Training and Practice of Wound Ostomy Continence Nurse Specialists in China

Approximately 100 million people in China require wound treatment every year, with approximately 30 million patients suffering from severe surface wounds that are difficult to heal.¹ Chronic wounds can cause pain, limit limb movement, impair appearance, increase medical expenses, and increase family and social burden. Wound care staff and practice scope keep increasing, and China’s nursing staff and wound care products are seeking to meet international standards. The National Nursing Development Plan (2016-2020)² clearly stated that specialized nurses should be vigorously trained to improve the level of specialized nursing to meet the needs of patients. China has set up professional nursing committees for the operating room, emergency department, oncology, intravenous infusion, wound ostomy & continence (WOC), critical illness, pediatrics, orthopedics, and other fields to organize the training of specialized nurses. In the nursing major, the training of wound specialist nurses was started earlier than other specialist nurses. This paper introduces the development status of wound nursing and the training of specialized wound nurses in China.

Data on the training and practice of wound specialist nurses in the Chinese Mainland were collected through literature review and hospital surveys. The hospital surveys included hospitals of different levels and regions, and the interviewers included nursing managers, wound specialist nurses, and wound instructors. The databases of document retrieval mainly included CNKI and Wanfang data. The search terms include "chronic wounds," "wound ostomy continence nurse specialist," "WOC nurse," "training," "hierarchical management," "community nursing," "management mode," "multi-site practice," and "nurse practitioners." To avoid omissions, a snowball search was conducted on some relevant references of the included articles.

1.1 Origin and development of WOC nurse training in China

Compared with other developed countries, the training of WOC nurses in China started late. Yu Dehong, an expert in anorectal surgery in China, initiated ostomy rehabilitation work in China and was honored as "the father of ostomy rehabilitation treatment in China" by the International Ostomy Association in 2000. In 1988, after he visited the Cleveland Clinic Foundation in the United States, the concept of ostomy nursing came into being in China. In 2001, the School of Nursing and the Affiliated Cancer Hospital of Sun Yat-sen University established the first school of enterostomal therapists (ET) in the Chinese Mainland through a combined project with the College of Advanced Studies of the University of Hong Kong and the Hong Kong Association of Fistulatotherapists. In 2003, a professional committee on wounds, stomas, and incontinence was established. By 2010, West China Hospital began to establish China's first international professional training school for wound, stoma, and incontinence nursing, with the school issuing WOCN certificates to students after graduation, and the first batch of students graduated in the same year. By 2017, there were 9 training schools in China that could train ETs.³ In addition, the Chinese Nursing Association holds professional academic conferences every year, which also promotes the rapid development of the WOC nursing profession.⁴

1.2 Training channels of WOC nurses in China

The training channels of wound specialist nurses in China consist of training courses organized by local or national nursing associations, the international WOC Therapist training school, or the international Enterostomic Therapist training school established by foreign academic organizations in cooperation with local medical institutions. Those foreign wound academic organizations mainly include the International Chronic Wound Association, the European Wound Management Association, and the World Council of Enterostomal Therapists. More than 20 training schools have been established in Beijing, Xi'an, Wuhan, Tianjin, and other locations. The training cost of these programs is about $1000 to $2000 USD.

1.3 Qualifications of Chinese wound nurses

The basic conditions for admission of specialized nurses in all provinces and cities are being a registered nurse, more than 5 years of nursing work experience, and more than 3 years of surgical or wound nursing experience. The admission requirements for specialized nurses of the Chinese Nursing Society include a bachelor's degree or above and more than 5 years of experience in WOC nursing. The training duration is generally 8 weeks, with theory and practice 4 weeks each in each province. However, the training duration for the Chinese Nursing Society is generally 12 weeks, with 4 weeks theory and 8 weeks practice. International wound therapists in China generally require a bachelor’s degree and are less than 40 years old. International wound therapist training is generally conducted over 6 to 8 weeks.

1.4 Theoretical training

There are no standardized teaching materials for the training in all provinces and cities; instead, teachers compile the course materials individually. In 2019, the Chinese Nursing Society published a textbook for training nurses specializing in WOC. The theoretical teaching of specialized nurses calls for a total of 140 hours, consisting of 56 hours of wound nursing, 42 hours of ostomy nursing, 14 hours of incontinence nursing, 14 hours of subject development (including teaching skills and scientific research ability training), and 14 hours of clinical nursing programs. The theoretical part of international WOC therapist training is 60% wound care, 15% ostomy care, 10% incontinence care, 5% lymphedema care, and 10% wound professional development (including clinical scientific research principles, scientific research skills, evidence-based nursing, etc.). The instructors mainly consist of domestic well-known medical professors and international wound ostomy therapists.

1.5 Practice base

WOC nurses receive clinical practice instruction in some hospital bases, which were certified by Provincial and Municipal Health Commissions. The instructors’ ability, population size, teaching facilities, and regulations of the hospital should be approved by a specialist group. In clinical practice, international ostomy therapists or experienced wound specialist nurses teach the students, using the "one instructor and two students” method to conduct demonstrations and provide guidance to the students. The practical teaching content includes a) wound ostomy incontinence classification and evaluation methods, b) wound dressing characteristics and application, c) commonly used wound debridement methods, d) wound dressing procedures, e) marks for preoperative ostomy patients, f) selection and use of ostomy supplies, h) identifying ostomy complications, i) nursing principals for incontinence, g) nutritional guidance, and k) psychological support, etc.

1.6 Completion examination

Completion assessments are organized by each school itself, and the assessments consist of a process assessment and a final check. The process assessment includes daily attendance throughout the nursing program and the quality of the student’s routine assignments; the final check includes a theoretical examination and a wound management skills examination. In addition, the training schools require the students to complete a case nursing record or a research study design related to the wound. After passing all the examinations, they are issued with a qualification certificate.⁵ At present, China lacks the authoritative institutions and the unified system for the certification of WOC specialized nurses and training institutions. This limits the development of the wound specialized nurses in China to some extent and is a problem that urgently needs to be solved.⁶

1.7 Continuing Education

The Wound, Ostomy, & Continence Nursing Certification Board requires specialist nurses to maintain wound management expertise annually by attending the Wound Treatment Associate (WTA) Program through online courses or by attending WTA-sponsored annual meetings, and by re-registering every 5 years. However, the current continuing education requirements and re-registration regulations of specialized wound nurses in China are the same as those of general nurses, with no special requirements. They must complete 25 credits of continuing education like general nurses, and there is no specific requirement for learning about whether wound treatment training is performed.

2. The use and training of SOP

Standardized operation procedure (SOP) is used to ensure that all caregivers follow the procedure each time, without missing any steps, so that patients receive consistent nursing care.⁷ Some regions have promoted SOP in training and clinical practice. For example, West China Hospital of Sichuan University has established SOP for common skills, including dressing changes, standardized management path of enterostomy, abnormal situation treatment, health education, image data collection, medical record writing, etc. Leshan People's Hospital standardized the workflow of enterostomy care as 1) removal, 2) cleaning, 3) drying, 4) sticking, 5) pressing, and 6) fixing. The above practice proved that the application of SOP can improve the quality of care and improve patient satisfaction, but SOP has not been widely implemented and needs further promotion.^8,9

3. Work setting of Chinese wound nurses

3.1 Hospital service

The main workplace of wound nurses in China is still in the hospital, serving inpatients or outpatients. In most general hospitals in China, the management of various wounds is mainly a 3-step clinical wound working mode. The wounds are divided into 3 types: acute, chronic, and complex. Generally, acute wounds are treated by general duty nurses or surgeons, chronic wounds are treated by trained specialist wound nurses, and difficult or complex wounds are treated jointly by trained specialist wound nurses and doctors in related departments such as endocrinology, orthopedics, the intensive care unit, or the nutrition department.¹⁰ This multidisciplinary model promotes medical cooperation to improve the efficiency of wound healing.

3.2 Out-of-hospital continuing care

In China, enterostomy patients have exceeded 1.15 million, and the number of new stoma patients has increased by 13.04% per year.¹¹ The reported incidence rates of colostomy complications in China were 18.1% to 86.2%.^12,13 It was revealed by a systematic review that rates of peristomal skin complications incidence range from 11% to 88%, which included studies conducted in the US, UK, Sweden, Switzerland, and Turkey.¹⁴ Many patients with wounds or ostomies are not treated in the hospital, and instead their care is provided in the community. China is vast in territory and with different degrees of economic development, the capacity of community health services varies greatly. As a result, a considerable number of patients do not receive proper care in the community.

Some provinces and cities have tried to provide continuous care for patients with wounds or ostomies at home. For example, a hospital in Nanjing developed a Weixin mini program on home care, in which patients can conveniently make appointments for door-to-door diagnosis and treatment and family visits through online video calls. The mini program can also provide online consultation and guidance services.¹⁵ The Anhui Province explored the idea of relying on hospital resources to promote the quality of treatment through innovative urban medical couplet work by setting up smart nursing teams with medical mobile phone application and wound ostomy care clinic access. The "Internet +" hospital-community-family trinity wound ostomy nursing service model provided hospital wound specialist nurse access to the community. This service model connected wound stoma care clinics, cultivated community wound care staff, and provided opportunities to introduce new types of dressing and dressing equipment to the community. This model also standardized the community patient information input process, improved patient medical records management, and provided data for analysis of outcomes and costs.¹⁶ Providing convenient and high-quality nursing services for wound-ostomy patients and establishing a continuous nursing network can increase the number of community visits, reduce the cost of wound care, improve patients' medical access, effectively improve the level of community specialist nursing, and promote the implementation of hierarchical diagnosis and treatment policies.

4. The role of a Chinese wound nurse

The wound specialist nurses in China play an important role in specialized nursing, education, scientific research, specialized consultation, and professional promotion, which is consistent with developed countries. A survey of 885 WOC specialist nurses found that 81.5% of wound nurses do not work full-time in the wound care field; instead, they also perform some work done by general nurses.¹⁷ The reason may be that China has no clear and uniform regulations on the positions and responsibilities of WOC specialist nurses, and the workload of wound management in some hospitals is not enough to set up different positions. These nurses are involved in the care of WOC patients, discussion of difficult cases, and training programs as teachers. In terms of scientific research, 40.8% of WOC nurses were involved in scientific research projects, and 41.2% of nurses published papers as a first or corresponding author.¹⁷ These specialist nurses provide WOC consultations to nursing staff, patients or family members, and physicians. WOC nurses also promote professional development by serving on professional committees, organizing academic conferences, and participating in the formulation of nursing standards.

5. Level management of Chinese wound nurses

WOC specialist nurses in the United States are divided into three levels: master's, bachelor's, and non-bachelor's, based on the level of educational certification examinations. In most of the hospitals in China, the 5-level professional title evaluation system of nurse, primary nurse, nurse in charge, associate senior nurse, and senior nurse promulgated in 1981 is still being used. In recent years, many hospitals have also divided nurses into N0-N4 levels, or classified them as certified nursing assistant, junior nurse in charge, or senior nurse in charge. In a survey by Hong et al,¹⁸ 7 aspects of WOC specialized nurses—including professional ability, specialized working hours, title, health education ability, management ability, education level, and scientific research ability—were used to distinguish between the ranks of nurses. However, the division of these aspects did not form a unified evaluation standard. Currently, a management system has not been established in China that can match the level of specialized nurses with their job responsibilities and salary distribution specifically. To a certain extent, this situation limits the long-term development of specialized nursing and the personal growth of specialized nurses.¹⁸

6. Practice of wound nurses in China

6.1 Nurse practitioners

The role of nurse practitioner originated in the United States in the 1960s and has been popularized in various regions, promoting the rapid development of the nursing profession. In 2017, Li Dachuan, director of the Medical and Nursing Department of the Medical Administration Bureau of the National Health and Family Planning Commission, proposed to establish a pilot training of nurse practitioners in Peking University, which marked the transformation of nurse practitioners in China from theory to practice.¹⁹ In August 2017, Anhui Province took the lead in carrying out the pilot project of community senior nurse practitioners in China, granting the wound specialist nurses the right to prescribe medications.²⁰ Since then, Chinese nurse practitioners entered the clinical practice stage officially. At present, China's practice and exploration of nurse practitioners are still in the initial stage, and there are no unified policies and regulations on the qualifications, job duties, or legal risks for nurse practitioners.

6.2 Multi-site practice

Multi-site practice means that nurses can engage in nursing activities at different medical institutions. As an important part of medical reform, it has attracted wide attention of health management and nursing professionals in China. However, the majority of Chinese nursing staff can only register and practice in a single medical institution. Some regions have introduced policies to encourage multi-site practice, such as Beijing and Guangdong. With the popularization of network technology and the increase and diversification of medical demand, WOC nurses are exploring ways to practice in multiple institutions in various forms; for example, by relying on the medical consortium to provide wound stoma care in community clinics. With the help of the "Internet + nursing service," specialist nurses can provide home wound care through virtual appointments and can establish community wound stoma clinics to provide more comprehensive services for patients.²¹

WOC specialized nursing in China is developing rapidly and serving more and more patients. The gap between China and world-class countries in wound-related equipment, facilities, and technologies is becoming smaller, and the number of specialized nurses is expanding. However, the development of WOC nurses in China started late. In the management system of WOC nurses, it is necessary to establish unified admission conditions, curriculum settings, teaching materials, assessment systems, and requirements for continuing medical education. The role of Chinese specialized wound nurses is mainly in specialized wound care, supplemented by educational consultation. Few specialized nurses are able to devote all their working hours to wound care; there is no unified tiered management system for specialized wound nurses in China, and universal multi-site practice and nurse practitioners are also rare. In summary, it is necessary to pursue government-level promotion and national-level design, combined with China's national conditions and actual demand, to focus on mirroring foreign specialized nurses training models and promote more pilot work of multi-site practice and nurse practitioners. National regulation should be introduced to the WOC nurse qualification, job responsibilities, and level management in order to cultivate more high-quality WOC specialist nursing talents and to meet the increasing patient demand in China.

¹The Fourth Central Hospital of Baoding City, Baoding, China; ²University of California Davis Medical Center

Ruihong Zhang, MA, Sc; No.28 XiangYang North Street, Tang County, Hebei Province, 072350, China; 13931391449@163.com

The authors report no financial or other conflicts of interest.

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