Abstract
An educational programme in wound healing was developed in France in 1998. The course lasts for 1 year and consists of 100 hours of interactive education including wound‐healing principles, management of pressure ulcers, leg ulcers, diabetic foot ulcers, burns and trauma. The programme mixes theoretical and practical issues and results in the award of a diploma that identifies students as having a level of expertise in wound healing. A large component of each student's evaluation is based on a thesis that has been developed by the student during the year. After 6 years of continual development and modification, this educational approach was analysed to evaluate its impact on wound healing in France. More than 500 individuals have been trained by this educational programme, including nurses, physicians, pharmacists, physiotherapists and employees of commercial concerns. In order to evaluate the impact of such a training programme on changing practice in France, a questionnaire was developed and a telephone survey carried out. The results of this survey are reported here and they show that education and training provided undertaking a university diploma has played an important role in the development of wound healing and the subsequent change in practice in France.
Keywords: change in practice, diploma, education, France, wound healing
Introduction
Education on wound healing for individuals wishing to specialise in this subject has been evolving in France since 1998. After 6 years of development, many individuals have taken and completed the course. These include the clinical specialities of nursing, medicine, pharmacy and physiotherapy in addition to employees of commercial concerns working in this field. In order to evaluate the impact of our training programme and the subsequent change of practice in this field, a survey of the graduates was undertaken.
Other countries have developed similar educational approaches with many of these being reported in the literature 1, 2, 3, 4, 5).
History of Wound Healing in France
Historically, the evaluation of wounds and the understanding of the associated pathologies have existed in France since Ambroise Paré's work during the eighteenth century (6). This knowledge has been transmitted to generations of physicians, mainly by surgeons and dermatologists. Baron Larrey developed the use of impregnated gauze (Balsam of Peru) during the Napoleonic wars (7).
In 1992, a number of regional initiatives began to develop in France (Paris, Montpellier and Angers). These meetings were attended by small numbers of participants (350–500). This was the first attempt at establishing links between all clinical professions working in this field and included nurses, doctors, pharmacists and physiotherapists. It was through these regional initiatives that the moist wound‐healing concept and the use of modern dressing materials based on this principle 8, 9, 10, 11, 12, 13) began to be adopted in our country.
The first national meeting (Conferences des Plaies et Cicatrizations) took place in Paris in 1997, bringing together many of these regional components and activities. The attendance grew rapidly from the initial 1700 delegates in 1997 to 3500 in 2003. More recently in 2004, this organisation and venue was chosen to host the 2nd Meeting of the World Union of Wound Healing Societies. This was a very successful meting bringing together over 6000 delegates representing a wide range of specialities from all over the world.
The annual meeting in France is held over 3 days, with alternating workshops and main plenary courses and lectures. This event provides the advantage of educating the medical, nursing and other clinical professions by providing new information from different speciality areas, including geriatrics, plastic surgery, dermatology, physical therapy and neurology.
The need for a recognised measure of expertise was identified during our first annual meeting. This was also echoed by other speciality groups, including private nurses and physicians, other important institutions and University Hospitals in France. As such, it was felt that France was keen to develop a common approach for the education of wound‐healing professionals.
Educational Programme Development
An educational programme was designed, which included several practical issues that had been identified by the students, and in accordance with the specifications of the Pedagogic (teaching) Committee of the Faculties of Medicine.
More than 500 students have undergone training using this programme in the first 6 years. The following is a summary of the diploma course.
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1
Several topics of interest were defined: pressure ulcer management, prevention and treatment of leg ulcers and diabetic foot ulcers, the prevention and care of burns, osteoradionecrosis, malignant wounds, dermatological conditions and recognition of unusual wound pathologies. Each topic was divided into three components: prevention, local management, aetiology and correction of underlying pathology.
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2
Each course is taught by nationally recognised specialists, who are evaluated by the students.
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3
The practical teaching sessions were developed essentially to reflect practical issues seen in clinical practice and discussion of specific cases. The practical training sessions took place in the clinical wards of the Burns Centre, the Rehabilitation Unit and the Geriatric Unit. Here questions were raised by students and addressed by the clinicians working in these units. Discussion of the clinical cases then took place with active participation of each student.
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4
Wound‐management plans, care strategies, clinical facts and appropriate references are all provided and organised in order to justify good practice.
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5
A short thesis is written (20–30 pages) by each student. The subject is defined by each individual student and is relevant to their clinical practice. Emphasis is placed on the methodology and implications for practice rather than on the scientific content. As the previous experience of each participant is extremely variable, guidance on research tools are provided to the students, encouraging them to search for documents and references in medical libraries and on the Internet. Students are also able to access the theses from previous students. This part of the examination is considered as difficult by many of the students but particularly nurses.
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6
Self‐study is required and expected at different levels:
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•
During the discussion of clinical cases, each student is expected to participate and evaluate their own knowledge gaps compared to tutors and fellow students.
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•
At the beginning and the end of each course, the same questions are asked of the students to evaluate improvement in knowledge base over the length of the course.
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•
The thesis must present the methodology of the study, any questionnaire used, the statistics used when analysing the results and a comprehensive bibliography.
Course Analysis Questionnaire
A survey questionnaire was produced with the help of the Department of Medical Informatics of Assistance Publique des Hôpitaux de Paris, who defined some of the principles to be applied to the questions asked.
The mode of survey (direct contact by phone without providing any previous information on the survey) was chosen in order to ensure the spontaneity of the student's responses, and to prevent them from reviewing their knowledge prior the interview. A copy of the questionnaire is shown in Table 1.
Table 1.
General questionnaire
| 1) What is your main activity? |
| □ General practitioner |
| □ Specialist |
| □ Registered nurse |
| □ Physiotherapist |
| □ Pharmacist |
| □ Other |
| 2) Your main arena of practice is? |
| □ Private |
| □ In hospital |
| □ Both |
| 3) Which part of your global activity is devoted to wound management? |
| □ 100% |
| □ 50% |
| □ 25% |
| □ 10% |
| □ 0% |
| 4) Do you participate in any teaching/training activity in wound healing? |
| □ Yes |
| □ No |
| 5) Have you heard about specific journals on wound healing? |
| □ Yes |
| □ No |
| If yes which one? |
| □ Journal des Plaies et cicatrisations |
| □ L'escarre |
| □ Journal of Wound Care |
| □ Wounds |
| □ Wound Ostomy Management |
| □ Wound Repair and Regeneration |
| □ Other |
| Did you read at least once one all or part of these journals? |
| □ Journal des Plaies et cicatrisations |
| □ Yes |
| □ No |
| □ L'escarre |
| □ Yes |
| □ No |
| □ Journal of Wound Care |
| □Yes |
| □ No |
| □ Wounds |
| □ Yes |
| □ No |
| □ Wound Ostomy Management |
| □ Yes |
| □ No |
| □Wound Repair and Regeneration |
| □ Yes |
| □ No |
| □ Other |
| 7) Did you attend the French ConfŽrence des Plaies et Cicatrisations? |
| □ Yes |
| □ No |
| □ How many times |
| Did you attend any other meeting on wound healing? |
| □ In France |
| □ Yes |
| □ No |
| □ Abroad |
| □ Yes |
| □ No |
| 8) Did you receive any training other than the UD on wound healing problems? |
| □ Yes |
| □ No |
| 9) Which type? |
| □ Teaching in nursing school |
| □ University teaching |
| □ Post‐University teaching/continuous training |
| 10) If you got a university diploma, which kind of benefits did you get? |
| □ To be recognised as expert |
| □ Yes |
| □ No |
| □ To be a facilitator in wound healing management |
| □ Yes |
| □ No |
| □ Being more confident in practical wound healing management |
| □ Yes |
| □ No |
| 11) Did your UD help you to become yourself a trainer? |
| □ Yes |
| □ No |
| 12) Since the UD, did you feel the necessity to? |
| □ Get an extra formation in wound healing |
| □ Yes |
| □ No |
| □ To implicate yourself more in the field |
| □ Yes |
| □ No |
| □ To regularly revisit your knowledge acquired in wound healing |
| □ Yes |
| □ No |
| 13) Were you a member of a wound‐healing scientific society before the start of the UD? |
| □ Yes |
| □ No |
| 14) Did you become a member of a wound‐healing society since your UD? |
| □ Yes |
| □ No |
| 15) Do you revisit your knowledge? |
| □ Yes |
| □ No |
| If yes with |
| □ Specialised journals |
| □ Congresses |
| □ Permanent formation |
| II Practical Questionnaire on Wound Management |
| 1) Do you know the moist wound‐healing principle? |
| □ Yes |
| □ No |
| 2) Can you define three stages of healing of a chronic wound? |
| 3) Biatain is |
| □ a hydrocolloid |
| □ a hydrogel |
| □ a foam |
| □ a hydrofibre |
| □ an alginate |
| □ an interface |
| 4) Aquacel™ is |
| □ a hydrocolloid |
| □ a hydrogel |
| □ a foam |
| □ a hydrofibre |
| □ an alginate |
| □ an interface |
| 5) Urgotul is |
| □ a hydrocolloid |
| □ a hydrogel |
| □ a foam |
| □ a hydrofibre |
| □ an alginate |
| □ an interface |
| 6) Regranex is indicated in |
| □ Leg ulcers |
| □ Pressure sores |
| □ Diabetic foot problems |
| □ Burns |
| 7) Among these pressure‐relieving systems, which are those recently approved by the French agency and reimbursed? |
| □ Memory foams |
| □ Yes |
| □ No |
| □ Silicone fibres |
| □ Yes |
| □ No |
| □ Air mattresses |
| □ Yes |
| □ No |
| □ Foam mattresses |
| □ Yes |
| □ No |
| 8) In case of black dry eschar which is your initial proposal? |
| □ Surgical/mechanical debridement |
| □ Hydrogel moisturising |
| □ Enzymes |
| □ Maggots |
| □ Honey |
| □ Betadine cream |
| □ Biafine |
| 9) Do you know the risk factor scale of Norton? If yes, can you indicate the score of high‐risk patients following this scale |
| 10) In arterial leg ulcers, which complementary examination should you realise first? |
| 11) In venous leg ulcers, which treatment should you promote? |
| 12) What is the amputation rate at 5 years in patients presenting a diabetic foot ulcer? |
| □ 60% |
| □ 20% |
| □ 10% |
| 13) Superficial second‐degree burns |
| □ Heal spontaneously within less than 2 weeks without any permanent scar |
| □ Yes |
| □ No |
| □ Heal spontaneously within more than 2 weeks with remaining scars |
| □ Yes |
| □ No |
| □ Need a skin graft |
| □ Yes |
| □ No |
| 14) Keloid is |
| □ A pseudotumour extending over the edges of the scar |
| □ Yes |
| □ No |
| □ A transitory thickening of the scar |
| □ Yes |
| □ No |
The survey enrolled 180 participants, who agreed to spend 8 minutes on the telephone to answer the questionnaire.
Results of the Questionnaire
The questionnaire was completed by 180 professionals (of the 280 listed professionals) to validate the University Diploma Courses (UD) in ‘Wound Healing‘ in both Paris and Montpellier.
The students’ impression of the training was mostly positive, with most of the participants satisfied with the mode of training during the diploma course. They were also satisfied with the quality of the teaching (some scope for improvement in the practical aspects of the course was identified).
Residual knowledge from the UD is good, even when students were no longer involved in the care of patients with wounds.
The differences in numbers of people completing the questionnaire are due to more students participating in the Paris UD (Figure 1).
Figure 1.
Location of the survey respondents.
The UD attracts more students from the nursing profession than any other (Figure 2). Obtaining a UD in wound healing allows nurses to obtain recognition from other professionals, although many nurses with this new qualification do not spend the majority of their professional practice time caring for patients with wounds (Figure 3).
Figure 2.
Professions of diploma graduates.
Figure 3.
Percentage of the time spent to treat wounds.
This suggests such participants undertake this UD, not with the aim of becoming full‐time ‘wound carers’, but rather to obtain a sound knowledge base, awareness of guidelines and recommendations for the care of patients presenting with the more difficult‐to‐treat wounds.
Professionals undertaking the UD recognise that it provides a good foundation for a continuing medical education in the field of wound healing. They also feel more comfortable conversing with colleagues and patients, using journals, attending professional association and generally being involved in wound caring. This process of ongoing education would appear to be essential for students to be aware of the changing standards of care in this subject.
In this survey, some specific questions were asked to evaluate the retained and expanded knowledge of students and were presented as multiple‐choice questions. We could then determine the level of knowledge retention and also the knowledge of recent developments in this area.
One question in the survey related to the classification of a dressing recently added to the reimbursement system in France, because it represented a transitional dressing between traditional dressings (i.e. tulle gras) and moist wound‐healing dressings (hydrocolloids). The correct answer was interface. Seventy‐two per cent of the diploma graduates answered correctly. The range of responses to the question is presented in Figure 4A.
Figure 4.
(A) Responses to ‘What type of dressing is Urgotul?’. (B) Response to question concerning the amputation risks in a diabetic patient presenting with a plantar ulcer.
Another question focused on the rate of amputation risk in diabetic patients presenting with a plantar ulcer. In Figure 4B, we observe that 58·3% of the interviewed students estimated the patient to be at 60% risk, 26·7% of students answered 20%, with a further 6 7% defining the patient as being at 10% risk. 8·3% of the respondents had no opinion.
Another question concerned a more drug‐like product (Regranex) which is reimbursed, in France, for non infected neuropathic diabetic foot ulcers (>5 cm2). The product can only be prescribed by endocrinologists and specialists in the management of diabetic foot ulcers.
The results (Figure 5) show that over 50% of respondents understood the exact clinical indication for the product, but 45% of the interviewed persons failed to correctly answer the question or have no opinion.
Figure 5.
Response to ‘What is Regranex approved for in the reimbursement system?’
Discussion
The appropriate knowledge level required for the high standards of clinical practice can be acquired after completing a 1‐year diploma course, consisting of 100 hours of interactive lessons concerning wound‐healing principles, management of pressure ulcers, leg ulcers, diabetic foot ulcers, burns and traumatic wounds, mixing theoretical and practical issues and the completion of a short research thesis.
Changing the practices
Obtaining an officially recognised qualification from a University provided the foundation for a change in the behaviour of the practitioners, especially nurses working in private practice. In some situations, the qualified nurse can be confronted by challenging circumstances. Dressing prescriptions are written by physicians, but nurses must feel comfortable with the products they have learned to use. However, education of individuals from all professional backgrounds can result in a good relationship developing with doctors taking care of the well‐being of the patient and nurses taking care of the wound and the dressing.
The diploma training and the obtained recognition occasionally changes the student into an educator themselves, usually in a nursing school or in a continuing education system as health care professionals are naturally drawn to educate and inform their colleagues on solving wound‐healing problems and providing solutions. Their expertise as graduates of our course is often sought by their colleagues, of all professional backgrounds.
Course value
The value of such a training programme is evident for several reasons:
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1
Recognition of the trainees expertise by a university diploma.
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2
The capacity for a Diploma course to provide, on a national scale, sufficient trained practitioners within a short period of time is limited. Initially as there were only two available sites, the waiting list for potential students increased to 2 years. To overcome this problem, this educational programme was recently adopted by most of the Medical Universities in France (Grenoble, Lille, Besançon and Nantes). This should keep waiting times to a minimum and reach the desired goal to have widespread expertise in wound care available across France.
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3
The need to develop a further qualification and training for successful students has been expressed. Revisiting the knowledge regularly, either annually or every 2 years, has been identified as being of potential value.
Conclusions
The development of a university diploma has been instrumental in changing the practices of both nurses and physicians. Some of the qualified students have become the point of reference for wound care within their environment and educators in wound healing. These individuals have a tendency to develop regional networks in wound healing, which provides an alternative solution to centralised wound‐healing units, a solution encouraged by the politicians in France.
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