Implementation of a Competency-based Pressure Ulcer Curriculum for Medical Students: Outcomes from an Educational Intervention Study

A paucity of research exists on medical student pressure ulcer education. PURPOSE: This study examines medical student competency outcomes following implementation of a competency-based curriculum that included a pressure ulcer component in its educational intervention. METHODS: Over a 5-year period, 645 medical students completed the curriculum, which included a preceptor-led didactic session, online study resources, clinical experiences, and a brief online competency assessment. The assessment involved knowledge of risk factors, wound staging/classification, and prevention and management strategies and included short answer and extended matching questions. A performance standard was set; students not achieving this standard underwent remediation and reassessment. The curriculum was implemented in 3 phases with quality improvement (QI) between each phase. The average competency assessment score and passing rates were determined for each phase. Mean scores for each phase were compared using an analysis of variance test. RESULTS: Mean competency assessment scores increased significantly after each QI from 17.5 (range 11–23) to 18.3 (range 12–24) to 19.8 (range 12–25) in phases 1, 2 and 3, respectively [F(2,642) = 59.502, P <.001]; the performance standard was raised after both QI points. Overall, 8.7% of students underwent remediation and reassessment, but all achieved the performance standard on their second attempt. CONCLUSION: Through a thoughtful QI process that involved carefully aligning all curricular elements (the instructional activities and the assessment), a focused and accountable curriculum was developed that ensured all medical students in the program would achieve a basic level of competency. Increasingly, accreditation agencies are asking medical schools to move toward competency-based curricula. This curriculum represents an important step in this direction.

Pressure ulcers (also known as pressure injuries) constitute an important challenge faced by health care professionals. According to the Agency for Healthcare Research & Quality,¹ an estimated 2.5 million individuals in the United States develop pressure ulcers every year. Findings from the National Medicare Patient Safety Monitoring System Study,² which examined data extracted from 51 842 Medicare inpatient discharges, revealed 3.5% to 4.5% of all patients developed potentially preventable pressure ulcers during their hospitalization. The rate of pressure ulcers is particularly high in the intensive care unit (ICU) setting. In a recent systematic review examining pressure ulcers at all stages in adult ICU patients, Chaboyer et al³ reported a prevalence of 16.9% to 23.8% (95% confidence interval). Hospital-acquired Stage 3 or Stage 4 pressure ulcers are considered “never events,” and the Centers for Medicare & Medicaid Services⁴ (CMS) no longer reimburses hospitals for pressure ulcer-specific care. In nursing homes, pressure ulcers are the second leading cause of litigation.⁵ Effective 2017, the Joint Commission National Patient Safety Goals⁶ listed preventing health-care associated pressure ulcers a top priority.

Leaders in medical education also have recognized the importance of this topic. The American Association of Medical Colleges⁷ (AAMC) delineated a set of 26 core geriatric competencies for medical students. One of these competencies states that graduating medical students must be able to identify potential hazards of hospitalization in older patients (including pressure ulcers) and identify potential prevention strategies. In addition, the AAMC stipulates graduating medical students must to be able conduct a surveillance exam of areas of the skin at high risk for pressure ulcers and to describe existing wounds.

Yet there is a paucity of existing research on how this topic is addressed in medical schools and whether students are adequately achieving these competencies. Studies on this subject have largely been limited to nursing education and generally only assess knowledge or attitudes. In a mixed-methods, observational study⁸ involving medical and nursing students, 41 teams of fourth-year medical students and senior nursing students (3 to 4 students per team) participated in a “Room of Horrors” exercise and were asked to identify hazards in a simulated ICU setting. Only 46% of the teams identified the presence of pressure ulcers. Another study⁹ among medical residents also found knowledge gaps. Residents were administered a pressure ulcer knowledge test and a wound photograph test. Residents answered 69% of the items correctly on the knowledge test compared with 78% for nurses. Residents correctly identified 57% of items on the wound identification test. They had the greatest difficulty identifying suspected deep tissue injury and unstageable ulcers. Despite receiving greater training on pressure ulcers, significant knowledge gaps also have been found among geriatric medicine fellows. In a survey study¹⁰ of 42 geriatric fellows, less than half recognized the Braden Scale as a widely used risk-screening tool, and when asked to rate their level of preparedness to teach others about pressure ulcers, they only scored a 3.3 on a 5-point Likert scale (1 = very little, 3 = adequate, 5 = very). These studies indicate a greater need for training on this topic so physicians at all levels can improve their knowledge and confidence with regard to pressure ulcer care. 

To meet the AAMC geriatric competency mandate, the University of Miami Miller School of Medicine (UMMSM; Miami, FL), created a competency-based curriculum for medical students targeting core geriatric syndromes, including pressure ulcers. The purpose of this study was to examine student competency outcomes after an educational intervention for the pressure ulcers component of this curriculum. 

Study setting. Medical students at the UMMSM participate in a longitudinal curriculum in Geriatrics, Pain Medicine, and Palliative Care that starts in the preclinical years (years 1 and 2) with a home visit program in which students interact with active older adults in the community and culminates with a 4-week required Geriatric and Palliative Medicine Clerkship in 1 of the clinical years (years 3 or 4), during which students work with more complex and frail older adults, including persons in a long-term care setting. With grant support from the Donald W. Reynolds Foundation (Las Vegas, NV), a team of geriatrics educators at the UMMSM developed a competency-based curriculum for 5 geriatric syndromes including dementia, delirium, falls, polypharmacy, and pressure ulcers. The delivery of this curriculum was spread over the 4 years of medical school training.

Curriculum development and implementation. For each of these syndromes, a team consisting of geriatricians, content experts from nursing or allied health disciplines, and instructional designers developed instructional and assessment activities. Members from the authors’ team led an earlier collaborative effort by medical schools in the state of Florida (the Florida Consortium for Geriatric Medicine Education) to develop medical student competencies for 10 geriatric syndromes. The specific learning objectives chosen for the curriculum were based on these competencies. For the pressure ulcers component, the learning objectives were as follows: 1) Given a case scenario, identify the factors that increase risk for skin breakdown; 2) Given descriptions of different types of wounds, identify the most likely diagnosis; and 3) Describe general measures for pressure ulcer prevention and management. 

The authors’ development team determined how much emphasis should be placed on each syndrome and the appropriate level at which each of the components of this competency-based curriculum should be introduced. For example, because falls are more common than pressure injuries, a more expanded curriculum was developed for this syndrome. Some of the Falls’ components also were introduced earlier in the preclinical years when students work with more mobile and active older adults. The pressure ulcers curriculum was determined to fit best in the clinical years along with the dementia and delirium curriculum because students rotated through inpatient venues where they routinely encounter these syndromes. 

The pressure ulcers curriculum included a preceptor-led didactic (case-based PowerPoint presentation), online study resources, clinical experiences, and a brief online competency assessment. A nurse practitioner with wound care expertise delivered the presentation on pressure ulcers and other skin lesions for each group of students. The presentation was revised during 1 of the quality improvement (QI) phases, but the final product specifically addressed the 3 learning objectives stated previously. Students were presented with a case and asked to identify risk factors. They were taught how to classify and distinguish among Stage 1 through Stage 4 pressure ulcers, unstageable wounds, deep tissue injuries, skin tears, diabetic ulcers, venous ulcers, and arterial ulcers. The presentation also covered prevention and management strategies. The PowerPoint presentation, which contained practice exercises for wound classification, was available on the institution’s online Geriatrics University (GeriU) platform for students to review afterwards. This learning platform is utilized by medical students throughout their 4-year geriatrics training and comprises all of the learning resources of the competency-based curriculum.

For their clinical experience, students rotated through several clinical venues at the Miami VA Health Care System, including Hospice, Post-Acute Care, and Long Stay Units. Students were supervised by geriatricians, geriatric medicine fellows, and nurse practitioners. Students participated in daily rounds with the team on each of the units and as a team assessed and discussed the management of any wounds present. Students were assigned individual patients to follow and were encouraged to perform routine complete skin assessments as part of their physical exams, but exposure to pressure ulcers and other skin lesions and involvement in wound assessment and care varied. No standardized methods or tools were established for this clinical component of the curriculum. To provide a standardized component, each student was assigned an older spinal cord injury resident to evaluate in the long-term care setting using the Braden Scale. They initially evaluated these patients individually and then rounded as a team with a geriatrician and met afterward for debriefing. 

At the end of their third week of training in the Geriatrics and Palliative Medicine clerkship, students completed an online, case-based competency assessment covering dementia, delirium, and pressure ulcers. The pressure ulcers component was approximately 10 to 15 minutes and consisted of 3 parts that were closely aligned with the 3 learning objectives for the curriculum. In part 1, students were given a case of a patient with diabetes, late-stage Alzheimer’s Disease, and multiple complications and asked to list all risk factors for skin breakdown. In part 2, students were asked to list general strategies for the prevention and management of pressure ulcers. The format for these 2 parts was short answer. In part 3, students were given 7 descriptions and images of different wounds and asked to select the most likely diagnosis from a list of 10 options using an extended matching format. For parts 1 and 2, potential responses for the open-ended questions for which credit would be received (10 risk factors and 9 management strategies in the initial phase) were identified. 

Faculty familiar with the curriculum determined a preliminary performance standard for this competency assessment after reviewing the performance of a pilot group of students. Although 3 separate components/learning objectives were specified, investigators opted to set the standard based on the combined score for the 3 components rather than set individual standards for each component. This approach was less complex and made it more feasible for students to receive remediation. Any student not achieving this standard was asked to review the PowerPoint presentation and the Braden Scale before undergoing reassessment. 

QI of the curriculum occurred at 2 main time points during faculty retreats where broader review of the clerkships was undertaken. After phase 1 of curriculum implementation (~14 months), the scoring categories for the short answer questions were refined and 1 scoring category was added for both the risk factor and prevention/management questions. Outcome data were reviewed with the nurse practitioner giving the lecture, so she was aware of areas with which students had more difficulty. After phase 2 (~10 months), the instructional activities (in particular, the PowerPoint) were revised to be more closely aligned with the learning objectives and the assessment. The questions in the competency assessment remained the same throughout. After each phase, performance standards were raised (see Table 1). In raising the standard, consideration was given to the feasibility (staff time required for reassessment) and the acceptability (on the part of students) of the remediation and reassessment plan. A remediation rate of 15% or less was considered suitable for this training environment. Although students provided no separate evaluation of the pressure ulcers competency curriculum, they were able to comment on it as part of their overall clerkship evaluation.

Data collection and analysis. Data for this project came from students who completed the curriculum between 2010 and 2014. For these analyses, data from all years and phases were combined in a single Excel sheet. All student names were removed; data for 19 students who completed the competency assessment during the reported time period but for whom data were missing in the Excel sheet were excluded. These students were administered a paper version of the assessment and their data were never recorded in the Excel sheet. Descriptive statistics (frequencies, means, ranges) were applied for the scores in each of the curriculum phases, and average scores were compared across phases by performing an analysis of variance test. 

Because this study involved a standard educational intervention, it was deemed exempt from full review by the institution’s review board.

Competency data were analyzed for 645 medical students. Table 1 shows the performance of students across the 3 phases of the QI process, the performance standard at each QI phase, and how many students achieved these standards. Mean scores on the competency assessment increased significantly after each QI from 17.5 (range 11–23) to 18.3 (range 12–24) to 19.8 (range 12–25) in the last phase [F(2,642) = 59.502, P <.001]. Overall, 8.7% of students needed to remediate, but all achieved the performance standard on their second attempt. At each phase, the remediation rate was <15%. However, had the performance standard been raised, this mark would have been exceeded. 

For the patient scenario provided, students most frequently identified malnutrition, peripheral neuropathy, and vascular disease as risk factors for skin breakdown (see Table 2, Part 1). In terms of pressure ulcer prevention and management strategies, the top responses were frequent position changes, pressure redistribution devices, and nutritional support (see Table 2, Part 2).  Overall, the accuracy rate of wound classification was 87%. Students had the greatest difficulty distinguishing between a Stage 4 pressure ulcer and an unstageable wound. Table 3 shows the most common areas of diagnostic confusion for the wound classification section of the competency assessment.

An examination of comments from students on the post-clerkship evaluations indicated some students felt they were “overassessed.” A few students commented that they were unsure of how many responses they should provide in the short-answer questions.

Pressure ulcers are an important quality-of-care indicator. All medical providers should be trained in the prevention, assessment, and management of these injuries and other types of wounds. The authors believe this is the first study to describe a competency-based curriculum on pressure ulcers for medical students. Although the pressure ulcers curriculum was a relatively small component of this institution’s overall competency-based curriculum compared to some of the other syndromes (eg, falls), it provided students with structured learning experiences and ensured students achieve a certain performance standard or level of competence.

Because there are no similar reports in the literature, current results cannot be fully compared to existing data, but it is worthwhile to note that overall, the students participating in this program classified 87% of wounds correctly on their wound identification test compared with the 57% reported by Levine et al⁹ for residents.

Results from the assessments facilitated a data-driven QI process that resulted in performance improvements over time. Although the initial improvement in the mean score on the competency assessment was largely due to the change in scoring categories, the subsequent improvement reinforced the need to carefully align all curricular components. As part of the QI process, the authors could feed data to the faculty involved in the delivery of the curriculum regarding any areas of the competency assessment students struggled with (eg, common errors made in wound staging/classification) and subsequently adjust future instruction.

Setting performance standards is a challenge and a somewhat arbitrary process that relies heavily on faculty judgment. This is especially the case in geriatric education, where curricular content is known to vary widely across medical schools and no national comparison groups exist. Ideally, an absolute criterion-referenced standard would be predetermined. In setting the initial standard, the authors of this study considered the score distribution of the first group of students. Thus, a relative (norm-referenced) aspect was incorporated into the standards that considered feasibility (ie, faculty and staff time required for reassessment and grading), not only for this competency assessment, but also for the assessment of other syndromes (dementia and delirium) during the clerkship.

The expected performance standard or bar set was based on the total score for the assessment, but 3 learning objectives were assessed, a summative approach that allowed for the possibility that students who were weak in 1 of the 3 areas still passed the overall bar for this assessment. In further review of the curriculum, faculty also decided that a component on wound assessment (eg, measuring the wound, checking for undermining, describing the wound) and documentation should be added. The authors currently are working on a training module that addresses these components more fully.

Classwide medical student competence can be achieved. It requires a significant commitment from faculty educators who must ensure all students achieve the performance standards. The authors believe their curriculum provides medical students an important foundation of knowledge and skills before entering residency. At the time, their institution was the only to offer a clerkship with a competency focus, and as such students were assessed more than they were used to (hence their perception that they were “overassessed”). This perhaps will change as accreditation agencies increasingly ask medical schools to move toward competency-based curricula.¹¹ The current curriculum is an important step in this direction. 

Aside from the aforementioned challenges in setting an appropriate performance standard, the competency assessment was largely limited to the assessment of knowledge. A pre-post test to verify that the learning actually occurred as a result of the intervention was not performed, but one of the authors is a member of the medical school’s Clinical Curriculum Advisory Committee that reviews all clerkship and verified with the other clerkship directors that this content is not formally included elsewhere. With the available resources, it also was not possible to assess whether students were able to apply this knowledge in actual practice and whether the educational intervention resulted in improved patient outcomes. Students were not asked to specifically evaluate this component of the curriculum, but faculty periodically reviewed the components. Moreover, the student outcome data are perhaps the most important way to evaluate the curriculum. Finally, the authors do not know how well these results will translate to other institutions. Although elements of the curriculum can be adopted by other institutions, these programs may not have the same resources to provide their trainees with an equivalent educational experience and may need to establish their own performance standard on the competency assessment.

The purpose of this study was to examine the impact of an educational intervention on student competency in the area of pressure ulcers. Ensuring all graduating medical students have a core foundation in the assessment and management of pressure ulcers requires a competency-based approach that rigorously assesses students and holds them accountable for achieving a certain level of performance, as was performed in the educational intervention described. Using a QI process, a competency-based pressure ulcers curriculum was implemented in which all educational components (learning objectives, instructional resources, clinical training opportunities, and the assessment) were clearly aligned. This curriculum resulted in 100% of medical students demonstrating competence.

To date, very little has been published about medical students’ and more advanced medical trainees’ pressure ulcer knowledge and even fewer data are available about the impact of educational interventions on learner competence. More research is needed to determine the most effective ways to improve knowledge and skills. Future research should focus particularly on educational interventions and assessments that effectively simulate real patient care settings and allow for an examination of the impact on patient outcomes. 

Dr. van Zuilen is an Associate Professor of Professional Practice, Division of Geriatrics and Palliative Medicine, Department of Medicine, University of Miami Miller School of Medicine; and an Investigator, Miami VA Healthcare Systems GRECC, Miami, FL. Ms. Kamath is a Medical Education Fellow, Department of Medical Education, University of Miami Miller School of Medicine. Dr. Palacios is an Assistant Professor of Medicine, Division of Geriatrics and Palliative Medicine, Department of Medicine, University of Miami Miller School of Medicine. Dr. Soares is an Assistant Professor of Medicine and Interim Chief, Division of Geriatrics and Palliative Medicine, Department of Medicine, University of Miami Miller School of Medicine. 

This project was funded in part with grant support from the Donald W. Reynolds Foundation. The authors retained full independence in the conduct of this work and have no conflicts of interest with respect to its authorship or publication. 

Please address correspondence to: Maria Hendrika van Zuilen, PhD, AGSF, Associate Professor of Professional Practice, Division of Geriatrics and Palliative Medicine, Department of Medicine, University of Miami Miller School of Medicine, VA Medical Center GRECC, 1201 NW 16th Street (11GRC), Miami, FL 33125; email: rzuilen@med.miami.edu.