Nurses' wound care competency in a sample of hospitals in Northern Vietnam

Wound care, especially for hard-to-heal and infected wounds, remains a global challenge for health professionals, causing high expenditure in terms of medical care and resources, and can adversely affect quality of life for the patient (Welsh, 2018; Rodrigues et al, 2019; Guest et al, 2020), with Vietnam being no exception. Consequently, there is a wealth of research citing assessment, processes and procedures (Haycocks et al, 2013; Janssen et al, 2016; Welsh, 2018; Kielo et al, 2019) and wound care education and training, but most of this is based in high income countries. A literature search revealed relatively few articles recently published from within middle and lower middle income countries (Haesler et al, 2017; Haesler and Rice, 2020), yet these countries face the same problems with wound healing and prevention of pressure sores. However, they also have different and specific needs, and these may not be addressed by suggestions given from high income countries. Thus, as Timmins et al (2018) pointed out, it can be difficult for educators and clinicians in lower middle income countries to assess which studies are applicable for their own setting. In addition, where the focus is on results of interventions, research may look promising, but without detail regarding processes, procedures and materials used, they are not easy to implement (Vuagnat and Comte, 2016; Watts and Frehner, 2016). Yet, as both Haesler and Rice (2020) and Welsh (2018) argued, it has been internationally agreed that there is a need to develop consensus regarding the knowledge and competence to assess, plan, implement and evaluate wound care in its entirety, together with an ability to develop individual (or tailored) care plans.

Vietnam, classified as a lower middle income country (World Bank, 2023) has over the last two decades worked hard to improve the health of the community. Nevertheless, it still faces a significant health burden from the varying types of ulcer and pressure sore, and, as do many countries, spends a considerable proportion of its budget on this group of patients, something that is not new. Vietnamese government records show that over a decade ago (2005-2006), for just three groups of patients with hard-to-heal wounds – venous ulcers of the lower extremities, foot ulcers caused by diabetes and pressure ulcers – the treatment costs were immensely high, and by 2018 globally, they were over £5 billion (Guest et al, 2020). Nguyen and Bui's (2015) study found that in 2014, of 430 patients admitted to the department of wound healing at the National Burns Institute, 87.7% (n=377) had hard-to-heal wounds, from a range of different causes. This finding fits with those of both Rodrigues et al (2019) and Larouche et al (2018), who pointed out that, disappointingly, changes and advances in treatment do not seem to have improved wound care healing, with costs increasing exponentially each year, and Guest et al (2020) have showed there continues to be a high financial burden on health services. The Ministry of Health in Vietnam is determined to address this, and raise the level of wound care across the country. In 2012, it issued Decision No. 1352/QD-BYT, which stated the requirement for basic competency standards for Vietnamese nurses. It argues that wound care is an important basic technique in nursing care for patients, directly affecting the outcome of all treatment, not just of the wound and that good wound care improves overall patient recovery.

The first hospital in Vietnam to formally adopt these competencies and develop a specific training programme linked to the national standards was Viet Duc University Hospital, Hanoi. This programme, designed to address nurses' knowledge and understanding of wound care, started with the collection of baseline measures indicating actual levels of practice. In an evaluation of the first training programme (Phan et al, 2017), researchers found a positive correlation between the training and improved competence, with the average scores of nurses regarding knowledge and clinical ability, increasing from 113.70 ± 14.75 before training to 129.7 ± 19.6 after training. This in turn improved the quality of care and the outcomes for patients (Phan et al, 2017). Following this, the Agricultural General Hospital also adopted the wound care programmes and materials from Viet Duc Hospital to train its nurses. This institution also found the training effective, recording that after 12 months of training, the average score of knowledge and practice of wound care by nurses was found to have improved significantly (Phan et al, 2020).

However, apart from Viet Duc University Hospital and the Agricultural General Hospital, no other hospitals have been able to implement the training, and meet the nursing standards due to a lack of educators and/or nurses trained in wound care. It was therefore seen as important to cascade the training, using expertise from the two hospitals, and to work with the additional hospitals. Eight were randomly selected to participate in this research to investigate the current situation of nursing wound care competency in a sample of hospitals in the northern part of Vietnam. The overall aim was to use the findings to develop a plan to scale up the standard of wound care and the capacity of nurses across this area.

Methods

Research design

This multicentre study used a descriptive cross-sectional method, to determine the mean score (average) of knowledge and practical capacity in the teaching and learning activities of the nurses including general information/characteristics of study participants, understanding of dressings, pain control and use of pain assessment methods. The methods used were a combination of self-completion survey and direct observation.

Ethics approval

The study was approved by the Ethics Committee of the University of Public Health under Decision No. 248/2020/YTCC-HD3. The study duration was 3 months from June 2020 to October 2020

Research sites

The study was carried out in the surgical departments of eight hospitals, across four provinces of North Vietnam: Thanh Nhan Hospital; Hanoi Obstetrics and Gynecology Hospital; Thai Nguyen Central Hospital; Thien An Obstetrics and Gynecology Hospital; Quang Ninh Provincial General Hospital; Quang Ninh Obstetrics and Children Hospital; Bac Ninh Provincial General Hospital; and Bac Ninh Obstetrics and Pediatrics Hospital.

Research sample

Eight hospitals were randomly selected, with the target group being nurses working in the surgical departments of each hospital, and directly involved in wound care. A total population sample was used, which yielded a possible total number of participants across the eight hospitals of 518. All nurses when asked volunteered to participate in the research.

Tools used

The study used the evaluation form developed by Phan (2016), which includes the following main areas:

• Biographical information of participants in study (14 questions);
• Assessment of knowledge: (50 questions – 48 closed and 2 open questions). The questions were divided into 10 distinct knowledge areas, as shown in Box 1. Each correct answer was worth 1 point, each wrong answer received 0 points; the total maximum possible score was 167. The two open questions covered knowledge of dressing types and knowledge of pain assessment.
• Evaluation of practice: (16 indicators). The practice competency score is a composite score derived from direct observation of knowledge, skills and attitudes in clinical practice. Each nurse was assessed for each point on the evaluation form, scoring from 1 to 10 points, depending on the level of proficiency in the various elements of wound care observed. The higher the score the more competent the nurse. The minimum total score is 10 and the maximum that could be achieved is 160 points. The final practical competency score comprises use of four key competencies with a total score of 381 points, as shown in Table 1

Box 1.Knowledge of wound care – areas considered

• General knowledge
• Infection control
• Communication and team work
• Health education for patients
• Management and professional development
• Clean wound care
• Infected wound care
• Suture removal
• Drainage
• Pressure ulcer care

Data collection

Data collection consisted of two distinct activities, which took place after investigators carefully checked that potential participants fully understood the purpose and main content of study, and were still willing to participate and gave informed consent:

• Activity 1. Assessment of knowledge: explaining to participants that the first step was a self-completion questionnaire. Participants were given time to complete and return the questionnaire
• Activity 2. Assessment of practice: two investigators were assigned to each of the participants. Each investigator observed the assigned nurses and made independent assessments on two different occasions.

The resulting data sets were analysed using SPSS 16.0 software. Descriptive statistics were used with univariate analysis, to describe the frequency and percentage of participant characteristics such as gender, education level, working seniority, participation in training or workshops on wound care, knowledge of dressing types and pain assessment.

Mean values of age, knowledge score and practical competency were computed. The t test for two mean values was calculated as was ANOVA, with Pearson produce correlation used to test the relationship between the independent variables and the respondents' knowledge and practice about clinical education.

Results

In all, 518 participants completed the study, the general characteristics of subjects are presented in Table 2. The majority of participants were young, average age was 32.25±7.31; with women accounting for the majority of 438 (84.6%); More than half (63.6%) had worked for less than 10 years (329). The education level answers showed that only 2 (0.4%) have a Bachelor's degree (the post university level here), with college education (diploma) accounting for more than half (301; 58.1%), followed by university (also diploma) (146; 28.2%), then intermediate level (certificate) (62; 12%), and elementary (7; 1.3%) (basic certificate). Of the total sample, only 211 (40.7%) had ever attended a training session or workshop on wound care.

Knowledge of wound care

Table 3 shows the mean scores in the various knowledge areas. The highest mean score of knowledge was regarding health education to patients (7.88±2.06), followed by clean wound care (1.55±0.57), and management and professional development (23.72±6.93). The lowest score on knowledge was on infection control (6.77 ± 1.53).

Table 4 relates to knowledge of types of dressing. All participants had knowledge of standard or regular dressings, and the majority (433, 83.6%) understood lipido-colloid with silver dressings. However, for other dressings such as alginates and hydrogels, the knowledge level was low with only 104 (20.1%) and 121 (23.4%) respectively. The lowest response rate was for foams, where only 94 (18.1%) understood their use.

Knowledge on pain assessment

When asked, less than 20% of participants had adequate knowledge of pain assessment (95/518, 18.3%), something that is a key nursing role. Of those 95 nurses, 87 (91.6%) knew how to use the visual analogue scale pain score for pain assessment, the other 8 (8.4%) reported only assessing pain by observation of the patient.

Practice competencies as listed in standards

Table 5, Table 6, Table 7 and Table 8 show the mean scores for assessed competency in identification, planning, implementation of plans and evaluation. The first line in each case gives the questions from which scores for each individual component of competency was taken.

In identification, the mean scores of all skills on this competency were above 8 points, out of a possible 10. However, the second knowledge element – knowledge of regulations, decision, the standard operating procedure (SOP) in infection control – yielded the lowest score, at only 6.77±1.53 points.

The mean score for competency in planning was 54.64±7. 23, out of a possible total of 74. This was deemed an acceptable level. Implementation of plans is the most complex score as it entails assessing a range of knowledge, skills and attitudes, each of which are key components. The mean score in this case was 127.88±16.02, out of a possible total of 161. This was deemed acceptable. For the competency of ‘evaluating’ the mean score was 39.58±7.54, of a possible 52.

Discussion

The team was granted approval to run this first multicentre study in Vietnam with a large sample size, using tested and validated tools, following the realisation that 8 years after the Vietnamese Ministry of Health had issued a ruling, there had been no dissemination, or implementation of appropriate training. It is globally recognised that nursing competence in wound care is a key component of nurse education, training and practice, directly affecting the quality of patient care (Welsh, 2018; Haesler and Rice 2020) with poor levels of competence increasing related healthcare costs. As these include prolonged hospital stay, increased use of medical dressings and pharmacology (Guest et al, 2020), as well as an extended need for pain relief, the research participants were assessed on both knowledge and practice. Care was taken to follow all instructions and guidelines for the validated tools, increasing the reliability and validity of the study, and as a result, its ability to be used to guide the development of training programmes based on the Vietnamese standards of competence.

When looking for studies with which to compare these results, it was difficult to find similar studies based in lower middle income countries, even though the need for research was clearly recognised (Haesler and Rice, 2020). Oseni and Adejumo (2014) carried out a study based in a Nigerian hospital with a sample of 251 nurses. However, they were evaluating nurses' reported practice and knowledge levels in pressure ulcer assessment, not looking at changes arising following training. The researchers found most respondents were unfamiliar with assessment tools and there was also a lack of knowledge regarding how to complete documentation. Given the deficits in knowledge and practice the authors argued that continuing professional development for nurses is necessary to improve care outcomes for all patients living with wounds, which fits with the rationale for, and findings from, this study.

In this study, the majority of participants were female, a pattern found internationally in nursing, and not surprisingly because of the age distribution, more than half (n=329, 63.6%) of them had worked as qualified nurses for less than 10 years. For 307 of the participants (58.1%), the education level was at college (diploma) level, and this was a welcome finding. Until around two decades ago, in Vietnam the majority of nurses were at the lower intermediate (certificate) education level, and this demonstrates the Ministry of Health's commitment to move nurse education upwards to meet the World Health Organization recommendations, increasing the college level and reducing numbers of intermediate level nurses.

The highest knowledge score was regarding health education to patients (7.88±2.06), followed by clean (uninfected) wound care (1.55±0.57). This result is similar to the results of previous research conducted at Viet Duc University Hospital (Phan, 2016). Again, as with the previous research, the lowest knowledge score compared with the standard was knowledge of infection control (6.77 ± 1.53), this may be because until recently nurses were not formally updated in changes in aseptic technique. Therefore nurses who qualified some time ago may not have studied wound care theory or infection prevention, and had less knowledge of these concepts. These findings, mirroring the results of previous research conducted at Viet Duc University Hospital (Phan, 2016), support the urgent need for hospitals to introduce wound care education and training for all nurses. Training programmes need to consider using a blended learning approach where theory is linked to clinical practice, to address the disconnect between knowledge and practice evident in this and previous studies of wound care (Phan et al, 2017; Phan et al, 2020). In high income countries, research (McCluskey and McCarthy, 2012; Kielo et al, 2019), revealed that nurses' theoretical knowledge of wound assessment is good, but that again, the relationship between knowledge and practice needs improvement. As Welsh (2018), Larouche et al (2018) and Rodrigues et al (2019) pointed out, every effort needs to be made to help nurses apply what they have learned theoretically, in the practice setting, and for that, regular education and training are essential. However, looking at these accumulated findings, it seems that even where there has been training, it has not overcome the theory–practice gap. Therefore, our recommendation is that training needs to include state of the art evidence in wound care, with accompanying assessed practical sessions checking that participants can use evidence and research in practice.

This study also assessed the nurses' understanding about dressing types such as lipido-colloid with silver, polyacrylate, lipido-colloid, alginates, foams, hydrocolloids, and hydrogels. The selection and use of suitable dressings for each type of wound contributes to improving the effectiveness of wound care with each type of dressing having its own characteristics suitable for each wound (Welsh, 2018). However, the nurses across the eight sites for this study had had little education and training on the range of dressings in this study, and this was evident when questioned, with their knowledge levels proving to be relatively low, with lipido-colloid with silver at 190 (37.7%), hydrogel at 121 (23.4%), alginate dressings at 104 (20.1%), and foams at 94 (18.1%). However, although still needing to improve, the findings from this study when compared with previous studies conducted at Viet Duc University Hospital, did show a higher understanding of dressings (Phan et al, 2017). This may in part be because as a leading hospital in the field of surgery, with diverse patients, referred from across the country, the varying and complex wounds seen increasingly require the use of a wide range of dressings to promote healing. The findings reflected actual product usage, with lipido-colloid dressings being the most commonly used, while foams are rarer, although they are useful to exudate wounds. Across the hospitals as a whole, ordinary dressings were the most used (91.4%), but it was a concern that between 72% and 91.4% of nurses had never used any other type of dressing. However, although initially the increase in range of dressings did seem encouraging, when checked, it emerged that the nurse's additional knowledge and expertise had been acquired through daily practice. This form of experiential learning does not include reflection on any advantages and limitations, and does not negate the need for formal education and training in today's changing world of wound care.

It is recognised that another integral element of wound care is pain control, and the findings regarding pain assessment methods were disappointing. Although 74.4% knew about pain assessment methods, only 63.8% could indicate any formal method for pain assessment, and across the whole sample, only one method for assessing pain, that of direct observation, was used in practice. This finding mirrors the previous study, that while nurses reported that they knew how to assess pain, rather than using pain assessment measures such as VAS, they decided on the need for analgesia using only observations (Phan et al, 2018). In the previous single centre study at Viet Duc University Hospital, 61.4% of the nurses reported knowing how to complete a pain assessment using VAS, and it had been hoped that by the time of this study, they would have moved towards the implementation of pain assessment measures. They had not done so, and this needs to change with training programmes focusing on how to assess and monitor for pain using a range of measures, and not observation alone. Nurses need to proactively assess patients for pain and, depending on the assessment, check that appropriate analgesia has been given before dressings are commenced.

The study had eight criteria for assessing the skills of nurses on wound care, and eight criteria on attitudes to wound care. The results once computed revealed all the assessed criteria had resulted in low scores ranging from 1.16 points to 4.90 points. This result, which confirmed the theory-practice gap, is lower than the results of the previous study at Viet Duc University Hospital by Phan et al (2017) when 14 criteria scored above average with scores ranging from 5.49 points to 8.26 points. The 2 criteria with the lowest scores were the ability to identify patients (4.71 points) and follow-up of patients after wound care (1.55 points) (Phan et al, 2017).

Conclusions

The results of assessment of the current situation of wound care competency according to the basic nursing competency standards issued by the Vietnamese Ministry of Health at eight hospitals in four northern provinces reveal that the average knowledge score of nurses showed a disconnect with the scores of practice competency even where confidence levels were good. It has not been possible to discuss in detail all findings, nevertheless, it would seem that if high-quality wound care is to be delivered by nurses, compounding factors such as ongoing education and training need to be addressed. The recommendation has to be that regularly updating knowledge according to new trends, as well as according to competency standards, will help enhance the quality of nursing facilities. Also that all training should use blended learning to enable staff to be formally assessed on their ability to implement theory in clinical practice.

The results from this study support the need for regular practice-linked education and training, and therefore the key recommendation is that hospitals need to identify staff with expertise in wound care who can deliver targeted, competency-based education and training programmes for nurses. This focuses on linking knowledge to practice and assessing not only knowledge, but also on the development of skills and attitudes, which together with knowledge constitute competency. Only that way will all hospitals skill up their workforce to meet the basic Vietnamese national competency standards and sustain improved quality of care.

KEY POINTS

• Nurses must be competent in all aspects of wound care
• Education and training is essential for high-quality care.
• There is a theory–practice gap that needs to be addressed for successful wound care.
• Wound care is one of the most resource-intensive aspects of patient care and nurses must be knowledgeable and efficient in their practice

CPD reflective questions

• Think about the essential clinical skills required to carry out your role, how would you provide evidence for reaching competence in them?
• How do the nursing competencies outlined for wound care in Vietnam align with the required competencies where you work?
• What approaches might be needed to address a ‘theory–practice gap’?