Changes in the Knowledge, Practice, and Confidence Levels of Nurses Following a Wound Care Training Program at Three Hospitals in Vietnam

2.1. Study Design and Setting

The study employed a quasi-experimental one-group pretest–posttest design. It was conducted over a period of 18 months (from June 1, 2022, to December 31, 2023) at three hospitals: Ha Dong General Hospital (n = 76), Hanoi Obstetrics and Gynecology Hospital (n = 50), and Bac Ninh Obstetrics and Pediatrics Hospital (n = 33).

2.2. Participants

A total sampling method was used to recruit 159 nurses and midwives providing wound care at the three hospitals (hereafter collectively referred to as nurses). No a priori sample size or power calculation was performed because all eligible nurses at the participating hospitals were enrolled. All eligible nurses were informed about the study objectives, procedures, and their right to withdraw at any time without consequences. Written informed consent was obtained from each participant prior to data collection. Because the training program was integrated into the hospital's continuing professional development monitoring framework, all 159 enrolled participants completed both the baseline assessments and the 12-month post-training evaluation, resulting in a 100% follow-up rate.

2.3. Training Program

Before participating in a one-month continuous training program on wound care, participants completed baseline assessments of knowledge, practice, and confidence. The training program comprised 24 contact teaching hours, structured as follows: theoretical instruction (8 hours) covering wound physiology, assessment frameworks, infection control principles, and evidence-based dressing selection; and supervised clinical practice (16 hours) conducted at bedside under the guidance of wound care specialists.

The self-study component lasted 17 days (approximately 8 hours per day) and was organized as follows: participants received structured study guides and training materials one week before the formal training; during the self-study period, they completed daily written assignments submitted via logbooks with instructor feedback within 24 hours (graded as Pass/Needs Improvement), engaged in clinical case-based learning and group discussions with presentations of learning outcomes, and maintained individual learning portfolios with self-assessment checklists. Monitoring mechanisms included: weekly supervisor review of learning diaries and written assignments to identify knowledge gaps early; formative assessments using competency evaluation forms at mid-course and end-of-module stages; and weekly group meetings for Q&A sessions and supplementary mentoring for participants who had not yet met competency benchmarks.

A post-training assessment covering all three domains (knowledge, practice, and confidence) was conducted 12 months after completion of the training program, using the same instruments as the pre-training assessment. Knowledge and confidence were assessed via self-administered questionnaires, whereas practice was evaluated through direct observation by trained research assistants.

2.4. Instruments

The instruments used in this study were adapted from those originally developed by Phan Thi Dung [9] and previously applied to evaluate a wound care training program at another Vietnamese hospital [10]. The adaptation process involved removing two domains from the original instrument that were not directly relevant to the clinical wound care focus of this study: (1) Knowledge of management and professional development, and (2) Knowledge of pressure injury care, as this content was incorporated into the confidence assessment and practical components instead. The remaining domains were retained without modification to preserve the established psychometric properties. Internal consistency of the adapted instrument was assessed using Cronbach’s alpha (α = 0.791), indicating acceptable reliability. Content Validity Index (CVI) and inter-rater reliability (ICC/kappa) were not formally assessed for the adapted version; these limitations are acknowledged in the Limitations section.

The battery comprised a self-administered Knowledge Questionnaire, a Direct Observation Checklist for Practice, and a Self-confidence Assessment Questionnaire.

The Knowledge Questionnaire covered eight domains: (1) Communication skills (17 points); (2) General wound knowledge (44 points); (3) Aseptic technique/infection control (10 points); (4) Clean wound care (2 points); (5) Infected wound care (20 points); (6) Wound care with drainage (8 points); (7) Suture removal (14 points); and (8) Health education and counseling (10 points). Each correct response was assigned 1 point and each incorrect response 0 points, yielding a maximum knowledge score of 125 points.

The Direct Observation Checklist for Practice comprised 16 items, each rated on a scale of 1 to 10 points (maximum practice score: 160). Practice was assessed by trained research assistants who conducted direct observations using the standardized checklist.

Nurses' confidence in wound care was evaluated using a 5-point Likert scale Self-confidence Assessment Questionnaire comprising 13 domains: communication skills, patient assessment, wound assessment, identifying wound care problems, planning wound care, making wound care decisions, performing clean wound care, performing infected wound care, performing exuding wound care, performing pressure injury care, changing dressings per procedure, health instructions and patient education, and evaluation.

2.5. Statistical Analysis

Data entry and analysis were performed using Microsoft Excel 2010 and SPSS version 27.0, respectively. Descriptive statistics were used to summarize variables: mean and standard deviation (SD) for continuous variables (e.g., age, knowledge, and practice scores), and frequencies with percentages for categorical variables (e.g., confidence level). The paired-sample t-test was used to compare pre- and post-training continuous scores. The Wilcoxon Signed-Rank test was used to compare pre- and post-training confidence levels, as these data are ordinal in nature. McNemar’s exact test was used to compare pre- and post-training use of each wound dressing type, dichotomized as ever used (occasionally or frequently) versus never used or unfamiliar; Cohen’s g, calculated as |c/(b + c) − 0.5| where b and c are the discordant pairs, was reported as the effect size. Cohen’s d was calculated as the mean pre–post difference divided by the pooled standard deviation of the two time points (√[(SD_pre² + SD_post²)/2]) for all paired continuous comparisons and interpreted as small (0.2), medium (0.5), or large (0.8). For the Wilcoxon signed-rank test, the effect size was calculated as r = |Z|/√N (N = 159 pairs) and interpreted as small (≈0.1), medium (≈0.3), or large (≈0.5). Analyses were conducted at the individual nurse level, as the training content and assessment tools were standardized across participating hospitals. A p-value of < 0.05 was considered statistically significant.

2.6. Ethical Considerations

The study received approval from the management boards of the three hospitals and the Ethics Committee of the Hanoi University of Public Health (Decision No. 248/2020/YTCC-HD3, dated June 19, 2020). Although ethical approval was granted in June 2020, the start of the study was postponed until June 2022 because of the COVID-19 pandemic. Written informed consent was obtained from all participants prior to enrollment. All participant information was coded, anonymized, and kept strictly confidential.

3.1. General Characteristics of the Participants

Participants were recruited from three hospital sites: Ha Dong General Hospital (n = 76, 47.8%), Hanoi Obstetrics and Gynecology Hospital (n = 50, 31.4%), and Bac Ninh Obstetrics and Pediatrics Hospital (n = 33, 20.8%).

As presented in Table 1, female participants constituted 95%, and married participants accounted for 91.2%. The mean age of all participants was 36.93 ± 6.88 years, with the 31–40 age group comprising 57.2%. Regarding educational level, most nurses held a college degree (64.8%), compared to 23.3%, 10.7%, and 1.3% with university, intermediate, and postgraduate qualifications, respectively. More than half (57.2%) of participants had permanent employment, and bedside nurses accounted for 97.5%. The mean years of experience was 7.54 years, with 45.3% having worked for fewer than five years.

3.2. Knowledge Scores

As shown in Table 2, mean scores across all eight knowledge domains increased significantly after training, with the total mean score improving from 88.10 ± 14.94 to 108.54 ± 13.18 (p < 0.001; Cohen’s d = 1.45, indicating a large effect size).

3.3. Wound Dressing Use

Use was defined as having used the dressing occasionally or frequently. *McNemar’s exact test for paired binary comparisons; g = Cohen’s g. Post-training data for conventional gauze were available for 158 nurses. Bold p-values indicate statistical significance (p < 0.05).

As shown in Table 3, the use of Lipido-Colloid with silver, Polyacrylate, Lipido-Colloid, and alginates increased significantly after training (McNemar’s test, p < 0.001), with effect sizes ranging from g = 0.22 (Polyacrylate) to g = 0.50 (Lipido-Colloid with silver). The use of conventional gauze remained high (99.4% before and 96.2% after training; p = 0.125), and changes in the use of foams and hydrogels were not statistically significant.

3.4. Practice Scores

Several domains showed significant post-training improvements, including patient assessment (d = 0.88), wound assessment (d = 0.68), care planning (d = 1.03), patient preparation (d = 0.73), ensuring a safe and private environment (d = 0.49), communication with patients (d = 0.27), procedure timing (d = 0.58), documentation (d = 0.35), and post-care observation (d = 1.13) (Table 4). Effect sizes ranged from −0.09 to 1.13. The largest improvements were observed in post-care observation (d = 1.13, large effect) and care planning (d = 1.03, large effect). Seven domains (items 3, 6, 7, 8, 9, 13, and 14) did not show statistically significant changes (items 3 and 13 were borderline, p = 0.050), with three domains showing minimal score decreases (items 6, 7, and 14).

3.5. Levels of Confidence in Wound Care

Confidence was measured at both pre- and post-training time points. At 12 months post-training, statistically significant changes were observed in seven of 13 domains (Table 5): communication skills (p < 0.001, r = 0.32), wound assessment (p = 0.010, r = 0.20), decision-making (p < 0.001, r = 0.38), clean wound care (p = 0.002, r = 0.25), pressure injury care (p = 0.002, r = 0.25), health education (p = 0.031, r = 0.17), and evaluation (p = 0.004, r = 0.23). Notably, these changes did not uniformly indicate increased confidence. In several domains, the proportion of nurses selecting “High” confidence increased while the proportion selecting “Very high” confidence decreased. For example, in communication skills, “High” confidence rose from 71.1% to 82.4%, whereas “Very high” decreased from 25.2% to 10.7%. Similar redistribution patterns were observed in wound assessment, clean wound care, health education, and evaluation, whereas in decision-making and pressure injury care the proportion of nurses reporting medium confidence decreased. Thus, of the seven significant changes, two reflected higher confidence (decision-making and pressure injury care), whereas five reflected lower confidence, mainly through fewer “Very high” ratings (communication skills, wound assessment, clean wound care, health education, and evaluation). Possible explanations for this pattern are discussed in Section 4.4.

4.1. Participant Characteristics and Vietnamese Context

The mean age of the 159 participating nurses was 36.93 ± 6.88 years, and female participants accounted for the majority (95%); both figures are higher than those reported by Phan Thi Dung (31.24 ± 6.65 years; 74.5% female) [7]. Among all participants, 64.8% held a college degree, and 54.7% had at least five years of nursing experience, which was lower than the 68% of participants with >5 years of experience reported by Niyongabo et al. [11]. Participants were distributed across three hospital sites with varying profiles: Ha Dong General Hospital contributed the largest proportion (47.8%), followed by Hanoi Obstetrics and Gynecology Hospital (31.4%) and Bac Ninh Obstetrics and Pediatrics Hospital (20.8%).

4.2. Knowledge Gains and Changes in Dressing Use

The overall mean knowledge score increased significantly from 88.10 ± 14.94 to 108.54 ± 13.18 (p < 0.001; Cohen’s d = 1.45), suggesting a substantial positive change associated with the training program that was sustained at 12 months post-training. This finding is consistent with results from a systematic review by Kim et al., studies by Tegegne et al. and Francis and Sharma, all of which reported a positive association between wound care training or educational intervention and nurses' wound care knowledge (p < 0.05) [8, 12, 13]. Ibrahim and Khdhir similarly demonstrated significant improvement in wound care knowledge following educational intervention (mean score: 10.84 ± 2.13 to 13.61 ± 2.53; p < 0.001) [14]. In addition, a previous study at another Vietnamese hospital reported significant improvements in knowledge and practice 12 months after a wound care training program [10].

After training, nurses more frequently used advanced dressings, including Lipido-Colloid with silver (47.8% to 99.4%), Polyacrylate (47.8% to 75.5%), Lipido-Colloid (6.3% to 27.0%), and alginates (0.6% to 10.7%). However, overall uptake of alginates (10.7%), foams (8.8%), and hydrogels (2.5%) remained limited, suggesting that factors beyond knowledge, such as cost, clinical indications, and hospital procurement constraints, may restrict uniform adoption of advanced wound care materials [15, 16].

4.3. Practice Performance Before and After Training

Practice scores improved significantly in nine of the 16 observational domains following the program. Pre-training, three domains had mean scores below 8; after training, all domains achieved mean practice scores above 8, with notable gains in patient assessment (d = 0.88), wound assessment (d = 0.68), care planning (d = 1.03), and post-care observation (d = 1.13). These findings suggest that the program may have contributed to strengthening nurses' capacity for evidence-based practice, with the largest effect sizes observed in domains requiring systematic clinical reasoning (care planning, patient assessment) and comprehensive post-procedural follow-up. Consistent with these results, Ibrahim and Khdhir reported a significant improvement in wound care skills (mean score: 42.93 ± 5.26 to 56.95 ± 5.91; p < 0.001) [14]. That certain domains (e.g., bandage changing, disinfection, equipment cleaning) showed no significant change may reflect ceiling effects, as pre-training scores in these areas were already above 8.4.

4.4. Confidence in Wound Care Skills

After training, nurses showed statistically significant changes in confidence levels in seven of 13 domains. Importantly, these changes were not uniformly in the direction of higher confidence. In several domains, the proportion of nurses selecting “Very high” confidence decreased while “High” confidence increased, so that the net shift was downward in five domains and upward only in decision-making and pressure injury care. This pattern may reflect more realistic self-appraisal following deeper engagement with wound care complexities, consistent with evidence that individuals with limited competence tend to overestimate their abilities, whereas improved competence enables more accurate self-assessment [17]. However, as the study lacked a control group, it is not possible to attribute these changes solely to the training program; maturation, clinical experience, or other concurrent factors may also have contributed. Osman et al. concluded that improved self-efficacy promoted more frequent use of advanced wound care dressings [16]. Gillespie et al. showed that with enhanced knowledge and skills gained through training, nurses felt more confident in using advanced wound care methods [18].