Competencies of specialised wound care nurses: a European Delphi study

Health care professionals responsible for patients with complex wounds need a particular level of expertise and education to ensure optimum wound care. However, uniform education for those working as wound care nurses is lacking. We aimed to reach consensus among experts from six European countries as to the competencies for specialised wound care nurses that meet international professional expectations and educational systems. Wound care experts including doctors, wound care nurses, lecturers, managers and head nurses were invited to contribute to an e‐Delphi study. They completed online questionnaires based on the Canadian Medical Education Directives for Specialists framework. Suggested competencies were rated on a 9‐point Likert scale. Consensus was defined as an agreement of at least 75% for each competence. Response rates ranged from 62% (round 1) to 86% (rounds 2 and 3). The experts reached consensus on 77 (80%) competences. Most competencies chosen belonged to the domain ‘scholar’ (n = 19), whereas few addressed those associated with being a ‘health advocate’ (n = 7). Competencies related to professional knowledge and expertise, ethical integrity and patient commitment were considered most important. This consensus on core competencies for specialised wound care nurses may help achieve a more uniform definition and education for specialised wound care nurses.


Introduction
Many patients with wounds require expert help from health care professionals (1). A mix of skills and experience of these professionals can improve the quality of care (2). A minimum level of education among professionals caring for (complex) wounds is a prerequisite to provide optimum wound care (3). This is particularly important for specialised wound care nurses, as they provide most of the direct care for such patients.

Key Messages
• consensus reached amongst experts about a set of core competencies specialised wound care nurses should have to ensure optimum wound care • the consensus may lead to a more uniform definition and education of specialised wound care nurses • the set of competencies may help make a proper distinction between general and specialist nurses In Western Europe, a range of educational opportunities are available to become a wound care nurse at the postgraduate level. These include degree-level courses (see Table 1). However, confusion still abounds regarding the scope of practice and expectations of graduates from such courses. Different titles are used to describe such individuals, for example, 'advanced wound care nurses', 'tissue viability nurses', 'wound consultants' or 'wound experts', which increases the confusion. Substantial curricular decisions are taken, and these are often based on informal consensus or local efforts and may depend on the context of the health care organisation. It is an educational challenge to determine what the content and level of wound care curricula should be (3).
Despite a lack of uniform education for those working as wound care nurses, the term 'specialised' or 'advanced' appears unequivocal to describe their role and position (4). The term 'specialised' nurse leads, in some instances, to disharmony between general and specialist nurses (5). In general, 'advanced' nurses are defined as nurses who are employed in a clinical area with direct patient contact, are able to set the pace for changes in practice and are innovators. These attributes are underpinned by educational experiences beyond the level required for initial registration (4). However, it remains unclear whether this is commensurate with the ideal profile of specialised wound care nurses.
A recently published Delphi study among 360 caregivers prioritised inclusion of wound education in all professional undergraduate and postgraduate nursing programs (6). This supports the need for all caregivers involved in wound care to achieve a uniform standard of education. However, the specific competencies required for a 'specialised wound care nurse' remain unclear. Therefore, the aim of this study was to reach a consensus within Western Europe on a core set of desired competencies for specialised wound care nurses compatible with international expectations and educational systems.

Design
The Delphi technique is considered as an effective way to measure and obtain group consensus (7). We used a modified three-round e-Delphi technique using an internetbased questionnaire to reach consensus among experts from six Western European countries on the desired competencies of specialised wound care nurses. This approach differed from the Delphi technique in that closed-and open-ended questions were posed and respondents were invited to suggest additional competencies to be judged.

Characteristics of 'specialised wound care nurses' and definition of 'core competencies'
The purpose of this study was to define a 'specialised wound care' as a qualified nurse who had successfully completed any additional wound-oriented education (including different levels of degree courses). In daily practice, these individuals would take care of patients with complex wounds, undertake consultations, decide on treatments appropriate for wounds and provide professional support for colleagues. Furthermore, they may also have responsibility for updating the protocols, and take evidence-based decisions regarding wound dressings and devices. This definition was provided to clarify terminology for the experts taking part in the survey.
A 'core competence' was defined as the functional adequacy and capacity to integrate knowledge and skills with attitudes and values into the specific context of practice (8). This principle should underpin the ideal competencies to be chosen for specialised wound care nurses.

Competency framework: CanMEDS domains
We searched in literatures to identify the current use of competency frameworks in clinical practice and to detect specific frameworks currently in use. Furthermore, we gathered information on current curricula and examples of course content from different educational institutions in Europe. Some curricula used the current or an adapted version of the Canadian Medical Education Directives for Specialists (CanMEDS) 2005 Physician Competence framework. Although there is no universally accepted framework, it was decided to use the CanMEDS as a structure for the development of the survey (9). This comprehensive framework comprises seven domains, each characterised by several attributes. Originally, this framework was designed to set out the core competencies for physicians, but has also been adopted by nurses to evaluate competencies. Currently, several countries in Europe (e.g. UK, the Netherlands and Denmark) are gradually adopting the CanMEDS framework in specialist education (10)(11)(12). This acceptance appears to indicate the applicability of such a framework in Europe. However, there is a lack of evidence to support the validity of this approach (13).
The purpose of this study was to covert the CanMEDS domain 'medical expert' into 'nursing expert'. Other CanMEDS domains include 'communicator', 'collaborator', 'manager', 'health advocate', 'scholar' and 'professional'. The descriptions of the different domains are found in Table 2.

Preparation of questionnaire
Before the commencement of the first Delphi round, we gathered relevant competencies by sending open-ended questions to ten Dutch caregivers (one doctor and nine specialised wound care nurses). This questionnaire was divided into seven Additionally, we undertook telephone interviews with all respondents to identify and resolve any issues with the questionnaire, for example, problems with the formulation and clarity of the questions. No particular issues were identified. We collected many additional competencies (n = 157) from this pilot. We categorised and restructured these competencies being careful to avoid duplication, which resulted in a list of 80 competencies. This was used as a starting point for the first questionnaire.

Participants in the main study
We invited experts in the field of wound care or education from six Western European countries (i.e. Belgium, Denmark, the Netherlands, Portugal, Switzerland and UK). The convenience sample of six countries has similar health care systems, in particular the reimbursement system of health care. We aimed to include four groups of experts to obtain a broad spectrum of relevant professionals: 6 doctors, 12 specialised wound care nurses, 6 university teachers and 6 managers or head nurses of wound centres or departments, totalling 36 experts. The numbers of specialised wound care nurses were double those of the other groups as the opinions of these individuals were fundamental to the aim of this study. This resulted in a group of experts that was homogenous as to the field of investigation, but heterogeneous in terms of professional background. All experts were selected purposefully to ensure that they could give a valuable contribution to the discussion from their specialist background. Inclusion criteria were as follows: (i) at least 3 years postqualification experience; (ii) involvement in wound care or wound care education and (iii) ability to proficiently communicate and write in English. To increase response rates, we used personalised letters, and contacted non-responders by email (14). If individuals did not respond to our initial invitation prior to the start of the study, and if they did not complete the first questionnaire, no further mailings or invitations were send. More experts were invited than planned beforehand to ensure that none of the expert groups would be underrepresented after finishing the study.

Data collection
All wound care experts received the link for the URL of the online questionnaire by email, using a commercially available online survey tool (http://www.surveymonkey.com). The experts were asked to complete each Delphi round within 2 weeks. The three questionnaires were sent out monthly between January and March 2012. The questionnaires included instructions for completion. Up to two reminders were sent per round if necessary. Furthermore, within 2 weeks of receipt of all questionnaires, the experts received feedback on the previous round and the invitation for the next round.

Likert scale and consensus
In all rounds, experts expressed their opinion about which competencies they thought the ideal specialised wound care nurse should have on a 9-point Likert scale, ranging from 1 -highly irrelevant -to 9 -highly relevant. We grouped these scores into five categories: a score of 1 represented 'strongly irrelevant'; scores of 2-3, 'irrelevant'; scores of 4-5, 'moderately relevant'; scores of 6-7, 'relevant'; and scores of 8-9, 'highly relevant'. This strikes a compromise between offering enough choice and the interpretability of the overall group response. No standard threshold for consensus exists (15). Therefore, through a process of group discussion by the authors, we defined consensus if at least 75% of the experts agreed that the competence was 'highly relevant', and thus a 'core competence' of specialised wound care nurses. If more than 25% of the experts scored the competence in one of the other categories, we defined these competencies as 'not a core competence' of specialised wound care nurses.

Round 1
The questionnaire in the first Delphi round consisted of three parts. The first part posed questions about baseline characteristics of the experts. The second part contained 80 competencies, compiled from the pilot and structured according to the CanMEDS categories. The third part contained open-ended questions to identify issues that might have been omitted, such as ideas for additional content and further competencies. When adding a competence, we advised experts that they should consider two points: (i) there is no right or wrong competency and (ii) the profile should not be about the current situation or local practices, but rather what they thought should be included in a European set of competencies.
We used the results of the first round to select competencies to be considered as core competencies. Competencies reaching at least 75% consensus in round 1 were retained as agreed competencies for the final consensus, and not discussed again in round 2.

Round 2
The second questionnaire consisted of two parts. The first part contained the remaining competencies from round 1 on which no consensus had been reached. We provided the experts with the overall group response from the first round. Experts could reconsider their original response or leave it unchanged. In the second part of the questionnaire, we presented the experts with the additional competencies as suggested by the experts in round 1.
If the results showed no consensus, after the experts had rated the same competencies twice, we rejected these competencies as core competencies for specialised wound care nurses. This decision was made after group discussion. No straightforward statements are available when to stop. The competencies that reached consensus in the second part of this questionnaire were retained. Thus, only the competencies that were added after round 1 that had not reached consensus here were presented again in round 3.

Round 3
The third questionnaire consisted of the competencies based on the suggestions made in round 1 on which no consensus had been reached after round 2. Again, we provided the experts with the overall group response of each competence.
If the results showed no consensus, the items were also rejected as core competence.

Ethical considerations
The local medical ethics committee waived the need for approval for this study. Willingness to participate was implied when the experts had given written consent before the start of the study or by response to the first questionnaire.

Data analysis
Data analysis was carried out using SPSS software (PASW statistics version 18.0, IBM, Armonk, NY). Summary descriptive statistics were calculated to determine the number of competencies that reached consensus after each round.
We conducted content analysis of all qualitative data from the pilot questionnaire as well as the first Delphi Round. All similar competencies were grouped into CanMEDS categories by the first author. This process was reviewed by three other authors who independently examined each category for similar competencies that could be collapsed into one.

Validation
Five external experts (one doctor from Denmark, two specialised wound care nurses from UK and two lecturers from Ireland) reviewed the final list of core competencies needed for specialised wound care nurses. None of them participated in the study and was recommended by experts in the field based on their reputation. We asked the reviewers to provide a brief narrative commentary on the face validity of the final list. Face validity was assessed by judging the relevance and comprehensiveness of items (16). This was considered essential to make sure that the competencies adequately reflect those of specialised wound care nurses in daily practice.

Results
Initially, 26 experts consented to participate. Of these, 20 responded in the first round (77%). To increase our number of experts, we sent out an additional invitation to 32 further experts; of these, 16 (50%) responded. In total, 36 participants (36/58 = 62%) completed round 1. Two experts only completed the baseline characteristics, so we excluded their data from the analysis. Only those experts who participated in the first round or gave permission before the start of the study received the second and third questionnaires. Response rates in these last two rounds were 86% (37/43).
The characteristics of the international expert panel are presented in Table 3. This panel appeared as the representative of the field of investigation.

Round 1
In the first round, we were able to reach consensus regarding 70 of the 80 competencies, whereas ten remained open for a further consensus discussion in the subsequent rounds. From the open-ended questions in round 1, we identified 16 additional competencies to be judged. Thus, 26 competencies were to be rated in round 2 (see Figure 1).

Round 2
In round 2, consensus was reached about 7 of the 26 competencies. Eight competencies that were open for further discussion after round 1 did not reach consensus in round 2, and were considered as 'not a core competence' of specialised wound care nurses.

Round 3
Eleven competencies remained open for further discussion in round 3. None of these reached the level of consensus and was also considered as 'not a core competence' of specialised wound care nurses.

Final list
A total of 96 competencies were considered by the experts during all the three rounds. The experts reached consensus regarding 77 of the 96 (80%) for inclusion in the final list of 'core competencies' ( Table 4). The distribution of competencies included in each CANMEDS domain is presented in Table 2. In Table 5, we give an overview of the competencies that did not reach consensus.
Overall, experts rated 'The application of a high level of wound care knowledge with regards to factors such as wound aetiology, underlying causes of problem wounds, and treatment options in patient care' (rank 1; mean, 8·86 on the 9-point Likert scale) as most important followed by 'the ability to protect information provided by or about patients, keeping it in confidence, and divulging it only with the patient's permission except when otherwise required by law' (rank 2; mean, 8·83) and 'honesty and integrity in patient care' and 'commitment to their patients, profession, and society through ethical practice' (both rank 3; mean, 8·72) as the top three most important. These competencies belong to the domains 'nursing expert' and 'professional'.

Excluded from final list
Conversely, they rated 'the ability to design a randomised clinical trial in wound care' (rank 96; mean, 4·97), 'the ability to write scientific articles for peer reviewed journals' (rank 95; mean, 5·67) and 'to communicate in English (oral as well as written), where English is not the native language' (rank 94; mean, 6·51) as the three least important competencies.

External review
The elected list of 77 competencies was presented to an external review panel to judge face validity. The following quotes were received: 'I think this list is useful and important and in line with international expectations and educational systems', 'In my opinion the list of core competencies for wound care nurses demonstrates good face validity and appears to reflect the essential competencies for an ideal wound care nurse', 'I absolutely agree with all the elements of the competencies which are well thought out. I would like to order 5 new nurses like these please!', 'Basically all of them are relevant' and the fifth reviewer answered 'the listed competencies are good, however, some could be listed as essential and others as desirable'. Some additional suggestions concerned adding competencies related to patients and staff's attitudes and basic knowledge about health economics. Finally, an advice was given to think about a numbering system for each within its subsection as this type of document will be useful for appraisals, teaching, etc. These points should be considered in future research.   In general, competencies related to professional knowledge and expertise, ethical integrity and patient commitment were considered to be essential competencies. These competencies are rather generic statements that do not strongly distinguish between general and specialist practice, but are competencies all health care professionals should have. Other competencies, such as teaching ability and research utilisation, may discern specialist nurses. Conversely, research activities (e.g. performing and publishing research) were considered less relevant. This is helpful to map the educational outcomes expected of specialised wound care nurses. This consensus may contribute to a more uniform education to and performance of specialised wound care nurses in developed countries. Moreover, it may standardise the definition and position of such specialised nurses in clinical practice. Such harmonisation is pivotal in the recognition of wound care as a large, multidisciplinary area within health care that deserves attention by highly trained professionals to ensure the quality of patient care.
The experts judged the competencies in the domain 'scholar', that is, performing, participating and publishing scientific research, as less relevant. The conceptual framework of Straus et al. (17), regarding the levels of usage of evidence-based medicine, was designed for doctors but can be extrapolated to specialised wound care nurses. Following this framework, our study indicates that one should practice evidence-based medicine as an 'user', instead of a 'replicator' or a 'doer'. The competencies referring to 'scholar' are in accordance with the view that not all caregivers should be involved in wound care research. However, stakeholders such as specialised wound care nurses should be able to critique and apply research pertinent to their area (18,19), and in teaching activities.
Besides the educational challenge in wound care, the shift of tasks from doctors to nurses is another emerging feature. The range of duties of nurses is changing (e.g. nurses prescribing drugs). This is the case not only in Europe but also in Canada and the USA. This change of responsibilities has burgeoned because of not only the increased demands and reforms in health care, but also the increasing specialisation and advanced educational opportunities in nursing (6,20,21). Concurrently, many developed countries are seeking to shift provision from doctors to nurses, while trying to cope with an increasing pressure to constrain costs (21). The consensus reached in this Delphi study may help clarify which competencies are required and also reduce uncertainty and confusion among specialised wound care nurses regarding their responsibilities in the medical and nursing fields. In various settings, appropriately trained nurses may produce health outcomes and quality of patient care that are equal to those achieved by doctors (21,22). Therefore, the results of our study may help doctors defer tasks and relinquish some control (e.g. coordination between care and provision of patient education) to specialised wound care nurses.
The main strength of this study was the use of a digital Delphi technique to achieve consensus in an area where empirical evidence is scarce (23). This method gives equal weight to the opinion of each expert, allows anonymous inclusion of experts across various countries and levels of expertise, and avoids the domination by one expert of the consensus process (15).
Attrition rates in questionnaire research are a recognised problem (15). Withdrawal can occur in each stage, but high dropout rates in the final round may substantially influence the results (24). In our study, the reason for withdrawal was not recorded. However, we achieved high response rates in every round. Therefore, we consider our results to be robust. A possible reason for the high response rate may be that the experts recognised the importance of the topic and considered themselves as partners in the study. Feeling involved is important to bridge the well-described gap between research and practice (25). Because of the range of specialties and countries involved in this Delphi study, this ultimate set of core competencies is likely to be generalisable to other specialised wound care nurses in other developed countries.
There are also some limitations in this study. First, we included only 6 of the 27 European countries (22%) and 5 external reviewers. However, we chose our contributors purposefully, based on their expertise in wound care. Furthermore, we included only English-speaking experts. This was done deliberately to make sure that the experts completely understood the described competencies. Second, the present consensus comprises numerous competencies. Stakeholders should organise these competencies thematically to make this framework easier to use in daily practice. However, these themes should include all competencies to reflect the full spectrum of tasks specialised wound care nurses should fulfil. Third, the level of consensus was chosen arbitrarily, because no standard threshold for consensus is available (15). If we had chosen a higher consensus level (e.g. 80%), more competencies were considered as 'not a core competence'. This may have provided a more compact, easier-to-use, but less comprehensive list of competencies. Conversely, we could have defined consensus at a lower level of agreement. In that case, competencies regarding implementing innovations and searching scientific evidence would also have been considered as core competencies. Additionally, some of the general competencies may benefit from further discussion to focus more on the specific tasks of wound care nurses. This study provides a set of competencies for specialised wound care nurses, which can serve as a basis for further polish and particularise their competencies. Finally, many studies in health care support the use of the CanMEDS framework to structure competencies (26)(27)(28). However, an officially adapted version of the CanMEDS for nurses is lacking, although we found that various curricula of nursing schools are based on the CanMEDS framework.
By means of the Delphi technique, we were able to reach an international consensus about core competencies for specialised wound care nurses. This consensus may be helpful to achieve a more uniform and better definition of specialised wound care nurses and, ultimately, a more uniform and better quality of wound care. The next step should be the acceptance and implementation of this set of competencies in education and clinical practice. Furthermore, support from European wound care organisations, such as the European Wound Management Association (EWMA), may be helpful to make these steps easier to take.