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Variables in a Research Study and Data Collection Post your initial response to the article, addressing the following criteria: ·      Read the process for data collection employed in the study. ·      Identify the method used in the study. ·      Provide a list of the tasks performed as part of data collection in the study, add comments as needed. ·      Draw conclusions about the

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PROFESSION AND SOCIETY
Course Content Related to Chronic Wounds in Nursing Degree
Programs in Spain
Angel Romero-Collado, PhD, MSc, RN1, Marta Raurell-Torreda, PhD, MSc, RN2, Edurne Zabaleta-del-Olmo,
MSc, RN3, Erica Homs-Romero, RN4, & Carme Bertran-Noguer, PhD, MSc, RN5
1 Professor of Nursing, Nursing Department, University of Girona, Spain
2 Professor of Nursing, Nursing Department, University of Girona, Spain
3 University Institute for Primary Care Research Jordi Gol (Institut Universitari d’Investigacio´ en Atencio´ Prima` ria (IDIAP) Jordi Gol), Barcelona, Spain and
Researcher associated with the Universitat Auto` noma de Barcelona, Bellaterra, Spain
4 Figueres Basic Healthcare Area (A` rea Ba` sica de Salut de Figueres) Catalan Health Institute (Institut Catala` de la Salut), Girona, Spain
5 Head of Nursing Department, University of Girona, Spain
Key words
Curriculum, nursing education research,
nursing students, pressure ulcer, professional
competence, Spain, wound healing
Correspondence
Dr. Angel Romero-Collado, Professor of
Nursing, Nursing Department, University of
Girona, C/ Emili Grahit, 77, 17071 Girona, Spain.
E-mail: angel.romero@udg.edu
Accepted: July 19, 2014
doi: 10.1111/jnu.12106
Abstract
Purpose: To analyze content related to chronic wounds in nursing degree
programs in Spain.
Design: Cross-sectional descriptive study.
Methods: Course descriptions available for online access during June and
July of 2012 were reviewed for the 114 centers in Spain that offer a nursing
degree, according to the official Registry of Universities, Centers, and Titles.
Findings: Of the 114 centers with degree programs, 95 (83.3%) post course
content online, which make it possible to analyze 2,258 courses. In 60 (63.1%)
of these centers, none of the courses included the concept of pressure ulcer
prevention, and the course content posted by 36 (37.9%) centers made no
mention of their treatment. None of the course descriptions contained any
reference to pain management in patients with chronic wounds. Of the 728
elective courses analyzed, only one was related to chronic wounds.
Conclusions: This review of available information about nursing degree
programs in Spain indicates that pain management in patients with chronic
wounds is not addressed in any course, and more courses consider the treatment
of pressure ulcers than their prevention.
Clinical Relevance: Degree programs responsible for the training of future
nurses should be reviewed and revised as needed to ensure that graduates
have acquired minimum basic competencies in the prevention and treatment
of chronic wounds that help to decrease the theory–practice gap in this field.
Chronic wounds are a major factor in morbidity, mortality,
and healthcare costs (Augustin, Brocatti, Rustenbach,
Sch¨ afer & Herberger, 2014; Sen et al., 2009). On healthcare
teams, nurses typically have the responsibility of caring
for patients who have these wounds or are at risk for
them (Caron-Mazet, Roth, & Guillaume, 2007; Romero-
Collado, Homs-Romero, & Zabaleta-del-Olmo, 2013).
Despite increased knowledge about chronic wound
prevention and treatment, scientific evidence is not
always translated into clinical practice to the extent that
would be desirable. The knowledge possessed by healthcare
professionals is one of the key factors most frequently
identified in efforts to explain the existence of
this theory–practice gap, although organizational and
environmental factors also have an impact (Moore,
2010). Cowman et al. (2012) conducted an international,
multidisciplinary eDelphi study to identify the research
and education priorities in wound management and tissue
repair. This study offers a point of reference to consider
where we are in

Course Content Related to Chronic Wounds Romero-Collado et al.
done to improve the preparation of healthcare professionals,
thereby improving the prevention and treatment
of chronic wounds.
Background
The Bologna Declaration (European Ministers of Education,
1999) establishes a new framework for European
universities and a convergence of university
degrees to facilitate mobility in the European job market
(Davies, 2008). It also encourages study of the major European
Union languages and discipline-specific study in
those languages.
For the nursing profession in Spain, the new framework
has led to the progressive disappearance of the
3-year nursing programs in universities (Zabalegui &
Cabrera, 2009), which are being expanded to 4 years,
240 European Credit Transfer System (ECTS) units, and
foreign language competency (level B2.1) in English,
French, German, or Italian. In contrast, nursing degrees
are completed in 3½ years and 210 ECTS in Denmark and
Finland, and 3 years and 180 ECTS in Norway and Sweden
(R°aholm, Hedegaard, L¨ ofmark & Slettebø, 2010). Full
implementation of the new degree program in Spain will
give the nursing profession equivalency with other degrees
with respect to future options and opportunities.
This includes access to higher academic degrees (master’s
and doctoral degrees) by way of their own discipline
rather than by way of disciplines such as biology
or psychology.
Another substantial impact of the Bologna process is a
change in the concept of learning. The previous model
was that learning was based on the knowledge considered
necessary to obtain the diploma. This could concur—
or not—with what the future professional would need to
know for success in the workforce, but there sometimes
appeared to be a large gap between the academic and
working worlds. Under the Bologna process, learning is
oriented toward skills and competencies and is student
centered (Zabalegui & Cabrera, 2009). To address the
theory–practice gap, courses must be designed to achieve
essential competencies, along with knowledge of theory.
This aligns with the white paper on the degree in nursing
published by Spain’s national accreditation agency,
which indicated that the cross-cutting competency most
valued by practicing nurses, university professors of nursing,
and nursing administrators is “the ability to apply
knowledge to practice” (Agencia Nacional de Evaluaci ´on
de la Calidad y Acreditaci ´ on, 2004).
The theory–practice gap, defined as the lack of matching
textbook descriptions of clinical situations with
the reality of practice, is a vitally important topic for
nursing education (Scully, 2011). For example, the lack
of education about the prevention of pressure ulcers
(PUs) is cited as a cause of their high prevalence and
incidence (Moore, 2010) and of the persistence of care
interventions that are not recommended, such as the
use of “doughnut”-type devices or massaging areas of
redness (Iranmanesh, Rafiei, & Foroogh Ameri, 2011;
Panagiotopoulou & Kerr, 2002; Pancorbo-Hidalgo,
Garc´ıa-Fern´andez, L´ opez-Medina, & L´ opez-Ortega, 2007;
Saleh, Al-Hussami, & Anthony, 2013). In other studies,
the majority of nurses in an intensive care unit had the
perception that their unit could improve its attention
to patients who had or were at risk for developing PUs
(Quesada Ramos & Garc´ıa D´ıez, 2008), and slightly more
than half of the nurses in 14 long-term care units considered
their knowledge of chronic wound management to
be “average” (Caron-Mazet et al., 2007).
The prevalence of PUs in Spain ranges from 5.9% to
13.5%, depending on whether the population is being
treated as part of a primary care home-health program
or in a hospital or long-term care center (Leyva-Moral &
Caixal-Mata, 2009; Soldevilla Agreda, Torra Bou, Verdu´
Soriano, & L´ opez Casanova, 2011). These values are
similar to those of other European countries, such as
Sweden’s 14.5% prevalence in nursing homes and 16.6%
in hospitals (Gunningberg, Hommel, B°a° ath, & Idvall,
2014), the 6.4% reported in a long-term care study in
France (Caron-Mazet et al., 2007), and the 9% observed
in a long-term care setting in the Republic of Ireland
(Moore & Cowman, 2012).
Training nurses in the prevention and treatment of PUs
is of fundamental importance. Nonetheless, there are major
deficiencies in undergraduate course content related
to this type of wounds (Ayello, Zulkowski, Capezuti, &
Sibbald, 2010). In a study of emergency care professionals
in Spain (Hinojosa-Caballero, 2012), just 23% considered
their university education about PU prevention to be
“good,” and the rate decreased to 19% when asked about
aspects of PU treatment. Other studies have reported that
25% of nurses reported never having received any specific
information about PUs in their professional program
(Zamora S´anchez, 2006), 53.1% received no training specific
to PU wound care (Romero-Collado et al., 2013), and
70% indicated they did not receive sufficient education
about chronic wounds in their basic nursing education
program (Ayello, Baranoski & Salati, 2005). These deficiencies
were also observed in textbooks recommended
by nursing educators (Wilborn, Halfens & Dassen, 2009),
and wide variation in PU-related textbook content has
been reported (Ayello & Meaney, 2003). However, nursing
textbooks are not the only element that requires
improvement to develop the needed skills. Educational
programs must combine textbook content with a variety
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Romero-Collado et al. Course Content Related to Chronic Wounds
of learning methods, including hands-on experience in
the laboratory.
An analysis of what undergraduate nursing students
know about PUs reported a low general level of knowledge
(Larcher Carili, Miyazaki, & Pieper, 2003), despite
evidence that even a small educational intervention (2-
hr lecture-laboratory session) is effective in the short
term (2-month follow-up) in improving students’ knowledge
about chronic wounds (Huff, 2011). Nursing students
also believe that the more time dedicated to guided
practice and clinical teaching, the greater will be the improvement
in their skills and knowledge about maintaining
skin integrity (Ousey, Stephenson, Cook, Kinsey,
& Batt, 2013).
Given the impact of chronic wounds in the general
population, a multidisciplinary, international eDelphi
study (Cowman et al., 2012) was conducted to
identify research and education priorities to improve
wound management and tissue repair. The purpose of the
present study was to analyze the content specified in descriptions
of the basic courses taught in the 114 degree
in nursing programs in Spain to identify instruction related
to the four priorities identified by Cowman et al.
(2012): pain management, PU prevention, wound bed assessment,
and selection of dressings.
Methods
Design
A cross-sectional design was used to analyze the content
on chronic wounds in nursing degree programs
in Spain.
Centers
We analyzed the degree programs offered by the 114
teaching centers that award the degree in nursing in
Spain, as indicated by Spain’s official database of universities,
centers, and diplomas offered, the Registro de
Universidades, Centros y T´ıtulos (RUCT; Gobierno de
Espan˜ a, 2008). Search terms included degree titles containing
“Nursing,” academic level of “Degree program,”
and discipline of “Health Sciences.” For each center, we
obtained the names of courses and number of credits for
each course in the nursing degree program.
Data Collection
From June 11 to July 6, 2012, we analyzed the degree
in nursing program information included in the RUCT,
accessed the web page for each center, and assessed the
program and course content that was available online. No
centers were excluded from the study. We would note,
however, that Spain has gradually implemented the undergraduate
nursing degree and not all universities have
proceeded at the same pace. Therefore, not all programs
have published course descriptions for the full 4-year degree
in nursing program.
Two researchers independently analyzed the content of
each course description or syllabus and reached a consensus
agreement. A third researcher was available to review
the course information in the event of any discrepancy.
A data collection form was designed ad hoc to record the
data obtained about each degree program and course. The
following variables were recorded for each program:
Access: The number of years of the 4-year undergraduate
degree in nursing for which online access to courses
was available.
Number of Required Courses: Total numbers of required
courses, basic courses, guided practice, and final
project (recorded to determine the nursing degree
requirements, excepting elective courses).
Courses Entirely Related to Chronic Wounds: Number
of required courses with a title explicitly containing the
words “chronic wound.”
Courses With Content Related to Wounds: Number of
required courses, basic courses, guided practice, and final
projects that included any of the following content
in the available description: Pain and chronic wounds,
Pain control or management (to capture any content
related to controlling pain in general), Prevention of
pressure ulcers, adults (assigned to a related “pressure
ulcer” variable because there could be courses with
only this content), Wound bed assessment, selection
of dressings, or the mention of any product related
to moist wound healing. These were later assigned to
a related variable covering a broader concept, “Treatment
of PU or other chronic wound (venous, arterial
or neuropathic/diabetic etiology).”
Other variables related to chronic wounds were
recorded to explore the availability of any content
about other aspects of chronic wound care, in addition
to the four educational priorities defined by
Cowman et al. (2012). At the same time, this approach
provided control variables to decrease the risk of information
bias in the primary variables studied: Nursing
or physiology—attention to patients with venous
and arterial disorders in the lower extremities or with
“diabetic foot”; Burns (adults, children, adolescents), extensive
burns; Wounds related to acute processes; Content
related to acute or chronic wound healing; Antisepsis
or antiseptics.
If the same content appeared two or more times in the
description of the same course, the content was recorded
only once; if two or more different content variables were
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identified in the same course, each one was counted as “a
course” containing that information.
Electives. All elective course options were recorded
and placed into the following categories: “chronic
wounds,” “language courses,” “palliative care,” “occupational
health,” “health promotion,” “Catholicism,”
“dependency and chronic illness,” “urgent, emergency
and/or catastrophic patient care,” “research,” “complementary/
alternative therapies,” “cooperation,” and
“school health.”
Ethical Considerations
All of the information recorded (degree programs,
course content) was found online, in the RUCT database,
and on the official web site of each university; therefore,
all data were publicly available. No personal data were
accessed (e.g., related to any individual who designed a
degree program or course) for this study.
Data Analysis
Univariate descriptive methods (i.e., frequencies, percentages,
means, and standard deviations [SD]) were
used to analyze the data. IBM SPSS Statistics 19
(IBM Corporation, Armonk, NY, USA) was used for
the analysis.
Results
The assessments completed by the two designated evaluators
were in consensus, eliminating the need for the
intervention of a third evaluator and for inter-rater reliability
analysis. The study included the 114 degree programs
available online, although detailed course analysis
was limited to the 95 (83.3%) centers that provided online
access to course content, of which 37 (32.5%) centers
had implemented 2 full years of the new degree requirements,
34 (29.8%) provided 3 years, and 24 (21.1%)
provided detailed information for the full content of the
4-year degree in nursing program.
Of the 3,436 required, basic, guided practice, and final
project course descriptions reviewed, representing
all of the nursing degree programs in Spain, 2,258
(65.7%) courses were analyzed in detail. The mean number
of courses required for degree completion was 30.1
(SD 3.56) required and 6.7 (SD 4.56) elective courses. Table
1 contains a descriptive analysis of the number and
type of courses.
The highest number of nursing degree programs are located
in 3 of Spain’s 17 autonomous communities, with
18 (15.8%) in Andalucia, and 15 (13.2%) in Catalunya
and in Madrid. Only 1 (0.9%) program is offered in 4
communities: Cantabria, Ceuta, La Rioja, and Melilla. The
remaining 62 (54.2%) programs are distributed across 10
autonomous communities.
Our analysis identified no course offered at any center
that was dedicated to chronic wounds or included content
on pain management specific to chronic wounds;
however, 94 (98.9%) centers offered at least one course
related to general pain control. Only 40 (46.9%) centers
offered a course with specific content on prevention
of PUs in adults, although some type of content specifically
related to PUs was offered at 62 (65.3%) centers
(Table 2). Only 10 (10.5%) centers indicated both of
these content areas in their courses and 37 (38.9%) centers
offered neither of them. “Wound bed assessment”
was identified in one course in 1 (1.1%) center, and
“How to select dressings” was found in 23 courses in 21
(22.1%) centers. “Treatment of pressure ulcers or other
chronic wounds” was contained in 98 courses distributed
across 59 (62.1%) centers (see Table 2).
Half of the centers offered no courses related to venous
or arterial disorders in the lower extremities, and
91 (95.8%) centers offered no course description with the
term “diabetic foot.” We included 131 courses offered by
75 (78.9%) centers in a “wounds, acute processes” category
(Table 3).
The analysis of elective courses showed 50 courses related
to the Bologna requirement for instruction in other
European Union languages in 42 (40.4%) centers, 44
courses related to instruction in research methods in 34
(32.7%) centers, and 36 courses related to complementary
or alternative therapies in 31 (29.8%) centers. In
all of Spain, only one center (1.0%) offered one elective
course that included the term “chronic wounds”
(Table 4).
Discussion
Analysis of course content in degree in nursing courses
at Spanish universities revealed that the education offered
future nurses about chronic wounds is insufficient
and largely fails to meet the four educational priorities
identified by Cowman et al. (2012). We considered our
results in the context of each of these priorities.
Pain Management
The first of the four education priorities in wound management
and tissue repair, pain management in chronic
wounds (Cowman et al., 2012), was not mentioned
in any of the nursing courses offering some content
related to chronic wounds. Although PUs produce “endless
pain and a restricted life” (Hopkins, Dealey, Bale,
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Table 1. Number of Courses in Nursing Degree Programs in Spain
Courses in the degree program
(n = number of centers) Minimum Maximum Total Mean SD
Number of required courses offered
(nonelective) (n = 114)
20 41 3436 30.14 3.55
Number of required courses
reviewed (n = 95)
0 40 2258 19.81 10.46
Number of elective courses offered
(n = 107)
0 23 728 6.68 4.56
Number of elective credits, ECTS
(n = 114)
0 30 1157.5 10.15 7.05
Note. ECTS = European Credit Transfer System.
Defloor, & Worboys, 2006), deficiencies exist in the importance
assigned to them in clinical practice (Caron-
Mazet et al., 2007) despite recommendations that wound
care should be incorporated into all patient care plans
(Gu¨ nes, 2008). We must be aware that all PUs cause pain
and that wound care treatments (e.g., dressing changes)
also can cause pain. Inadequate knowledge of pain management
is a barrier to proper treatment. This deficiency
must be addressed by including content about pain assessment
and management in training related to chronic
wounds (Pieper, Langemo & Cuddigan, 2009). In Spain,
for example, the needed change could readily be accommodated
by incorporating a unit on “pain management
and chronic wounds” into the appropriate courses as, in
response to the mandates of the Bologna Plan, the 3-year
diploma program is converted to a 4-year university degree
and credit hours in pharmacology are increased.
How to Prevent Pressure Ulcers
In the courses we reviewed, this second priority was
absent from the content of the degree courses offered at
nearly two thirds of the centers that award the degree
of nursing in Spain. We consider this lack of training in
PU prevention alarming because this is a cross-cutting
problem that can affect patients of any age—children,
adults, the elderly—in any healthcare setting (primary
care, hospitals, long-term care). This limited presence of
the topic in nursing studies could be related to the finding
by Zamora S´anchez (2006) that 25% of Spanish nurses
reported receiving no specific PU training during their official
program of study, or to the 23% of health professionals
on the other end of the spectrum who indicated
that they had received “good” training in PU prevention
(Hinojosa-Caballero, 2012). We must add that, despite
clinical guidelines that recommend against particular care
interventions (such as massaging reddened skin or using
doughnut cushions), many nurses in different countries
and of different professional generations continue to use
them (Iranmanesh et al., 2011; Panagiotopoulou & Kerr,
2002; Pancorbo-Hidalgo et al., 2007).
Basic theory taught in nursing programs should explain
what is and is not recommended by clinical guidelines for
the prevention of PUs. This should be complemented by
guided practice and the involvement of clinical instructors
in practical training to ensure that traditional interventions
give way to current, evidence-based standards
of practice (Saleh et al., 2013; Zamora S´anchez, 2006).
Other researchers have reported a lack of course offerings
on certain related topics in other university degree
programs (e.g., medicine, physical therapy). For example,
required courses related to aging are needed in Spain
(Jim´enez D´ıaz, Pulido Jim´enez, Villanueva Lupi ´ on, Villar
D´ avila, & Calero Garc´ıa, 2011), and gerontological care is
not adequately addressed in nursing education programs
in Flanders, Belgium (Deschodt, de Casterl ´ e, & Milisen,
2010). Although PU prevention tends to be considered
a nursing task, some researchers have advocated that it
should be the responsibility of the entire medical team
and therefore should also be incorporated into physician
education (Levine, Ayello, Zulkowski, & Fogel, 2012).
Wound Bed Assessment and How to Select
Dressings
The third priority, wound bed assessment, was present
in just one course at only one center. On the other
hand, 23 courses at 21 (22.1%) centers included content
on the selection of dressings, the fourth priority
in the eDelphi study and an area in which another recent
study (Ousey et al., 2013) also found that students
are underprepared. The inclusion of “Treatment of PU
and other chronic wounds” (a more general term that
could potentially incorporate the third and fourth education
priorities, “wound bed assessment” and “selection
of dressings,” respectively) added 98 courses (4.34%) at
59 (61.8%) centers to the analysis.
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Table 2. Number of Courses Included in Degree Programs, by Content Criteria Related to Chronic Wounds, Prevention, and Treatment
Total courses with Centers without this content Centers with one Centers with two Centers with three or
Course content Maximum in a this content, n (%) in any course in the degree course having this courses having this more courses having
criteria degree program (N = 2,258 courses) program, n (%) (N = 95 centers) content, n (%) content, n (%) (N = 95 centers) this content, n (%)
Pain management, chronic
woundsa
0 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Pain management (in
general)
2 96 (4.2) 1 (1.1) 93 (97.9) 1 (1.1) 0 (0.0)
Prevention of pressure
ulcersa
4 50 (2.2) 60 (63.1) 25 (26.3) 7 (7.4) 3 (3.2)
Pressure ulcers 3 39 (1.7) 62 (65.3) 28 (29.5) 4 (4.2) 1 (1.1)
Wound bed assessmenta 1 1 (0.0) 94 (98.9) 1 (1.1) 0 (0.0) 0 (0.0)
How to select dressingsa 2 23 (1.0) 74 (77.9) 19 (20.0) 2 (2.1) 0 (0.0)
Treatment of pressure ulcers
or other chronic wounds
5 98 (4.3) 36 (37.9) 33 (34.7) 18 (18.9) 8 (8.5)
Note. Types of courses consulted: required, basic, guided practice, final project.
aThe top four education priorities in wound management and tissue repair defined by Cowman et al. (2012).
Table 3. Number of Courses in Each Nursing Degree Program, According to the Content Criteria Related to Acute and Chronic Wounds, Used as Controls
Maximum in a Total courses with Centers without this content Centers with one Centers with two Centers with three or
Course content degree program this content, n (%) in any course in the degree course having this courses having this more courses having
criteria (N = 95 centers) (N = 2,258 courses) program, n (%) content, n (%) content, n (%) (N = 95 centers) this content, n (%)
Venous disorders of the
lower extremities
3 55 (2.4) 48 (50.5) 40 (42.1) 6 (6.3) 1 (1.1)
Arterial disorders of the
lower extremities
3 56 (2.5) 48 (50.5) 39 (41.1) 7 (7.4) 1 (1.1)
Diabetic foot 1 4 (0.2) 91 (95.8) 4 (4.2) 0 (0.0) 0 (0.0)
Burns (adult patients) 2 42 (1.9) 54 (56.8) 40 (42.1) 1 (1.1) 0 (0.0)
Burns (children and
adolescents)
1 10 (0.4) 85 (89.5) 10 (10.5) 0 (0.0) 0 (0.0)
Severe burns 1 19 (0.8) 76 (80.0) 19 (20.0) 0 (0.0) 0 (0.0)
Wounds related to acute
processes
6 131 (5.8) 20 (21.1) 40 (42.1) 19 (20.0) 16 (16.8)
Wound healing 2 25 (1.1) 71 (74.7) 23 (24.2) 1 (1.1) 0 (0.0)
Antisepsis and antiseptics 6 95 (4.2) 38 (40.0) 33 (34.7) 17 (17.9) 7 (7.4)
Note. Types of courses consulted: required, basic, guided practice, final project.
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These data show that the treatment of PUs and other
chronic wounds is emphasized more than prevention in
the degree programs (4.34% vs. 2.21% of courses and
61.8% vs. 36.9% of centers, respectively). Our finding
is not consistent with other reports on the knowledge
base of healthcare professionals, primarily nurses, which
have found better results in the prevention than the
treatment of PUs (Hinojosa-Caballero, 2012; Pancorbo-
Hidalgo et al., 2007; Quesada Ramos & Garc´ıa D´ıez, 2008;
Saleh et al., 2013). Our results highlight a problem in
nursing education that can be addressed very directly
when students are assigned to clinical training. In recent
years, there have been more changes in PU treatment
than in prevention strategies, and therefore prevention
has taken a back seat in continuing professional education
(Pancorbo-Hidalgo et al., 2007); however, we cannot
allow this tendency to affect the preparation of new nursing
professionals. The clinical supervisor is a key player
in ensuring that students acquire skills in both the prevention
and treatment of PUs, not least because the student
spends many more hours at the clinical site than
in university courses on clinical practices. It is difficult to
make changes in what students learn and to improve clinical
practices if outdated (even nonrecommended) procedures
persist at clinical training sites. Therefore, it is
essential that clinical supervisors teach evidence-based
best practice and ensure that it is demonstrated by example
at the clinical site.
Acute Wounds
We included the term “wounds, acute processes” as a
control indicator to assess whether this type of wound
is given importance similar to the category of “treatment
of pressure ulcers and other chronic wounds.” This term
was more prevalent than “chronic wounds” in 30% of
the courses (5.8% vs. 4.34%) and was at least present in
some course at 16 more centers (75 vs. 59). These results
concur with Ayello et al. (2005), who reported that 70%
of nurses responded that they had not received sufficient
education on chronic wounds in their basic nursing education
program. Although more courses and more centers
indicate content related to “wounds, acute processes”
than to “treatment of pressure ulcers and other chronic
wounds,” acute wound care remains an area of concern
because all centers should be providing this instructional
content, independently of the present study’s focus on
chronic wounds.
Lower Extremity Wounds
We also considered it important to identify content
related to assessing nursing care of patients with diabetic
foot or venous and arterial disorders in the lower
limb, which are the other large groups of chronic wounds
and have great impact on patients’ quality of life (Feinglass
et al., 2012). We found content on “venous and
arterial disorders of the lower extremities” to be slightly
more prevalent than “prevention of pressure ulcers” (55
vs. 50), and more centers offered at least one related
course (47 vs. 35). We consider this a deficiency because
future nurses must know the characteristics, diagnosis,
progression, and treatment of ulcers with venous
or arterial etiology. These deficiencies have also been reported
in specialized training of internal medicine residents
(Schwarcz, Quijano, Olin, & Ostfeld, 2012; Wyatt
et al., 2010). Researchers have recommended a greater
emphasis on lower extremity wounds in medical school
and residency programs (Georgakarakos et al., 2013;
Wyatt et al., 2010).
Content on “diabetic foot” is almost anecdotal in the
courses analyzed, and was found only in four courses in
four different centers. Between 15% and 25% of diabetic
patients present with a foot ulcer at some point, and 14%
to 20% of them are amputated (Conferencia Nacional de
Consenso sobre U´ lceras de la Extremidad Inferior, 2009).
The training of nursing professionals in foot care is one
of the implementation objectives that support patient education
and the prevention of possible disorders (van
Houtum, 2012); therefore, it is critical to include this content
in the curriculum.
Elective Courses
When we analyzed the presence of elective courses,
we were surprised to find only one elective course in
all of Spain that offered the possibility of consolidating
and deepening students’ knowledge of chronic wounds,
far below other fields such as complementary or alternative
therapies (1 vs. 36). It could be argued that there
is no need to offer elective courses related to chronic
wounds because sufficient content is provided in the degree
courses. However, the same case could be made for
elective courses about research methods (the second most
frequent elective offering); urgent, emergency, or disaster
care (the third most frequent elective); or dependency,
disability, and chronic disease (sixth in frequency). All
of these topics were represented in required courses,
but electives offer an opportunity to gain a deeper
understanding.
In Spain, opportunities for specialization exist in elective
courses and in 2-year graduate residency programs
in one of seven specialty nursing areas (family and community
health, geriatrics, gynecology/obstetrics/midwife,
medical-surgical care, mental health, occupational
health, and pediatrics). Although caring for chronic
Journal of Nursing Scholarship, 2015; 47:1, 51–61. 57
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Course Content Related to Chronic Wounds Romero-Collado et al.
Table 4. Number of Elective Courses, Grouped by Topics Included in the Degree Program
Total courses with Centers without this content Centers with one Centers with two Centers with three or
Content criteria Maximum in a this content, n (%) in any of the courses in the degree course having this courses having this more courses with this
consulted degree program (N = 728 courses) program, n (%) (N = 104 centers) content, n (%) content, n (%) (N = 104 centers) content, n (%)
Content related to learning
other languages
3 50 (6.9) 62 (59.6) 35 (33.7) 6 (5.8) 1 (0.9)
Content related to research
methods
4 44 (6.0) 70 (67.3) 27 (26.0) 5 (4.8) 2 (1.9)
Content related to urgent,
emergency, and/or
disaster care
3 43 (5.9) 68 (65.4) 31 (29.8) 3 (2.9) 2 (1.8)
Content related to
occupational health
2 40 (5.5) 66 (63.5) 36 (34.6) 2 (1.8) 0 (0.0)
Content related to
complementary/
alternative therapies
3 36 (31.6) 73 (70.2) 28 (26.9) 1 (0.9) 2 (1.9)
Content related to
dependency and/or
chronic disease
3 24 (3.3) 83 (79.8) 19 (18.2) 1 (1.0) 1 (1.0)
Content related to
cooperation
2 20 (2.7) 85 (81.7) 18 (17.3) 1 (1.0) 0 (0.0)
Content related to health
promotion
1 13 (1.8) 91 (87.5) 13 (12.5) 0 (0.0) 0 (0.0)
Content related to palliative
care
1 11 (1.5) 93 (89.4) 11 (10.6) 0 (0.0) 0 (0.0)
Content related to school
health
1 3 (0.4) 101 (97.1) 3 (2.9) 0 (0.0) 0 (0.0)
Content related to
Catholicism
1 2 (0.3) 102 (98.1) 2 (1.9) 0 (0.0) 0 (0.0)
Content related to chronic
wounds
1 1 (0.1) 103 (99.0) 1 (1.0) 0 (0.0) 0 (0.0)
58 Journal of Nursing Scholarship, 2015; 47:1, 51–61.
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Romero-Collado et al. Course Content Related to Chronic Wounds
wounds is of obvious concern in the geriatric population
and in medical-surgical hospital nursing, awareness of
their preventability and of current best practices in the
prevention and treatment is a competency that can
contribute to quality patient care in any setting. This can
be addressed by site protocols and continuing education
workshops, but it is also key that universities adequately
address the topic in their curricula. Unlike countries that
offer a specialization in wound care or diabetes care,
universities in Spain need to provide elective courses and
units of required degree courses that make it possible for
students in any program to acquire this important area of
competency and be prepared to provide affected patients
with the needed care.
Limitations
An important limitation of our data collection was the
lack of a common set of official criteria governing nursing
course content descriptions. Some centers provide extensive
descriptions and others offer rather scant information
about the content of their courses. We also did not
have access to all courses in all programs because Spain
has gradually implemented the university-level degree in
nursing and not all centers have proceeded at the same
pace. Nonetheless, we were able to review course content
from 83.3% of the centers, more than 80% of them
through the second year, and had access to 65.72% of all
listed courses. Therefore, our results are drawn from an
extensive panorama of the undergraduate nursing degree
programs in Spain.
Another limitation of this study is the lack of electronic
access to the course content taught at 16.7% of
the centers that award the degree in nursing. However,
we gained access to more than 80% of the relevant information
through the second year of the degree program,
at which point students have completed the bulk of their
required and introductory courses.
The analysis was confined to nursing degree programs
in Spain. Although we found no studies with similar
methodology, we located several reports of these
same deficiencies in other countries: in Germany, using
content analysis of nursing textbooks (Wilborn
et al., 2009); in England, where students in the final
year of their nursing degree reported a perception
that they did not know how to manage patients’ skin
integrity effectively (Ousey et al., 2013); and a U.S.
study of faculty perceptions and documentation of PU
content in all 50 states and the District of Columbia
(Ayello et al., 2010).
Conclusions
In this study, we observed differences in the presence
of the four top educational priorities in wound management
and tissue repair (Cowman et al., 2012) in courses
that comprise the degree in nursing in Spain. Content on
pain management in patients with chronic wounds (top
priority) is nonexistent and about PU prevention (second
priority) is deficient, compared to content about PU treatment
(third and fourth priorities).
The course content related to chronic wounds that is
offered to future nurses in Spain appears to be deficient.
This situation must improve in order to phase out the
use of nursing interventions not recommended for PU
prevention. In the 21st century, we simply cannot allow
more than half of the teaching centers that offer a degree
in nursing to ignore the prevention of PUs in their course
content. This change must be implemented in required
courses, because there are almost no elective courses related
to the prevention and treatment of chronic wounds.
Degree programs responsible for preparing future
nurses must guarantee the acquisition of minimum basic
skills in the prevention and treatment of chronic wounds.
University programs in all countries should review their
curricular offerings and take steps to reduce the theory–
practice gap in this field.
Acknowledgments
We appreciate the translation and manuscript editing
provided by Elaine Lilly, PhD. Preliminary results of this
study were presented at a GNEAUPP Symposium (IX
Simposio Nacional GNEAUPP. Ciencia, Arte y Compromiso)
held in Sevilla November 14–16, 2012.
Clinical Resources
European Pressure Ulcer Advisory Panel: http://
www.epuap.org
European Wound Management Association: http://
ewma.org/english.html
Spain’s official database of universities, centers,
and diplomas [Registro de Universidades, Centros
y T´ıtulos (RUCT)]: https://www.educacion.
gob.es/ruct/home#
Spanish Pressure Ulcer and Chronic Wounds Advisory
Panel: http://www.gneaupp.org
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Week 3: Discussion Question 2 (Choose one article)

Study 1: Course content related to chronic wounds in nursing degree programs in Spain.

Brief Description of Method Employed:

Conclusion: