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CLINICAL SCHOLARSHIP Health Empowerment Among Immigrant Women in Transnational Marriages in Taiwan Yung-Mei Yang, PhD, RN1 , Hsiu-Hung Wang, PhD, RN, FAAN2 , Fang-Hsin Lee, PhD, RN3 , Miao-Ling Lin, MN, RN4 , #038; Pei-Chao Lin, MSN, RN5 1 Assistant Professor, College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan 2 Professor, College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan 3 Assistant Professor, Department of Nursing, Chung Hwa University of Medical Technology, Tainan, Taiwan 4 Section Head, Department of Health, Kaohsiung City Government, Kaohsiung, Taiwan 5 Doctoral Candidate, College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan Key words Marriage migrant women, health empowerment, participatory action research Correspondence Dr. Hsiu-Hung Wang, Professor, No. 100, Shih-Chuan 1st Rd., Kaohsiung 80708, Taiwan. E-mail: [email protected] Accepted: August 31, 2014 doi: 10.1111/jnu.12110 Abstract Purpose: The aim of this study was to develop, implement, and evaluate a theory-based intervention designed to promote increased health empowerment for marriage migrant women in Taiwan. The rapid increase of international marriage immigration through matchmaking agencies has received great attention recently because of its impact on social and public health issues in the receiving countries. Design and Methods: A participatory action research (PAR) and in-depth interviews were adopted. Sixty-eight women participated in this study. Eight workshops of the health empowerment project were completed. Findings: Through a PAR-based project, participants received positive outcomes. Four outcome themes were identified: (a) increasing health literacy, (b) facilitating capacity to build social networks, (c) enhancing sense of selfworth, and (d) building psychological resilience. Conclusions: PAR was a helpful strategy that enabled disadvantaged migrant women to increase their health literacy, psychological and social health, and well-being. Clinical Relevance: The findings can be referenced by the government in making health-promoting policies for Southeast Asian immigrant women to increase their well-being. Community health nurses can apply PAR strategies to plan and design health promotion intervention for disadvantaged migrant women. The rapid increase of international marriage immigration through matchmaking agencies has received great attention recently because of its impact on social (e.g., demographic structure and culture) and public health (e.g., healthcare services) issues in the receiving countries. The U.S. Citizenship and Immigration Services (2013) reported that the “mail-order bride” business results in 4,000 to 6,000 marriages between U.S. men and foreign women each year. In Asian countries, an increasing number of women from Mainland China, Vietnam, Indonesia, the Philippines, Thailand, Malaysia, and Cambodia have migrated through international marriage to Taiwan, Journal of Nursing Scholarship, 2015; 47:2, 135–142. C 2014 Sigma Theta Tau International Singapore, Japan, South Korea, and Hong Kong (Hsia, 2010). In Taiwan, the immigration of Southeast Asian brides started in 1987 in rural areas of Taiwan (Yang #038; Wang, 2012). However, the number of undocumented international marriage immigrant women is often underestimated. According to Taiwan’s Ministry of the Interior (2012), there has been an influx of 410,000 foreign spouses in Taiwan, including 140,000 from Southeast Asia and approximately 260,000 from Mainland China. The Ministry of the Interior (2012) reported that the overall immigrant population in Taiwan has grown dramatically, especially immigrants from Mainland China 135 Health Empowerment Among Immigrant Women Yang et al. (318,390; 67.45%), Vietnam (87,274; 18.49%), Indonesia (27,648; 5.86%), Thailand (8,333; 1.77%), and the Philippines (7,468; 1.58%), making the influx of racial or ethnic immigrant minorities an increasingly challenging social and public health issue. For many women in developing countries, international marriage immigration has emerged as a way to escape poverty and achieve a better life by marrying men from more financially developed countries. For men in East Asia who experience difficulties finding a wife, matchmaking agencies can arrange a trip to allow men to locate a partner in a few days and return to their homeland with a new bride. The bridal candidates, however, are called by many derogatory terms, such as “mail-order brides” or “foreign brides,” and are often treated with disrespect and derision in the receiving country (Choe, 2005). personal relationships, and social support in their host country intensifies their loneliness and social isolation (Yang #038; Wang, 2011b). Marriage migrant women’s marginalized status and difficulties in accessing adequate health care indicate a lack of empowerment to effectively seek the resources they need to improve their health and well-being. Shearer (2007) asserted that health empowerment may increase one’s awareness in health and one’s own healthcare decisions. Ensuring health empowerment among marriage migrant women may improve their ability to access health care, achieve better health, and overcome their marginalized status in their receiving country. The aim of this study was to develop, implement, and evaluate a theory-based intervention designed to promote increased health empowerment for marriage migrant women in Taiwan. Health Care Among Immigrant Women in Transnational Marriages Methods The growing number of immigrant women has become a significant global concern in the social and public health sectors. According to the United Nations’ Committee on the Elimination of Discrimination Against Women (2009), immigrant women may not only be subject to sex discrimination in their receiving country but also face specific health challenges. Indeed, one of the primary goals outlined in Healthy People 2020 is to eliminate health disparities among different segments of vulnerable populations, such as immigrants (U.S. Department of Health and Human Services, 2013). Studies showed that immigrant women in Taiwan not only tended to be more vulnerable to illness but also experienced more barriers to their health care than nonimmigrants. A cross-cultural comparison indicated that Vietnamese immigrant women in Taiwan had a generally lower health-related quality of life than native Taiwanese women (Yang #038; Wang, 2011a). Lin and Wang (2008) investigated Southeast Asian pregnant immigrant women and found they had irregular prenatal examination behavior. Immigration is a stressful, unexpected life event in which immigrants experience a complicated process of re-adaptation in the host society (Meleis #038; Lipson, 2004). To cope with the challenges of living in a new country, marriage migrant women in Taiwan are also vulnerable to psychological distress, which can negatively impact their health and well-being (Yang, Wang, #038; Anderson, 2010). Moreover, greater acculturative stress increases the risk for developing psychological problems, particularly in the initial months of immigrating to the new host society (Berry, 1997). The lack of true friendships, 136 Design and Theoretical Framework Action research is an interactive research process that equalizes problem-solving actions implemented in a collaborative framework with data-driven analysis or an inquiry to understand underlying causes enabling future expectations about personal and organizational change (McNiff, 2013). Participatory action research (PAR) is based on critical social theory; it is conducted to realize and transform the world, collaboratively and reflectively (Reason #038; Bradbury, 2008). PAR was used to develop the intervention of this health empowerment project (HEP). The bottom-up approach of PAR was chosen as the most appropriate method to develop and evaluate an intervention program designed to empower an especially marginalized and oppressed population (Minkler #038; Wallerstein, 2010). Previous researchers have documented PAR as an empowerment-based inquiry methodology that bridges the gaps between knowledge and daily lives and equalizes the power between researcher and participants (Tapp #038; Dulin, 2010). It promotes the research participants’ ability to identify their own problems, make their own priorities, handle their own solutions, and control their own progress. In addition, Etowa, Bernard, Oyinsan, and Chow (2007) considered PAR a user-friendly framework for community-based inquiry and provided the model for researchers and community members to work together to identify problems, take action, and achieve the goal. The essential elements of PAR are collaboration, participation, and reflection, which take place during multiple cycles of planning, acting, and reviewing (Koshy, 2005). Journal of Nursing Scholarship, 2015; 47:2, 135–142. C 2014 Sigma Theta Tau International Yang et al. Intervention Planning cycles. During the planning phases of our PAR-based HEP, the specific health concerns of the participants had been identified based on the previous literature (Lee, Wang, Yang, #038; Tsai, 2013; Tsai, Cheng, Chang, Yang, #038; Wang, 2014; Yang #038; Wang, 2011b), including social isolation, acculturative stress, lack of health information, and lack of health literacy. Investigators established a collaborative relationship with community partners, and integrated community resources. The research team met with community partners several times to discuss the appropriateness and effectiveness of the health promotion strategies presented in the workshops. Investigators established a preliminary curriculum. To recruit participants, the research team established community partnerships such as the local neighborhood managers (the heads of the subdivisions of the districts), the local Christian church, the primary healthcare center, and the Management of Assistance Center for Foreign Spouses. The community of interest was considered and the appropriate consent procedures were implemented for participants who were involved in the design of the curriculum. We formalized an arrangement with community leaders to establish contacts with community partners, to build a trusting relationship between participants and our research team, and to agree on a time frame for the HEP. Acting cycles. The goal of the various acting cycles of our PAR project was to develop an HEP, implemented as a series of eight workshops, in order to generate positive psychological and social changes among the participants. A major component of the HEP’s curriculum was a holistic health concept, which included physical, psychological, and social well-being. The curriculum addressed the following six topics: reproductive health (maternal health and family planning); disease prevention (human immunodeficiency virus, sexually transmitted illnesses, cancer screening); healthcare system utilization (health information and health insurance); cultural competence (social support and acculturation); mental health (interpersonal relationships and stress management); and the special issue (domestic violence prevention and management). The study’s principal investigator designed and developed the preliminary curriculum based on previous studies (Lee et al., 2013; Wang #038; Yang, 2002) and discussion with community leaders, and two instructors presented the health information by means of various activities conducted in the workshops, such as lectures, demonstrations, drama, role-play exercises, group discussions, and group presentations. Journal of Nursing Scholarship, 2015; 47:2, 135–142. C 2014 Sigma Theta Tau International Health Empowerment Among Immigrant Women Reviewing cycles. During the multiple reviewing cycles of the PAR project, the research team worked with community partners to evaluate and reassess the HEP during intermittent periods and at the final stage of the program. Participatory observations and group discussions during the workshops, as well as in-depth individual interviews with each participant at the conclusion of the program, provided the participants’ points of view and reflections during the PAR process. Feedback from the participants was ongoing. For exle, many participants complained their husbands beat them after quarrels, so the special session on domestic violence in the curriculum was in response to participants’ feedback in the reviewing cycles. Data generation and analysis occurred concurrently and began in the early stages of the HEP, which enabled the use of emerging themes and issues to guide group discussions in the workshops. The researchers’ role throughout the reviewing cycles was to explore and stimulate the participants’ reflections on their experience during the HEP. Participants and Setting Among the 87 women who were invited to participate in this study, 68 completed the eight workshops of the HEP. The reasons of those who did not complete the study included transportation problems, being forbidden to go outside by their mother-in-law, taking care of young children, or moving out of the community. Eligible participants were women who fit the following criteria: (a) were marriage migrants from Vietnam, Indonesia, the Philippines, Thailand, or Cambodia; (b) were married to a Taiwanese man; (c) had a basic conversation ability in Taiwanese or Mandarin; and (d) were willing to participate in the study. Although immigrants from Mainland China comprise the majority of the marriage migrants, they were not included as part of the inclusion criteria. This is because Mainland China migrants share the same culture and speak the same language (Mandarin) with Taiwanese. They can access more information by themselves with no language barrier and have better acculturation in Taiwan. The women from Vietnam, Indonesia, the Philippines, Thailand, or Cambodia who were included have all learned a new language since immigrating. They need to learn Mandarin or Taiwanese dialect to communicate with their husband and in-laws. From June 2009 to February 2010, eight workshops with 1-month intervals were held in a local church located in Pingtung County, southern Taiwan. Each workshop lasted approximately 3 hr, for a total of 24 hr of contact time with study participants throughout the intervention 137 Health Empowerment Among Immigrant Women program. The participants were grouped into five groups by ethnicity. Taiwanese dialect and Mandarin were the languages used while conducting the workshops. Data Collection Two qualitative methods were used to collect data: participatory observation and in-depth individual interviews. Participatory observation involved a member of the research team taking field notes to record the interactions and activities in each of the eight workshops throughout the entire health empowerment program. The content of these field notes included observations on the setting arrangement, the participants, group dynamics, and interactions between participants, group presentations, and the premeeting with community partners. At the conclusion of the program, another member of the research team conducted in-depth individual interviews to gain a deeper understanding of the personal experience of each study participant. We developed a semistructured interview guide to elicit responses from each participant. The individual interviews were conducted for 60 to 90 min and were tape recorded and transcribed. Yang et al. for the second coding cycle. They met together and, through peer discussion and agreement, recategorized the 36 coding units. Finally, on the basis of the coding, the principal investigator of our research team identified themes that integrated substantial sets of the coding units. Data were collected by two trained, bilingual research assistants who were proficient in Taiwanese dialect and Mandarin and had each obtained a bachelor’s degree in nursing. Rigor Rigor was guided by the process of trustworthiness (Lincoln #038; Guba, 1985). Prolonged engagement and peer debriefing were used to assess the credibility of the themes. To ensure dependability, the principal investigator conducted an 8-hr training session for the research assistants, advising them on the inclusion and exclusion criteria of the study and instructing them in the use of interviewing techniques, participatory observation skills, and field-study knowledge to ensure reliability. In addition, thick description of text and field notes enhanced research transferability. Ethical Considerations Results The institutional review board of Kaohsiung Medical University, Taiwan, approved the research and procedures before the study began. The participants in the study did not experience any physical harm, discomfort, or psychological distress. They were fully aware of participating in a study, and they understood the purpose of the research by giving their informed consent. The study procedures were fully described in advance to each participant, the participants had an opportunity to decline to participate, and appropriate consent procedures were implemented. Sixty-eight marriage migrant women in Taiwan participated in and completed this study. Participants ranged in age from 20 to 42 years, with a mean age of 32.4 years (SD = 4.6). Their spouses’ ages ranged from 27 to 72 years, with a mean age of 42.5 years (SD = 4.34). The participants’ original nationalities were Vietnamese (n = 42, 61.8%), Thai (n = 12, 17.6%), Indonesian (n = 8, 11.8%), Filipino (n = 5, 7.3%), or Cambodian (n = 1, 1.5%). The women’s length of residency in Taiwan ranged from 2 to 12 years, with a mean length of stay of 8.3 years (SD = 2.6). The levels of education for most of the participants before immigrating to Taiwan were elementary school and junior high school (n = 62, 91.2%). The highest level of education for most of the women’s spouses was junior high school or high school (n = 60, 88.2%). Among the participants, 53 (77.9%) were housewives. Through an inductive thematic analysis, the following four outcome themes emerged from the data: (a) increasing health literacy; (b) facilitating capacity to build social networks; (c) enhancing sense of self-worth; and (d) building psychological resilience. Data Analysis Following guidelines recommended by Miles and Huberman (2013) for qualitative data analysis, three members of the research team used the transcribed data for a thematic analysis to examine the qualitative data, which were categorized based on prominent theme patterns expressed in the text of the individual interviews with participants. First, the researchers applied categories to each transcript code. They read and analyzed all the transcripts in a three-stage process of data analysis and synthesis, as recommended by Rice and Ezzy (2001). The verbatim transcripts of the 68 interviews in our study generated a codebook of 36 units. In the next stage, the same three researchers used the focused coding method 138 Increasing Health Literacy Health literacy is defined as the degree to which individuals have the capacity to obtain, process, and Journal of Nursing Scholarship, 2015; 47:2, 135–142. C 2014 Sigma Theta Tau International Yang et al. Health Empowerment Among Immigrant Women understand basic health information and services (Speros, 2005). The immigrant women in our study had poor health literacy and, consequently, experienced many barriers to accessing and using healthcare services. For instance, one woman said she didn’t know “what is Pap smear or cervical cancer screening and how much it cost.” Participants were not aware that the Taiwan’s National Health Insurance (NHI) program in Taiwan offers a free annual cervical screening to women 30 years of age and older. They not only lacked awareness about NHI and affordable medical care resources but also experienced language difficulties that prevented them from learning about illness prevention and health promotion. One woman shared her experience about feeding her baby: “I chose wrong baby milk formula because I cannot read the instruction on milk bottle.” After attending the workshops for our HEP, the participants reported that they felt more informed about healthcare information and resources. For exle, one of the participants said: homeland. Moreover, their husbands and in-laws often forbid them to leave the house, preventing them from developing new friendships with others. The women reported that attending these workshops helped alleviate their sense of loneliness and facilitate their capacity to build social networks in the community. By the end of program, participants had developed small, informal groups that would arrive early to the workshops in order to chat with each other and enjoy the company of other participants. These advantages of attending the program’s workshops are described in the following statements from participants: When I arrived here [in Taiwan], I very quickly became pregnant. Because I am not a citizen, I thought I am not covered by the National Health Insurance. My husband and I didn’t know that we can have free prenatal examinations and obstetrical services provided by primary healthcare centers. We spent a lot of money to visit a private clinic. Now, through this workshop, I know where I can get medical care to help me. The women’s shared ethnicities and personal interactions with other participants at the workshops provided them the opportunity to develop friendships that offered strong emotional support, which reduced their feelings of loneliness and social isolation. Attending the workshops helped them facilitate their capacity to build social networks and communicate with their husbands and inlaws to decrease social isolation. One participant stated that “After the teaching, I have learned to use better way to talk with my husband and mother-in-law, not just always keep silent. They have more patience to communicate with me.” The participants’ increased health literacy and knowledge about illness prevention and health promotion prompted them to change their behavior in favor of more healthy choices. For exle, one of the participants decided to change her use of an oral pill to the use of condoms for contraception and safer sex. The increased exchange of health-related information and resources provided in the workshops improved the immigrant women’s decision-making skills and their ability to apply these skills in health-related situations. For exle, one of the participants who experienced domestic violence stated: From the special issue workshop on domestic violence prevention and management, I learned that nobody has the right to hurt another’s body. My husband beat me and the kids. Now, I will call 113 for help and will have free-of-charge medical treatment. Facilitating Capacity to Build Social Networks Many of the participants experienced extreme loneliness and isolation in their community. They missed their friends and family and the familiar culture of their Journal of Nursing Scholarship, 2015; 47:2, 135–142. C 2014 Sigma Theta Tau International To get in touch with other immigrant friends is the happiest thing I have. I look forward to the workshops because this is a chance I can go out and meet friends from the same country. My family is afraid that the “bad friends” might influence me. Enhancing Sense of Self-Worth The participants in our study reported that they suffered discrimination and oppression from their new family. The women’s original culture was ignored, suppressed, and even discriminated against by their Taiwanese in-laws. Moreover, because most of the women spoke Mandarin, they could easily be identified as foreigners by their accent in the eyes of the Taiwanese public. Consequently, the women remained silent and were submissive to their in-laws. The workshops used role-play activities, team presentations, and group discussions designed to increase the women’s confidence in their ability to speak out for themselves. After attending the workshops, the participants described feeling more confident in problemsolving and seeking better health care for themselves and their family members. As one participant noted, “I had a better understanding of taking care of myself and my family.” Another participant said: 139 Health Empowerment Among Immigrant Women My mother-in-law won’t let my children get close with me. They [in-laws and husband] say I am a foreigner. They try to persuade the kids their mother is an ignorant person, don’t ask me questions because I know nothing. Now, I have learned lots of things. I have more knowledge to manage my life. I can teach my children. Some of the participants experienced physical abuse by their husbands and, in some cases, their in-laws. In the special section workshop on domestic violence prevention and management, participants learned about rescue resources, their legal rights, and the hidden health problems related to abuse. After attending the workshop, the women described feeling more self-empowered and more confident in dealing with and overcoming domestic violence. For exle, one participant mentioned: Now I know my human rights, that nobody can beat me. I can call the 113 protection hotline for help. They [mother-in-law and husband] have no right to beat me. Before attending the workshops, I thought I was stupid. If I do something wrong, my mother-in-law will slap me, and my husband will kick me when he is drunk. Building Psychological Resilience The participants felt burdened with the stress of acculturation and its psychological effects, such as emotional distress. This form of distress was reflected in the following statement from one of the women: I can’t sleep very well, and I often cry in the middle of the night. I miss my home town. Immigration marriage in Taiwan is a challenge and a bet. Our lives are filled with hardships, such as no money in my pocket most of the time. If I fight with my husband, I have nowhere to go. Attending the HEP, however, helped the participants transform their life distress into a more positive outlook. They resolved to make a greater effort to successfully adapt to their new home in Taiwan. During the workshops, they discussed the need to increase their ability to endure the difficulties in life by accepting the challenges as their destiny and focusing on their children’s future. Successfully caring for and raising their children became the women’s main purpose in life. For exle, one participant stated: I have learned this for my children. I can bear the hardships in life. Sisters, we must stay in Taiwan, because this is our home, now we are mothers and daughters-in-law. In the future, we will be other 140 Yang et al. women’s mother-in-law. So we keep going and take care of our kids; they are our roots in Taiwan. Discussion The findings from our study not only confirm the disadvantaged status of marriage immigrant women in Taiwan and their vulnerability to health risks, but also demonstrate the effectiveness of PAR as a useful strategy to empower these women to make sustainable and beneficial changes in their health and well-being. The study participants had poor health literacy and limited knowledge about medical care resources. This finding is consistent with previous studies that found immigrant women tend to have low levels of health literacy, which acts as a barrier to seek out and access appropriate health care (Kreps #038; Sparks, 2008; Lee et al., 2013; Tsai et al., 2014). The women in our study were unaware of such helpful resources as Taiwan’s NHI, migrant welfare program, free services and medical checkups provided by the local health centers, and the telephone hotline number for domestic violence protection. Findings from previous studies showed that health literacy is vital for promoting health and health-promoting behaviors (Speros, 2005; Von, Knight, Steptoe, #038; Wardle, 2007). However, the health literacy of the marriage immigrant women in our study was poor. Therefore, we recommend that health promotion strategies and interventions for migrant women focus on improving their health literacy. Strategies can include the development of comprehensive, translated health information media for distribution to the women. The study participants’ difficulties with language and communication created another barrier to their ability to effectively seek out and use Taiwan’s healthcare services and resources. This finding supports similar results from other studies that examined the health concerns of marriage immigrant women (Hsia, 2010; Hung, Wang, Chang, Jian, #038; Yang, 2012). Having difficulties in learning to speak and understand a new language often prohibited the women from effectively communicating with healthcare providers. The study participants were further isolated by the actions of their husbands and in-laws who intentionally prevented the women from going out alone and making social contacts for fear the women might try to run away and return to their homeland. This form of marginalization and oppression is evident in other studies that focus on health and social issues of marriage migrant women in Taiwan (Yang #038; Wang, 2003). Our results are consistent with previous studies in which PAR was found to be a valuable strategy for developing a model of health Journal of Nursing Scholarship, 2015; 47:2, 135–142. C 2014 Sigma Theta Tau International Health Empowerment Among Immigrant Women Yang et al. empowerment that promotes positive health behaviors, improves access to community health services, and enhances healthcare policies that support the rights of individuals (Meyer, Torres, Cermeño, MacLean, #038; Monzón, 2003; Minkler #038; Wallerstein, 2010). We also found that healthcare professionals can play an important role in advocating for disadvantaged women by participating in community advocacy organizations and serving as spokespersons for the needs of immigrant women within the community and the healthcare system. During the research process, we collaborated with the local media to call attention to the challenges that marriage migrant women face and to arouse community concern. The local newspaper published an article on the workshop activities, and a reporter from a television program interviewed the research team members who described the problems and needs of migrant women in Taiwan. Study Limitations The study has some limitations. First, in our study, convenience and snowball sling was used to recruit participants. The methods could have led to a homogeneous sle, resulting in findings that are not representative of the entire population. Second, the inclusion criteria of the participants were limited to those who had basic conversation ability in Taiwanese and Mandarin. This would exclude those who could not speak Taiwanese and Mandarin. A third limitation is that the average length of residency in Taiwan was 8.3 years. However, our participants live in a very remote area. The social isolation is very severe, and health resources and culturally appropriate education are limited. Even though they have stayed in Taiwan for several years, these women are still facing immigrant distress. And because recruiting was done in a remote area, transferability of our findings may be limited to women who immigrate into a remote area, and our findings may not reflect the experiences of immigrant women in urban areas. primary care centers offer counseling and support groups for migrant women. Increasing the women’s social participation through women-to-women discussion groups, conducted in an atmosphere of confidence and trust, can reduce their isolation. Also, providing immigrant women with the opportunity to meet and share experiences with other migrant women, especially those from the same native country, can improve their social support. The findings of this study can be used not only to understand the current situation of health empowerment among marriage migrant women in Taiwan but also to advocate for the health rights of all disadvantaged immigrant women and their families. Health professionals are encouraged to continuously emphasize the importance of identifying and addressing immigrant women’s health needs in practice, theory, research, and health policy. Acknowledgments The authors extend appreciation to all the research participants and community partners for sharing their experience. This study was funded by the National Science Council, Taiwan (NSC 96–2628-B-037–041-MY3). Clinical Resources r r r r r Bureau of Consular Affairs, Ministry of Foreign Affairs, Republic of China (Taiwan): http:// www.boca.gov.tw/mp?mp=2 Committee on the Elimination of Discrimination Against Women: http://www.un.org/ womenwatch/daw/cedaw/ National Health Insurance Administration Ministry of Health and Welfare: http://www.nhi.gov.tw National Immigration Agency: http://www. immigrat-ion.gov.tw Lite-on Cultural foundation: http://liteoncf.org. tw/wealth/a2.htm Conclusions References The study provides an exle of a successful health empowerment model for disadvantaged immigrant women and offers a framework for using the PAR approach to advance the efforts of community agencies and healthcare professionals. The present study can inform government agencies in making appropriate healthcare policies and in shaping a comprehensive, health-promoting program that improves marriage migrant women’s well-being. It is also recommended that Berry, J. W. (1997). 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C 2014 Sigma Theta Tau International Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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 , #038; 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’Investigació en Atenció Primària (IDIAP) Jordi Gol), Barcelona, Spain and Researcher associated with the Universitat Autònoma de Barcelona, Bellaterra, Spain 4 Figueres Basic Healthcare Area (Àrea Bàsica de Salut de Figueres) Catalan Health Institute (Institut Català 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: [email protected] 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, Schäfer #038; 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, #038; Guillaume, 2007; RomeroCollado, Homs-Romero, #038; 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 Journal of Nursing Scholarship, 2015; 47:1, 51–61. C 2014 Sigma Theta Tau International 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 this field and what should be 51 Course Content Related to Chronic Wounds 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 #038; 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 (Råholm, Hedegaard, Löfmark #038; 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 #038; 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 Evaluación de la Calidad y Acreditación, 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 52 Romero-Collado et al. nursing education (Scully, 2011). For exle, 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, #038; Foroogh Ameri, 2011; Panagiotopoulou #038; Kerr, 2002; Pancorbo-Hidalgo, Garcı́a-Fernández, López-Medina, #038; López-Ortega, 2007; Saleh, Al-Hussami, #038; 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 #038; Garcı́a Dı́ez, 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 #038; Caixal-Mata, 2009; Soldevilla Agreda, Torra Bou, Verdú Soriano, #038; López 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, Bååth, #038; 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 #038; 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, #038; 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 Sánchez, 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 #038; Salati, 2005). These deficiencies were also observed in textbooks recommended by nursing educators (Wilborn, Halfens #038; Dassen, 2009), and wide variation in PU-related textbook content has been reported (Ayello #038; 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 Journal of Nursing Scholarship, 2015; 47:1, 51–61. C 2014 Sigma Theta Tau International Romero-Collado et al. 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, #038; Pieper, 2003), despite evidence that even a small educational intervention (2hr 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, #038; 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 Tı́tulos (RUCT; Gobierno de España, 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 Journal of Nursing Scholarship, 2015; 47:1, 51–61. C 2014 Sigma Theta Tau International Course Content Related to Chronic Wounds 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: r Access: The number of years of the 4-year undergraduate degree in nursing for which online access to courses was available. r 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). r Courses Entirely Related to Chronic Wounds: Number of required courses with a title explicitly containing the words “chronic wound.” r 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 53 Course Content Related to Chronic Wounds 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 54 Romero-Collado et al. 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, Journal of Nursing Scholarship, 2015; 47:1, 51–61. C 2014 Sigma Theta Tau International Course Content Related to Chronic Wounds Romero-Collado et al. Table 1. Number of Courses in Nursing Degree Programs in Spain Courses in the degree program (n = number of centers) Number of required courses offered (nonelective) (n = 114) Number of required courses reviewed (n = 95) Number of elective courses offered (n = 107) Number of elective credits, ECTS (n = 114) Minimum Maximum Total Mean SD 20 41 3436 30.14 3.55 0 40 2258 19.81 10.46 0 23 728 6.68 4.56 0 30 1157.5 10.15 7.05 Note. ECTS = European Credit Transfer System. Defloor, #038; Worboys, 2006), deficiencies exist in the importance assigned to them in clinical practice (CaronMazet et al., 2007) despite recommendations that wound care should be incorporated into all patient care plans (Günes, 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 #038; Cuddigan, 2009). In Spain, for exle, 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 Sánchez (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 Journal of Nursing Scholarship, 2015; 47:1, 51–61. C 2014 Sigma Theta Tau International them (Iranmanesh et al., 2011; Panagiotopoulou #038; 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 Sánchez, 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 exle, required courses related to aging are needed in Spain (Jiménez Dı́az, Pulido Jiménez, Villanueva Lupión, Villar Dávila, #038; Calero Garcı́a, 2011), and gerontological care is not adequately addressed in nursing education programs in Flanders, Belgium (Deschodt, de Casterlé, #038; 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, #038; 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. 55 56 0 (0.0) 96 (4.2) 50 (2.2) 39 (1.7) 1 (0.0) 23 (1.0) 98 (4.3) 2 4 3 1 2 5 Total courses with this content, n (%) (N = 2,258 courses) 0 Maximum in a degree program 62 (65.3) 94 (98.9) 74 (77.9) 36 (37.9) 60 (63.1) 1 (1.1) 0 (0.0) Centers without this content in any course in the degree program, n (%) (N = 95 centers) 28 (29.5) 1 (1.1) 19 (20.0) 33 (34.7) 25 (26.3) 93 (97.9) 0 (0.0) Centers with one course having this content, n (%) 4 (0.2) 42 (1.9) 10 (0.4) 19 (0.8) 131 (5.8) 25 (1.1) 95 (4.2) 1 6 2 6 56 (2.5) 3 1 2 1 55 (2.4) Total courses with this content, n (%) (N = 2,258 courses) 3 Maximum in a degree program (N = 95 centers) Note. Types of courses consulted: required, basic, guided practice, final project. Venous disorders of the lower extremities Arterial disorders of the lower extremities Diabetic foot Burns (adult patients) Burns (children and adolescents) Severe burns Wounds related to acute processes Wound healing Antisepsis and antiseptics Course content criteria 71 (74.7) 38 (40.0) 76 (80.0) 20 (21.1) 91 (95.8) 54 (56.8) 85 (89.5) 48 (50.5) 48 (50.5) Centers without this content in any course in the degree program, n (%) 23 (24.2) 33 (34.7) 19 (20.0) 40 (42.1) 4 (4.2) 40 (42.1) 10 (10.5) 39 (41.1) 40 (42.1) Centers with one course having this content, n (%) 1 (1.1) 17 (17.9) 0 (0.0) 19 (20.0) 0 (0.0) 1 (1.1) 0 (0.0) 7 (7.4) 6 (6.3) Centers with two courses having this content, n (%) (N = 95 centers) 4 (4.2) 0 (0.0) 2 (2.1) 18 (18.9) 7 (7.4) 1 (1.1) 0 (0.0) Centers with two courses having this content, n (%) (N = 95 centers) Table 3. Number of Courses in Each Nursing Degree Program, According to the Content Criteria Related to Acute and Chronic Wounds, Used as Controls Note. Types of courses consulted: required, basic, guided practice, final project. a The top four education priorities in wound management and tissue repair defined by Cowman et al. (2012). Pain management, chronic woundsa Pain management (in general) Prevention of pressure ulcersa Pressure ulcers Wound bed assessmenta How to select dressingsa Treatment of pressure ulcers or other chronic wounds Course content criteria Table 2. Number of Courses Included in Degree Programs, by Content Criteria Related to Chronic Wounds, Prevention, and Treatment 0 (0.0) 7 (7.4) 0 (0.0) 16 (16.8) 0 (0.0) 0 (0.0) 0 (0.0) 1 (1.1) 1 (1.1) Centers with three or more courses having this content, n (%) 1 (1.1) 0 (0.0) 0 (0.0) 8 (8.5) 3 (3.2) 0 (0.0) 0 (0.0) Centers with three or more courses having this content, n (%) Course Content Related to Chronic Wounds Romero-Collado et al. Journal of Nursing Scholarship, 2015; 47:1, 51–61. C 2014 Sigma Theta Tau International Course Content Related to Chronic Wounds Romero-Collado et al. 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; PancorboHidalgo et al., 2007; Quesada Ramos #038; Garcı́a Dı́ez, 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 exle at the clinical site. betic 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, #038; 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 utated (Conferencia Nacional de Consenso sobre Úlceras 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. Acute Wounds Elective Courses 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. 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 Lower Extremity Wounds We also considered it important to identify content related to assessing nursing care of patients with diaJournal of Nursing Scholarship, 2015; 47:1, 51–61. C 2014 Sigma Theta Tau International 57 58 Content related to learning other languages Content related to research methods Content related to urgent, emergency, and/or disaster care Content related to occupational health Content related to complementary/ alternative therapies Content related to dependency and/or chronic disease Content related to cooperation Content related to health promotion Content related to palliative care Content related to school health Content related to Catholicism Content related to chronic wounds Content criteria consulted 20 (2.7) 13 (1.8) 11 (1.5) 2 1 1 1 (0.1) 24 (3.3) 3 1 36 (31.6) 3 2 (0.3) 40 (5.5) 2 1 43 (5.9) 3 3 (0.4) 44 (6.0) 4 1 50 (6.9) Total courses with this content, n (%) (N = 728 courses) 3 Maximum in a degree program 103 (99.0) 102 (98.1) 101 (97.1) 93 (89.4) 91 (87.5) 85 (81.7) 83 (79.8) 73 (70.2) 66 (63.5) 68 (65.4) 70 (67.3) 62 (59.6) Centers without this content in any of the courses in the degree program, n (%) (N = 104 centers) Table 4. Number of Elective Courses, Grouped by Topics Included in the Degree Program 1 (1.0) 2 (1.9) 3 (2.9) 11 (10.6) 13 (12.5) 18 (17.3) 19 (18.2) 28 (26.9) 36 (34.6) 31 (29.8) 27 (26.0) 35 (33.7) Centers with one course having this content, n (%) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (1.0) 1 (1.0) 1 (0.9) 2 (1.8) 3 (2.9) 5 (4.8) 6 (5.8) Centers with two courses having this content, n (%) (N = 104 centers) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (1.0) 2 (1.9) 0 (0.0) 2 (1.8) 2 (1.9) 1 (0.9) Centers with three or more courses with this content, n (%) Course Content Related to Chronic Wounds Romero-Collado et al. Journal of Nursing Scholarship, 2015; 47:1, 51–61. C 2014 Sigma Theta Tau International Course Content Related to Chronic Wounds Romero-Collado et al. 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). Journal of Nursing Scholarship, 2015; 47:1, 51–61. C 2014 Sigma Theta Tau International 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. 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