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Certification and Education

Do They Affect Pressure Ulcer Knowledge in Nursing?

Zulkowski, Karen DNS, RN, CWS; Ayello, Elizabeth A. PhD, RN, APRN, BC, CWOCN, FAPWCA, FAAN; Wexler, Sharon MA, RN, CNA, BC

Author Information
Advances in Skin & Wound Care: January 2007 - Volume 20 - Issue 1 - p 34-38
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Without knowledge, how can practice be changed? Conversely, can someone have knowledge but not contribute to change in practice? Because little is available in the literature regarding the connection between nursing certification and improved patient outcomes, this study examined pressure ulcer (PrU) knowledge among 3 groups of registered nurses (RNs): those certified in wound care, those certified in specialty areas other than wound care, and those not certified in any specialty area.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare & Medicaid Services (CMS) have focused significant attention on outcomes and quality of care for patients with wounds. A 2005 CMS meeting sought an answer to the question: "What are the knowledge gaps in current evidence pertaining to the usual care of chronic wounds?"1 The participants at this meeting also addressed the recognition of wound care as a specialty and the importance of training and educating health care professionals to appropriately care for present-day complex wound care patients.1 With increased interest in delivery of care to prevent and treat PrUs, attention has turned to the transdisciplinary wound care team.1

Although the transdisciplinary PrU team is composed of multiple disciplines, it is typically the nurses who are responsible for day-to-day implementation of prevention and treatment strategies. Communicating and functioning effectively cannot be overemphasized. Studies show that nurses who are more comfortable with research are more likely to make changes in their practice.2,3 However, deficits in a nurse's wound care knowledge, regardless of certification status or difference in education, are not well known.

Nurses can acquire specialty certification in areas other than wound care certification, including diabetes education, critical care, rehabilitation, or medical/surgical nursing. Research supporting the supposition that certification improves nursing practice, however, is inconclusive or contradictory.4 Although outcomes of care are important quality indicators, it is difficult to improve patient care if topic knowledge is lacking.


Transdisciplinary team knowledge levels

Physicians. Although physicians report competence when caring for persons with PrUs, objective measurement reveals a low level of PrU knowledge. Garcia et al5 found that only 8 of 50 medical residents scored more than 50% on a 20-question test measuring PrU knowledge, with a high score of 65% (range, 13.04% to 76.09% correct). Prevention, secondary complications, wound care specialist interaction, and mattress ordering guidelines were identified as deficient areas.5

One pilot study reported that geriatric fellows (42) from 10 of 17 programs in New York (81% return rate) felt adequately prepared to lead a team and teach others about PrUs.6 However, their low mean score (56; ±18%)6 on the knowledge test supports the research of Garcia et al.5 Although 77% could identify a Stage I PrU, only 52% could identify a Stage IV PrU. Only 48% of the geriatric fellows in the study could identify the Braden Scale. Their sources of information included bedside rounds (78%), nurses (71%), lectures (67%), textbooks (67%), and geriatric attending physicians (60%). The Internet was not used as a resource. It is interesting to note that physicians rank nurses so highly, considering research shows that certain nurses lack confidence in their knowledge of PrUs.7

Nurses. A recent survey of 692 RNs found that 70% considered their basic wound education to be insufficient.7 Less than 50% of new nurses believed they could consistently identify PrU stages, and only 62% of hospital nurses expressed confidence in ulcer staging.7 Although most certified wound care nurses correctly answered a question regarding the Braden Scale, the answers from noncertified wound care nurses were almost evenly divided.7 Certified wound care nurses correctly answered a question about the classic signs and symptoms of wound infection; nurses not certified in wound care did not.7 Furthermore, certified wound care nurses were more comfortable making wound dressing recommendations all or most of the time than noncertified nurses.7

Educational programs for nursing students should include current wound prevention and treatment methods. Nursing medical/surgical textbooks contain sparse or outdated information.8 High PrU prevalence rates have been linked to poor or inappropriate knowledge and education.9-12

Researchers have used various measurement tools to examine PrU knowledge among nurses.2,13-15 Pieper and Mott14 studied knowledge of PrU prevention, staging, and description. Higher knowledge scores were associated with how recently a nurse had attended a lecture or read an article about PrUs.

Gould16 concluded that undergraduate nurses receive inadequate PrU prevention and management education. Although their sample size was small (14 subjects), Lamond and Farnell10 compared knowledge base and decision-making accuracy in PrU management among novices and experts and found that experts made clinical decisions more accurately than novices. For the novices, the difference was determined by quality of the knowledge base; those with a sounder knowledge base made better decisions than those with a poorer knowledge base.

Jordon and Brian17 showed that the incidence of Stage I and Stage II PrUs decreased following nurses attending an educational session on skin assessment and the subsequent implementation of prevention protocols. After studying 6 Minimum Data Set (MDS) quality indicators, Bostick18 discovered a lower prevalence of Stage I to Stage IV PrUs in facilities with increased RN staff time; 6 minutes was associated with a 3% reduction of 1 resident developing a PrU.


The present study was approved by the Institutional Review Board of Montana State University Bozeman, Bozeman, MT. A convenience sample of nurses located in both urban and rural areas provided demographics and PrU knowledge. The PrU knowledge test for nurses in rural Montana was distributed by mailings to all rural state facilities; testing for nurses in urban areas was conducted by mail and prior to attendance at educational offerings.

Demographic information collected in this study included age, facility type, length of nursing employment, length of time since attending an educational lecture or reading a book or journal article on PrUs, and use of the Internet for PrU information. The participants were also asked if they had read the PrU prevention and prediction and the PrU treatment clinical practice guidelines from the Agency for Healthcare Research and Quality21,22 (Tables 1 and 2).

Table 1
Table 1:
Table 2
Table 2:

The Pieper Pressure Ulcer Knowledge Tool was used to assess PrU knowledge. This standardized assessment test is divided into 3 categories: prevention, staging, and general wound knowledge. The tool's 47 questions require responses of "yes," "no," or "do not know." Reliability and validity have been reported elsewhere.3 Total scores were obtained and converted to percentage correct (Table 3). Descriptive statistics were used for demographic items. The study used t tests to examine differences among groups and Pearson correlations to examine relationships among items. All data were analyzed using SPSS 14.0 statistical software (University of Arizona, Tucson, AZ).

Table 3
Table 3:


Overall sample

Sample size in this study was expanded from Zulkowski and Ayello's19 previous study regarding differences between urban and rural results. Of 460 RNs completing the PrU knowledge test in the current study, 75% (n = 346) were from urban areas and 25% (n = 114) were from rural areas; 96% were women, with a mean age of 45 ± 9 years.

The nurses in the study reported the following education: associate's degree (40%), bachelor's degree (35%), master's degree (12%), diploma (10.5%), doctoral degree (1%); 34 nurses did not report their educational level. Thirty-six percent reported some type of certification, with 8% certified in wound care.

Most of the nurses (68%) had been in practice for longer than 10 years; 48% were currently employed as staff nurses, and 18% were in an administrative position. The mean test score for the total sample was 78%.

Certification in wound care

The study included 39 nurse certified in wound care. Those certified in wound care had the following nursing degrees: bachelor's (54%), master's (30%), diploma (8%), associate's (3%), and doctoral (3%). The remainder (2%) did not report their education. The majority (87%) had more than 10 years of nursing experience, with 53% practicing in a hospital, 26% practicing in home health care, and 16% practicing in a long-term-care setting.

The nurses reported attending lectures on PrUs (95%) or reading books or journal articles (100%) within the last year. The Internet was used for PrU information, and both Agency for Healthcare Research and Quality guidelines had been read by 97% of the study group. The mean test score for nurses certified in wound care was 89%.

Other certification, non-wound care

The study included 126 nurses certified in areas other than wound care, including medical/surgical (7%), geriatrics (5%), nurse practitioner (4%), and oncology (2.5%). Nursing degrees included bachelor's (33%), associate's (32%), master's (23%), diploma (11%), and 3% unreported. The majority (76%) had more than 10 years of nursing practice, with 56% practicing in a hospital setting and 26% practicing in a long-term-care setting.

Within the last year, 36% of certified RNs had attended a lecture and 64% had read a book or journal article on PrUs. The Internet was used for PrU information by 35% of the nurses. Of the certified nurses, 30% reported reading the Agency for Healthcare Research and Quality's clinical practice guideline on prevention of PrUs and 32% reported reading the Agency for Healthcare Research and Quality's clinical practice guideline on treatment of PrUs. The mean test score for nurses certified in an area other than wound care was 78%.

Nurses not certified

The study included 295 RNs who were not certified in a specialty area. Nursing degrees in this group included associate's (49%), bachelor's (33%), diploma (10%), and master's (4%). The majority (63%) had practiced for more than 10 years, with 43% working at a hospital and 35% working in long-term care.

Within the last year, 35% of noncertified RNs had attended a lecture about PrUs, and 63% had read a book or journal article about PrUs. Approximately 29% used the Internet to obtain information about PrUs. Of the group, 23% had read the Agency for Healthcare Research and Quality's clinical practice guideline on prevention of PrUs and 27% had read the Agency for Healthcare Research and Quality's clinical practice guideline on treatment of PrUs. The mean test score for noncertified nurses was 76.5%.

Incorrect answers

Interestingly, the following 3 questions were answered incorrectly among all nursing groups:

"Persons who can be taught should shift their weight every 30 minutes while sitting in a chair." (false)

"A low humidity environment may predispose a person to PrUs." (true)

"Vascular boots protect the heels from pressure." (false).

Nurses not certified as wound specialists also answered the following questions incorrectly:

"It is important to massage bony prominences." (false)

"A Stage III PrU is a partial-thickness skin loss involving the epidermis and/or dermis." (false)

"Cornstarch, creams, transparent dressings (eg, Tegaderm, Opsite), and hydrocolloid dressings (eg, DuoDERM, Restore) do not protect against the effects of friction." (false)

"Heel protectors relieve pressure on the heels." (false)

"In a side-lying position, a person should be at a 30-degree angle with the bed." (true).

Differences among groups

Knowledge scores showed a significant difference (89% vs 76.5%) between nurses certified in wound care and those who were not (P <.00). Significant differences between these groups included PrU lecture attendance (95% vs 35%), reading books or articles (100% vs 63%), Internet use (97% vs 29%), and familiarity with the Agency for Healthcare Research and Quality's clinical practice guidelines on prevention of PrUs and treatment of PrUs (97% vs 23% and 97% vs 27%, respectively). Significance was not found between nurses certified in an area other than wound care and those who were not certified in any area.


Wound care certification makes a difference. A relationship between certification and increased topic knowledge has long been assumed. Results of this study support the previously reported research of Ayello et al7 in sustaining this supposition. The present study showed little difference in knowledge scores by levels of nursing education, years in practice, or facility type. Differences were found between nurses certified as wound specialists by the Wound Ostomy Continence Nursing Certification Board (WOCNCB) and the American Academy of Wound Management (AAWM) and nurses not certified in wound care or any nursing specialty.

There was a significant correlation (P < .05) among attending lectures or reading books or journal articles, using the Internet, and reading Agency for Healthcare Research and Quality's guidelines. These results are similar to earlier research14 and should be helpful to nurse educators planning educational offerings for clinical staff. Future research may wish to address if the quantity and quality of educational programs attended or material read impact knowledge scores.

The questions missed by both groups are similar to findings in previous studies by Zulkowski and Ayello19 and Ayello et al.7 Turning, repositioning, and offloading of heels are not well understood by nursing staff. Small shifts in body weight are critical for chairbound individuals, and appropriately turning bedbound patients is critical for a successful prevention program. Vascular boots and heel protectors do not adequately prevent PrUs. These specific areas need reinforcement and education for staff working in clinical practice settings.

Results of this study should be used by health care facilities and policymakers when planning transdisciplinary wound care teams. As quality indicators include PrUs, the need for trained wound care nurses is critical. Educational programs should incorporate questions consistently answered incorrectly in this study. In addition, facilities must support staff who seek improved practice through certification.


Both experience and education are vital for a successful and effective wound management. Although achieving certification may be expensive and time consuming, decision making is poor without an educational base. Conversely, education without clinical experience may have limited value. Educators may want to consider a 2-pronged approach for persons interested in additional education: 1) adult educational programs should offer either a specialist or generalist level of program, and 2) certification should be encouraged in any specialty area.


Factors that influence a nurse's behavior are certainly multifactorial and include personal attitudes, as well as social pressures.20 Nurses certified in wound care who participated in this study demonstrated significantly higher scores on the PrU knowledge test. In addition, they attended more lectures about wound care and were more up-to-date with their readings and use of the Internet for PrU information.

Although it is important to note that higher knowledge does not always change practice, the next step must be for research studies to examine if higher knowledge leads to better care outcomes. Outcomes research is needed to determine if educational programs alone or more elusive constructs are most important in improving care outcomes for patients with PrUs.

Finally, it is important to remember that a nurse does not act alone. Because the knowledge base of other disciplines certainly plays a role, providing prevention and treatment strategies must be an effort of the entire transdisciplinary wound care team.


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© 2007 Lippincott Williams & Wilkins, Inc.