This article is based on a questionnaire survey carried out at Svendborg Hospital (part of Odense University Hospital) in years of 2020-2022. Svendborg Hospital is a small hospital in southern Denmark located approximately 40 km south of Odense. It has been named the best small hospital of the year in Denmark in 2024 by the magazine Dagens Medicin (Daily Medicine) (Odense University Hospital, 2024).
The study was carried out in the Geriatric Department, which has room for 32 elderly medical patients. The patient category is diverse, and typically, the patients have a number of health-related problems, including different types of wounds. It is an interdisciplinary department with highly specialised staff, such as physiotherapists, doctors, dieticians, social and healthcare assistants and nurses.
Background
The background and purpose of the project were to use e-learning to increase the professional knowledge and skills of a large group of staff, including both nurses and social and health assistants, regarding wound care treatment in the department.
Several companies offer e-learning about wound care treatment, but one company was selected, and the product was purchased for the entire Odense University Hospital. The product was adapted to the department’s specific needs by the wound care specialist nurses and doctors.
From the start, the product contained 10 modules with different topics, which were continuously updated with new knowledge. These are depicted in Figure 1.
The e-learning product later changed provider from Guide2know to Gyldendal and the number of modules was cut to 8, however this had no impact in this project.
Purpose
The purpose of this article is to evaluate the impact of the e-learning that took place around wound care and treatment. The entire project took place between 2020 and 2024.
The evaluation is based on the staff’s own perception of their experience and competencies before and after they completed the e-learning modules. In addition, the factual level of knowledge has been examined via targeted factual questions.
Methods
A survey that used both closed and a few open questions was chosen to create measurable data (Billhult et al, 2024).
A self-constructed questionnaire was prepared using the Funnel technique and the Likert scale (Kruuse, 2007). It was chosen to construct a new questionnaire locally so that it could be precisely adapted to the needs of this study, rather than choosing a validated questionnaire that had already been created. A search into previous questionnaires was carried out, however it was analysed and decided that no previous questionnaire hit the mark on what this study wanted to investigate. The desire was to have both questions regarding factual knowledge as well as the staff’s own perceived experiences about wound care and treatment of wounds, which previous questionnaires did not include.
The new questionnaire was tested several times before it was put into use. It was tested by two clinical development nurses and several wound care nurses from different places in different departments and municipalities around Denmark. Furthermore, it was tested by a specialised wound care doctor from another hospital. Subsequently, small changes were made to the questioning technique to ensure a better understanding of the questions themselves thus avoiding misunderstandings about what was being asked.
Following confirmation of the validity and repeatability, the final survey was sent electronically to the respondents in the Geriatric Department via Survey Exact, which is a survey programmed by the global consultancy firm Rambøll.
The questionnaire was distributed to the staff via private links to each individual on their work e-mail. The inclusion criteria were, among other things, that you had to be permanently employed or have a long-term temporary job of more than 2 months to be able to participate in this study.
Unfortunately, there was an error in the distribution of questionnaire 2 (everyone was sent the same link, meaning everyone entered answers in the same form). Therefore, this data could not be used in further processing and was completely removed. Table 1 shows the timeline of the survey.
In addition, there was a longer period of time between measurements than initially planned, among other things, due to the COVID-19 pandemic.
Ethical considerations
The department’s head nurse approved the study before the study began.
The informants were informed that they were fully anonymised in all data before data processing. Subsequently, some of the intervals in specific questions have been changed to ensure the anonymity of the informants in order to reduce the recognisability of the individual, for instance, when it came to age. This has had no effect on the data itself, but it obscures the recognisability of the staff’s identity.
Respondents
The respondents were permanent members of staff, including both nurses and social and health assistants, as well as staff employed in long-term temporary positions with regular attendance in the department as permanent substitutes.
The questionnaires were distributed to different numbers of staff in the two measurements.
In measurement 1, the questionnaire was sent to 52 members of staff, of whom 43 people gave a full answer. This corresponds to an approximate response rate of 82%.
In measurement 3, the questionnaire was sent to 66 members of staff, of whom 32 people responded. This corresponds to an approximate response rate of 48%.
Several staff members started to respond in both surveys, but did not complete the survey due to reasons described below. Therefore, these responses have been removed from the survey. Hence, the response rate is lower than expected.
For the analysis, there in fact ended up being two sets of respondents. This happened due to several factors, such as the COVID-19 pandemic and staff changes between the measurements.
The two sets of respondents constitute a bias in the data, as it makes it difficult to say with certainty whether increases and decreases in the answers between the two measurements are due to the e-learning or staff changes.
However, one has to bear in mind the characteristics of the two sets of respondents, whose characteristics will be described in more detail in the next section. In measurement 3, more newly trained and less experienced staff members participated. In addition, of the two groups of respondents, 16 respondents answered both surveys. This group consisted of experienced staff members with strong professional competencies, who answered factual questions correctly with over 90% in the first survey. It would therefore be difficult to assess whether there had been significant changes in this target group due to e-learning, which means to only focus on them for the entire analysis would also have skewed the data and would not have given the whole picture.
It was decided that comparisons between the two full data sets could still be made with caution due to the increased number of new and inexperienced employees. The thinking behind it is, that if the numbers from measurement 1 to measurement 3 improve, e.g. on factual questions, despite a whole range of new and inexperienced employees, then part of it should be attributable to the e-learning.
Data and results
Table 2 shows the data of the respondents, and it depicts the above-mentioned changes in the staff group between measurements 1 and 3. In measurement 3, there are more newly trained and less experienced staff.
All new employees are asked to take e-learning modules as part of their training at the Geriatric Department. The goal is to give every staff member a professional and detailed knowledge base about wounds, which is subsequently improved upon via blended learning.
Analysing the results, an increase can be observed in the number of correct answers to factual wound questions. Table 3 gives an example of this.
Taking the above-mentioned changes of staff into account, one should be able to say with some caution that e-learning has had a positive effect on the respondents’ factual knowledge about wound care. However, it must also be emphasised that in several of the sub-questions a ceiling effect is seen (Nikolopoulou, 2023), which means that even before the e-learning, the correct response percentages were very high and above 90%. This left little for improvement. This effect can be seen in the example in Table 4.
Some of the questions in the questionnaire deal with the respondents’ own perception of their own knowledge and confidence in the wound treatment of the elderly medical patient.
The questions in this category were divided into different topics, so that they covered different topics within wounds and wound care, but also a broader question about the person’s own perception in general.
Table 5 is an example of one of the questions and the answer distribution.
By observing the improvements and deteriorations in the respondents’ own attitudes towards their own skills, both on the graphs and via the numbers, it can be seen that most respondents in measurement 1 placed themselves in the middle of the five answer options with “to some extent”. After measurement 3, the “middle” has become larger, i.e., far more now feel that they have “some degree” of knowledge, confidence and competence in wound care. If you look at the numbers for “to some extent”, it has now been achieved that all wound categories have a result of 50% and above (some even over 70%).
Another trend in all the wound categories is that after measurement 3, there are far fewer than in measurement 1 answering with “very low degree” about their ability. The percentages fluctuate between 12% and 34% for the diabetic wounds, which is an area we can already see that needs to be improved. Although we do not know exactly where the respondents have moved between the measurements, it must be safe to say that some respondents have moved from “a very low degree” to “some degree”.
Overall, it can therefore be said that there is a large middle group of employees who, to some degree, have self-confidence about their skills in wound assessment and wound care treatment after measurement 3. Although, as mentioned, it can be difficult to assess how much of the increase in knowledge and practical skills is due to e-learning, some of the increase should, written with caution, have been caused by e-learning due to the changes to staff.
Limitations
The biggest limitation to this project has been the two different populations between measurements 1 and 3, where only 16 members of staff participated in both. There were various reasons why this happened. A number of experienced staff members retired or left the department for different reasons during the study, whilst new and inexperienced members joined. Furthermore, due to the COVID-19 pandemic, the investigation took considerably longer than planned, and as staff members went in and out of COVID-units, it was difficult to gather the same set of respondents.
In addition, and as a result of the above, quite a long time passed for some respondents between taking the e-learning module and answering questionnaire 3. This time interval could have had an impact on, for example, the answers to factual questions, in the sense that if you do not put learnings into practice immediately, one risks to forget it. This means that, although being very high in some categories, the number of correct answers could potentially have been higher in others, had the original time frame been followed.
Overall, it was decided that comparisons between the two full data sets could still be made with caution due to the increased number of new and inexperienced employees between the measurements. The thinking behind being, that if the numbers from measurement 1 to measurement 3 improve, e.g. on factual questions, despite a whole range of new and inexperienced employees, then part of it should be attributable to the e-learning.
Discussion
Looking at things that could have been done differently when conducting this study, it could have been beneficial to dive even deeper into the respondents’ own perception of what they gained from the e-learning. This study gives insights into their perception of their skills before and after e-learning, however it could be beneficial to know their thoughts about the e-learning itself. Therefore, future studies in the department could focus on qualitative studies into e-learning and what staff members believe that they gain from it. This could be explored through individual and focus group interviews.
In terms of teaching methods, one method that could be beneficial in future would care development is blended learning. Throughout the period of this investigation, the authors started to have a look into blended learning and organised a couple of teaching sessions and small workshops as well as sharing information via posters and info screens. It was not to such an extent that it would have had an effect on the study’s results, however it gave an idea on how blended learning in the future could add positively to the outcomes of e-learning.
In addition to e-learning, themed meetings and full course days could also add to staff members’ knowledge and competencies. Once a member of staff has taken a specific module of e-learning, one could sign up for themed meetings on the subject in question at Odense University Hospital.
The two wound care specialists, Åse Fremmelevholm and Britt Hansen, from the department in Odense have offered such teachings that are currently on pause; however, discussions into reactivating should be held.
The biggest challenge, however, is when and how often people could go to such meetings in a busy schedule. This is going to be a challenging discussion into resources versus development at management level.
Conclusion and implementation in clinical practice
In the past, a lot of nurses in our department have stated that wound care was difficult and the treatment of patients could become quite overwhelming. Some colleagues have previously indicated that they were almost afraid of taking off bandages as they did not know what could be hidden underneath and what to do with a wound.
After this study, the authors have experienced that staff members’ approach to patients with wounds has changed to the better after e-learning. Now, the bandages are opened, and the staff indicate to us that they feel less nervous about what they find under them.
Based on this study’s results, the e-learning seems to have given the staff knowledge which enables them to better carry out ordinary wound care. Progress can be seen in this, although it cannot be interpreted as a pure effect of the e-learning alone. Colleagues state, however, that it has given them a good basic knowledge, and it is easier to build more knowledge on top of that.
Due to the limitations of this study, it can only be said with caution that the e-learning product has increased the staff’s professional knowledge. However, it is assessed that it provides a good basic knowledge for the individual, on which more specialized knowledge can be built.
All new employees in the department will have time allocated in the work schedule to take the e-learning modules on wounds to give everyone the same basic knowledge. It is concluded that blended learning in various forms will have a positive effect in the long run.
This requires that the e-learning modules will be followed up with other measures, for example, in the form of bedside teaching, other teaching courses, as well as other forms of knowledge sharing. It is important to keep up the momentum and ensure that the implementation of the latest knowledge in the wound area continues.
This survey with a questionnaire could advantageously be followed up by an interview survey, either individual or in focus group interviews, in order to examine the staff’s experiences and perspectives directly and obtain statements that can be analysed further. Here, the focus must be on speaking to as many staff members as possible in order to obtain the most nuanced knowledge possible.
In conclusion, the e-learning can provide good basic knowledge to a broad group of staff, but e-learning cannot stand alone. Follow-up must be carried out, and blended learning must be used.
