Establishing Educational Programs for Existing & Aspiring Wound Clinic Staff: A Facility-Based Approach

If the wound care industry is going to trend toward better education standards, improvement of facility-offered orientation and mentorship could be what’s needed most.

It was quite possibly one of the most unequivocally accurate promises ever given by anyone: “I guarantee that this flight will be delayed,” the airport terminal attendant announced to the irritable group of passengers that this author was recently among while returning from teaching a lymphedema certification course in Calgary. The plane would go on to be four hours late when it finally departed; however, a certain suitcase has not yet made it’s way back to the United States, as of this writing, something that not even the most honest of all attendants could guarantee will happen.

Likewise, there are few assurances that anyone can make for any of us in today’s wound care environment. Despite this being a medical field that involves the input and expertise of practitioners from various disciplines and that offers advanced, sophisticated treatment interventions, the level of clinician skill and competency in our field varies. There’s also a lack of formal, consistent advanced training to ensure appropriate quality of care is delivered regularly.¹ Further exacerbating this dilemma is that some, if not many, wound care clinicians enter into practice without a firm grasp on the basics of treatment and etiology that allows one to provide proper interventions. Interestingly enough, we are all entering the “reimbursement era” of quality outcomes.  

Literature often cites nurses, therapists, and physicians do not have adequate opportunities to learn about wound care while in school.² On average, U.S. medical schools teach 9.2 hours of required education on wounds.³ Most of the curriculum time is accounted for by courses teaching physiology of wound healing and tissue injury while wound care and wound education were not specifically addressed in the various practices. Wound education most frequently occurs in courses on emergency medicine, geriatrics, and physical medicine and rehabilitation. Most schools do not require clerkships in these areas.³ The data are similar compared to other countries.⁴ 

True, there are wound care residency programs that exist for physical therapists, wound fellowship programs for podiatrists, formal wound care education elective courses offered at universities, and organized programs offered by nonprofits for physicians seeking specialization in wound care (as well as other available programs that promote formal training); but there’s a long way to go in order to uniformly prepare clinicians to effectively treat and educate chronic wound patients and their family members across the country.  

If we’re not more proactive about the need to better prepare new and tenured wound care clinicians on how to better assess and treat chronic, nonhealing wounds and the comorbid conditions likely presenting with them, the result is going to be too many outpatient centers that aren’t equipped to “survive” the financial pressures of the pay-for-performance system we’re all expected to adhere to. This article will present a potential universal solution to this avoidable trend — appropriate strategies for implementing and conducting educational programs for wound care practitioners in the outpatient clinic setting. 

Committing to Education 

We all know the disconnect between the idea that wound care clinics possess knowledgeable staff members who practice standards of effective wound care and the actuality of these modalities appropriately being followed consistently. For example, offloading of diabetic foot ulcers (DFUs) has widely been recommended as best practice, but the increasing number of DFUs shows poor usage of this intervention. A 2014 study by Fife et al indicated total contact casting was underutilized for DFUs treated in wound care settings, suggesting a gap in practice for adequate offloading methods.⁵ In addition, approximately 17% of clinics provide appropriate compression for chronic venous insufficiency patients, according to the U.S. Wound Registry. Positive outcomes and following evidence-based information become linked since patients in the outpatient wound clinic will experience life-changing events if best practices are being underutilized or ignored. At some point it becomes incumbent upon those of us who take the initiative to apply our education to best practices to serve as mentors for those who aren’t providing best practices as well as those entering into a field in which there’s no consistent formal or organized training. This does not have to start at the academic level.

At the local level, budgets are going to vary related to the costs of everything from facility space and products purchased to marketing and staff training/education. When faced with funding cuts that affect educational opportunities, employers and employees alike may find themselves trying to be “creative” in order to meet professional educational requirements. When attending large (and costly) conferences becomes difficult, providers may instead seek out webinars, local classes, and on-the-job training from their peers in order to “advance” their practice. While there’s certainly nothing theoretically wrong with leaning on experienced staff members for education (nor webinars and/or local classes if they are indeed reputable), a structured, formal approach to education is needed to be truly impactful. (The Table provides a checklist outlined approach to establishing an educational in-service program at the clinician, industry, and community levels.) 

Multiple Approaches to Structured Training

Regardless of the educational method, mentorship should be the priority. Mentorship is generally defined as a relationship in which a more experienced or more knowledgeable person helps to guide a less experienced or less knowledgeable person. The mentor may be older or younger, but a certain knowledge level in an area of expertise is expected. Likewise, concentrating on the clinician’s needs is paramount when the goal is to create a commitment to best practice that ultimately benefits the patient. Basic wound care knowledge becomes imperative in this sense, and the educator’s philosophy should be that anytime a clinician has a question it becomes a teaching opportunity. Carrying a camera at all times in order to capture any educational moment that arises can be very beneficial and timely for those practitioners serving as educators. (Note that this tactic requires adherence to HIPAA privacy and security guidelines related to the use of photos⁶ as well as appropriate consent among those being photographed.) Whenever multiple staff members can be consulted in this fashion together, the more valuable the learning moment can be. 

At Natchitoches (LA) Regional Medical Center, current and future clinicians are offered proper and evidence-based education through a free preceptorship program as well as a job-shadowing program, both of which are unique from the typical internships additionally available to nursing and allied health students in that they are open-ended in length based on the needs of the individual. 

The Preceptorship Program

Preceptorship is generally defined as a short-term relationship between a student as a novice and an experienced staff member who will provide individual attention to the student’s learning needs and feedback regarding performance. At Natchitoches Regional, the preceptorship program is open to any healthcare clinician interested in wound care — including those employed outside of the health system. A start date for the program is typically preselected and educational goals are set beforehand. This training is tailored to the individual’s needs within various healthcare settings. Prior to the start date, the clinician, if not employed within this system, will attend orientation through the human resources (HR) department, which will administer required tests, education, and paperwork requirements prior to the preceptorship.  

From that point, a wound care department orientation occurs as well as lectures on the phases of healing, assessment, wound bed preparation, dressing categories, and effective communication among patients and fellow clinicians. Clinicians are not permitted to be hands-on with patients, but are able to observe closely. (New residents treating their first patients often self-report “nerves, fear, and a lack of confidence” in safely performing new procedures on live patients by themselves.³) Guidance that’s conducted on a one-on-one basis is the standard at this time and, if desired, the trainee may practice learned skills on staff or the instructor. A coordinated learning experience among various departments within acute care, skilled nursing, long-term acute care, and others will also occur during this time. Additionally, clinicians meet key personnel, including specialists, in an effort to learn how each member fits within the team approach. 

The Job-Shadowing Program

Through this initiative, high school students who are pursuing a career in the healthcare world and pre-med college students rotate throughout the hospital as they explore different aspects of the medical continuum. Most medical schools recommend experience in shadowing before officially submitting an application. (This program partners with local universities including Northwestern State University.)  The program begins at the beginning of the school year with a lecture at the college for students enrolled in pre-med, pre-physical therapy, biology, hospital business administration, and health and human performance majors. Students are given the opportunity to sign up for the shadowing program and, in regards to those who will pursue wound care, they gain proper training well before they become physicians who’ve developed habits.

Before a student is approved to shadow, just as with the preceptorship, he/she must be oriented, trained, and have necessary documentation (such as HIPAA consent and vaccination records) before stepping into the department. Students are also required to reveal information regarding their current major, their personal goals for the shadowing experience, their available times to shadow, and other details that help clarify their agenda and availability. After meeting with HR they undergo wound care clinic-specific orientation that includes dress code explanation, communication skills, and obtaining each patient’s consent to participate in the treatment room. During the past school year, on average, each student shadowed anywhere between 10-18 hours per week. Students who are in a school-affiliated internship receive an education on wound differentiation, wound bed preparation, objective testing, colonization, infection control, and dressing selection. They also receive published research and journal articles that pertain to current case studies and standards of care to review. Depending on the performance of individual students, some may be invited to participate in a quid pro quo assignment such as creating marketing pamphlets for facility units/services, assisting with community education efforts, and creating surveys for clinicians on various topics. Future goals of the program include recruiting industry representatives to assist in the educational efforts to foster more effective communication for students among those they could one day be working with from outside the facility. All education provided through the program is evidence-based content that’s expected to ensure positive patient outcomes. 

Frank Aviles, Jr is wound care service line director at Natchitoches Regional Medical Center, wound care and lymphedema instructor at the Academy of Lymphatic Studies, physical therapist/wound care consultant at Louisiana Extended Care Hospital, and physical therapist/wound care consultant at Cane River Therapy Services LLC.

References 

1. Ennis W.  Wound care specialization: the current status and future plans to move wound care into the medical community. Adv Wound Care (New Rochelle). 2012;1(5):184-8.  

2. Yim E, Sinha V, Diaz SI, Kirsner RS, Salgado CJ. Wound healing in US medical school curricula. Wound Repair Regen. 2014;22(4):467–72. 

3. Patel NP, Granick MS. Wound education: American medical students are inadequately trained in wound care. Ann Plast Surg. 2007;59(1):53-5; discussion 55. 

4. Patel NP, Granick MS, Kanakaris NK, Giannoudis PV, Werdin F, Rennekampff HO. Comparison of wound education in medical schools in the United States, United Kingdom, and Germany. Eplasty. 2008;8:e8. 

5. Fife CE, Carter MJ, Walker D, Thomson B, Eckert KA. Diabetic foot ulcer off-loading: the gap between evidence and practice. Data from the US Wound Registry. Adv Skin Wound Care. 2014;27(7):310-6.  

6. Shindell R. HIPAA privacy & security compliance: managing the use of photographs and videos in the wound clinic. TWC. 2016;10(7):29-31.