IN THE SEPTEMBER issue of Nursing2004, we asked you to respond to 23 questions and statements on wound care knowledge and practices. We received responses from 692 readers from 48 states, five Canadian provinces, and seven other countries. (See Respondent profile.) Our purpose was to learn whether nurses are implementing current “best practice” wound care interventions according to current professional standards. The good news is that nurses know a lot about wound care, and their expertise grows with age and years of experience. But our findings also reveal that younger nurses, less experienced nurses, and those in certain patient-care settings, including hospitals, need more education about wound care.
Here, we'll examine each survey item and discuss whether nurses' answers reflect current best practice standards in wound care. Please note that percentages have been rounded and that not all respondents answered every question. Study results were based on a convenience nonprobability sample.
Question 1: Moist wound therapy is the gold standard for chronic wound management.
In the 1960s, researchers demonstrated that keeping partial-thickness wounds moist accelerates healing. This concept, along with the development of dressings that maintain a moist healing environment, revolutionized chronic wound care practice.
By a 3:1 margin, our survey respondents acknowledged this important standard. Older nurses (age 51 and over) and those with more experience (over 20 years) answered correctly by a 4:1 margin. Not surprisingly, wound-care-certified (CWN and CWOCN) nurses overwhelmingly supported moist wound therapy.
Nurses who work in the community and long-term-care settings, who deal with chronic wounds over the long haul, answered this item correctly in significantly higher percentages than nurses who work primarily in hospitals, as the following figures show:
Question 2: Wound pain should be rated by the clinician, not the patient.
The patient, not the clinician, should rate pain, regardless of its source. According to noted pain researcher Margo McCaffery, “Pain is whatever the experiencing person says it is and exists whenever he says it does,” so the patient's self-report is more reliable than anyone else's. This view is consistent with standards set by the Joint Commission on Accreditation of Healthcare Organizations and the American Pain Society.
Clinicians increasingly recognize the need to assess and control wound pain, especially during dressing changes. The European Wound Management Association has a position document on wound pain that can be downloaded from their Web site. (See Selected Web sites at the end of this article for this and other resources.)
All geriatric nurses answered this correctly, as did nearly all respondents across all educational groups.
Question 3: Wound assessment is a cumulative process of observation, data collection, and evaluation.
Because wounds are dynamic and change as they heal, they must be assessed regularly. The holistic nature of wound assessment requires nurses to look at the patient's overall condition as well as many wound characteristics. Poor nutrition, chronic disease, immobility, and the patient's inability to communicate or understand teaching increase the risk of wounds and impair wound healing.
Although most nurses understand the importance of this ongoing process, wound care experts don't agree on what constitutes a minimal wound assessment for various wound types. The Agency for Healthcare Research and Quality (AHRQ)—formerly the Agency for Health Care Policy and Research—1994 pressure ulcer guidelines recommend that assessment include location, stage, sinus tracts, undermining, tunneling, exudate, necrotic tissue, and presence or absence of granulation tissue and epithelialization for pressure ulcers.
Question 4: The Braden risk assessment tool is used to assess a patient's potential to develop a vascular ulcer.
The Braden risk assessment tool was developed to identify those at risk for developing pressure ulcers, not vascular ulcers. The six subscales in the Braden scale (sensory perception, moisture, activity, mobility, nutrition, and friction/shear) are based on pressure ulcer risk factors: pressure intensity, pressure duration, and tissue tolerance of pressure.
Although most respondents answered the first three survey questions correctly, many nurses—especially younger ones—failed to correctly identify the Braden tool's purpose. However, the proportion of nurses answering “false”—the correct answer—rose with years of experience. (See Understanding the Braden risk assessment tool.)
Age was significant too, with more older nurses responding correctly as follows:
- age 30 and younger: 40%
- ages 31 to 40: 55%
- age 41 and older: 60%.
Looking at educational levels, we found that a higher proportion of nurses with master's degrees (72%) answered correctly compared with those at other educational levels, although a relatively high percentage of nurses with an associate degree also answered correctly (59%). Nurses who weren't certified in wound care were almost evenly divided on this survey item, but nearly all wound-care-certified nurses knew the statement was false.
Among hospital-based nurses, only 52% correctly identified the Braden tool, compared with over 63% of nurses in long-term/subacute care and 68% in home/community health. This suggests that hospital-based nurses need more education about risk assessment tools.
Question 5: The classic signs of infection may not be present in patients with chronic wounds or in those who are immunosuppressed.
Most respondents knew that the classic signs and symptoms of infection—erythema, heat, edema, pain, and purulent exudate—aren't always present in patients with chronic wounds or in those who are immunosuppressed. (An exception may be pain, a symptom that immunosuppressed patients may experience.)
In the case of chronic wounds with a high bioburden, the mechanism is believed to be diminished systemic or inflammatory response. Bioburden is the polymicrobial mix of bacteria and fungi that populate a wound, both on the surface and in deeper layers.
Because classic signs and symptoms of infection may be absent, clinicians may find the clinical signs and symptoms checklist developed by Gardner, Frantz, and colleagues a helpful alternative in assessing wound infection. These signs and symptoms are increasing pain in the ulcer area, erythema, edema, heat, purulent exudate, delayed ulcer healing, discoloration or friable granulation tissue, pocketing at the base of the wound, foul odor, or wound breakdown.
Over 90% of older nurses (age 41 and over) and those with more than 20 years of experience answered this item correctly. Educational level also influenced responses: 93% of those with baccalaureates or higher answered correctly, compared with 79% of students and 78% of LPNs/LVNs.
Wound-care-certified nurses were almost unanimous in answering this item correctly, compared with 88% of noncertified nurses.
Question 6: Wet-to-dry gauze dressings are best used to treat clean granulating chronic wounds.
Wet-to-dry dressings can be used as a type of mechanical debridement in necrotic wounds, but avoid using them on clean granulating wounds. Besides failing to maintain a moist healing environment, wet-to-dry dressings attach to the wound bed as they dry out; when you remove them, they pull off healthy granulating tissue.
Some nurses may have confused wet to dry with wet to moist, explaining the lack of consensus in our survey findings. Wet-to-moist dressings are gauze dressings moistened with saline solution that aren't allowed to dry out between dressing changes. Because the dressing is always moist, it supports wound healing. In contrast, a wet-to-dry dressing is permitted to dry out and adhere to the wound bed. When it's changed, it removes wound tissue adhering to it, mechanically debriding the wound.
Age and experience seemed to color people's opinions. Nurses younger than age 40 and those with less than 10 years of experience tended to respond to this statement incorrectly. Most nurses over age 40 and most of those with more than 10 years of experience knew that the statement is false.
Most respondents who work in hospitals answered correctly (58%), but at a significantly lower rate than their counterparts in long-term/subacute care (69%) and in home/community health (79%).
Ninety-two percent of wound-care-certified nurses (61 out of 66 respondents) answered this item correctly, compared with 59% of nurses who aren't certified (358 out of 607 respondents). A similar percentage of nurses with graduate degrees answered correctly. (Thirty-four percent of wound-care-certified respondents had a master's degree.)
Question 7: In a chronic wound, the only good bacteria are dead bacteria.
Some bacteria in the wound bed can be beneficial: Bacteria colonizing a wound help prevent overgrowth of more virulent strains in the wound bed.
All chronic wounds contain bacteria at levels ranging from contamination and colonization to infection. According to AHRQ clinical guidelines, colonization is the presence of bacteria on the wound surface or in wound tissue without indication of infection.
Research indicates that at low levels, bacteria may actually support healing. In animal studies, low levels of Staphylococcus aureus (102 microorganisms/ml) were found to stimulate the inflammatory response and increase monocytes, macrophages, collagen hydroxyproline, granulation tissue, and blood flow. Bacterial colonization of a chronic wound may also provide a physical barrier that prevents more virulent organisms from adhering to the wound bed.
Once the level of bacteria exceeds 105 microorganisms/ml, the wound is considered infected. Infection hinders wound healing.
Regardless of age, education, or experience, most respondents answered this item correctly.
Question 8: Your selection of a wound dressing should be based on wound bed characteristics (such as dry, draining, clean, or necrotic).
All wounds are not alike, and dressing selection ought to be driven by each wound's particular characteristics; for example, necrotic versus viable tissue, infected versus noninfected tissue, amount of exudate, and pain. Also remember that as the wound heals, its characteristics change and you need to change the type of dressing accordingly. Rarely is the same dressing type appropriate throughout the healing process.
A small minority of home/community health nurses (7%) disagreed with this survey statement. Does this response reflect different practice in the community setting, or does it reflect other variables, such as resource availability? Nurses in community and home health care settings may be more strongly influenced by reimbursement issues.
Question 9: Stage I pressure ulcers are easily identified in persons with darkly pigmented skin.
Until the 1990s, the literature contained little information about identifying Stage I pressure ulcers in persons with darkly pigmented skin. Failure of clinicians to identify pressure ulcers at an early stage in dark skin is one reason why these patients have more Stage II than Stage I pressure ulcers.
To address this problem, the National Pressure Ulcer Advisory Panel (NPUAP) revised its definition of a Stage I pressure ulcer in 1998. Recommendations now include looking for darkened areas; purple, brown, or black in color over bony prominences; change in the texture of the skin over bony prominences; boggy or hard skin; or change in skin temperature, initially warmer then cooler.
Question 10: Enzymes are effective for removing necrotic tissue in chronic wounds.
Enzymes have been used to debride wounds for over 40 years. Other ways to debride wounds include surgical, autolytic, and mechanical debridement and maggots.
Agreement with this survey statement is fairly consistent across all levels of experience. Though nearly all nurses knew that this is a true statement, those over age 50 were almost unanimous in their agreement, as were those with baccalaureates and graduate degrees. However, a fairly high proportion of hospital nurses disagreed with the statement (13%), suggesting a need for more education.
Many students were apparently unfamiliar with use of enzymes, as over 30% disagreed with the statement. If the students who responded to this survey are representative of all nursing students, educators should consider redesigning curricula to include more information on enzyme debridement.
Question 11: My facility has a policy for how often a wound assessment should be completed and documented.
To meet licensing and accreditation standards, health care facilities should have such a policy in place. Although most of our respondents said that their facility has a wound assessment policy, long-term/subacute care nurses responded yes at the highest rate (95%). Younger, less experienced nurses and students were most likely to say they don't know if their facility has a policy, suggesting that facilities need to place more emphasis on this issue in orientation programs for both students and new graduates.
All nurses need to know if a wound assessment policy exists and where to find it because wound assessment is the basis for care decisions as the wound heals. Including information about the facility's policy in a nurse's orientation can help her incorporate the policy into her practice.
Question 12: I can identify the four stages of pressure ulcers in my patients.
These responses definitely illustrate the adage “with age comes experience”—and apparently, with age and experience comes confidence as well. Less than half of new nurses felt they could consistently identify all stages of ulcers, compared with over 70% of more experienced nurses.
The accurate staging of pressure ulcers is important for care planning as well as for regulatory bodies that drive reimbursement. The NPUAP has identified the ability to stage a pressure ulcer as a basic competency for nurses, yet research continues to show that nurses lack skill in staging pressure ulcers, especially Stage I pressure ulcers.
The difficulty nurses have in staging wounds was discussed at the NPUAP consensus conference in February 2005. Specifically, many nurses are unclear about how to stage a purple wound with intact skin that rapidly deteriorates to a full-thickness Stage III or IV pressure ulcer (deep tissue injury), and many are unclear about Stage II pressure ulcers and skin injury from incontinence. Check the NPUAP Web site for the latest information on these topics. (See Selected Web sites.)
Wound-care-certified nurses again were nearly unanimous in reporting that they can identify the four stages, compared with only 67% of noncertified nurses. From 83% to 87% of those in long-term/subacute care, home/community health, and geriatric practice were sure of their wound assessment ability, but only 62% of hospital nurses expressed the same confidence. A high proportion of hospital nurses (32%) said they can identify ulcer stages only “sometimes,” another indication that hospital-based nurses need more education in wound assessment and care.
Question 13: Specialty beds or mattresses are used in my facility to prevent pressure ulcers.
When available, specialty beds should be utilized to help maintain skin integrity and prevent pressure ulcers in high-risk patients. Although these beds seem to be widely available in acute and subacute inpatient settings, over 20% of home/community health nurses indicated that they don't have access to them.
Essential care for maintaining tissue integrity includes managing pressure loads on skin and soft tissue. Components of a comprehensive care plan must include appropriate support surfaces, adequate periodic pressure relief (such as repositioning), protection of especially vulnerable bony prominences (such as heels), and consideration of special patient needs (such as nutritional support or assistance with ambulation).
Reimbursement of support surfaces remains a challenge. Many patients requiring support surfaces are covered under Medicare. In acute care and long-term-care facilities, specialty beds and other support surfaces are covered by the Medicare A prospective payment per diem rate. In home health care settings, reimbursement is covered under Medicare B and specific criteria must be met for Medicare to pay for coverage. Third-party and private insurance carriers usually require prior approval before they'll cover specialty beds and other support surfaces.
Question 14: Wound culture specimens are obtained in my facility by the following methods. (Check all that apply.)
Tissue biopsy is the gold standard for obtaining specimens for wound cultures because it identifies pathogens in viable tissue most reliably. However, this method isn't readily available in all health care settings.
Swab culture was used universally across all settings, probably because it's noninvasive, inexpensive, and practical. But the result can be an unreliable indicator of infection because the specimen isn't always obtained correctly. Culturing microorganisms living in viable wound tissue, not on the wound surface, is important.
For best results, clean the wound before taking a swab specimen to remove surface microorganisms. Also make sure you take the culture specimen by rotating and pressing down on the swab over a 1-cm2 area to express wound fluid from viable, not necrotic, tissue.
With needle aspiration, the clinician obtains fluid by inserting a needle into tissue surrounding the wound and aspirates fluid into a syringe. If the specimen is obtained correctly from the wound perimeter, not the wound bed, culture results are similar in reliability to those of biopsy. However, technique and availability hamper universal use of this technique.
Question 15: Nurses in my facility wear sterile gloves for dressing changes on chronic wounds.
The use of nonsterile gloves to change a dressing on a chronic wound is accepted nursing practice. Sterile gloves are required for acute wound care, surgical procedures, and contact with normally sterile areas of the body. Aseptic technique, the application of principles for preventing cross-contamination, is important for infection control and wound management regardless of whether you're wearing sterile or nonsterile gloves.
Overall, only 65% of nurses said they don't use sterile gloves to change a dressing on a chronic wound. But the proportion jumped to 91% among wound-care-certified nurses.
With this survey item, we found another interesting contrast between the perceptions of younger, less experienced nurses and their older, more experienced colleagues. With the exception of one group, the percentage of nurses who knew that sterile gloves aren't indicated to change a dressing on a chronic wound steadily increased with years of experience (see Do you wear sterile gloves to change a dressing?).
The progression is similar with regard to age: 50% of nurses under age 30 chose the best practice response to this survey item, compared with 70% of nurses over age 50.
In terms of work setting and clinical area, the largest proportion of nurses reporting the unnecessary use of sterile gloves worked in hospitals and medical/surgical settings.
Question 16: I know how to apply a compression wrap dressing.
Below-knee compression wraps graduated from toe to knee are standard treatment for venous leg ulcers in the absence of significant arterial disease. Nurses should be knowledgeable about venous leg ulcer management, including patient assessment and compression wrap application.
Most respondents with less than 1 year's experience stated they don't know how to apply a compression dressing, but the proportion of “yes” answers rose rapidly with experience. (See Can you apply a compression wrap?)
Home/community health nurses (88%) and those who listed their work setting as “other” (83%) answered yes to this item in higher proportions than nurses in acute and subacute settings (67%). This may be because compression wraps are used more often in home, community, and clinic settings.
Among wound-care-certified nurses, 96% (64 out of 67 respondents) said they can apply a compression wrap, compared with 68% of noncertified nurses.
Question 17: Povidone-iodine (Betadine) is used to clean chronic wounds in my facility.
Although povidone-iodine was once widely used to clean wounds, the AHRQ currently recommends noncytotoxic wound cleansers instead. Unlike antibiotics, which can selectively kill bacteria without harming healthy tissue, povidone-iodine and other harsh topical antiseptics damage all cells on contact and do little to reduce bacteria in wound tissue.
As with many other survey items, we found that age and years of experience were significant. The highest percentages of best practice responses came from nurses age 51 and older and those with 16 or more years' experience.
Questions 18/19: Nurses are licensed in my state or province to do minor surgical debridement. (Question 19 asked respondents to identify their state or province.)
Many nurses are unsure of the scope of practice in this area. Those who frequently perform wound care need to clarify this point with their state board of nursing. The Wound Ostomy and Continence Nurses Society (WOCN) has a position statement outlining standards for nurses permitted to perform conservative sharp wound debridement: See http://www.wocn.org/pulications/posstate/debride.html.
Question 20: Skin assessment is a part of my daily nursing assessment for all my patients.
A skin assessment should be performed and documented daily on all patients in acute and long-term care and at each visit for home health care patients. Regular skin assessment lets you detect and treat pressure injuries, skin tears, and other problems early. This is an important nursing function, so be cautious about delegating it to unlicensed assistive personnel.
Though most respondents answered yes to this question, those with less than 1 year of experience seem especially conscientious about skin assessment; all but one person in this group (98%) answered yes, and the remaining person answered sometimes. This rate was slightly higher than that for wound-care–certified nurses (96%). Hospital nurses and those in home/community health answered yes at similar rates. Nurses in long-term/subacute care settings were less likely to do daily skin assessments.
Daily skin assessments should be a part of patient care in all settings. The MDS and OASIS documentation forms used in long-term care and home health care aren't comprehensive assessment tools. Additional documentation is needed, either on flow sheets or in narrative notes.
Question 21: A computerized wound assessment tool is used in my facility.
Computerized wound assessment tools aren't available in all health care settings. As computerized documentation becomes more widely available to health care workers, screens for skin and wound care will need to be implemented to support nursing interventions and treatments. Until then, many facilities will continue to rely on manual documentation.
Regardless of whether wound assessment is documented with computerized technology or the old-fashioned way with paper and pen, the best tools have a uniform structure and use consistent terminology to help clinicians make good decisions and improve outcomes.
Among respondents working in a hospital, less than half (46%) have access to a computerized wound assessment tool. These tools are even scarcer outside the hospital: Only 15% of nurses working in home/community health and 13% of nurses working in long-term/subacute care reported access to computerized wound assessment tools. Those who work in geriatrics likewise have poor access to computerized assessment tools, with only 13% answering yes to this item. Considering that the elderly are highly susceptible to skin breakdown and chronic wounds, this is particularly troubling.
Question 22: I received sufficient education on chronic wounds in my basic nursing education program.
Younger, less experienced nurses felt better about their level of wound care education than did older, more experienced nurses. In fact, the percentage of those who felt they were sufficiently educated declines steadily over time and experience, from over 50% for those 30 and younger and those with less than 1 year of experience to about 20% of those over 50 and those with more than 20 years of experience. These findings suggest that either education on wound care has improved in the past 5 years or our collective memory about our educational experience has dimmed.
Another explanation is that you don't know what you don't know until you've had some experience. Wound-care-certified nurses gave the highest percentage of no votes of any group, 88%. Similarly, 85% of master's-prepared nurses answered no.
When looking at those who presumably work with the most vulnerable population, home/community health and long-term/subacute care nurses, the numbers are particularly dismal: Only about 20% felt they'd received sufficient education.
What constitutes sufficient education? Is a nurse's perception of his level of preparation influenced by his practice setting? Or does he become more aware of the flaws in his education as he gains “real-world” experience?
Wound care and dressing application have always been central to nursing, and the American Association of Colleges of Nursing (AACN) includes wound care as an essential competency for baccalaureate-prepared nurses. Yet research has shown wide variation in the amount of pressure ulcer content in nursing textbooks. Some textbooks include as few as 45 lines of text on pressure ulcer care.
Model curricula are available to schools of nursing who want to improve in this area from the NPUAP, The John A. Hartford Foundation Institute for Geriatric Nursing (http://www.hartfordign.org) and the AACN (http://www.aacn.nche.edu).
Question 23: I'm comfortable making recommendations to practitioners on appropriate wound dressings for my patients.
Once again, with age and experience comes confidence—and rightfully so. The more we see and learn, the more comfortable we feel about our knowledge. Nurses age 51 and older expressed the most confidence, with 60% saying they're comfortable making recommendations all or most of the time. Nearly all wound-care-certified nurses said they're comfortable making recommendations all the time or most of the time. Among hospital nurses, however, only 42% of nurses expressed this level of confidence.
Overall, 41% answered “sometimes.” In part, this may reflect interdisciplinary communication issues rather than lack of confidence in wound care expertise.
How to improve your wound care expertise
Providing quality wound care for your patients starts with a good understanding of wound care principles, products, and treatment. Keeping abreast of wound dressing choices and various application techniques is an ongoing challenge.
You can learn more about wound care in various ways. Read journals that specialize in wound care and look for 1-day seminars, national symposiums, and programs that can expand your expertise, such as those accredited by the WOCN. Some programs are offered over the Internet. For more information, visit the WOCN Web site. If you want to learn more about wound care certification, visit Web sites of the WOCN Certification Board and the American Academy of Wound Management.
Wound care practice continues to evolve as we learn more about the healing process and develop better products and techniques to prevent injury and support healing. By staying abreast of advances in the field, you can give your patients the best possible nursing care.
Here's a snapshot of respondents to our survey (total respondents: 692).
- Age. The mean age was 44, with the largest number of respondents falling into the 41-to-50 age-group (31%/214 respondents). The second largest was the 51-to-65 age-group (29%/197 respondents).
- Years of experience.Respondents averaged 15 years of experience in nursing. Nearly 40% reported over 20 years of experience.
- Educational level. Most respondents reported their highest level of education as either a BSN/BS (38%/254 respondents) or an associate degree (19%/125 respondents). Another 14% (95 respondents) were LPN/LVNs, 13% (87 respondents) had an RN diploma, and 12% (80 respondents) had an MSN/MS degree. Fourteen students and two nurses with doctorates also responded to the survey.
- Clinical setting. Thirty percent of respondents work in a medical/surgical setting. Another 21% work primarily in geriatrics and 15% in critical care and emergency.
- Work setting. Over 61% work in a hospital, 20% in a long-term or subacute care facility, and 10% in home health care or community care.
- Wound certification Only 10% of respondents (67) were wound-care–certified nurses (CWN or CWOCN).
What nurses have to say about wound care
- “Even though I have several years of critical care experience, I don't feel that I have ever felt competent regarding the best product to assist in wound healing. Education is needed!”
- “I have been a wound care manager for 6 years, and I am shocked at how little the physicians know about proper wound care. I routinely come head to head with surgeons about using wet-to-dry dressings. It's a never-ending battle.”
- “One of the problems with wound care in every facility I've worked is a poor knowledge base with the nurses who are doing the treatments every shift, every day. Treatments are inconsistent, and everyone thinks she knows how to treat wounds. I become very discouraged; although I'm considered nursing administration, I don't have much voice in the process.”
- “On the skilled-nursing facility units, I'm house supervisor. This situation doesn't allow my personal inspection of 120 residents' skin. We need to depend on the certified nursing assistants (CNAs) to fulfill this task. I feel very fortunate to work in a facility that hires quality CNAs and is willing to pay more to get them.”
- “Wound care has evolved much like many other nursing specialties. We have highly trained, specialized nurses in the wound area while the ‘average nurse’ doesn't possess this same knowledge and instead relies on the specialist. This is problematic if the specialist isn't available or is overloaded.”
SELECTED WEB SITES
American Academy of Wound Management
Braden Risk Assessment Scale
The European Wound Management Association
National Pressure Ulcer Advisory Panel
Wound Ostomy and Continence Nurses Society
Wound Ostomy and Continence Nurses Certification Board
Agency for Healthcare Research and Quality 1994 pressure ulcer guidelines
Click on “Clinical information: Clinical practice guidelines”
Last accessed on May 2, 2005.
Elizabeth A. Ayello is faculty member at Excelsior College School of Nursing in Albany, N.Y., and senior adviser for The John A. Hartford Institute for Geriatric Nursing in New York, N.Y. Sharon Baranoski is administrative director of home health care at Silver Cross Hospital in Joliet, Ill. David S. Salati is staff paramedic at Virtua Health in Mount Laurel, N.J.
The authors have disclosed that they have no significant relationship with or financial interest in any commercial companies that pertain to this educational activity.
To take this test online, visit http://www.nursingcenter.com/ce/nursing.