Abstract
This article considers the effects of two different types of educational programme on community nurse clinical practice in venous ulceration. One group of nurses (the experimental group) attended an educational programme designed to take account of training needs and learning styles. A second group of nurses (the control group) attended a standardised educational programme. A multiple‐choice question examination and Objective Structured Clinical Examination were used to measure knowledge and skills. Kolb’s Learning Styles Inventory was used to measure learning styles. Findings were that experimental nurses failed to show improved post‐intervention clinical practice compared with the control group.
Keywords: Knowledge, Learning Styles, OSCE, Skills, Venous
Introduction
Difficulties in quantifying the extent of venous ulceration in the UK and elsewhere are reported (1). It is estimated, however, that between 75 000 and 100 000 patients receive treatment for this condition in Great Britain at any one time 2, 3, 4, 5, 6, 8. Venous ulceration is not unique to the UK. It is reported to be common in populations across Western countries (7).
The negative effects of leg ulceration upon population morbidity and quality of life are well documented 9, 10, 11, 12, 13, 14, 15, with total costs of treating venous leg ulcers in the UK estimated to range between £230 million and £400 million per annum 13, 16.
A number of studies report that the assessment and treatment of leg ulceration falls mainly to community nurses 17, 18, 19. Very few studies report on the design of educational programmes with regard to venous ulceration and the subsequent effects on student knowledge 20, 21, 22, 23, 24. One study refers to the assessment of student skills (20). Failing to identify the full extent of training needs in the design of educational programmes could consequently limit the learning experience and in turn the patient experience.
This article examines the effects of two different types of educational programme on community nurse venous leg ulcer clinical practice.
Methods
To examine the effects of the two types of educational programme on clinical practice, knowledge and skills for participating nurses were measured, firstly to identify any bias between experimental and control groups, and secondly, to assist in the identification of training needs for the experimental group.
A Royal College of Nursing Continuing Education 21 multiple‐choice question (MCQ) examination paper (25) was used to measure the level of knowledge for experimental and control group community nurses, prior to and following each of the educational programmes.
A 12‐Task Station Venous Leg Ulcer Objective Structured Clinical Examination (OSCE) (26) was designed to measure the level of skill for experimental and control group community nurses, prior to and following each of the educational programmes. In designing the OSCE, three procedure stations and nine enquiry stations were constructed.
The three procedure stations were concerned with Doppler assessment, bandaging technique and size measurement. At procedure stations where Doppler assessment and bandaging technique were to be assessed, an expert examiner (a specialist research nurse) was present.
The examiner used a checklist to record the performance of each community nurse as they rotated through two of the procedure stations. No examiner was present at the third procedure station. Results were recorded on acetate tracing and inserted into an envelope at the designated task station.
The nine enquiry stations were concerned with patient history taking, venous disease awareness, arterial disease awareness, infection recognition, patient education, dressing application, compression bandaging and Doppler interpretation. At enquiry stations, community nurses were required to complete a standardised multiple‐choice answer sheet.
Community nurses were required to rotate around the venous leg ulcer OSCE, spending 5 minutes at each of the OSCE’s 12 task stations.
At the end of the examination, the examiner’s checklists and the standardised answer sheets were to be marked according to a previously agreed scheme.
Table 1 illustrates each of the OSCE’s 12 task stations by subject area. Total OSCE scores available to each community nurse ranged between 0 (minimum) and 48 (maximum).
Table 1.
OSCE task stations and subjects
| Task station | Subject |
|---|---|
| 1 | Patient history taking |
| 2 | Doppler assessment |
| 3 | Venous disease awareness |
| 4 | Arterial disease awareness |
| 5 | Bandaging technique |
| 6 | Infection recognition |
| 7 | Educating patient |
| 8 | Skin care |
| 9 | Size measurement |
| 10 | Dressing application |
| 11 | Compression bandaging |
| 12 | Doppler interpretation |
Learning styles were identified through the application of Kolb’s Learning Styles Inventory. Experimental and control nurses were each assigned a preferred learning style according to inventory output (inventory subset: assimilator, accommodator, converger and diverger).
The experimental educational programme was designed according to identified training needs and preferred learning styles. The control educational programme was designed to discount training needs and learning styles.
In contrast to the control group, participants in the experimental group were exposed to identified training needs and preferred learning styles during the course of the experimental educational programme in an attempt to establish ‘educational gain’ for those progressing through a programme designed according to the student’s need.
A 4‐hour intensive experimental educational programme was designed so that experimental group nurses were exposed most of all to the subject of patient history taking [lowest scoring subject within MCQ examination paper and OSCE]. Experimental group nurses were exposed least of all to the subject of size measurement [highest scoring subject within MCQ examination paper and OSCE].
Assimilator (n = 6; 42·9%) and diverger (n = 4; 28·6%) learning style categories were determined to be dominant for the experimental group. The experimental educational programme was furthermore designed to take account of assimilator and diverger learning styles.
The educational programme was designed to assist improved retention of subject matter for experimental group students compared with any standard learning environment. Specifically, the educational programme was designed to include a combination of education techniques reported to be consistent with assimilator and diverger learning styles.
Techniques applied in the design and delivery of the experimental educational programme consisted of a formal lecture programme, individual and collective off‐the‐job instructional techniques, separate problem‐solving discussion groups in the form of a three‐case vignette, brainstorming and collective debates and group discussion.
Each of the techniques applied within the educational programme contained subject matter relevant to student knowledge and skill‐related training needs, identified through application of the MCQ examination paper and OSCE.
Subjects included within the educational programme, delivered through a diverse range of instructional techniques, included: patient history taking, Doppler assessment, venous and arterial disease awareness, bandaging technique, infection recognition, patient education, skin care, size measurement, dressing application, compression bandaging and Doppler interpretation.
A questionnaire was designed to capture data relevant to post‐educational programme clinical practice. Table 2 illustrates that the Clinical Practice Variation Questionnaire contained 18 questions relevant to venous ulceration.
Table 2.
Clinical Practice Variation Questionnaire
| Q. | Subject |
|---|---|
| 1 | Emollients/dressings |
| 2 | Wound dressings |
| 3 | Graduated compression |
| 4 | Dry/flaky skin |
| 5 | Compression therapy |
| 6 | Patient advice |
| 7 | Venous insufficiency |
| 8 | Assessment frequency |
| 9 | Assessment frequency |
| 10 | Combination treatment |
| 11 | Wound measurements |
| 12 | Patient compliance |
| 13 | Venous disease awareness |
| 14 | Arterial disease awareness |
| 15 | Doppler interpretation |
| 16 | Doppler machine usage |
| 17 | Patient history taking |
| 18 | Infection recognition |
Each of the 18 questions was divided into three subcomponents of knowledge, skill and behaviour. The subject of emollients/dressings in question 1, for example, included three subcomponents.
The first subcomponent included the statement: ‘I feel better informed about the subject of emollients/dressings’ (knowledge component). The second subcomponent included the statement ‘I have consciously changed the way in which a clinical task concerned with emollients/dressings is approached’ (skill component). The third subcomponent included the statement: ‘I have changed my clinical behaviour by undertaking clinical tasks concerned with emollients/dressings differently’ (behaviour component).
The student was required to indicate the degree of concordance against each statement within the range ‘strongly agree’ to ‘strongly disagree’.
Results
Results concerned with the Royal College of Nursing MCQ examination paper and OSCE are reported in Table 3.
Table 3.
Royal College of Nursing (RCN) MCQ examination and OSCE, T2 and T1 difference
| Mean | SD | Mean difference | t‐value | d.f. | Significance | |
|---|---|---|---|---|---|---|
| RCNCE Examination T2 and T1 difference | ||||||
| Experimental (n = 14) | −0·5 | 4·67 | −2·14 | 0·529 | 32 | 0·60 |
| Control (n = 20) | 0·4 | 5·02 | ||||
| OSCE T2 and T1 difference | ||||||
| Experimental (n = 14) | 7·75 | 6·13 | 0·65 | 0·37 | 32 | 0·72 |
| Control (n = 20) | 7·1 | 4·18 | ||||
Statistical test: t‐test.
MCQ, multiple choice question; OSCE, Objective Structured Clinical Examination.
Results indicate that no statistically significant difference existed between experimental and control group Royal College of Nursing (RCN) MCQ examination and OSCE scores between pre‐educational intervention T1 and post‐educational intervention T2. The inference from this was that no statistically consistent knowledge and skills gap existed between experimental and control groups over the study period.
The clinical practice variation questionnaire was used to measure post‐educational intervention venous leg ulcer clinical practice over a 6‐month period, by experimental and control group.
Table 4 reports on post‐intervention Clinical Practice Variation Questionnaire results by output of: better informed (BI) (knowledge), consciously changed (CC) (skill) and changed behaviour (CB) (behaviour).
Table 4.
Clinical Practice Variation Questionnaire
| Group | n | Mean | Mean difference | t‐value | d.f. | Significance | |
|---|---|---|---|---|---|---|---|
| BI* (knowledge) | Experimental | 8 | 61·44 | 5·44 | 0·774 | 26 | 0·45 |
| Control | 20 | 66·88 | |||||
| CC† (skill) | Experimental | 8 | 57·7 | 3·8 | 0·527 | 23 | 0·60 |
| Control | 17 | 61·5 | |||||
| CB‡ (behaviour) | Experimental | 13 | 26·92 | 22·01 | 2·079 | 31 | 0·046 |
| Control | 20 | 48·93 |
Statistical test: t‐test.
Better informed about a particular clinical subject (knowledge).
Consciously changed way in which clinical task was approached (skill).
Changed clinical behaviour by undertaking clinical task differently (behaviour).
No statistically significant difference existed between experimental and control groups for BI (knowledge) and CC (skill) outputs.
Surprisingly, however, control group nurses demonstrated improved clinical practice when compared with experimental group nurses within the CB (behaviour) output category.
Discussion
The main conclusion reached was that nurses in the experimental group failed to show improved clinical practice compared with nurses in the control group.
At least four reasons could help to explain this. The first was that experimental group nurses had failed to show improved learning compared with the control group. The second was that this study was underpowered, with the implication that these results need to be treated with caution. The third was that this study was potentially non sensitive to capturing change in clinical behaviour between experimental and control groups. The fourth was potentially that conditions concerned with barriers to learning and the transfer of learning to the clinical environment had presented.
Conclusions drawn from this study were contrary to evidence reported in literature concerned with the application of evidence‐based principles in educational intervention design.
Evidence‐based principles of training needs and learning styles reported to enhance student learning did not have a significant impact upon student learning here.
The paucity of rigorous evaluations concerned with the impact of training needs and learning style‐designed educational programmes upon post‐education venous leg ulcer clinical practice means that this subject is not well researched.
Further research is required to establish the genuine effect of designing clinically based educational programmes, designed to take into account training needs and learning styles, upon post‐education knowledge, skill and clinical practice.
Furthermore, benefits of research to establish the genuine effects of designing clinically based educational programmes designed to take into account training needs, combined with alternative evidence‐based principles in educational programme design was evident.
Acknowledgements
The authors thank CJW Foy, MA MSc C. Stat, Medical Statistician, Gloucestershire R&D Support Unit, UK and PE Price, PhD, Director, Wound Healing Research Unit, Cardiff University, UK.
References
- 1. Callam MJ, Ruckley CV, Harper DR, Dale JJ. Chronic ulceration of the leg. Extent of the problem and provision of care. BMJ 1985;290:1855–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Moffatt CJ, Oldroyd MI. A pioneering service to the community: the Riverside Community Leg Ulcer Project. Prof Nurse 1994;9:486, 488, 490. [PubMed] [Google Scholar]
- 3. Bosanquet N. Costs of venous ulcers: from maintenance theory to investment programmes. Phlebology 1992;7 Suppl 1:44–6. [Google Scholar]
- 4. Moffatt CJ, Dorman M. Changing clinical practice. J Community Nurs 1996;10:20, 22, 24. [Google Scholar]
- 5. Cornwall JV, Dore CJ, Lewis JD. Leg ulcers: epidemiology and aetiology. Br J Surg 1986;73:693–6. [DOI] [PubMed] [Google Scholar]
- 6. Anand SC, Dean C, Nettleton R, Praburaj DV. Health‐related quality of life tools for venous‐ulcerated patients. Br J Nurs 2003;12: 48–59. [DOI] [PubMed] [Google Scholar]
- 7. Fowkes FG, Evans CJ, Lee AJ. Prevalence and risk factors of chronic venous insufficiency. Angiology 2001;52:5–15. [DOI] [PubMed] [Google Scholar]
- 8. Graham ID, Harrison MB, Nelson EA, Lorimer K, Fisher A. Prevalence of lower‐limb ulceration: a systematic review of prevalence studies. Adv Skin Wound Care 2003;16:305–18. [DOI] [PubMed] [Google Scholar]
- 9. Moffatt CJ, Harper P. Leg ulcers. London:Churchill Livingstone, 1997. [Google Scholar]
- 10. Callam MJ, Harper DR, Dale JJ, Ruckley CV. Chronic leg ulceration. Socio‐economic aspects. Scott Med J 1988;33;358–60. ISSN: 0036‐9330. [DOI] [PubMed] [Google Scholar]
- 11. Franks PJ, Oldroyd M, Moffatt CJ. Do social factors influence the healing of venous ulcers? Paper presented at the 4th European Conference on Advances in Wound Management, 6–9 September, Copenhagen. London: Macmillan Magazines Ltd, 1994. [Google Scholar]
- 12. Price PE, Harding KG. Measuring health‐related quality of life in patients with chronic leg ulcers. Wounds: Compend Clin Res Pract 1996;8:91–4. [Google Scholar]
- 13. Ruckley CV. Socio‐economic impact of chronic venous insufficiency and leg ulcers. Angiology 1997;48:67–9. [DOI] [PubMed] [Google Scholar]
- 14. Franks PJ, Moffatt CJ. Who suffers most from leg ulceration. J Wound Care 1998;7:383–5. [DOI] [PubMed] [Google Scholar]
- 15. Price PE. Health‐related quality of life and patients’ perspectives. J Wound Care 1998;7:365–6. [DOI] [PubMed] [Google Scholar]
- 16. Mallett J, Charles H. Defining the leg ulcer problem. J Dist Nurs 1990;8:5–10. [Google Scholar]
- 17. Morrison M, Moffatt C. Colour guide to the assessment and management of leg ulcers, 2nd edn. Toronto: Mosby, 1994. [Google Scholar]
- 18. Mallett J, Dougherty I. The Royal Marsden Hospital of cllinical nursing procedures, 5th edn. Oxford: Blackwell Science, 2000. [Google Scholar]
- 19. Oien RF, Hakansson A, Ovhed I, Hansen BU. Wound management for 287 patients with chronic leg ulcers demands 12 full‐time nurses. Leg ulcer epidemiology and care in a well‐defined population in southern Sweden. Scand J Prim Health Care 2000;18:220–5. [DOI] [PubMed] [Google Scholar]
- 20. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA 1995;274:700–5. [DOI] [PubMed] [Google Scholar]
- 21. Jones AC, Lambourne LA, Moffatt CJ, Franks PJ. Community nurse education in leg ulcer management. J Wound Care 1997;6:201–3. [DOI] [PubMed] [Google Scholar]
- 22. Jones JE, Nelson EA. Evaluation of an education package in leg ulcer management. J Wound Care 1997;6:342–3. [DOI] [PubMed] [Google Scholar]
- 23. Luker, KA , Kenrick, M . Towards knowledge‐based practice; an evaluation of a method of dissemination. Int J Nurs Stud 1995;32:59–67. [DOI] [PubMed] [Google Scholar]
- 24. Wong I. Assessing the value of a leg ulcer education programme in Hong Kong. J Wound Care 2003;12:17–9. [DOI] [PubMed] [Google Scholar]
- 25. Cameron J. Venous leg ulcers. Nurs Stand 1995;9:25–32. [DOI] [PubMed] [Google Scholar]
- 26. Harden RM, Gleeson FA. Assessment of clinical competence using an OSCE. Med Educ 1979;13:41–54. [PubMed] [Google Scholar]