Introduction
Acute and chronic wounds are a growing cause of morbidity in Western countries with an ageing population [1]. In particular, patients with chronic wounds are severely affected by their condition. Their quality of life is significantly reduced and they are limited in their ability to participate in everyday life and work due to factors such as pain, restricted mobility and financial burdens [2, 3].
Frequent use of health care services plus high nursing and medical needs increase the socio‐economic burden [1, 4, 5]. These high healthcare costs are often accompanied by insufficient medical care for wound patients [6, 7]. A lack of systematic diagnostic work‐ups or the necessary prescriptions for dressings and medical aids, as well as the use of ineffective treatment methods, leads to a further increase in healthcare costs and delays in providing adequate care [7].
Although the costs of wound care vary considerably between different countries and healthcare systems depending on local regulations, they generally account for a large proportion of the total healthcare costs [8].
One possible reason for this inadequate care of patients' needs might be the insufficient training of future professionals during medical school [9, 10]. A UK study showed that only 65% of doctors had received training in wound care during medical school, and 25% were given the opportunity to deepen their knowledge about wound care during postgraduate training [11]. Across specialties, this can lead to a direct impact on patient care.
For example, gaps in physicians' knowledge about wound infections were also noted [12]. Rising numbers of wound infections, in turn, increase the clinical and economic burden on the healthcare systems [13]. The literature suggests that education on wound care is currently inadequately implemented within undergraduate medical training, not only in Germany but also internationally [14, 15, 16].
Medical training for future doctors is not yet aligned with this requirement, and teaching content on wound management is usually only covered in a fragmentary manner in individual courses during the curriculum [10, 17, 18]. The total amount of teaching time spent on wound care often covers only a few hours in the curriculum, although wounds are a relevant problem for almost all clinical disciplines [15, 19, 20]. There is no consistency or standards for an integrated approach to teaching basic knowledge about wound healing and linking this to a wide range of practical skills required for adequate patient care [21].
The learning goals and competence requirements for undergraduate and postgraduate wound care education are quite well defined for nurses and nursing students [22] and are implemented in several European frameworks [23, 24, 25]. However, such concepts are rare for medical students [16, 26]. In various surveys [10, 27], medical students expressed their wish for additional wound care education during medical school.
To address these requirements, the appropriate management of patients with acute or chronic wounds should be reflected in the educational curriculum for medical students.
The next step in a curriculum development process is to clearly define the learning goals and objectives [28]. Since such a catalogue of learning objectives requires broad acceptance for implementation, the widest consensus possible should be sought and theoretical demands should be reconciled with practical real‐life requirements.
Therefore, the aim of this study was to define learning objectives within an interprofessional group of certified wound experts and to assess the clinical relevance of these objectives within a multidisciplinary committee of physicians with lower wound expertise, but with direct practical experience in their respective medical specialties. Finally, a third perspective was added by the German National Competence Based Learning Objectives Catalogue for Medicine 2.0 (Nationaler Kompetenzbasierter Lernzielkatalog 2.0., NKLM). It was checked whether the newly described learning objectives are already part of this general German framework.
Material and Methods
In this study, we systematically collected and evaluated the viewpoints and arguments of various medical “stakeholders” about wound care learning objectives (LO) in order to create a solid basis for decision‐making when planning a LO catalogue for wound care in medical school.
Participants
A three‐step approach was chosen to develop the catalogue. As a first step to collect a number of relevant LO and the required competencies to be learned, a working group of wound experts was recruited from leading wound experts of the medical society for wound care in Germany, the “Initiative Chronische Wunden e.V.” (ICW). The association's executive committee and advisory board members were asked to find interested participants on a voluntary basis.
This interprofessional group, further referred to as “Expert Group”, consisted of 18 wound experts with longstanding experience in treating patients with wounds and representing different medical specialties (Table 1). These experts featured the following characteristics: (a) a certification as wound expert, (b) intensive work experience in clinical practice, (c) involvement in teaching health care professionals and/or a background in medical education. To enhance the interprofessional aspect of the group, additionally, two advanced medical students with work experience in the field of wound management were asked to join the committee.
In a second phase of the project, clinicians from different specialties were involved, further referred to as “Clinicians”. To receive broad approval for the LO catalogue, 41 German medical societies (see https://www.awmf.org/fachgesellschaften) of any kind of wound‐related disciplines were contacted by mail and asked to send up to three delegates for participation in the project. Finally, 24 clinicians representing 16 medical societies could be named by their medical society to participate.
Further details of both groups are shown in Table 1.
All participants were deliberately not given any further details about literature, existing curricula, or frameworks for wound care education in other healthcare professions to avoid an information bias or priming effect during the process.
First Collection of Learning Objectives
After an initial didactic training about defining learning objectives according to the SMART criteria [29] by one of the authors (C.E.), all members of the Expert Group were asked to phrase as many LO in wound care for medical students as they felt to be necessary and relevant. The LO were defined under the premise: “What should a physician on Day 1 after graduation from medical school know about wound care?” After discussion, also content concerning acute wounds was included due to the close connection between treatment of acute and chronic wound patients. The submissions were sent to the project manager (C.E.), who collected and sorted the content.
Thematic duplications were semantically revised and merged by the authors of the study (C.E., J.D., P.C.). The collection of LO was presented to the members of the Expert Group several times for completion and consensus by email circulation. There was deliberately no reduction of individual LO that were only mentioned by one or a few members of the Expert Group; instead, all suggestions were initially included.
In the next step, the depth of competence of the LO was to be agreed by the Expert Group. The members of the Expert Group were again trained by the project leader on the taxonomy of verbs used in the wording of LO [30]. To reach a consensus within the Expert Group, the collected LO were assigned verbs with different depths of competence and presented to the members of the Expert Group in an online survey procedure (created with SoSci Survey Version 3.5.07 [31]).
The verbs were chosen according to the four depths of competence used in the NKLM (Table 2). Where necessary, the exact wording was carefully adapted semantically to the content of the learning objective.
A value of > 50% agreement was set as the cut‐off value for accepting the competence depth for the LO in the draft for the further project. For learning objectives where no clear result for competence grade could be achieved in the first round of voting, the two depths of competence (out of the maximum of 4) with the highest agreement in the first round of voting were put to the vote again in a direct comparison. During all voting phases, there was an option to submit comments in free text form.
These comments were incorporated into the draft by the authors or discussed again in the group.
Online Votings
The CHERRIES criteria (Checklist for Reporting Results of Internet E‐Surveys) were used to develop all online voting procedures [32]. All participants received a privacy policy before the start of the online survey and gave their consent to participate. The data were analysed anonymously.
Participants were informed about the purpose and aim of the project, the evaluation procedure and the duration of the survey. They were given instructions on how to complete the online questionnaire. No personal data were stored during the survey.
A contact email address for the project group was provided for any queries. The usability and technical functionality of the online questionnaire were tested in a pre‐test version before the official surveys began. An invitation to the survey was sent to all participants by e‐mail.
A reminder email was sent 3 days before the end of each survey round. All participants were informed that they should not share the survey link with other colleagues without consulting the project team. An ethics vote was not required following assessment by the local ethics committee (Nr.
25–118‐ANF). Anonymity was achieved as any possible identifiers were removed prior to analysis of the data by the external data gatekeeper.
Clinical Relevance Voting Round
To assess the collected LO's real‐life relevance and to reduce the draft of objectives to a practical number, the clinical representatives of different medical specialties (“Clinicians Group”) were now involved in the second phase of the project. To gain insights in both groups' judgements about the LO, both groups (“Experts” and “Clinicians”) were asked to assign each of the LO that resulted from the experts' initial collection to a Likert scale from 1 (“not relevant”) to 4 (“very relevant”) in relation to the relevance for a medical graduate on Day 1 in the clinic. There was also the option to select “I consider this learning objective to be part of further specialist training” if the proposed learning objective was better suited for further postgraduate training.
Only a single choice of answer options was possible in each case. To simplify the voting procedure, the competence level agreed by the Experts beforehand was used for the LO presentation. The online survey was prepared and performed under the criteria described above.
The purpose of the study and the data analysis were explained to the participants before starting the questionnaire. It was possible to contact the project management via email at any time. Figure 1 summarises the described process.
Finding Consensus and Evaluating Internal Agreement
There are no clear guidelines on what level of agreement in any voting or Delphi‐like procedure should be accepted as so‐called consensus [33]. For the final relevance assessment process, we defined beforehand an agreement level of > 70% for rank 3 or 4 in the Likert scale together (LO relevant or very relevant) to be assessed as consensus [34, 35, 36]. There were also a number of LO found with a level of agreement > 80%, so both levels were acknowledged in the final selection of LO.
A relevance ranking of the different LO could then be established for each group individually, but also for both groups together. This allowed distinguishing which wound care topics might be seen as highly relevant by the experts, but not by the clinicians in daily life.
To additionally evaluate the grade of internal agreement within the single voting groups (Experts vs. Clinicians), a method used by Wijnen‐Meijer before [36] was adapted. Here, not only a single agreement on one item was evaluated, but also the totaled results for two adjacent items on the Likert scale (Table 3).
Alignment With the NKLM
The NKLM represents the basic content for the medical faculty's teaching and the competences and requirements for a medical graduate in Germany. NKLM Version 2.0 was used to align the LO catalogue developed in this project with the NKLM. The mapping of the projects' LO with the NKLM 2.0 was performed with the web‐based, dynamic Learning Opportunities, Objectives and Outcome Platform (LOOOP) [37].
The project team decided to postpone this mapping process until the end of the consensus‐building phase in order to avoid bias among participants and simplify the search process in the highly complex NKLM.
Data Analysis
Data presentation is descriptive only. Excel Version 2108 was used. We calculated means, medians, and standard deviations for both groups.
Results
First Collection of Learning Objectives
After collecting the individual LO from the Expert Group, we found a total of 81 LO. By grouping similar learning objectives into one statement and reducing duplication, the initial 81 learning objectives could be merged into 66 statements (Figure 1). They could be sorted into 13 thematic categories (Table 4).
The exact ratings for the different learning objectives and their competence levels are shown in the Appendix S1. Due to the initial design of the online questionnaire, it was not possible for the Expert Group during the competence assessment to interrupt the survey and continue it later. This resulted in different numbers of voters per learning objective and its competence levels.
A maximum of 18 of the 20 members of the Expert Group took part in the competence vote.
Relevance Assessment
The LO catalogue draft with 66 final items was presented to both groups, Expert Group and clinician delegates, respectively. Both assessed the relevance by Likert scale rating via the online survey as described above. A ranking of the LO according to the relevance rated by both groups was established by the mean value from the Likert scale of both groups together.
Some LO are ranked in the same position due to the same results in the evaluation. Details are shown in Table 5 including differences in the relevance scoring between the two groups. The LO list in Table 5 is sorted according to the joint ranking of both groups.
In addition to this ranking by the relevance scoring via Likert scale, the level of agreement was calculated as described above. Twenty‐six LO (39.4%) could be found with an agreement of > 80% of all voters. Together with 6 LO with an agreement of > 70% (9.1%) a total of 32 LO could be identified for a final recommendation which LO for wound care should be taught during medical school and what can be expected from a new graduate on their first day in clinic.
Seven LO (10.6%) were voted to be better assigned for postgraduate training (Table 6). While knowledge of the indications for certain diagnostic examinations such as sonography or tissue sampling was still considered relevant, voters agreed that in‐depth knowledge of the practical performance or interpretation of findings can only be acquired during specialist training. Knowledge about the number of existing wound products as well as specific classifications was also considered to be part of the later resident training, as was knowledge of the financing of healthcare costs.
The remaining 27 LO (40.1%) did not reach an agreement level of > 70% and were therefore not included in the finally recommended LO catalogue (Table 5).
In order to provide medical teachers in wound care with a practical guide, the 32 final LO were further summarised and categorised by topic (Appendix S2).
National Learning Objectives Catalogue Alignment
Mapping of the 66 LO of this project with the NKLM via LOOOP revealed that 39 LO (59.9%) were already represented in the NKLM (detailed data not shown). From the 32 LO of our final catalogue, 13 were not represented in the NKLM. This may be due to the search procedure using LOOOP or due to imprecise wording in one of the two catalogues.
However, there are also individual, very wound‐specific LOs that can be assumed to have not yet been included in the NKLM, for example, applying compression therapy, local wound therapies, or debridement techniques. From the seven LO voted to be more suitable for postgraduate training, five were also not found in the NKLM. Only to explain the performance and possible findings of duplex sonography of the peripheral venous system would be required from a German medical graduate according to the current NKLM version.
A further alignment should be performed after final approval of the currently revised NKLM version 3.0.
Discussion
The need to improve the management of patients with wounds is widely recognised [1]. The use of diagnostic and therapeutical standards can provide guidance, particularly for physicians not experienced in wound care, to ensure structured patient care and control of treatment outcome and cost efficiency [6, 38]. There are several analyses showing that the topic of wound management is underrepresented in various countries and training systems during medical school [10, 15, 19, 39, 40].
At the same time, there is a desire among students for more intensive teaching on this topic [10, 27] and proven knowledge deficiencies among postgraduates [12]. As part of the structured approach in this study and in order to involve the requirements of a group of wound experts, an extensive collection of possible learning objectives was initially carried out. However, prioritisation is also necessary in curriculum development [41].
Therefore, the number of learning objectives was reduced in the relevance assessment and by a ranking system. By involving a multidisciplinary group of clinically and practically experienced physicians as representatives of various medical specialities, it was also possible to create a broad consensus as a basis for subsequent implementation. A final catalogue of 32 relevant LO was developed.
While only a small number of LO were identified for specialist training, there remain 27 LO which did not reach the necessary level of agreement during voting. However, they could be used for additional educational programs or intensive courses for advanced student learners seeking to deepen their knowledge. The deselected LO from the Experts' first draft could also be used to develop a catalogue of LO for wound care for postgraduate physicians, either within the different specialties or in a more generalistic and interdisciplinary way.
There already are a number of postgraduate supplementary qualification possibilities as “wound experts” for physicians besides resident training. The presented LO catalogue for medical students could be cross‐checked with existing frameworks and curricula for postgraduation healthcare professionals [42], but also for nursing students [22, 25]. By identification of shared learning objectives, interprofessional education concepts could be developed.
However, there was a number of LO which had a low internal agreement in the specific groups. It is interesting that really low agreement was found more frequently among the group of clinicians. This may be due to the fact that individual clinicians consider these skills to be of little relevance in their specific field or whether they deal with acute wounds more than chronic ones in their medical specialty.
The Expert Group, on the other hand, may have a high level of internal agreement because they are deeply immersed in the subject matter and have the same level of training due to their activity in the professional wound association. The individual LO ranking in the relevance assessment also differed significantly between both groups for specific LO. Among those were: knowledge about factors influencing wound healing (rank 1 vs.
18 for experts vs. clinicians, resp.), communication skills with wound patients (rank 5 vs. 35), knowledge about wound healing physiology (rank 28 vs. 8), or the assessment of associated complaints of patients with chronic wounds, for example, pain, quality of life, restricted mobility (rank 23 vs.
48). Due to their wound care training, it is possible that the experts have different expectations of the students than the clinicians, who may be thinking of situations from their daily hospital routine where wound care is not the main focus.
The wound care LO catalogue for medical students provided by this study can serve as a consensual basis for a more intensive debate and constructive discussion on the topic at medical schools and within faculties. It can facilitate the development and implementation of future curricula for wound care in basic medical training. The fact that two different committees from different medical backgrounds highly agreed on the importance of certain objectives strengthens the relevance of these for medical education.
However, the definition of LO is only one part of a complete curriculum development process, whether at a national level, within individual medical schools or by individual faculty members. Based on the proven need for wound‐related teaching and the interdisciplinary consensus of the catalogue, specific courses can now be planned, implemented and evaluated in follow‐up projects. Various options are available for this purpose [43, 44].
A scoping review by Reiter et al. [16] showed that there are only a few evaluated teaching interventions for medical students related to wound care while—maybe due to competence authority and structures in healthcare systems—the number of studies with a teaching focus on graduated nurses or nursing students is significantly higher [45, 46, 47].
The additional assessment from the perspective of the NKLM in Germany shows that some of the LO are already covered here. However, in some areas the specific reference to wound care itself is missing and the relation to wounds as an application example can only be interpreted. This reflects the various possibilities for incorporating teaching of wound care content into the curriculum.
Knowledge about hygiene, wound infections including diagnostics and therapy, as well as basic expertise about skin, wound healing pathophysiology and general diagnostic measures for wounds were ranked high in the final LO catalogue. These topics will also be a general part of any medical curriculum. Therefore, wound care, for acute as well as chronic wounds, represents a perfect example for clinical links of lectures, bedside teaching or practical skills training [7] and can combine preclinical knowledge with clinical competence.
In addition to the development of an independent wound curriculum, wound‐related learning experiences could be integrated into existing curricula. The topic of wound care offers many starting points for this, for example, for interdisciplinary or interprofessional teaching concepts. Longitudinal or spiral curricula are also conceivable.
It is also possible to include wound‐related topics into integrative curricula by teaching basic knowledge in wound care (e.g., anatomy, physiology, pathophysiology) in the context of clinical practice and professional behaviour [48]. The mix of cognitive, affective, and psychomotoric learning objectives in the presented catalogue offers a variety of possibilities for implementing the topic in courses, for example, interprofessional communication.
Interprofessional teaching and learning is of particular importance when it comes to wound management. The involvement of interprofessional teaching teams, but also the interprofessional composition of the group of learners can have positive effects on the teaching effect [15, 27, 49]. Joint learning in clinical‐practical scenarios or in the context of courses on interprofessional communication in particular enables all the professions involved to learn from each other and reflect on their mutual perceptions [50, 51].
The presented LO catalogue can be compared to, aligned with and brought together in the future with a number of other collections of wound care education content for nursing students [22, 34, 52] which have been carried out before and revealed a number of matches for both learner groups, medical and nursing students.
At the postgraduate level, such experiences can be of great value for interprofessional co‐operation and optimal patient care [53]. In addition to nurses, other healthcare professions such as podiatrists, physiotherapists, or medical technicians should also be considered when planning courses [54]. The differing expectations of experts and clinicians towards learners shown in this study may point to the importance for teachers to improve LO coordination before course planning.
Limitations
From the 41 medical specialties invited to join the consensus process, only 16 medical societies sent representatives as delegates for the voting. With regard to medical specialties not covered in this study, there may be various key areas of wound care that are potentially overlooked in this process. However, the fact that the “major” disciplines that deal with wounds on a daily basis, such as surgery, internal medicine, or dermatology, were represented is a strong argument in favour of most relevant aspects having been taken into account.
In their Delphi consensus process, Clegg et al. [55] focused on the question of when which wound care content should be taught during a 3‐year undergraduate nursing degree programme in Australia and gave distinct recommendations. This question has not been addressed in our survey. Medical schools in Germany have in parts autonomy in planning the exact structure of their curricula (regular, longitudinal, spiral), although there are central medical licensing regulations (“Approbationsordnung”).
Therefore, it might not be very beneficial for the acceptance of new teaching content to give medical schools overly detailed specifications. In addition to our definition of relevant LO, similar groups of experts and practitioners could discuss which year of medical school is best for teaching certain learning content and in which format. However, we have deliberately left these questions open in order to provide everyone with a rational LO catalogue as a basis.
This allows a concrete implementation plan to be developed in line with individual circumstances.
The cross‐check of our LO catalogue to the NKLM revealed that there is often no direct learning content for wound care mentioned or LO for wound care are subsumed under other topics, for example, surgery. A certain degree of interpretative flexibility was therefore applied during the assessment of the NKLM wording.
In order to avoid further bias due to individual opinions, particularly given by the expected possibility of a reduced number of participants in future voting rounds, the team of authors decided not to conduct another round of voting for relevance. Although it cannot be ruled out, no significant change in the result was expected.
Conclusion
Wound care requires extensive knowledge and understanding, ranging from physiological basics and disease concepts to dealing with patients and their specific needs. Possible learning content for wound care is extensive and specific learning objectives have to be prioritised. By this, a basic curriculum for any medical student can be developed to cover precisely those skills that are crucial for every future practising physician, regardless of their future postgraduate medical specialty.
The results and the LO catalogue of the present study represent a first step towards standardising the implementation of wound care content into the medical curriculum.
Funding
The authors have nothing to report.
Ethics Statement
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information