Nurses’ Knowledge, Practice, and Confidence after the Training Program on Wound Care at the Agriculture General Hospital in Vietnam

Aims: Wound care is the basic technique in patient care which has direct effects on treatment outcome. However, the Agriculture General Hospital (AGH), Vietnam, has never organized a continuing professional development (CPD) training program based on Vietnam’s Basic Nursing Competency Standards (VNBNCS) for their nurses. This study aimed to examine the knowledge, practice, and confidence level among nurses at the AGH after 12 months of implementing a VNBNCS-based wound care training program. Methodology: This descriptive and comparative study assessed the changes in knowledge, practice, and confidence scores of 43 nurses at five clinical departments before and 12 months after the training program (April 2018 to June 2019). Data were collected using a self-administrated knowledge questionnaire with 48 items, a 13-item confidence checklist, and a 16-item skills checklist. EpiData 3.1 and SPSS 18.0 were used to enter and analyze data, re-spectively. Results: The mean scores of knowledge (113.70 ± 14.75 vs. 129.7 ± 19.6), and practice (63.21 ± 19.99 vs. 132.07 ± 4.31) statistically significantly increased 12 months after training (p < 0.001). The mean score of confidence in performing wound


Introduction
Wound care is the basic technique in patient care which has direct effects on treatment outcomes [1] [2]. In Britain, 3% of the total health budget is dedicated to wound care, equivalent to 2.3 -3.1 billion pounds per year [3]. In the United States of America, about 5.7 million people suffered from chronic wounds while complications, bacterial infections, amputations, and pressure ulcers could be prevented if chronic wounds were well cared and managed at early stages [4]. In 2012, the "Vietnam's Basic Nursing Competency Standards" (VNBNCS) was approved by Vietnam's Ministry of Health [5]. Viet Duc University Hospital is the first hospital to develop a wound care training program based on these Standards, and the effectiveness of the program was examined in two articles by Phan et al. in 2014 and2017. According to the former study, the knowledge and practice scores of nurses significantly improved after 12 months of training [6].
The latter study suggested that the rate of nurses with adequate practice competency increased after training, and that the NCS-based wound care training program was effective in improving nurses' competency [7].

Study Population
Our present study recruited all of the 43 nurses directly taking care of patients.
These nurses had participated in the pre-training survey and the continuous training program on VNBNCS-based wound care. Their participation in the post-training survey was also voluntary.  [8].
The AGH provided training for the nurses based on this training program, including taught sessions and self-study, and these materials. The taught sessions consisted of 11 theoretical hours and 24 practical hours, and the self-study duration for each nurse was 16 days (8 hours/day). Nurses participated in the pre-training survey and the post-training survey which was conducted 12 months after the nurses attended the program. The effectiveness of the training program was assessed by comparing mean scores of knowledge, practice, and confidence between the two surveys.
We used a questionnaire and two checklists by Phan et al. [6]  Data were presented as frequencies and percentages for continuous variables or means ± standard deviations (SD) for categorical variables. The paired t-test was used to analyze the differences between mean scores of knowledge, practice, and confidence.

Ethical Considerations
This study was an institutional-level scientific research which received the AGH's approval on December 21, 2018. All of the nurses voluntarily participated in the study and were entitled to withdraw from the study at any time. Their personal information was kept confidential and only served the objectives of this study.

Wound Care Knowledge before and 12 Months after Training
The nurses' mean total knowledge score increased by 15

Wound Care Practice before and 12 Months after Training
The study results show that the mean total practice score increased by 68.86

Confidence in Performing Wound Care before and 12 Months after Training
Nurses felt more confident in practicing wound care after 12 months of training.
The mean confidence score statistically significantly increased in all of the 13 skills (p < 0.001), especially in problem identification (1.42 points), planning (1.35 points), and decision-making (1.33 points). The smallest increase was observed in patient assessment (0.95 points) ( Table 4).

Discussion
Training in wound care knowledge and practice helps improve wound care outcomes, reduce treatment costs, and lower the recurrence of wounds [9]. Knowledge has been demonstrated to influence practice while practice and self-experience help learners memorize the knowledge they acquire [10] [11]. Peter Lewis et al.
suggested that nurses' characteristics and needs should be surveyed before training [12]. Besides, the training program should consider the results of the pre-training survey to identify the aspects of knowledge that need improving

Wound Care Knowledge before and 12 Months after Training
Twelve months after training, the mean knowledge score increased in all aspects, especially the general knowledge of wound care (4.69 points). This indicated that the training program had a positive effect on nurses' knowledge on wound care.
The mean knowledge score improved significantly in only six aspects of knowledge, namely general wound care, infection control, health education for patients, clean wound care, exuding wound care, and pressure ulcer care. However, the other four aspects show no significant differences after training (i.e., communication, career management and development, infected wound care, and suturing technique). This may result from the nurses' lack of opportunities to experience these aspects in practice. Therefore, future workshops and training courses should help nurses better understand the importance of these knowledge aspects. Previous studies showed that clinical experience before and after training helped improve nurses' knowledge and skills [13] [14] [15], and education contributed to improving their knowledge, attitude, and skills related to wound care [16].

Wound Care Practice before and 12 Months after Training
Our study results showed that the mean scores in all 16 aspects of wound care practice statistically significantly improved after 12 months of training. Before training, nurses scored relatively low in aspects such as patient assessment, medical record documentation, and monitoring and assessment of patients' pain and bleeding after wound care. However, their practice of wound care became better after 12 months of training, especially when it came to monitoring and assessment of pain and bleeding after wound care (6.62 points). The scores for medical record documentation, patient assessment, and strict compliance with disinfection and sterilization principles increased by 5.58, 5.07, and 4.65 points, respectively. Patient assessment plays an essential role in the provision of comprehensive care. Particularly, assessments conducted within several days after surgical operations are crucial to the timely detection of pain and bleeding. Based on these assessments, healthcare teams can customize wound care plans for patients and provide them with effective and high-quality services. The World Health Organization (WHO) and the United Nations (UN) consider access to pain treatment as a fundamental human right and one of the fundamental objectives of today's health care [17]. Previous studies revealed that nurses had poor knowledge and attitude toward pain management [18] while pain management is a challenge to every health care facility [19]. Therefore, they should be continuously trained in knowledge and attitude regarding pain management [20] [21].
Our study results showed that in the pre-training survey, nurses had the lowest score of practice in pain and bleeding management (1.47 ± 2.67 points). Being aware of this weakness, nurses in our study paid more attention to this aspect and used the pain assessment scale about which they were instructed during the training program. Accordingly, their mean score increased in the post-training survey (8.09 ± 0.53 points). With regard to medical record documentation, Vietnam's Ministry of Health specifies it as one of the 12 tasks of nurses [22]. The proper and timely documentation of medical records can assist nurses in making wound care decisions. The mean score for medical record documentation in the pre-training survey was 2.72 ± 2.86 points. Both trainees and trainers realized and therefore focused on overcoming this weakness. Thanks to this, the mean score of practice in the aspect increased by 8.30 ± 0.67 points over 12 months. This result is consistent with those in two studies by Phan et al. [23] [24] at Viet Duc University Hospital which showed that practical sessions in the program were suited for nurses. Twelve months after training, nurses in our study had built up good habits and skills of wound care using the wound care procedure acquired from the training program. The reasons behind their improvements might be that they had well-defined, specific, and feasible objectives, and experienced a learning process based on real situations [25].

Confidence in Performing Wound Care before and 12 Months after Training
In our study, the nurses' level of confidence in practicing 13 basic skills of wound care improved significantly after 12 months of training (p < 0.001). This  The strength of the study lies in its prospective nature. However, it has some limitations that need to be addressed. First, it had a small sample size of 43 nurses. Second, the study used a self-administered knowledge questionnaire, which possibly led to bias. Finally, we could not establish an association of confidence with knowledge and practice. Therefore, future studies with large sample sizes and longer terms are required to further increase the validity of the study results and focus on examining whether nurses' level of confidence is linked with their knowledge and practice.

Conclusion
Nurses' knowledge, practice, and confidence related to wound care improved af- informing suitable interventions that aim to improve the quality of wound care.