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Cite this article: Adejumo PO, Ilesanmi RE (2016) Issues in Contemporary Wound Management: Evaluation of Knowledge and Practices among Nurses in Two Municipalities in Osun State, Nigeria. Ann Nurs Pract 3(6): 1065.

*Corresponding authorRose Ilesanmi, Department of Nursing, College of Medicine, University of Ibadan, Nigeria, Tel: 234-8035-195504; Email:

Submitted: 23 August 2016

Accepted: 22 September 2016

Published: 24 September 2016

ISSN: 2379-9501

Copyright© 2016 Ilesanmi et al.

Keywords•Wound management•Nurses’ knowledge•Nurses’ practice

Research Article

Issues in Contemporary Wound Management: Evaluation of Knowledge and Practices among Nurses in Two Municipalities in Osun State, NigeriaPrisca Olabisi Adejumo and Rose Ekama Ilesanmi*Department of Nursing, University of Ibadan, Nigeria

Abstract

Introduction: Issues around wound management is constantly evolving with introduction of newer approaches based on evidence. Nurses’ knowledge about the contemporary issues have been reported differently. The aim of this descriptive study was to examine the wound management knowledge of nurses prior to a skills building workshop.

Materials and methods: A descriptive study of 317 nurses who attended a preconference skill acquisition workshop on contemporary issues in management of chronic wounds was undertaken in May, 2012. Participants were nurses working in different hospitals in Ife and Osogbo municipalities in Osun State, Nigeria. Data collected included types of wounds and common management strategies. Data were analyzed using SPSS version 15.0, and presented using frequencies and percentages.

Results and discussion: The mean age of nurses was 41.8 ± 9.0 years. Of the 317 nurses, 97 (30.3%) had university degree while 159 (50%) had diploma certificates in nursing. Majority110 (35%) practiced in community and home based care, with 184 (58%) in primary healthcare facilities. Respondents treated both chronic and acute wounds in their practice; ranging from puncture wounds (38.8%), lacerations (65.4%), leg ulcers (44%) and pressure ulcer (10%). The mean knowledge score on wound care practices was 23.0 ± 14.0. Only 6% of the respondents had a good knowledge of wound care practices (i.e. score >50). The mean wound assessment practice score was 21.1±14.2. Only 5% of the respondents had a good wound assessment practice.

Conclusion: Despite the plethora of information on wound care practices, respondents in this study demonstrated low levels of knowledge regarding contemporary wound care practices. There is therefore an urgent need for continuing education programs in healthcare facilities to enhance knowledge translation and effective wound care practice.

INTRODUCTIONResearch evidence has brought a paradigm shift in wound

management, from the traditional principle of dry-to-moist healing to wound-bed preparation and moist healing principles [1,2]. Interestingly, wound management represents a large proportion of what nurses do in acute and community settings. It is documented that many physicians rely on nurses’ opinion and

evaluation in wound care [3,4], suggesting that some expertise and an up-to-date knowledge is expected of nurses in wound care practice. Studies however provide evidence suggesting that nurses have not lived to that expectation. For example, the report of a descriptive study in Nigeria which assessed nurses’ reported knowledge and practice of wound assessment, noted a less than adequate knowledge and practice of wound assessment

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and documentation [5]. The same study noted that respondents’ years of experience and level of education significantly influenced their reported knowledge and practice of wound assessment. In another study also in Nigeria, Ogunfowankan et al., [6] examined knowledge and perception of nurses about modern wound dressings. Findings indicated that of the 183 nurses in that study, 60.1% had poor knowledge of modern wound dressings. Similarly findings from a UK study to explore nurses’ knowledge and competency in wound management [7], suggested that despite good knowledge of the parameters for wound assessment, a statistically significant correlations existed between knowledge and competence only among respondents who had updated their wound care knowledge in the previous 2years. It follows that consistent update in knowledge of current trends will improve competency among nurses.

Wound dressing is an integral part of wound management, and in the past two decades, there have been a myriad of choices available. Importantly, decisions to choose any specific dressing type of dressing must informed by adequate knowledge and evidence. It is therefore a natural expectation that the health outcome of a wound patient would be significantly influenced by the practitioners’ knowledge and practice. It follows therefore that education and consistent capacity building in this area of practice is important to achieve good clinical outcome [8]. Few studies conducted in Nigeria consistently reported insufficient knowledge of nurses about contemporary wound management strategies. However, respondents who possess knowledge of the modern dressings noted non-availability of the materials in their hospitals as a barrier [6].

Nurses who are certified in wound care are better informed for decision making. This is not exactly so with every nurse, even though every Registered Nurse (RN); possess a basic knowledge to handle wounds. Certification/licensure bestows on the nurse a public confidence, which also makes him/her accountable for whatever actions and inactions.

As of today and to the best knowledge of the researchers, wound care nursing does not exist as a certificated program in Nigeria, except for Burns and Plastic Nursing, yet every RN in Nigeria attend to patients with diverse wounds. In view of the plethora of evidence surrounding wound management, the focus of this study was to examine how much of the contemporary issues in wound management that the nurses in this cohort are familiar with, and also implement in their respective practice. This was a baseline evaluation prior to a skills-building workshop on current trends in wound care.

MATERIALS AND METHODS The study was a descriptive survey conducted among nurses

who attended a 2-day skills building workshop on contemporary wound care practices at Ife and Osogbo in Osun State, Nigeria. The aim was to determine the entry knowledge of the participants at the workshop. Osun state is located in the South West geo-political zone in Nigeria. It consists of thirty (30) local government areas, with Osogbo as the state capital. Institutional approval was obtained for the conduct of the study.

The nurses were gathered for the proposed workshop in an

auditorium in Ife. Participants were selected using convenient sampling and only those who provided consent to participate were recruited. In all, 500 nurses participated in the workshop but only 317 nurses were willing to participate (63.4% participation rate).

A structured questionnaire developed from a literature review of similar studies was used. It consisted of 61 items. A test-re-test reliability was conducted. The Content Validity -ALL was .80. Each of these 61 items was evaluated critically. Some were eliminated (n = 4), and nine (9) were revised as suggested by the experts. The content validity index for each of the item was used to inform decisions about discarding or revising any item. The 61 items were categorized into four sections: Section A of 7 items is the biodata. Section B tapped information on knowledge and consisted of 14 items, while section C focused on assessment of current wound care practices comprising 11 items. The last section; D consisted of 29 items eliciting information on wound assessment.

Data analysis

Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 15.0 (SPSS, Chicago, IL), for individual items using descriptive statistics: frequencies, percentages, mean and standard deviations.

RESULTS The study was purely a description of what nurses do in their

practices; we did not make comparisons, therefore hypotheses were not tested. Most of the participants 276 (87%) were females. The mean age was 41.8 ± 9.0 years (range 24–70 years) with 89 (28%) aged 24-35 years and 228 (72%) aged 36 years or older. The majority 159 (50%) possessed diploma nursing certificates, 97 (30.3%) had university degree (Table 1). One third of the participants 110 (35%) worked in community and home care facilities.

Respondents managed patients with both chronic and acute wounds. For acute wounds, 178 (65.4%) treated lacerations, while 157 (49.5) managed surgical wounds. For chronic wounds 159 (44.2%) managed patients with leg ulcer while 32 (10%) managed patients with pressure ulcers (Table 2).

A large percentage of respondents 219(69%) were involved in wound dressing, and 144 (45%) performed wound care on daily basis (Table 3). The proportion of nurses who assess wound-related pain was 263 (83%). Out of this 82 (25%), assess pain only when patients complain, while 126 (39. 7%) assess patient’s pain anytime during wound care procedure.

Table 3 also shows that 206 (65%) measured the rate of healing in ulcer. Among those who assess the rate of healing, 143(45%) was by intuition, and 79 (25%) claimed they use the traditional observation method without a specific measuring tool. Only 95 (30%) made used of wound measurement tools.

We also examined the specific wound documentation record available in the facilities. Findings showed that 260 (82%) were not using any specific wound documentation record. On existence of a functional wound care team in the facilities, 272 (86%) indicated that wound care team does not exist in their hospitals.

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Table 1: Respondents demographic Characteristics (n=317).

Variables Frequency (%)

A. Gender : MaleFemale

41 (13%)276 (87%)

B. Age group(years)24-35≥ 35

89 (28%)228 (72%)

C. Professional cadreStaff nurse

Nursing sisterSenior nursing sister

Principal Nursing sister

Chief Nursing officerAssistant director of

Nursing

76 (24%)70 (22.1%)46 (14.5%)39 (12.3%)

35 (11.0)51 ((16.1%)

D. Educational Qualification

Diploma in NursingBachelor in Nursing

MS.cPhD

159 (50%)97 (30.3%)32 (10%)31 (9.7%)

E. Area of practiceMedical &surgical

inpatientAccident &Emergency

Surgical OutpatientCommunity/home

careMedical outpatient

Others

41 (13%)

10 (3%)38 (12%)

110 (35%)22 (7%)

95 (30%)

F. Type of Hospital/workplace

Teaching hospitalState hospital

Missionary hospitalPrivate hospital

Primary healthcare centre

95 (30%)16 (5%)6 (2%)

16 (5%)184 (58%)

Table 2: Common wounds managed regularly at work.

Acute Wounds Frequency (%) Chronic Wounds

Frequency (%)

Punctured wounds

LacerationsBurn injuries

Surgical wounds

Fractures & Amputations

123 (38.8)

178(65.4)75 ( 23.7)

157(49.5)

22(4.7)

Pressure ulcer

Diabetic foot ulcers

Leg Ulcers

Necrotic Abscesses

32 (10)11 (3.5)

159(44.2)

10(3.1)

Respondents were asked about the contemporary wound management techniques which they have read about. A large number; 143 (45%) have not read about any one type. However, 95 (30%) have read about hydrogels dressings and 25 (8%) about negative pressure wound therapy. On wound prevention, we assessed respondents’ knowledge of 60 seconds foot screening for diabetic patients, and almost all the nurses; 307(97%) have neither heard about it, nor observed it done before the study.

Specific practices during wound dressing procedure were examined (Table 4). Findings show that 213 (67.2%) reported

that they never used the same dressing type throughout the wound healing trajectory, while 41 (4.4%) continued with same dressing type till complete healing was achieved. On the use of hydrogels, hydrocolloid or film dressing, 101 (31.9%) indicated not knowing anything about such dressings, while 60 (16.9%) sometimes used it their practice. Hydrogen peroxide was noted as the regular wound cleansing solution for 34 (10.7%) respondents.

On the right procedure for taking a wound swab to diagnose wound infection, 110 (34.7) nurses would sometimes dip the swab stick into wound exudate, while only 59 (18.9) would never dip the swab in the slough without first irrigating the wound bed. Attempt to identify a better technique for wound cleansing in order to remove debris from the wound bed showed that; 116(36.6%) sometimes irrigate the wound to remove debris while 50(15.8%) would rather swab the wound.

Table 3: Respondents’ Wound care –related activities (n=317).

Variables Frequency (%)

A. Wound care ActivitiesWound AssessmentWound Prevention

Wound dressingDebridement

Suture removal

32 (10%)38 (12%)

219 (69%)19 (6%)10 (3%)

B. Frequency of wound careDaily

Once a weekTwo times in a month

Once in a month

144 (45%)48 (15%)57 (18%)68 (22%)

C. Pain Assessment during wound dressing

YesNo

263 (83%)54 (17%)

D. Time when pain is assessedWhen patient complain

Before wound care procedureAnytime during procedure

Never

82 (25.8%)79 (25%)126 (39.7)27 (8.5%)

E. Who conducts wound assessment in the hospital

NursesDoctors

The multidisciplinary teamNo idea

197 (62.0%)30 (9.5%)

82 (26.0%)

8 (2.5%)

F. Measuring rate of ulcer Healing in the facility

YesNo

206 (65%)111 (35%)

G. How rate of ulcer healing is measured

By intuitionUsing measurement tools

Traditional observation method

143 (45%)95 (30%)

79 25%)

H. Using specific wound documentation form

YesNo

57 (18%)260 (82%)

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Table 4: Respondents’ specific wound dressing practices.

Wound dressing practices Rarelyn (%)

Nevern (%)

Sometimes n (%)

Alwaysn (%)

I don’t known (%)

I use the same dressing type for the entire wound healing process 6 (1.9) 213 (67.2) 23 (7.3) 41 (4.4) 18 (5.7)

Treatment plans changes as wound fills with granulation tissue and epithelialization 1 (0.3) 5 (1.6) 145 (45.7) 113 (35.6) 12 (3.8)

I use foam dressing for deep and heavily exuding wounds 3 (0.9) 40 (12.6) 112 (35.3) 55 (17.4) 53 (16.7)

Hydrogels, hydrocolloid or film dressings are used in my practice 7 (2.2) 68 (21.5) 60 (18.9) 23 (7.3) 101 (31.9)

I use hydrogen peroxide for wound cleansing 3 (0.9) 51 (16.1) 164 (51.7) 34 (10.7) 21 (6.6)I use Darkin’s solution for wound cleansing 10 (3.2) 79 (24.9) 31 (9.8) 12 (3.8) 117 (36.9)

I use water for wound cleansing 9 (2.8) 189 (59.6) 36 (11.4) 21 (6.6) 21 (6.6)I use normal saline for wound cleansing 0 (0.0) 25 (7.9) 149 (47.0) 99 (31.2) 8 (2.5)

When taking wound culture, the swab is dipped in wound drainage to assess infection 3 (0.9) 59 (18.9) 110 (34.7) 85(26.8) 12 (3.8)

Irrigation removes debris from wound better than swabbing 6 (1.9) 50 (15.8) 116 (36.6) 74 (23.3) 26 (8.2)

Recommended pressure for irrigation is 15psi 1 (0.3) 19 (6.0) 47 (14.8) 9 (2.8) 165 (52.1)

Overall, the mean score for wound care practice was 21.1 ± 14.2 (range 0 – 75). Only 5% of the respondents had a good wound assessment score for practice (Figure 1). The mean knowledge of contemporary wound management was 23.0 ± 14.0 (range 0 – 63). Only 6% of the respondents had a good knowledge of contemporary wound care issues (Figure 2).

DISCUSSIONThe aim of this study was to provide a description of the

regular wound care practices of the respondents, and the extent to which contemporary trends in wound care were implemented in their practices. The study did not make comparisons so no hypotheses were tested. Participants were experienced nurses with varied academic and professional certifications, but none with specialty practice in wound care. Despite this, all the nurses within the study cohort handle wounds, some on daily basis. It goes to confirm the fact that wound care is one of the basic components of nursing practice.

Findings from our study suggest that nurses were not knowledgeable of the current trends in contemporary wound management. Although respondents were engaged in managing different wound types; from simple lacerations to complex wounds such as diabetic ulcers and pressure ulcers; it appears that nurses were not driving wound care decisions. This can be deduced from the less than optimum level of knowledge of current wound practice demonstrated by the respondents. Of note is the fact that a greater percentage of study respondents practiced in the community and home care settings. The findings nonetheless highlight their significant roles in wound management.

To corroborate this Waters [9] and Whitlock et al., [10] observed that most chronic wounds are managed in the community settings rather than in acute care. This suggests a need for competence and up-to-date knowledge in wound care practices for nurses working in the community settings. Undoubtedly, the findings correctly accentuate inadequate knowledge of current trends in contemporary wound care issues. For example, wound assessment is very a crucial aspect of wound management, as it provides baseline information upon which to judge the effectiveness of treatment [11] and the progress or otherwise.

Literature documents that objective measurement of the wound volume and area is considered a routine practice when caring for a wound patient [12,13]. This practice guides the

Figure 1 The mean wound assessment practice score was 21.1±14.2 (range 0 – 75). Only 5% of the respondents had a good wound assessment practice.

Figure 2 Respondents level of knowledge on contemporary wound care issues.

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clinician to determine a need for change in treatment modality. In the current study, 45% of respondents claimed to be monitoring the rate of healing, most of which was done by intuition, suggesting that no objective measurement tool was in use. This result is perhaps not surprising in the light of the fact that none of the respondents was a certified wound care nurse; and there was no report of any standing wound care team in the settings.

Also of concern in the study findings is the fact that no wound documentation form was used in practice and only 95 (30%) of respondents have read about hydrogel dressings. A previous study on nurses’ reported practice of wound assessment in Nigeria [5] corroborates our findings. This suggest an urgent need for update programs for nurses. Furthermore, the principle of moist wound healing is strongly advocated in literature for chronic wound healing, through the newer dressing materials, rather than the traditional gauze14. Our findings suggest that these moisture-retentive dressings were not in use in these facilities. We conclude therefore that the traditional gauze dressings was the usual dressing type in these facilities.

On assessment of respondents’ wound dressing practices, a good number of respondents did not know about hydrogels, hydrocolloid or film dressings. Literature [14] noted that despite technological advances in wound care and research evidence, the traditional wet-to-dry gauze dressing was still popular, particularly among surgeons, whom according to Baronosky and Ayello [15] have not been influenced by the modern wound dressings. If this statement holds true, it suggests that in countries where nurses do not drive wound care decisions, modern dressings may not be a popular practice.

An effective wound care assessment always culminates into wound dressing decisions, which with the modern dressings goes beyond an inert covering, but the materials interact with the wound environment [8]. Within the context of holistic practice, such decisions should be based on an overall patient’s expected outcome. The National Pressure Ulcer Advisory Panel and the European Pressure Ulcer Advisory Panels [16] condemned the use of same dressing type throughout the wound healing trajectory. This is because the characteristic of the wound always determine the dressing type and changes in the course of management. Sadly some respondents in our study reported that same dressing materials were used throughout the healing process. A possible explanation for this practice may be linked to unavailability and inaccessibility to a wide range of dressing choices. Some respondents reported not to have either read nor use modern dressings like hydrogels, negative pressure wound therapy.

The low overall mean knowledge score of the respondents in our study reflects inadequate information on modern wound care practices. Akin to the use of same dressing is the fact that no two wounds are exactly the same. It follows that wound etiology influences care decisions, therefore, a comprehensive history and assessment is significant. In our study, a very small percentage (10%), of the respondents carry out wound assessment. We did not however examine the component of the wound assessment performed by nurses.

Interestingly, wound pain was assessed by the respondents,

either when patients complain or routinely during wound dressing procedure. Obilor et al., [17] examined the experience of wound-related pain among patients. Authors reported that pain was experienced by wound patients during activities such as positioning, wound cleansing and removal of dressings. It follows that assessing wound-related pain is an integral part of wound care.

Wound prevention is an important aspect of nursing practice; therefore we examined the respondents’ knowledge of 60 seconds foot screening, which is used to identify patients at risk for diabetic neuropathy and consequent ulceration. Almost all the respondents had never heard about the foot screening. On the contrary, Adejumo et al., [18, in a study on the outcome of 60-seconds foot screening among nurses, doctors and physiotherapists in Ibadan, Nigeria reported that over 80% of the respondents scored over 50 percent, indicating some level of knowledge. It should be recalled that the respondents in our study were majorly from the community and home care facilities, and may not be providing care to patients with complex problems.

SUGGESTION FOR FUTURE STUDIESThe respondents in this study were from two small

municipalities, therefore the findings may not necessarily represent the general wound care practice among nurses in Nigeria. We therefore suggest a study with a wider scope among nurses in large tertiary hospitals in Nigeria.

A comparative study of wound management practices among nurses in acute and community settings may also be undertaken in the future.

CONCLUSION Respondents in this study provide care to patients with

a variety of wound type, using mostly traditional practices. A knowledge gap regarding contemporary wound care practices was identified. There is therefore a need to undertake a work to translate current trends in wound care into clinical practice among nurses in acute and community based practice.

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Adejumo PO, Ilesanmi RE (2016) Issues in Contemporary Wound Management: Evaluation of Knowledge and Practices among Nurses in Two Municipalities in Osun State, Nigeria. Ann Nurs Pract 3(6): 1065.

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