The WOCN Society recognizes that to fulfill its mission of ensuring access to quality care to patients with acute and chronic wounds, there is a need to extend education to other providers.1 This led to the development of the Wound Treatment Associate (WTA) program as a continuing education (CE) program to further empower WOC specialty nurses to improve patient outcomes by enhancing their wound care team. The course is designed to prepare more skilled providers in all health care settings and prepares graduates to provide optimal care for patients with acute and chronic wounds as members of a collaborative team.2
The WOCN Society recognizes the following levels of wound care providers: WOC specialty nurses (ie, WOC RNs [baccalaureate prepared]; WOC graduate-level prepared RNs; WOC advanced practice RNs; and WTAs trained through the WTA program). The evidence-based WTA education program was instituted in 2012 to prepare clinicians to serve as a resource for clinical staff and to provide optimal care for patients with acute and chronic wounds. The WTA-educated clinician functions under the direction of a supervising WOC specialty nurse; a physician, a physician assistant (PA), or a nurse practitioner; or other qualified health care providers experienced in wound care, such as a clinical nurse specialist or certified wound specialist.2 The American Nurses Credentialing Association (ANCC) approved the WTA program for 32.25 contact hours. The program includes didactic lessons as well as hands-on learning and demonstration of competency in selected clinical skills.
A license to provide the WTA program and access to the educational content and materials is purchased from the WOCN Society. Each program is delivered under the direction of a qualified course coordinator (CC), who is certified in wound care by the Wound, Ostomy and Continence Nurses Certification Board (WOCNCB), and is a member of the WOCN Society. The didactic portion of the course is presented by online, video lectures, and presentation slides. The CC oversees the demonstration and evaluation of the clinical skill competencies. To successfully complete the course, participants must satisfactorily complete the online posttest and case scenarios and demonstrate satisfactory competency in the selected clinical skills. Graduates of the program are eligible for the WTA-C certification through the WOCNCB.
The educational program includes the following major content areas: principles of anatomy and physiology of skin, causes of tissue loss, risk assessment for skin breakdown, measures to keep skin healthy, pressure injury prevention, physiology of wound healing and factors affecting repair, wound assessment and documentation, wound management, selection of topical therapy, and assessment and management of lower extremity ulcers. The program is aimed at licensed health care personnel such as RNs, licensed vocational nurses, physical therapists, physical therapy assistants, and military medics. The program has also been modified for PAs, specifically to include content and skills related to the management of complex wounds and fistulas at an urban cancer center.3 To date, there are 275 CCs with 167 active program licenses and 6957 graduates of the program. However, up to this point, there has been no summarization of the value or report of outcomes.
The need for the survey information arose out of direction from WOCN Leadership, CC feedback, and the Wound Treatment Associate Advisory Committee's (WTAAC's) own experiences. Having responses noting the impact on practice was deemed critical for many to participate in or continue with this education activity. During a strategic planning meeting of the WOCN Leadership in 2016, the following metrics were prioritized for analysis: reduction in hospital-acquired pressure injuries (HAPIs) for acute care and long-term care facilities, reduction in visits per episode (VPE), and supply utilization for the home health setting. Based on these metrics, a survey was developed by the WTAAC to evaluate the impact of the program from the CC's perspective. The WTAAC comprises members of the WOCN Society who serve as CCs or participated in the development of the WTA curriculum. The questions were developed by 2 members of the committee and reviewed by 5 other committee members for accuracy. In November 2017, the WOCN Society sent this survey to all CCs, with 22 questions focusing on the impact of the WTA program. The CCs responded based on their practice setting. The questions and results appear in Table 1.
Regular formative evaluations were conducted during each iteration of the WTA program to assess learning and satisfaction and to be consistent with ANCC criteria, as well as due to requests from CCs. In order to evaluate the impact of the WTA program on clinical practice and patient outcomes, an additional survey was distributed in 2018 to all individuals who had completed the WTA program within the previous year (1494 total participants). There were 153 responses (10.2%). The WOCN Society's CE provider unit developed these survey questions (Table 2).
Both the CC and participant surveys were conducted through SurveyMonkey. Participants were not required to provide any identifying information such as name, e-mail address, or facility name. Houston Methodist Hospital's institutional review board (IRB) determined that IRB approval was not required for the reporting of these survey findings.
SUMMARY OF COURSE COORDINATOR RESPONSES
Of the 225 surveys that were e-mailed to the CCs, 48 (21%) responded: 26 in acute care, 8 in long-term care, 8 in home health care, and 6 listed as “none of the above.” Responses were reviewed and summarized by members of the WTAAC and categorized by CC care setting (Table 3).
Impact of WTA Education on Long-term Care: Practice Changes and Patient Outcomes
In response to the question, “Has this training influenced the employee's ability to collaborate with other members of the health care team to enhance prevention of pressure injuries and management of wound and skin care?” 83.33% stated the WTA training had influenced the employees' ability to collaborate. Another 16.67% responded not applicable (N/A) or unknown. To the question, “Have there been improvements in staff documentation to meet regulatory guidelines?” 66.67% of respondents said there have been improvements while 33.33% responded N/A or unknown. None said “no improvement” (Table 4).
Impact of WTA Education on Acute Care: Practice Changes and Patient Outcomes
Just over half of respondents (54.17%) reported a decrease in their HAPI rate. Responses are summarized in Table 5. Since implementing the WTA program, 54.17% responded that they have changed their pressure injury prevention practices; 41.67% said they did not. Responses to a question about quality improvement initiatives indicated that the majority of WTAs (83.33%) are participating in some type of initiative. To the question, “Have there been improvements in staff documentation to meet regulatory guidelines?” 58.33% responded “yes” there have been improvements and 33.33% responded “no” to improvements. The majority of respondents (87.5%) responded that the WTA training has enhanced the wound care of their patients. Only 12.5% responded that their wound care has not improved. A high percentage of respondents (95.83%) responded that this training has influenced the employee's ability to collaborate with other members of the health care team to enhance prevention of pressure injuries and management of wound and skin care.
Impact of WTA Education on Home Health/Hospice: Practice Changes and Patient Outcomes
In response to the question, “Has there been a reduction in the percentage of residents or patients with pressure injuries (stage 2 or higher) that are new or worsened at your facility/agency?” 50% responded “yes” and 50% responded N/A or unknown. In response to the question, “Has there been a decrease in daily dressing changes since implementation of the WTA program?” 66.67% responded “yes” and only 16.67% responded “no.” The remaining 16.67% responded N/A or unknown. Half (50%) of respondents also noted a decrease in VPE after implementation of the WTA program. The remaining 50% responded N/A or unknown. In addition, 66.67% of respondents reported a decrease in monthly wound care supply costs after the WTA program was initiated. One hundred percent of respondents indicated that WTA training has influenced the employee's ability to collaborate with other members of the health care team to enhance prevention of pressure injuries and management of wound and skin care; 66.67% noted improvements in staff documentation to meet regulatory guidelines (Table 6).
SUMMARY OF WTA GRADUATE RESPONSES
Participants of the WTA program (n = 153) responded to the summative evaluation survey (Table 7).
Impact of WTA Education on Practice/Skills
A majority (83%; n = 127) of respondents stated they gained new or updated knowledge in nursing practice, including the ability to complete accurate wound assessments, understand treatment options, appreciate the importance of critical and accurate documentation, communicate with the health care team, classify and manage wounds, educate patients and colleagues, and promote prevention strategies. Respondents' quotes included statements such as “able to make better decisions about dressings,” “more awareness about appropriate staging of wounds,” “I am more knowledgeable about the pathological processes occurring with wounds,” and “I am also more knowledgeable on which dressings should be used for wounds and why they are appropriate.”
Just under half (47.06%) of respondents identified an impact on leadership skills (Table 7). One nurse reported a sense of empowerment to participate in plans to develop a wound center. Respondents also took responsibility for the education of colleagues to decrease HAPIs. Critical thinking skills (75.82%) were enhanced with better ability to differentiate wound types and design more patient-centered and patient-specific care plans. Responding nurses (73.86%) indicated improvement in competencies especially related to the ability to complete a more accurate wound assessment, appropriate treatments, and prevention techniques. Quotes suggest improvements in knowledge: “I have a much more detailed understanding of wound types and treatment possibilities after taking this course, and I have been able to communicate with MDs for patients about dressing changes that are more effective.” “I have been able to identify and stage pressure injuries more accurately effecting overall quality outcomes for hospitals and patient safety.” “I have been able to confidently advocate for patients at my job and have seen improvements in some outcomes.” “I have been able to share information with the other wound care nurse about enzyme debriding agents requiring normal saline for cleansing the wound prior to application.”
Participants in the program report that the most important impact of the WTA education is the improvement in patient outcomes. Having a skills component to the program with demonstration of competencies is seen as important as noted by 74% reporting an improvement in their skills. Respondents also noted enhanced critical thinking skills. Course coordinators noted a reduction in the HAPI rate as well as changes to the pressure injury prevention programs. Almost all the respondents responded that the WTA education influenced the clinician's ability to collaborate with other members of the health care team to enhance prevention of pressure injuries. Barriers to practice were also reported and included limited opportunity to practice, a change in role, and pressure to produce rapid discharges with limited teaching time (Table 8).
Impact of WTA Education on Patient Outcomes
A majority (71.24%) of survey respondents reported improved patient outcomes (Table 7). Statements by nurses related to patient outcomes include “quicker healing times and more comfort,” “improved patient outcomes due to improved knowledge and treatment strategies,” “wounds are being prevented and if a wound develops, it resolves faster with proper treatment,” and “increased confidence in wound care recommendations which has led to better patient outcomes.” Seventeen (13%) respondents indicated that they have not yet seen the direct impact on patient outcomes due to recent completion of the program, or limited opportunity to implement their new knowledge and skill (no longer providing direct patient care, very short-term contact with patients, or have not recently had any patients with wound care on their units).
The need for education of health care professionals is demonstrated in guidelines for pressure injury prevention such as the National Pressure Ulcer Advisory Committee Clinical Practice Guidelines as well as the WOCN Society guidelines.4,5 Increasingly, there is a call to evaluate the outcomes of CE programs to demonstrate the return on investment and improved patient outcomes rather than exclusively monitoring reaction and demonstration of learning. It is well established that it is not enough to provide the education; the impact of the education must be measured.6
With this in mind, a literature review was performed that examined the impact of education on pressure injury reduction. A summit on pressure injury prevention hosted by Virginia Commonwealth University noted the important role of unit-based skin champions in sustaining pressure injury prevention practices.7 Pressure injury prevention is multifaceted, so outcomes associated strictly with nursing education are limited, but there are some data to show this connection. Asimus and colleagues8 noted a 16.4% reduction in pressure injury prevalence with the incorporation of education. A program dedicated to the development of skin resource nurses was associated with a 77% reduction in pressure injury prevalence.9 Another project that assessed unit-based resource nurses or skin champions was reported to lower the incidence of HAPIs from 7% to 4% within the first year.10 A “best practice” project targeting prevention and management of pressure injuries in cardiac patients was implemented in 2 phases: the first incorporated education and the second targeted operating room practices. Within 2 months, the pressure injury rate was reduced to 0%; this rate has been maintained for 4 years.11 The role of wound education has also been noted in home health care, long-term care, and among other disciplines.12–14
Impact of WTA education on outcomes
Since inception of the WTA program, there have been poster presentations that have noted the impact of this education on patient outcomes. Much of the focus has been on pressure injury reduction in the acute care setting. Pittman and Mosier15 reported on several evidence-based unit projects performed by WTAs on the respective units. They reported a decrease in the pressure injury rate from 2.8% to 1.8%, with a further reduction to 1.15%. The results were attributed to pressure injury prevention initiatives on the unit. In another poster presentation, WTA-educated nurses were involved in the development of high-risk pressure injury prevention protocols in a surgical/liver transplant intensive care unit (ICU).16 The WTA-educated nurses served as unit-based experts, with escalation to the WOC nurse as needed. After implementation of the protocol, there were 3 successive months of 0 HAPIs in this high acuity unit. Averaging the 4 quarters prior to implementation with 4 quarters postimplementation, the average HAPIs decreased 25% postimplementation. Ramundo and Henderson17 looked at the utilization of WTA-educated nurses in a medical intensive care unit (MICU) and noted a reduction in unit-acquired pressure injuries from 11.11% to 0% in the first 2 quarters of 2017 based on National Database of Nursing Quality Indicators (NDNQI)–reported data. This coincided with the initiation of 4 WTA nurses based in the unit. Another poster presentation also focused on the critical care setting and reported a decrease in pressure injuries.18 At the onset of the study, there was a 29.6% incidence of pressure injuries in the MICU and a 24.0% incidence in the surgical intensive care unit (SICU). By day 99, this had decreased to 3.4% in the MICU and 7.4% in the SICU. In addition, 19% of the documented pressure injuries healed prior to transfer from the unit and were attributed to the education leading to early recognition, documentation, and treatment of skin breakdown. Another ICU experience was reported by Klahn and colleagues,19 which focused on interventions for reduction of unit-acquired pressure injuries in a high acuity cardiovascular ICU in an academic medical center. The interventions included education of 2 staff RNs in the WTA program, daily skin assessments, weekly audits for pressure injuries, development of an algorithm for prevention and utilization of positioners, and heel offloading directly from the operating room. During the 12 months following the initiation of the interventions, the unit pressure injury rates decreased from 6.76% to 4.53%. Ritter and Kennedy20 provided the WTA education program in the home health care setting and reported improved outcomes in several areas within the first 6 months of implementation of the WTA program. These outcomes encompassed inclusion of orders for pressure injury prevention within the physician plan of care aligning with improved clinician documentation of interventions provided for patients and caregivers. Also noted in Centers for Medicare & Medicaid Services published Home Health Outcomes were an improvement in status of surgical wounds (increase of 1%), a 1.7% decrease in emergent care visits for patients with deteriorating wounds, and an overall decrease in VPE for patients with a wound diagnosis. All are important metrics for the home health setting.17
There are limitations noted with this project. Much of the data are self-reported and not subject to verification and different metrics may be used, for example, HAPI rate versus NDNQI data. The small number of respondents does not allow for generalization among all who have completed the WTA program. In addition, it is difficult to determine the exact impact of education as this is often one component of comprehensive programs. It is hard to make assumptions of those who responded “no” (20.83%) or N/A or unknown (25%) to the question regarding a decrease in the HAPI rate. For those who said “no,” it could mean there were no changes or they were already at a high level prior to the WTA program implementation. For those responding N/A or unknown, it likely means they are not measuring or are unable to measure this outcome. Hospital-acquired conditions may be impacted by staffing, equipment, documentation, and implementation of best practice protocols. Thus, it is difficult to draw conclusions from the home health and long-term care setting due to the low response rate (6% and 8%, respectively).
It is important for providers of CE to evaluate the impact of the education on professional practice and quality patient outcomes in order to demonstrate the value and benefit of the education to the providers, participants, and employers. As a result of course surveys from participants and CCs, additional content and competencies were added. These additions focus on risk assessment for pressure injuries, accurate completion of the Braden Scale with interpretation of score, implementation of prevention protocols, as well as accurate identification and staging of pressure injuries. According to survey responses from both groups, the WTA program had a positive impact on nursing practice skills, quality patient outcomes such as faster wound healing and reduced HAPI rates, and favorable financial outcomes for the facility such as decreased cost of supplies and equipment. The addition of the WTA program to the WOC specialty enables stronger wound care teams that lead to quality patient care and improved outcomes.
1. Wound, Ostomy and Continence Nurses Society. WOCN Society Position Statement: Role and Scope of Practice for Wound Care Providers. Mt Laurel, NJ: Wound, Ostomy and Continence Nurses Society; 2017. https://cdn.ymaws.com/www.wocn.org/resource/resmgr/publications/Role-Scope_of_Practice_for_W.pdf
. Accessed September 30, 2019.
2. Wound Treatment Associate
(WTA) program. Wound Ostomy and Continence Nurses Society Web site. https://www.wocn.org/page/WTAProgram#
. Accessed October 1, 2019.
3. Isaac D, Jankowski I, Guttenberg NJ, Maydick-Youngberg D, Larson E, Liucci T. Adjusting the Wound Treatment Associate
program to enhance knowledge of physician assistants in a large cancer center. Scientific and Clinical Abstracts from the WOCN Society's 50th Annual Conference. J Wound Ostomy Continence Nurs. 2018;45(3S):S1–S100.
4. National Pressure Ulcer Advisory Panel, European Ulcer Advisory Panel, and Pan Pacific Pressure Injury
Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Haesler E, ed. Perth, Australia: Cambridge Media; 2014.
5. Wound, Ostomy and Continence Nurses Society. Guideline for Prevention and Management of Pressure Ulcers (Injuries). Mt Laurel, NJ: Wound, Ostomy and Continence Nurses Society; 2016. WOCN Clinical Practice Guideline No. 2.
6. Garafalo L. Continuing nursing education
and outcomes: making a difference in patient care. J Contin Educ Nurs. 2016;47(3):103–105.
7. Creehan S, Cuddigan J, Gonzales D, et al The VCU Pressure Ulcer Summit—developing centers of pressure ulcer prevention excellence: a framework for sustainability. J Wound Ostomy Continence Nurs. 2016;43(2):121–128.
8. Asimus M, MacLellan L, Li P. Pressure ulcer prevention in Australia: the role of the nurse practitioner in changing practice and saving lives. Int Wound J. 2011;8(5):508–513. doi:10.1111/j.1742-481X.2011.00824.x.
9. Beinlich N, Meehan A. Resource nurse program: a nurse-initiated, evidence-based program to eliminate hospital acquired pressure ulcers. J Wound Ostomy Continence Nurs. 2014;41(2):136–141. doi:10.1097/WON.0000000000000001.
10. Taggart E, McKenna L, Stoelting J, Kirkbride G, Mottar M. More than skin deep: developing a hospital-wide Wound Ostomy Continence Unit Champion program. J Wound Ostomy Continence Nurs. 2012;39(4):385–390. doi:10.1097/WON.0b013e318258292e.
11. Paul R, McCutcheon SP, Tregarthen JP, Denend LT, Zenios SA. Sustaining pressure ulcer best practices in a high-volume cardiac care environment. Am J Nurs. 2014;114(8):34–44. doi:10.1097/01.NAJ.0000453041.16371.16.
12. Paquay L, Verstraete S, Wouters R, et al Implementation of a guideline for pressure ulcer prevention in home care: a pretest-postest study. J Clin Nurs. 2010;119(13/14):1803–1811. doi:10.1111/j.1365-2702.2009.03170.x.
13. Shannon R, Brown L, Chakravarthy D. Pressure Ulcer Prevention Study: a randomized, controlled evaluation of 2 pressure ulcer prevention strategies in nursing and rehabilitation centers. Adv Skin Wound Care. 2012;25(10):450–464. doi:10.1097/01.ASW.0000421461.21773.32.
14. Young D, Chakravarthy D, Mirkia K. Evidence for the validity of the MEDLINE Pressure Ulcer Prevention Program. J Acute Care Phys Ther. 2012;13(2):211–216.
15. Pittman J, Mosier J. Enhancing quality, expertise, and evidence-based practice. J Wound Ostomy Continence Nurs. 2017;44(3S):S1–S72.
16. Kaczorowski K. Development of a high risk pressure ulcer prevention program in surgical and liver ICU (SLICU). Poster presented at: ANCC Magnet Conference; 2017; Houston, TX.
17. Ramundo J, Henderson V. Impact of the Wound Treatment Associate
Program on unit acquired pressure injuries in the medical ICU. J Wound Ostomy and Continence Nurs. 2018;45(3S):S1–S100. doi:10.1097/WON.0000000000000432.
18. Sacerio J, Geiger D, Acedera P, Meyer A, Jenkins O. Implementation of the Wound Treatment Associate
Program in the ICU to reduce pressure ulcers. J Wound Ostomy Continence Nurs. 2015;42(3S):S1–S74. doi:10.1097/WON.0000000000000148.
19. Klahn S, Clark T, Moubark M, Powers J. Got HAPU? Our strive to reduce in a high-acuity CVICU. Poster presentation at: American Association of Critical Care Nurses National Teaching Institute; 2017; Houston TX.
20. Ritter D, Kennedy S. WOCN-sponsored WTA program enhances wound outcomes for home care company. J Wound Ostomy Continence Nurs. 2013;40(3S):S1–S112. doi:10.1097/WON.0b013e31828f9649.