [accessed on 24 June 2010.
- 3. Falk Craven R, Bassett DuHamel R. Certificate programs in continuing professional education. J Contin Educ Nurs 2003;34:14–8. [DOI] [PubMed] [Google Scholar]
- 4. Kitson A, Straus SE. The knowledge‐to‐action cycle: identifying the gaps. Can Med Assoc J. 2010;182:E73–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, Robinson N. Lost in knowledge translation: time for a map. J Contin Educ Health Prof 26:13–24. [DOI] [PubMed] [Google Scholar]
- 6. SCCPD Position Paper on University CME/CPD Offices and Industry Relations. Ottawa, ON: Standing Committee on Continuing Professional Development, Association of Faculties of Medicine.
- 7. Registered Nurses' Association of Ontario. Client Centred Care (rev suppl). Toronto, ON: Registered Nurses' Association of Ontario, 2006.
- 8. Sibbald RG, Alavi A, Sibbald M, Sibbald D, Rath D, Davis D. Effective adult education principles to improve outcomes in patients with chronic wounds. In: Krasner DL, Rodeheaver G, Sibbald RG, editors. Chronic wound care: a clinical resource book for healthcare professionals, 4th edn. Wayne, PA: HMP Communications, 2007:29–43. [Google Scholar]
- 9. Health Canada. Interprofessional Education for Collaborative Patient‐Centred Practice. URL http://www.hc‐sc.gc.ca/hcs‐sss/hhr‐rhs/strateg/interprof/index‐eng.php [accessed on 24 June 2010].
- 10. Canadian Interprofessional Health Collaborative. Stronger Together: Collaborations for System Wide Change. URL http://www.cihc.ca [accessed 24 June 2010].
- 11. Standards Revision Committee of the IDF Consultative Section on Diabetes Education. International Standards for Diabetes Education. 3rd edn.
- 12. Registered Nurses' Association of Ontario. Toolkit Implementation of Clinical Practice Guidelines. Chapter 3: Assessing your environmental readiness. Toronto, ON: Registered Nurses' Association of Ontario, 2002. [Google Scholar]
- 13. Baranoski S, Brenczewski M. Developing educational programs: a blueprint for success. Chronic wound care: a clinical resource book for healthcare professionals, 4th edn. Wayne, PA: HMP Communications, 2007:51–73. [Google Scholar]
- 14. Orsted H, Keast D, Campbell K. Best practice guidelines, algorithms, and standards: tools to make evidence‐based practice available and user friendly. In: Krasner DL, Rodeheaver G, Sibbald RG, editors. Chronic wound care: a clinical resource book for healthcare professionals, 4th edn. Wayne, PA: HMP Communications, 2007:177–83. [Google Scholar]