Wound, ostomy, and continence (WOC) nurses receive specialty training and certification to provide acute and rehabilitative care for people with abdominal stomas, ostomies, wounds, fistulas, drains, pressure injuries, and incontinence. WOC nurses play a vital role in reducing health care costs and achieving positive outcomes in this specialty population (Bliss, Westra, Savik, & Hou, 2013; Westra, Bliss, Savik, Hou, & Borchert, 2013). More than 4,900 nurses in the US are certified to provide care for people with these conditions; More than 5 million Americans annually experience repeated treatments, prolonged hospital stays, and reduced productivity due to nonhealing wounds and pressure injuries (Wound, Ostomy and Continence Nurses Society [WOCN], 2014). Seventy-five thousand people currently have an ostomy (WOCN, 2014), and it is estimated that, annually, 120,000 individuals will have new fecal and urinary diversions (ostomy surgeries).
The goal of establishing a wound and ostomy education program in California was to train more qualified nurses in this specialty to address the growing shortage and improve patient outcomes. We followed the ADDIE instructional design framework to develop the program in a five-step process: Analyze, Design, Develop, Implement, and Evaluate (Briggs, 1975).
PROGRAM DEVELOPMENT
Analysis
In 2011, of eight accredited WOC precertificate programs nationwide (WOCN, 2011), one was online, six were on the east coast, and one was onsite in the state of Washington. The majority of onsite programs offered either onsite courses or a split option with both onsite and online courses. Each program might offer only the wound course, a wound and ostomy course, or WOC courses.
Registered nurses in California wishing to take a precertification course would need to attend a program onsite in another state or complete the online section of the program and then search for qualified preceptors in their home state. The loss of workdays and the financial burden deterred nurses from precertification programs. The results of our needs assessment affirmed a large need for a formal education program in California.
Design
Certified WOC nurses were invited from local areas near the public university to form a community task force. The task force, consisting of six or seven nurses, met with the program director bimonthly, beginning in 2012, for about two years. The meetings involved brainstorming ideas, resolving barriers, disseminating information about the new hybrid program, and facilitating student and preceptor recruitment. The community task force's cumulative efforts contributed greatly to the program's success.
The hybrid program offered two courses within one semester: wound care and ostomy care. The program did not include a continence course due to the difficulty in finding clinical placements focused only on continence care. Each course consisted of 15 class meetings in a five-week period, which covered all didactic course materials. Interactive classes were held on weekday evenings and Saturday mornings. In addition, students and faculty met face-to-face on campus for an intensive two-day weekend session as part of the didactic curriculum for each course.
The curricula for both courses were developed based on standardized requirements in the WOCN Accreditation Curriculum Blueprint. Individual instructors developed the actual course content and teaching materials. Course syllabi on wound, ostomy, and practicum were created using the format designated by the university. Exam questions and item analysis were constructed before the start of the program, with students required to complete two individual assignments per course. Written and oral presentation assignments were designed to enhance student learning by integrating clinical experiences with evidence-based practice. The two face-to-face days per course were packed with activities, which included exams, skills practice, guest lectures, seminar discussions, and vendor exhibits.
Upon completion of the didactic portion of a single course, students began the 40-hour practicum. The one-on-one practicum with expert WOC nurses allowed students to apply theories and skills in actual practice. At the end of practicum, all students were encouraged to participate in anonymous online evaluations on course content, classroom instructors, clinical preceptors, guest lecturers, and the program as a whole.
We used the university's web-learning platform as our online classroom. Course materials, final exams, lecture recordings, and external links to the evaluation surveys were accessible via the classroom site. All interactive lectures were delivered using an online webcast venue, which was also part of the university's existing technical support system. Students could use the online university library system and had access to a designated nursing librarian for assistance with evidence-based assignments.
Development
The development of the program took place during an economic recession when there were no start-up funds available from the university. Therefore, the wound and ostomy education program required a self-sustaining budget proposal that became the basis for financial decisions. The fee structure was established after examining the cost of similar programs nationwide. Faculty full-time equivalent units and nonteaching full-time equivalent units, application and registration procedures, and marketing strategies were then determined.
The most successful funding effort came from vendors who provided a total of $4,000 in grants for start-up use. Revenues generated from the program were used to offset university mandatory costs and operational spending. Expenses included teaching release time; salaries paid to team teachers and the project manager; conference expenses for the program director and codirector; books and supplies; honoraria, fees, and gifts for speakers; and hospitality/office expenses.
Because the program had its own specialty practicum requirements, new clinical placement contracts had to be established in preparation for future placements. Certified nurses in wound and ostomy care throughout California were asked to serve as volunteer preceptors; recruitment was done via email and at local conferences. After a nurse agreed to precept, the agency was contacted to request a clinical placement agreement. Creating placement agreements required anywhere from a few months to years. Student enrollment is capped to provide optimal preceptorship experiences.
Implementation
The WOCN accreditation manual (2016) provided detailed guidelines for the establishment of a new education program. The scaffold of the program took shape in the process of compiling the self-study report. The program was originally scheduled to open in fall 2013 with an intensive instructional design and daily classes for three weeks. Because of unforeseen withdrawals before the semester began for various reasons (unemployment, health issues, financial concerns), the program was postponed. The decision was made to institute a hybrid design to better accommodate students' work schedules and reduce travel and lodging costs the revised program was launched in fall 2014.
It took about two years from submitting the first paperwork to finalization of a site visit to complete the accreditation process. The initial step included writing a feasibility report, helped formulate a program development plan. The next step involved preparing an in-depth self-study report. Because each section on the report had to be addressed in great detail, gathering the required information was a stepping stone in establishing the program. The report became a working protocol when the program was implemented. Site visitors from the accreditation committee chose to visit when the program was live so that they could talk to students and preceptors. The visit by experienced assessors served to provide valuable advice. The program was granted seven-year full accreditation.
Evaluation
A total of 113 students have taken one or both specialty courses over the past six semesters. The majority (91 percent) came from California; a few were from out of state and one was from Canada. During the first two years, 18 nurses obtained national certification in wound care; 11 were certified in ostomy care; 98 percent of graduating students practiced in the specialty area of wound and/or ostomy care.
Preliminary analysis of evaluation data showed that all areas (teaching, practicum, course content, and overall program) received student ratings of 4 to 5 on a 5-point Likert scale (with 5 being the highest). Written comments were mostly positive. Students liked the interactive online classroom setting where they could talk to the instructor and fellow students. They found the guest lectures invaluable. They valued the hands-on onsite days, and some asked for increased hours in this physical learning environment. They also enjoyed learning from peers by critiquing other classmates' assignments. A few students suggested lengthening the program to allow more time to learn the content. Some students complained of difficulty in uploading assignments to the online learning platform. Because the program has been only in its sixth semester, we are still collecting evaluation data for ongoing benchmarking and quality improvement.
CONCLUSION
Even though the wound and ostomy program is a small-scale continuing education program, we hope that it will eventually produce enough certified nurses to provide quality care to this specialty population, both in California and beyond. Plans include expanding the preceptor pool to accommodate an increase in enrollment and to identify best pedagogical practices in the hybrid delivery model.
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