PROFESSION AND SOCIETYCourse Content Related to Chronic Wo.docx

PROFESSION AND SOCIETY
Course Content Related to Chronic Wounds in Nursing Degree
Programs in Spain
Angel Romero-Collado, PhD, MSc, RN1, Marta Raurell-
Torreda, PhD, MSc, RN2, Edurne Zabaleta-del-Olmo,
MSc, RN3, Erica Homs-Romero, RN4, & Carme Bertran-
Noguer, PhD, MSc, RN5
1 Professor of Nursing, Nursing Department, University of
Girona, Spain
2 Professor of Nursing, Nursing Department, University of
Girona, Spain
3 University Institute for Primary Care Research Jordi Gol
(Institut Universitari d’Investigació en Atenció Primària
(IDIAP) Jordi Gol), Barcelona, Spain and
Researcher associated with the Universitat Autònoma de
Barcelona, Bellaterra, Spain
4 Figueres Basic Healthcare Area (Àrea Bàsica de Salut de
Figueres) Catalan Health Institute (Institut Català de la Salut),
Girona, Spain
5 Head of Nursing Department, University of Girona, Spain
Key words
Curriculum, nursing education research,
nursing students, pressure ulcer, professional
competence, Spain, wound healing
Correspondence
Dr. Angel Romero-Collado, Professor of

Nursing, Nursing Department, University of
Girona, C/ Emili Grahit, 77, 17071 Girona, Spain.
E-mail: [email protected]
Accepted: July 19, 2014
doi: 10.1111/jnu.12106
Abstract
Purpose: To analyze content related to chronic wounds in
nursing degree
programs in Spain.
Design: Cross-sectional descriptive study.
Methods: Course descriptions available for online access during
June and
July of 2012 were reviewed for the 114 centers in Spain that
offer a nursing
degree, according to the official Registry of Universities,
Centers, and Titles.
Findings: Of the 114 centers with degree programs, 95 (83.3%)
post course
content online, which make it possible to analyze 2,258 courses.
In 60 (63.1%)
of these centers, none of the courses included the concept of
pressure ulcer
prevention, and the course content posted by 36 (37.9%) centers
made no
mention of their treatment. None of the course descriptions
contained any
reference to pain management in patients with chronic wounds.
Of the 728
elective courses analyzed, only one was related to chronic
wounds.

Conclusions: This review of available information about nursing
degree
programs in Spain indicates that pain management in patients
with chronic
wounds is not addressed in any course, and more courses
consider the treat-
ment of pressure ulcers than their prevention.
Clinical Relevance: Degree programs responsible for the
training of future
nurses should be reviewed and revised as needed to ensure that
graduates
have acquired minimum basic competencies in the prevention
and treatment
of chronic wounds that help to decrease the theory–practice gap
in this field.
Chronic wounds are a major factor in morbidity, mortal-
ity, and healthcare costs (Augustin, Brocatti, Rustenbach,
Schäfer & Herberger, 2014; Sen et al., 2009). On health-
care teams, nurses typically have the responsibility of car-
ing for patients who have these wounds or are at risk for
them (Caron-Mazet, Roth, & Guillaume, 2007; Romero-
Collado, Homs-Romero, & Zabaleta-del-Olmo, 2013).
Despite increased knowledge about chronic wound
prevention and treatment, scientific evidence is not
always translated into clinical practice to the extent that
would be desirable. The knowledge possessed by health-
care professionals is one of the key factors most fre-
quently identified in efforts to explain the existence of
this theory–practice gap, although organizational and
environmental factors also have an impact (Moore,
2010). Cowman et al. (2012) conducted an international,
multidisciplinary eDelphi study to identify the research
and education priorities in wound management and tis-

sue repair. This study offers a point of reference to con-
sider where we are in this field and what should be
Journal of Nursing Scholarship, 2015; 47:1, 51–61. 51
C© 2014 Sigma Theta Tau International
Course Content Related to Chronic Wounds Romero-Collado et
al.
done to improve the preparation of healthcare profes-
sionals, thereby improving the prevention and treatment
of chronic wounds.
Background
The Bologna Declaration (European Ministers of Ed-
ucation, 1999) establishes a new framework for Eu-
ropean universities and a convergence of university
degrees to facilitate mobility in the European job market
(Davies, 2008). It also encourages study of the major Eu-
ropean Union languages and discipline-specific study in
those languages.
For the nursing profession in Spain, the new frame-
work has led to the progressive disappearance of the
3-year nursing programs in universities (Zabalegui &
Cabrera, 2009), which are being expanded to 4 years,
240 European Credit Transfer System (ECTS) units, and
foreign language competency (level B2.1) in English,
French, German, or Italian. In contrast, nursing degrees
are completed in 3½ years and 210 ECTS in Denmark and
Finland, and 3 years and 180 ECTS in Norway and Swe-
den (Råholm, Hedegaard, Löfmark & Slettebø, 2010). Full
implementation of the new degree program in Spain will

give the nursing profession equivalency with other de-
grees with respect to future options and opportunities.
This includes access to higher academic degrees (mas-
ter’s and doctoral degrees) by way of their own disci-
pline rather than by way of disciplines such as biology
or psychology.
Another substantial impact of the Bologna process is a
change in the concept of learning. The previous model
was that learning was based on the knowledge consid-
ered necessary to obtain the diploma. This could concur—
or not—with what the future professional would need to
know for success in the workforce, but there sometimes
appeared to be a large gap between the academic and
working worlds. Under the Bologna process, learning is
oriented toward skills and competencies and is student
centered (Zabalegui & Cabrera, 2009). To address the
theory–practice gap, courses must be designed to achieve
essential competencies, along with knowledge of theory.
This aligns with the white paper on the degree in nurs-
ing published by Spain’s national accreditation agency,
which indicated that the cross-cutting competency most
valued by practicing nurses, university professors of nurs-
ing, and nursing administrators is “the ability to apply
knowledge to practice” (Agencia Nacional de Evaluación
de la Calidad y Acreditación, 2004).
The theory–practice gap, defined as the lack of match-
ing textbook descriptions of clinical situations with
the reality of practice, is a vitally important topic for
nursing education (Scully, 2011). For example, the lack
of education about the prevention of pressure ulcers
(PUs) is cited as a cause of their high prevalence and
incidence (Moore, 2010) and of the persistence of care
interventions that are not recommended, such as the

use of “doughnut”-type devices or massaging areas of
redness (Iranmanesh, Rafiei, & Foroogh Ameri, 2011;
Panagiotopoulou & Kerr, 2002; Pancorbo-Hidalgo,
Garcı́a-Fernández, López-Medina, & López-Ortega, 2007;
Saleh, Al-Hussami, & Anthony, 2013). In other studies,
the majority of nurses in an intensive care unit had the
perception that their unit could improve its attention
to patients who had or were at risk for developing PUs
(Quesada Ramos & Garcı́a Dı́ez, 2008), and slightly more
than half of the nurses in 14 long-term care units consid-
ered their knowledge of chronic wound management to
be “average” (Caron-Mazet et al., 2007).
The prevalence of PUs in Spain ranges from 5.9% to
13.5%, depending on whether the population is being
treated as part of a primary care home-health program
or in a hospital or long-term care center (Leyva-Moral &
Caixal-Mata, 2009; Soldevilla Agreda, Torra Bou, Verdú
Soriano, & López Casanova, 2011). These values are
similar to those of other European countries, such as
Sweden’s 14.5% prevalence in nursing homes and 16.6%
in hospitals (Gunningberg, Hommel, Bååth, & Idvall,
2014), the 6.4% reported in a long-term care study in
France (Caron-Mazet et al., 2007), and the 9% observed
in a long-term care setting in the Republic of Ireland
(Moore & Cowman, 2012).
Training nurses in the prevention and treatment of PUs
is of fundamental importance. Nonetheless, there are ma-
jor deficiencies in undergraduate course content related
to this type of wounds (Ayello, Zulkowski, Capezuti, &
Sibbald, 2010). In a study of emergency care profession-
als in Spain (Hinojosa-Caballero, 2012), just 23% consid-
ered their university education about PU prevention to be
“good,” and the rate decreased to 19% when asked about
aspects of PU treatment. Other studies have reported that

25% of nurses reported never having received any spe-
cific information about PUs in their professional program
(Zamora Sánchez, 2006), 53.1% received no training spe-
cific to PU wound care (Romero-Collado et al., 2013), and
70% indicated they did not receive sufficient education
about chronic wounds in their basic nursing education
program (Ayello, Baranoski & Salati, 2005). These defi-
ciencies were also observed in textbooks recommended
by nursing educators (Wilborn, Halfens & Dassen, 2009),
and wide variation in PU-related textbook content has
been reported (Ayello & Meaney, 2003). However, nurs-
ing textbooks are not the only element that requires
improvement to develop the needed skills. Educational
programs must combine textbook content with a variety
52 Journal of Nursing Scholarship, 2015; 47:1, 51–61.
Romero-Collado et al. Course Content Related to Chronic
Wounds
of learning methods, including hands-on experience in
the laboratory.
An analysis of what undergraduate nursing students
know about PUs reported a low general level of knowl-
edge (Larcher Carili, Miyazaki, & Pieper, 2003), despite
evidence that even a small educational intervention (2-
hr lecture-laboratory session) is effective in the short
term (2-month follow-up) in improving students’ knowl-
edge about chronic wounds (Huff, 2011). Nursing stu-
dents also believe that the more time dedicated to guided
practice and clinical teaching, the greater will be the im-
provement in their skills and knowledge about main-

taining skin integrity (Ousey, Stephenson, Cook, Kinsey,
& Batt, 2013).
Given the impact of chronic wounds in the gen-
eral population, a multidisciplinary, international eDel-
phi study (Cowman et al., 2012) was conducted to
identify research and education priorities to improve
wound management and tissue repair. The purpose of the
present study was to analyze the content specified in de-
scriptions of the basic courses taught in the 114 degree
in nursing programs in Spain to identify instruction re-
lated to the four priorities identified by Cowman et al.
(2012): pain management, PU prevention, wound bed as-
sessment, and selection of dressings.
Methods
Design
A cross-sectional design was used to analyze the con-
tent on chronic wounds in nursing degree programs
in Spain.
Centers
We analyzed the degree programs offered by the 114
teaching centers that award the degree in nursing in
Spain, as indicated by Spain’s official database of uni-
versities, centers, and diplomas offered, the Registro de
Universidades, Centros y Tı́tulos (RUCT; Gobierno de
España, 2008). Search terms included degree titles con-
taining “Nursing,” academic level of “Degree program,”
and discipline of “Health Sciences.” For each center, we
obtained the names of courses and number of credits for
each course in the nursing degree program.

Data Collection
From June 11 to July 6, 2012, we analyzed the degree
in nursing program information included in the RUCT,
accessed the web page for each center, and assessed the
program and course content that was available online. No
centers were excluded from the study. We would note,
however, that Spain has gradually implemented the un-
dergraduate nursing degree and not all universities have
proceeded at the same pace. Therefore, not all programs
have published course descriptions for the full 4-year de-
gree in nursing program.
Two researchers independently analyzed the content of
each course description or syllabus and reached a consen-
sus agreement. A third researcher was available to review
the course information in the event of any discrepancy.
A data collection form was designed ad hoc to record the
data obtained about each degree program and course. The
following variables were recorded for each program:
� Access: The number of years of the 4-year undergradu-
ate degree in nursing for which online access to courses
was available.
� Number of Required Courses: Total numbers of re-
quired courses, basic courses, guided practice, and fi-
nal project (recorded to determine the nursing degree
requirements, excepting elective courses).
� Courses Entirely Related to Chronic Wounds: Number
of required courses with a title explicitly containing the
words “chronic wound.”
� Courses With Content Related to Wounds: Number of

required courses, basic courses, guided practice, and fi-
nal projects that included any of the following content
in the available description: Pain and chronic wounds,
Pain control or management (to capture any content
related to controlling pain in general), Prevention of
pressure ulcers, adults (assigned to a related “pressure
ulcer” variable because there could be courses with
only this content), Wound bed assessment, selection
of dressings, or the mention of any product related
to moist wound healing. These were later assigned to
a related variable covering a broader concept, “Treat-
ment of PU or other chronic wound (venous, arterial
or neuropathic/diabetic etiology).”
Other variables related to chronic wounds were
recorded to explore the availability of any content
about other aspects of chronic wound care, in ad-
dition to the four educational priorities defined by
Cowman et al. (2012). At the same time, this approach
provided control variables to decrease the risk of in-
formation bias in the primary variables studied: Nurs-
ing or physiology—attention to patients with venous
and arterial disorders in the lower extremities or with
“diabetic foot”; Burns (adults, children, adolescents), ex-
tensive burns; Wounds related to acute processes; Con-
tent related to acute or chronic wound healing; Antisepsis
or antiseptics.
If the same content appeared two or more times in the
description of the same course, the content was recorded
only once; if two or more different content variables were

al.
identified in the same course, each one was counted as “a
course” containing that information.
Electives. All elective course options were recorded
and placed into the following categories: “chronic
wounds,” “language courses,” “palliative care,” “oc-
cupational health,” “health promotion,” “Catholicism,”
“dependency and chronic illness,” “urgent, emergency
and/or catastrophic patient care,” “research,” “com-
plementary/alternative therapies,” “cooperation,” and
“school health.”
Ethical Considerations
All of the information recorded (degree programs,
course content) was found online, in the RUCT database,
and on the official web site of each university; therefore,
all data were publicly available. No personal data were
accessed (e.g., related to any individual who designed a
degree program or course) for this study.
Data Analysis
Univariate descriptive methods (i.e., frequencies, per-
centages, means, and standard deviations [SD]) were
used to analyze the data. IBM SPSS Statistics 19
(IBM Corporation, Armonk, NY, USA) was used for
the analysis.
Results
The assessments completed by the two designated eval-

uators were in consensus, eliminating the need for the
intervention of a third evaluator and for inter-rater reli-
ability analysis. The study included the 114 degree pro-
grams available online, although detailed course analysis
was limited to the 95 (83.3%) centers that provided on-
line access to course content, of which 37 (32.5%) centers
had implemented 2 full years of the new degree require-
ments, 34 (29.8%) provided 3 years, and 24 (21.1%)
provided detailed information for the full content of the
4-year degree in nursing program.
Of the 3,436 required, basic, guided practice, and fi-
nal project course descriptions reviewed, representing
all of the nursing degree programs in Spain, 2,258
(65.7%) courses were analyzed in detail. The mean num-
ber of courses required for degree completion was 30.1
(SD 3.56) required and 6.7 (SD 4.56) elective courses. Ta-
ble 1 contains a descriptive analysis of the number and
type of courses.
The highest number of nursing degree programs are lo-
cated in 3 of Spain’s 17 autonomous communities, with
18 (15.8%) in Andalucia, and 15 (13.2%) in Catalunya
and in Madrid. Only 1 (0.9%) program is offered in 4
communities: Cantabria, Ceuta, La Rioja, and Melilla. The
remaining 62 (54.2%) programs are distributed across 10
autonomous communities.
Our analysis identified no course offered at any center
that was dedicated to chronic wounds or included con-
tent on pain management specific to chronic wounds;
however, 94 (98.9%) centers offered at least one course
related to general pain control. Only 40 (46.9%) cen-
ters offered a course with specific content on prevention
of PUs in adults, although some type of content specif-

ically related to PUs was offered at 62 (65.3%) centers
(Table 2). Only 10 (10.5%) centers indicated both of
these content areas in their courses and 37 (38.9%) cen-
ters offered neither of them. “Wound bed assessment”
was identified in one course in 1 (1.1%) center, and
“How to select dressings” was found in 23 courses in 21
(22.1%) centers. “Treatment of pressure ulcers or other
chronic wounds” was contained in 98 courses distributed
across 59 (62.1%) centers (see Table 2).
Half of the centers offered no courses related to ve-
nous or arterial disorders in the lower extremities, and
91 (95.8%) centers offered no course description with the
term “diabetic foot.” We included 131 courses offered by
75 (78.9%) centers in a “wounds, acute processes” cate-
gory (Table 3).
The analysis of elective courses showed 50 courses re-
lated to the Bologna requirement for instruction in other
European Union languages in 42 (40.4%) centers, 44
courses related to instruction in research methods in 34
(32.7%) centers, and 36 courses related to complemen-
tary or alternative therapies in 31 (29.8%) centers. In
all of Spain, only one center (1.0%) offered one elec-
tive course that included the term “chronic wounds”
(Table 4).
Discussion
Analysis of course content in degree in nursing courses
at Spanish universities revealed that the education of-
fered future nurses about chronic wounds is insufficient
and largely fails to meet the four educational priorities
identified by Cowman et al. (2012). We considered our
results in the context of each of these priorities.

Pain Management
The first of the four education priorities in wound man-
agement and tissue repair, pain management in chronic
wounds (Cowman et al., 2012), was not mentioned
in any of the nursing courses offering some content
related to chronic wounds. Although PUs produce “end-
less pain and a restricted life” (Hopkins, Dealey, Bale,
Wounds
Table 1. Number of Courses in Nursing Degree Programs in
Spain
Courses in the degree program
(n = number of centers) Minimum Maximum Total Mean SD
Number of required courses offered
(nonelective) (n = 114)
20 41 3436 30.14 3.55
Number of required courses
reviewed (n = 95)
0 40 2258 19.81 10.46
Number of elective courses offered

(n = 107)
0 23 728 6.68 4.56
Number of elective credits, ECTS
(n = 114)
0 30 1157.5 10.15 7.05
Note. ECTS = European Credit Transfer System.
Defloor, & Worboys, 2006), deficiencies exist in the im-
portance assigned to them in clinical practice (Caron-
Mazet et al., 2007) despite recommendations that wound
care should be incorporated into all patient care plans
(Günes, 2008). We must be aware that all PUs cause pain
and that wound care treatments (e.g., dressing changes)
also can cause pain. Inadequate knowledge of pain man-
agement is a barrier to proper treatment. This deficiency
must be addressed by including content about pain as-
sessment and management in training related to chronic
wounds (Pieper, Langemo & Cuddigan, 2009). In Spain,
for example, the needed change could readily be accom-
modated by incorporating a unit on “pain management
and chronic wounds” into the appropriate courses as, in
response to the mandates of the Bologna Plan, the 3-year
diploma program is converted to a 4-year university de-
gree and credit hours in pharmacology are increased.
How to Prevent Pressure Ulcers
In the courses we reviewed, this second priority was
absent from the content of the degree courses offered at
nearly two thirds of the centers that award the degree
of nursing in Spain. We consider this lack of training in
PU prevention alarming because this is a cross-cutting
problem that can affect patients of any age—children,

adults, the elderly—in any healthcare setting (primary
care, hospitals, long-term care). This limited presence of
the topic in nursing studies could be related to the finding
by Zamora Sánchez (2006) that 25% of Spanish nurses
reported receiving no specific PU training during their of-
ficial program of study, or to the 23% of health profes-
sionals on the other end of the spectrum who indicated
that they had received “good” training in PU prevention
(Hinojosa-Caballero, 2012). We must add that, despite
clinical guidelines that recommend against particular care
interventions (such as massaging reddened skin or using
doughnut cushions), many nurses in different countries
and of different professional generations continue to use
them (Iranmanesh et al., 2011; Panagiotopoulou & Kerr,
2002; Pancorbo-Hidalgo et al., 2007).
Basic theory taught in nursing programs should explain
what is and is not recommended by clinical guidelines for
the prevention of PUs. This should be complemented by
guided practice and the involvement of clinical instruc-
tors in practical training to ensure that traditional inter-
ventions give way to current, evidence-based standards
of practice (Saleh et al., 2013; Zamora Sánchez, 2006).
Other researchers have reported a lack of course offer-
ings on certain related topics in other university degree
programs (e.g., medicine, physical therapy). For exam-
ple, required courses related to aging are needed in Spain
(Jiménez Dı́az, Pulido Jiménez, Villanueva Lupión, Villar
Dávila, & Calero Garcı́a, 2011), and gerontological care is
not adequately addressed in nursing education programs
in Flanders, Belgium (Deschodt, de Casterlé, & Milisen,
2010). Although PU prevention tends to be considered
a nursing task, some researchers have advocated that it
should be the responsibility of the entire medical team
and therefore should also be incorporated into physician

education (Levine, Ayello, Zulkowski, & Fogel, 2012).
Wound Bed Assessment and How to Select
Dressings
The third priority, wound bed assessment, was present
in just one course at only one center. On the other
hand, 23 courses at 21 (22.1%) centers included con-
tent on the selection of dressings, the fourth priority
in the eDelphi study and an area in which another re-
cent study (Ousey et al., 2013) also found that students
are underprepared. The inclusion of “Treatment of PU
and other chronic wounds” (a more general term that
could potentially incorporate the third and fourth edu-
cation priorities, “wound bed assessment” and “selection
of dressings,” respectively) added 98 courses (4.34%) at
59 (61.8%) centers to the analysis.
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(4
.3
)
3
6
(3
7
.9
)
3
3
(3
4
.7

)
1
8
(1
8
.9
)
8
(8
.5
)
N
o
te
.
T
yp
e
s
o
f
co
u
rs
e
s
co
n
su
lt

e
d
:r
e
q
u
ir
e
d
,b
as
ic
,g
u
id
e
d
p
ra
ct
ic
e
,fi
n
al
p
ro
je
ct
.
a
T
h

e
to
p
fo
u
r
e
d
u
ca
ti
o
n
p
ri
o
ri
ti
e
s
in
w
o
u
n
d
m
an
ag
e
m
e
n
t
an

d
ti
ss
u
e
re
p
ai
r
d
e
fin
e
d
b
y
C
o
w
m
an
e
t
al
.(
2
0
1
2
).
T
a
b

le
3
.
N
u
m
b
e
r
o
f
C
o
u
rs
e
s
in
Ea
ch
N
u
rs
in
g
D
e
g
re
e
P
ro
g
ra

m
,A
cc
o
rd
in
g
to
th
e
C
o
n
te
n
t
C
ri
te
ri
a
R
e
la
te
d
to
A
cu
te
an

d
C
h
ro
n
ic
W
o
u
n
d
s,
U
se
d
as
C
o
n
tr
o
ls
M
ax
im
u
m
in
a
T
o

ta
lc
o
u
rs
e
s
w
it
h
C
e
n
te
rs
w
it
h
o
u
t
th
is
co
n
te
n
t
C
e
n
te

rs
w
it
h
o
n
e
C
e
n
te
rs
w
it
h
tw
o
C
e
n
te
rs
w
it
h
th
re
e
o
r

C
o
u
rs
e
co
n
te
n
t
d
e
g
re
e
p
ro
g
ra
m
th
is
co
n
te
n
t,
n
(%
)
in

an
y
co
u
rs
e
in
th
e
d
e
g
re
e
co
u
rs
e
h
av
in
g
th
is
co
u
rs
e
s
h
av
in

g
th
is
m
o
re
co
u
rs
e
s
h
av
in
g
cr
it
e
ri
a
(N
=
9
5
ce
n
te
rs
)
(N
=

2
,2
5
8
co
u
rs
e
s)
p
ro
g
ra
m
,n
(%
)
co
n
te
n
t,
n
(%
)
co
n
te
n
t,
n

(%
)(
N
=
9
5
ce
n
te
rs
)
th
is
co
n
te
n
t,
n
(%
)
V
e
n
o
u
s
d
is
o
rd
e

rs
o
f
th
e
lo
w
e
r
e
x
tr
e
m
it
ie
s
3
5
5
(2
.4
)
4
8
(5
0
.5
)
4
0

(4
2
.1
)
6
(6
.3
)
1
(1
.1
)
A
rt
e
ri
a
ld
is
o
rd
e
rs
o
f
th
e
lo
w
e

r
e
x
tr
e
m
it
ie
s
3
5
6
(2
.5
)
4
8
(5
0
.5
)
3
9
(4
1
.1
)
7
(7
.4
)

1
(1
.1
)
D
ia
b
e
ti
c
fo
o
t
1
4
(0
.2
)
9
1
(9
5
.8
)
4
(4
.2
)
0
(0
.0

)
0
(0
.0
)
B
u
rn
s
(a
d
u
lt
p
a
ti
e
n
ts
)
2
4
2
(1
.9
)
5
4
(5
6
.8
)

4
0
(4
2
.1
)
1
(1
.1
)
0
(0
.0
)
B
u
rn
s
(c
h
ild
re
n
a
n
d
a
d
o
le

sc
e
n
ts
)
1
1
0
(0
.4
)
8
5
(8
9
.5
)
1
0
(1
0
.5
)
0
(0
.0
)
0
(0
.0
)

S
e
v
e
re
b
u
rn
s
1
1
9
(0
.8
)
7
6
(8
0
.0
)
1
9
(2
0
.0
)
0
(0
.0

)
0
(0
.0
)
W
o
u
n
d
s
re
la
te
d
to
a
cu
te
p
ro
ce
ss
e
s
6
1
3
1

(5
.8
)
2
0
(2
1
.1
)
4
0
(4
2
.1
)
1
9
(2
0
.0
)
1
6
(1
6
.8
)
W
o
u
n

d
h
e
a
lin
g
2
2
5
(1
.1
)
7
1
(7
4
.7
)
2
3
(2
4
.2
)
1
(1
.1
)
0
(0

.0
)
A
n
ti
se
p
si
s
a
n
d
a
n
ti
se
p
ti
cs
6
9
5
(4
.2
)
3
8
(4
0
.0
)

3
3
(3
4
.7
)
1
7
(1
7
.9
)
7
(7
.4
)
N
o
te
.T
yp
e
s
o
f
co
u
rs
e
s

co
n
su
lt
e
d
:r
e
q
u
ir
e
d
,b
as
ic
,g
u
id
e
d
p
ra
ct
ic
e
,fi
n
al
p
ro
je
ct

.
Wounds
These data show that the treatment of PUs and other
chronic wounds is emphasized more than prevention in
the degree programs (4.34% vs. 2.21% of courses and
61.8% vs. 36.9% of centers, respectively). Our finding
is not consistent with other reports on the knowledge
base of healthcare professionals, primarily nurses, which
have found better results in the prevention than the
treatment of PUs (Hinojosa-Caballero, 2012; Pancorbo-
Hidalgo et al., 2007; Quesada Ramos & Garcı́a Dı́ez, 2008;
Saleh et al., 2013). Our results highlight a problem in
nursing education that can be addressed very directly
when students are assigned to clinical training. In recent
years, there have been more changes in PU treatment
than in prevention strategies, and therefore prevention
has taken a back seat in continuing professional educa-
tion (Pancorbo-Hidalgo et al., 2007); however, we cannot
allow this tendency to affect the preparation of new nurs-
ing professionals. The clinical supervisor is a key player
in ensuring that students acquire skills in both the pre-
vention and treatment of PUs, not least because the stu-
dent spends many more hours at the clinical site than
in university courses on clinical practices. It is difficult to
make changes in what students learn and to improve clin-
ical practices if outdated (even nonrecommended) pro-
cedures persist at clinical training sites. Therefore, it is
essential that clinical supervisors teach evidence-based

best practice and ensure that it is demonstrated by ex-
ample at the clinical site.
Acute Wounds
We included the term “wounds, acute processes” as a
control indicator to assess whether this type of wound
is given importance similar to the category of “treatment
of pressure ulcers and other chronic wounds.” This term
was more prevalent than “chronic wounds” in 30% of
the courses (5.8% vs. 4.34%) and was at least present in
some course at 16 more centers (75 vs. 59). These results
concur with Ayello et al. (2005), who reported that 70%
of nurses responded that they had not received sufficient
education on chronic wounds in their basic nursing ed-
ucation program. Although more courses and more cen-
ters indicate content related to “wounds, acute processes”
than to “treatment of pressure ulcers and other chronic
wounds,” acute wound care remains an area of concern
because all centers should be providing this instructional
content, independently of the present study’s focus on
chronic wounds.
Lower Extremity Wounds
We also considered it important to identify content
related to assessing nursing care of patients with dia-
betic foot or venous and arterial disorders in the lower
limb, which are the other large groups of chronic wounds
and have great impact on patients’ quality of life (Fe-
inglass et al., 2012). We found content on “venous and
arterial disorders of the lower extremities” to be slightly
more prevalent than “prevention of pressure ulcers” (55
vs. 50), and more centers offered at least one related
course (47 vs. 35). We consider this a deficiency be-

cause future nurses must know the characteristics, diag-
nosis, progression, and treatment of ulcers with venous
or arterial etiology. These deficiencies have also been re-
ported in specialized training of internal medicine resi-
dents (Schwarcz, Quijano, Olin, & Ostfeld, 2012; Wyatt
et al., 2010). Researchers have recommended a greater
emphasis on lower extremity wounds in medical school
and residency programs (Georgakarakos et al., 2013;
Wyatt et al., 2010).
Content on “diabetic foot” is almost anecdotal in the
courses analyzed, and was found only in four courses in
four different centers. Between 15% and 25% of diabetic
patients present with a foot ulcer at some point, and 14%
to 20% of them are amputated (Conferencia Nacional de
Consenso sobre Úlceras de la Extremidad Inferior, 2009).
The training of nursing professionals in foot care is one
of the implementation objectives that support patient ed-
ucation and the prevention of possible disorders (van
Houtum, 2012); therefore, it is critical to include this con-
tent in the curriculum.
Elective Courses
When we analyzed the presence of elective courses,
we were surprised to find only one elective course in
all of Spain that offered the possibility of consolidating
and deepening students’ knowledge of chronic wounds,
far below other fields such as complementary or alterna-
tive therapies (1 vs. 36). It could be argued that there
is no need to offer elective courses related to chronic
wounds because sufficient content is provided in the de-
gree courses. However, the same case could be made for
elective courses about research methods (the second most
frequent elective offering); urgent, emergency, or disaster
care (the third most frequent elective); or dependency,

disability, and chronic disease (sixth in frequency). All
of these topics were represented in required courses,
but electives offer an opportunity to gain a deeper
understanding.
In Spain, opportunities for specialization exist in elec-
tive courses and in 2-year graduate residency programs
in one of seven specialty nursing areas (family and com-
munity health, geriatrics, gynecology/obstetrics/midwife,
medical-surgical care, mental health, occupational
health, and pediatrics). Although caring for chronic
al.
T
a
b
le
4
.
N
u
m
b
e
r
o
f
El

e
ct
iv
e
C
o
u
rs
e
s,
G
ro
u
p
e
d
b
y
T
o
p
ic
s
In
cl
u
d
e
d
in
th
e
D
e
g
re

e
P
ro
g
ra
m
T
o
ta
lc
o
u
rs
e
s
w
it
h
C
e
n
te
rs
w
it
h
o
u
t
th
is
co

n
te
n
t
C
e
n
te
rs
w
it
h
o
n
e
C
e
n
te
rs
w
it
h
tw
o
C
e
n
te
rs

w
it
h
th
re
e
o
r
C
o
n
te
n
t
cr
it
e
ri
a
M
ax
im
u
m
in
a
th
is
co
n

te
n
t,
n
(%
)
in
an
y
o
f
th
e
co
u
rs
e
s
in
th
e
d
e
g
re
e
co
u
rs
e
h
av

in
g
th
is
co
u
rs
e
s
h
av
in
g
th
is
m
o
re
co
u
rs
e
s
w
it
h
th
is
co
n
su
lt

e
d
d
e
g
re
e
p
ro
g
ra
m
(N
=
7
2
8
co
u
rs
e
s)
p
ro
g
ra
m
,n
(%
)(
N

=
1
0
4
ce
n
te
rs
)
co
n
te
n
t,
n
(%
)
co
n
te
n
t,
n
(%
)(
N
=
1
0
4
ce
n

te
rs
)
co
n
te
n
t,
n
(%
)
C
o
n
te
n
t
re
la
te
d
to
le
a
rn
in
g
o
th
e
r
la

n
g
u
a
g
e
s
3
5
0
(6
.9
)
6
2
(5
9
.6
)
3
5
(3
3
.7
)
6
(5
.8
)
1
(0

.9
)
C
o
n
te
n
t
re
la
te
d
to
re
se
a
rc
h
m
e
th
o
d
s
4
4
4
(6
.0
)

7
0
(6
7
.3
)
2
7
(2
6
.0
)
5
(4
.8
)
2
(1
.9
)
C
o
n
te
n
t
re
la
te
d
to

u
rg
e
n
t,
e
m
e
rg
e
n
cy
,
a
n
d
/o
r
d
is
a
st
e
r
ca
re
3
4
3
(5
.9
)

6
8
(6
5
.4
)
3
1
(2
9
.8
)
3
(2
.9
)
2
(1
.8
)
C
o
n
te
n
t
re
la
te
d
to

o
cc
u
p
a
ti
o
n
a
lh
e
a
lt
h
2
4
0
(5
.5
)
6
6
(6
3
.5
)
3
6
(3
4
.6

)
2
(1
.8
)
0
(0
.0
)
C
o
n
te
n
t
re
la
te
d
to
co
m
p
le
m
e
n
ta
ry
/
a

lt
e
rn
a
ti
v
e
th
e
ra
p
ie
s
3
3
6
(3
1
.6
)
7
3
(7
0
.2
)
2
8
(2
6
.9
)

1
(0
.9
)
2
(1
.9
)
C
o
n
te
n
t
re
la
te
d
to
d
e
p
e
n
d
e
n
cy
a
n
d
/o

r
ch
ro
n
ic
d
is
e
a
se
3
2
4
(3
.3
)
8
3
(7
9
.8
)
1
9
(1
8
.2
)
1
(1
.0

)
1
(1
.0
)
C
o
n
te
n
t
re
la
te
d
to
co
o
p
e
ra
ti
o
n
2
2
0
(2
.7
)
8

5
(8
1
.7
)
1
8
(1
7
.3
)
1
(1
.0
)
0
(0
.0
)
C
o
n
te
n
t
re
la
te
d
to
h

e
a
lt
h
p
ro
m
o
ti
o
n
1
1
3
(1
.8
)
9
1
(8
7
.5
)
1
3
(1
2
.5
)
0
(0

.0
)
0
(0
.0
)
C
o
n
te
n
t
re
la
te
d
to
p
a
lli
a
ti
v
e
ca
re
1
1
1
(1
.5

)
9
3
(8
9
.4
)
1
1
(1
0
.6
)
0
(0
.0
)
0
(0
.0
)
C
o
n
te
n
t
re
la
te
d

to
sc
h
o
o
l
h
e
a
lt
h
1
3
(0
.4
)
1
0
1
(9
7
.1
)
3
(2
.9
)
0
(0
.0

)
0
(0
.0
)
C
o
n
te
n
t
re
la
te
d
to
C
a
th
o
lic
is
m
1
2
(0
.3
)
1
0
2

(9
8
.1
)
2
(1
.9
)
0
(0
.0
)
0
(0
.0
)
C
o
n
te
n
t
re
la
te
d
to
ch
ro
n
ic

w
o
u
n
d
s
1
1
(0
.1
)
1
0
3
(9
9
.0
)
1
(1
.0
)
0
(0
.0
)
0
(0
.0
)

Wounds
wounds is of obvious concern in the geriatric population
and in medical-surgical hospital nursing, awareness of
their preventability and of current best practices in the
prevention and treatment is a competency that can
contribute to quality patient care in any setting. This can
be addressed by site protocols and continuing education
workshops, but it is also key that universities adequately
address the topic in their curricula. Unlike countries that
offer a specialization in wound care or diabetes care,
universities in Spain need to provide elective courses and
units of required degree courses that make it possible for
students in any program to acquire this important area of
competency and be prepared to provide affected patients
with the needed care.
Limitations
An important limitation of our data collection was the
lack of a common set of official criteria governing nursing
course content descriptions. Some centers provide exten-
sive descriptions and others offer rather scant informa-
tion about the content of their courses. We also did not
have access to all courses in all programs because Spain
has gradually implemented the university-level degree in
nursing and not all centers have proceeded at the same
pace. Nonetheless, we were able to review course con-
tent from 83.3% of the centers, more than 80% of them

through the second year, and had access to 65.72% of all
listed courses. Therefore, our results are drawn from an
extensive panorama of the undergraduate nursing degree
programs in Spain.
Another limitation of this study is the lack of elec-
tronic access to the course content taught at 16.7% of
the centers that award the degree in nursing. However,
we gained access to more than 80% of the relevant infor-
mation through the second year of the degree program,
at which point students have completed the bulk of their
required and introductory courses.
The analysis was confined to nursing degree pro-
grams in Spain. Although we found no studies with sim-
ilar methodology, we located several reports of these
same deficiencies in other countries: in Germany, us-
ing content analysis of nursing textbooks (Wilborn
et al., 2009); in England, where students in the fi-
nal year of their nursing degree reported a perception
that they did not know how to manage patients’ skin
integrity effectively (Ousey et al., 2013); and a U.S.
study of faculty perceptions and documentation of PU
content in all 50 states and the District of Columbia
(Ayello et al., 2010).
Conclusions
In this study, we observed differences in the presence
of the four top educational priorities in wound manage-
ment and tissue repair (Cowman et al., 2012) in courses
that comprise the degree in nursing in Spain. Content on
pain management in patients with chronic wounds (top
priority) is nonexistent and about PU prevention (second
priority) is deficient, compared to content about PU treat-
ment (third and fourth priorities).

The course content related to chronic wounds that is
offered to future nurses in Spain appears to be deficient.
This situation must improve in order to phase out the
use of nursing interventions not recommended for PU
prevention. In the 21st century, we simply cannot allow
more than half of the teaching centers that offer a degree
in nursing to ignore the prevention of PUs in their course
content. This change must be implemented in required
courses, because there are almost no elective courses re-
lated to the prevention and treatment of chronic wounds.
Degree programs responsible for preparing future
nurses must guarantee the acquisition of minimum basic
skills in the prevention and treatment of chronic wounds.
University programs in all countries should review their
curricular offerings and take steps to reduce the theory–
practice gap in this field.
Acknowledgments
We appreciate the translation and manuscript editing
provided by Elaine Lilly, PhD. Preliminary results of this
study were presented at a GNEAUPP Symposium (IX
Simposio Nacional GNEAUPP. Ciencia, Arte y Compro-
miso) held in Sevilla November 14–16, 2012.
Clinical Resources
� European Pressure Ulcer Advisory Panel: http://
www.epuap.org
� European Wound Management Association: http://
ewma.org/english.html
� Spain’s official database of universities, centers,

and diplomas [Registro de Universidades, Cen-
tros y Tı́tulos (RUCT)]: https://www.educacion.
gob.es/ruct/home#
� Spanish Pressure Ulcer and Chronic Wounds Advi-
sory Panel: http://www.gneaupp.org
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permission.
CLINICAL SCHOLARSHIP
Health Empowerment Among Immigrant Women in

Transnational Marriages in Taiwan
Yung-Mei Yang, PhD, RN1, Hsiu-Hung Wang, PhD, RN,
FAAN2, Fang-Hsin Lee, PhD, RN3, Miao-Ling Lin, MN,
RN4, & Pei-Chao Lin, MSN, RN5
1 Assistant Professor, College of Nursing, Kaohsiung Medical
University, Kaohsiung, Taiwan
2 Professor, College of Nursing, Kaohsiung Medical University,
Kaohsiung, Taiwan
3 Assistant Professor, Department of Nursing, Chung Hwa
University of Medical Technology, Tainan, Taiwan
4 Section Head, Department of Health, Kaohsiung City
Government, Kaohsiung, Taiwan
5 Doctoral Candidate, College of Nursing, Kaohsiung Medical
University, Kaohsiung, Taiwan
Key words
Marriage migrant women, health
empowerment, participatory action research
Correspondence
Dr. Hsiu-Hung Wang, Professor, No. 100,
Shih-Chuan 1st Rd., Kaohsiung 80708, Taiwan.
E-mail: [email protected]
Accepted: August 31, 2014
doi: 10.1111/jnu.12110
Abstract
Purpose: The aim of this study was to develop, implement, and
evaluate
a theory-based intervention designed to promote increased

health empower-
ment for marriage migrant women in Taiwan. The rapid increase
of interna-
tional marriage immigration through matchmaking agencies has
received great
attention recently because of its impact on social and public
health issues in the
receiving countries.
Design and Methods: A participatory action research (PAR) and
in-depth
interviews were adopted. Sixty-eight women participated in this
study. Eight
workshops of the health empowerment project were completed.
Findings: Through a PAR-based project, participants received
positive out-
comes. Four outcome themes were identified: (a) increasing
health literacy,
(b) facilitating capacity to build social networks, (c) enhancing
sense of self-
worth, and (d) building psychological resilience.
Conclusions: PAR was a helpful strategy that enabled
disadvantaged migrant
women to increase their health literacy, psychological and
social health, and
well-being.
Clinical Relevance: The findings can be referenced by the
government in
making health-promoting policies for Southeast Asian
immigrant women to
increase their well-being. Community health nurses can apply
PAR strategies
to plan and design health promotion intervention for
disadvantaged migrant
women.
The rapid increase of international marriage immigration

through matchmaking agencies has received great atten-
tion recently because of its impact on social (e.g., demo-
graphic structure and culture) and public health (e.g.,
healthcare services) issues in the receiving countries.
The U.S. Citizenship and Immigration Services (2013)
reported that the “mail-order bride” business results in
4,000 to 6,000 marriages between U.S. men and foreign
women each year. In Asian countries, an increasing num-
ber of women from Mainland China, Vietnam, Indone-
sia, the Philippines, Thailand, Malaysia, and Cambodia
have migrated through international marriage to Taiwan,
Singapore, Japan, South Korea, and Hong Kong (Hsia,
2010). In Taiwan, the immigration of Southeast Asian
brides started in 1987 in rural areas of Taiwan (Yang &
Wang, 2012). However, the number of undocumented
international marriage immigrant women is often under-
estimated. According to Taiwan’s Ministry of the Inte-
rior (2012), there has been an influx of 410,000 foreign
spouses in Taiwan, including 140,000 from Southeast
Asia and approximately 260,000 from Mainland China.
The Ministry of the Interior (2012) reported that the
overall immigrant population in Taiwan has grown dra-
matically, especially immigrants from Mainland China
Health Empowerment Among Immigrant Women Yang et al.
(318,390; 67.45%), Vietnam (87,274; 18.49%), Indone-
sia (27,648; 5.86%), Thailand (8,333; 1.77%), and the
Philippines (7,468; 1.58%), making the influx of racial or
ethnic immigrant minorities an increasingly challenging

social and public health issue.
For many women in developing countries, interna-
tional marriage immigration has emerged as a way to
escape poverty and achieve a better life by marrying
men from more financially developed countries. For
men in East Asia who experience difficulties finding a
wife, matchmaking agencies can arrange a trip to al-
low men to locate a partner in a few days and return
to their homeland with a new bride. The bridal candi-
dates, however, are called by many derogatory terms,
such as “mail-order brides” or “foreign brides,” and are
often treated with disrespect and derision in the receiving
country (Choe, 2005).
Health Care Among Immigrant Women
in Transnational Marriages
The growing number of immigrant women has be-
come a significant global concern in the social and public
health sectors. According to the United Nations’ Commit-
tee on the Elimination of Discrimination Against Women
(2009), immigrant women may not only be subject to
sex discrimination in their receiving country but also face
specific health challenges. Indeed, one of the primary
goals outlined in Healthy People 2020 is to eliminate
health disparities among different segments of vulnera-
ble populations, such as immigrants (U.S. Department of
Health and Human Services, 2013). Studies showed that
immigrant women in Taiwan not only tended to be more
vulnerable to illness but also experienced more barriers
to their health care than nonimmigrants. A cross-cultural
comparison indicated that Vietnamese immigrant women
in Taiwan had a generally lower health-related quality
of life than native Taiwanese women (Yang & Wang,
2011a). Lin and Wang (2008) investigated Southeast

Asian pregnant immigrant women and found they had
irregular prenatal examination behavior.
Immigration is a stressful, unexpected life event in
which immigrants experience a complicated process of
re-adaptation in the host society (Meleis & Lipson, 2004).
To cope with the challenges of living in a new coun-
try, marriage migrant women in Taiwan are also vulnera-
ble to psychological distress, which can negatively impact
their health and well-being (Yang, Wang, & Anderson,
2010). Moreover, greater acculturative stress increases
the risk for developing psychological problems, partic-
ularly in the initial months of immigrating to the new
host society (Berry, 1997). The lack of true friendships,
personal relationships, and social support in their host
country intensifies their loneliness and social isolation
(Yang & Wang, 2011b).
Marriage migrant women’s marginalized status and dif-
ficulties in accessing adequate health care indicate a lack
of empowerment to effectively seek the resources they
need to improve their health and well-being. Shearer
(2007) asserted that health empowerment may increase
one’s awareness in health and one’s own healthcare
decisions. Ensuring health empowerment among mar-
riage migrant women may improve their ability to access
health care, achieve better health, and overcome their
marginalized status in their receiving country. The aim
of this study was to develop, implement, and evaluate a
theory-based intervention designed to promote increased
health empowerment for marriage migrant women in
Taiwan.
Methods

Design and Theoretical Framework
Action research is an interactive research process that
equalizes problem-solving actions implemented in a col-
laborative framework with data-driven analysis or an in-
quiry to understand underlying causes enabling future
expectations about personal and organizational change
(McNiff, 2013). Participatory action research (PAR) is
based on critical social theory; it is conducted to realize
and transform the world, collaboratively and reflectively
(Reason & Bradbury, 2008).
PAR was used to develop the intervention of this
health empowerment project (HEP). The bottom-up
approach of PAR was chosen as the most appropriate
method to develop and evaluate an intervention program
designed to empower an especially marginalized and
oppressed population (Minkler & Wallerstein, 2010).
Previous researchers have documented PAR as an
empowerment-based inquiry methodology that bridges
the gaps between knowledge and daily lives and equal-
izes the power between researcher and participants (Tapp
& Dulin, 2010). It promotes the research participants’
ability to identify their own problems, make their own
priorities, handle their own solutions, and control their
own progress. In addition, Etowa, Bernard, Oyinsan, and
Chow (2007) considered PAR a user-friendly framework
for community-based inquiry and provided the model for
researchers and community members to work together
to identify problems, take action, and achieve the goal.
The essential elements of PAR are collaboration, partici-
pation, and reflection, which take place during multiple
cycles of planning, acting, and reviewing (Koshy, 2005).

Yang et al. Health Empowerment Among Immigrant Women
Intervention
Planning cycles. During the planning phases of
our PAR-based HEP, the specific health concerns of the
participants had been identified based on the previous
literature (Lee, Wang, Yang, & Tsai, 2013; Tsai, Cheng,
Chang, Yang, & Wang, 2014; Yang & Wang, 2011b), in-
cluding social isolation, acculturative stress, lack of health
information, and lack of health literacy. Investigators
established a collaborative relationship with community
partners, and integrated community resources. The re-
search team met with community partners several times
to discuss the appropriateness and effectiveness of the
health promotion strategies presented in the workshops.
Investigators established a preliminary curriculum.
To recruit participants, the research team established
community partnerships such as the local neighborhood
managers (the heads of the subdivisions of the districts),
the local Christian church, the primary healthcare center,
and the Management of Assistance Center for Foreign
Spouses. The community of interest was considered and
the appropriate consent procedures were implemented
for participants who were involved in the design of
the curriculum. We formalized an arrangement with
community leaders to establish contacts with community
partners, to build a trusting relationship between par-
ticipants and our research team, and to agree on a time
frame for the HEP.
Acting cycles. The goal of the various acting cycles

of our PAR project was to develop an HEP, implemented
as a series of eight workshops, in order to generate pos-
itive psychological and social changes among the partici-
pants. A major component of the HEP’s curriculum was a
holistic health concept, which included physical, psycho-
logical, and social well-being. The curriculum addressed
the following six topics: reproductive health (maternal
health and family planning); disease prevention (human
immunodeficiency virus, sexually transmitted illnesses,
cancer screening); healthcare system utilization (health
information and health insurance); cultural competence
(social support and acculturation); mental health (inter-
personal relationships and stress management); and the
special issue (domestic violence prevention and manage-
ment). The study’s principal investigator designed and
developed the preliminary curriculum based on previ-
ous studies (Lee et al., 2013; Wang & Yang, 2002) and
discussion with community leaders, and two instructors
presented the health information by means of various
activities conducted in the workshops, such as lectures,
demonstrations, drama, role-play exercises, group discus-
sions, and group presentations.
Reviewing cycles. During the multiple reviewing
cycles of the PAR project, the research team worked
with community partners to evaluate and reassess the
HEP during intermittent periods and at the final stage
of the program. Participatory observations and group dis-
cussions during the workshops, as well as in-depth indi-
vidual interviews with each participant at the conclusion
of the program, provided the participants’ points of view
and reflections during the PAR process. Feedback from
the participants was ongoing. For example, many partic-
ipants complained their husbands beat them after quar-
rels, so the special session on domestic violence in the
curriculum was in response to participants’ feedback in

the reviewing cycles.
Data generation and analysis occurred concurrently
and began in the early stages of the HEP, which enabled
the use of emerging themes and issues to guide group dis-
cussions in the workshops. The researchers’ role through-
out the reviewing cycles was to explore and stimulate
the participants’ reflections on their experience during
the HEP.
Participants and Setting
Among the 87 women who were invited to participate
in this study, 68 completed the eight workshops of the
HEP. The reasons of those who did not complete the
study included transportation problems, being forbid-
den to go outside by their mother-in-law, taking care of
young children, or moving out of the community. Eligible
participants were women who fit the following criteria:
(a) were marriage migrants from Vietnam, Indonesia, the
Philippines, Thailand, or Cambodia; (b) were married to
a Taiwanese man; (c) had a basic conversation ability in
Taiwanese or Mandarin; and (d) were willing to partic-
ipate in the study. Although immigrants from Mainland
China comprise the majority of the marriage migrants,
they were not included as part of the inclusion criteria.
This is because Mainland China migrants share the
same culture and speak the same language (Mandarin)
with Taiwanese. They can access more information by
themselves with no language barrier and have better
acculturation in Taiwan. The women from Vietnam,
Indonesia, the Philippines, Thailand, or Cambodia who
were included have all learned a new language since
immigrating. They need to learn Mandarin or Taiwanese
dialect to communicate with their husband and in-laws.
From June 2009 to February 2010, eight workshops with

1-month intervals were held in a local church located
in Pingtung County, southern Taiwan. Each workshop
lasted approximately 3 hr, for a total of 24 hr of contact
time with study participants throughout the intervention
program. The participants were grouped into five groups
by ethnicity. Taiwanese dialect and Mandarin were the
languages used while conducting the workshops.
Data Collection
Two qualitative methods were used to collect data:
participatory observation and in-depth individual inter-
views. Participatory observation involved a member of
the research team taking field notes to record the in-
teractions and activities in each of the eight workshops
throughout the entire health empowerment program.
The content of these field notes included observations on
the setting arrangement, the participants, group dynam-
ics, and interactions between participants, group presen-
tations, and the premeeting with community partners. At
the conclusion of the program, another member of the re-
search team conducted in-depth individual interviews to
gain a deeper understanding of the personal experience
of each study participant. We developed a semistructured
interview guide to elicit responses from each participant.
The individual interviews were conducted for 60 to 90
min and were tape recorded and transcribed.

Ethical Considerations
The institutional review board of Kaohsiung Medical
University, Taiwan, approved the research and proce-
dures before the study began. The participants in the
study did not experience any physical harm, discomfort,
or psychological distress. They were fully aware of par-
ticipating in a study, and they understood the purpose of
the research by giving their informed consent. The study
procedures were fully described in advance to each par-
ticipant, the participants had an opportunity to decline
to participate, and appropriate consent procedures were
implemented.
Data Analysis
Following guidelines recommended by Miles and
Huberman (2013) for qualitative data analysis, three
members of the research team used the transcribed data
for a thematic analysis to examine the qualitative data,
which were categorized based on prominent theme pat-
terns expressed in the text of the individual interviews
with participants. First, the researchers applied categories
to each transcript code. They read and analyzed all the
transcripts in a three-stage process of data analysis and
synthesis, as recommended by Rice and Ezzy (2001). The
verbatim transcripts of the 68 interviews in our study
generated a codebook of 36 units. In the next stage, the
same three researchers used the focused coding method
for the second coding cycle. They met together and,
through peer discussion and agreement, recategorized
the 36 coding units. Finally, on the basis of the coding,
the principal investigator of our research team identi-
fied themes that integrated substantial sets of the coding
units. Data were collected by two trained, bilingual re-

search assistants who were proficient in Taiwanese dialect
and Mandarin and had each obtained a bachelor’s degree
in nursing.
Rigor
Rigor was guided by the process of trustworthiness
(Lincoln & Guba, 1985). Prolonged engagement and
peer debriefing were used to assess the credibility of the
themes. To ensure dependability, the principal investiga-
tor conducted an 8-hr training session for the research
assistants, advising them on the inclusion and exclusion
criteria of the study and instructing them in the use of
interviewing techniques, participatory observation skills,
and field-study knowledge to ensure reliability. In addi-
tion, thick description of text and field notes enhanced
research transferability.
Results
Sixty-eight marriage migrant women in Taiwan partic-
ipated in and completed this study. Participants ranged
in age from 20 to 42 years, with a mean age of 32.4
years (SD = 4.6). Their spouses’ ages ranged from 27 to
72 years, with a mean age of 42.5 years (SD = 4.34).
The participants’ original nationalities were Vietnamese
(n = 42, 61.8%), Thai (n = 12, 17.6%), Indonesian
(n = 8, 11.8%), Filipino (n = 5, 7.3%), or Cambodian
(n = 1, 1.5%). The women’s length of residency in Tai-
wan ranged from 2 to 12 years, with a mean length of
stay of 8.3 years (SD = 2.6). The levels of education for
most of the participants before immigrating to Taiwan
were elementary school and junior high school (n = 62,
91.2%). The highest level of education for most of the
women’s spouses was junior high school or high school
(n = 60, 88.2%). Among the participants, 53 (77.9%)

were housewives.
Through an inductive thematic analysis, the follow-
ing four outcome themes emerged from the data: (a) in-
creasing health literacy; (b) facilitating capacity to build
social networks; (c) enhancing sense of self-worth; and
(d) building psychological resilience.
Increasing Health Literacy
Health literacy is defined as the degree to which
individuals have the capacity to obtain, process, and
understand basic health information and services (Speros,
2005). The immigrant women in our study had poor
health literacy and, consequently, experienced many bar-
riers to accessing and using healthcare services. For in-
stance, one woman said she didn’t know “what is Pap
smear or cervical cancer screening and how much it cost.”
Participants were not aware that the Taiwan’s National
Health Insurance (NHI) program in Taiwan offers a free
annual cervical screening to women 30 years of age and
older. They not only lacked awareness about NHI and
affordable medical care resources but also experienced
language difficulties that prevented them from learn-
ing about illness prevention and health promotion. One
woman shared her experience about feeding her baby:
“I chose wrong baby milk formula because I cannot read
the instruction on milk bottle.” After attending the work-

shops for our HEP, the participants reported that they
felt more informed about healthcare information and re-
sources. For example, one of the participants said:
When I arrived here [in Taiwan], I very quickly became
pregnant. Because I am not a citizen, I thought I
am not covered by the National Health Insurance.
My husband and I didn’t know that we can have
free prenatal examinations and obstetrical services
provided by primary healthcare centers. We spent a
lot of money to visit a private clinic. Now, through
this workshop, I know where I can get medical care to
help me.
The participants’ increased health literacy and knowl-
edge about illness prevention and health promotion
prompted them to change their behavior in favor of
more healthy choices. For example, one of the par-
ticipants decided to change her use of an oral pill to
the use of condoms for contraception and safer sex.
The increased exchange of health-related information
and resources provided in the workshops improved the
immigrant women’s decision-making skills and their
ability to apply these skills in health-related situations.
For example, one of the participants who experienced
domestic violence stated:
From the special issue workshop on domestic violence
prevention and management, I learned that nobody
has the right to hurt another’s body. My husband beat
me and the kids. Now, I will call 113 for help and will
have free-of-charge medical treatment.
Facilitating Capacity to Build Social Networks
Many of the participants experienced extreme lone-

liness and isolation in their community. They missed
their friends and family and the familiar culture of their
homeland. Moreover, their husbands and in-laws often
forbid them to leave the house, preventing them from
developing new friendships with others. The women
reported that attending these workshops helped alleviate
their sense of loneliness and facilitate their capacity to
build social networks in the community. By the end
of program, participants had developed small, informal
groups that would arrive early to the workshops in order
to chat with each other and enjoy the company of other
participants. These advantages of attending the program’s
workshops are described in the following statements
from participants:
To get in touch with other immigrant friends is the
happiest thing I have. I look forward to the workshops
because this is a chance I can go out and meet friends
from the same country. My family is afraid that the
“bad friends” might influence me.
The women’s shared ethnicities and personal interac-
tions with other participants at the workshops provided
them the opportunity to develop friendships that offered
strong emotional support, which reduced their feelings
of loneliness and social isolation. Attending the work-
shops helped them facilitate their capacity to build social
networks and communicate with their husbands and in-
laws to decrease social isolation. One participant stated
that “After the teaching, I have learned to use better way
to talk with my husband and mother-in-law, not just al-
ways keep silent. They have more patience to communi-
cate with me.”
Enhancing Sense of Self-Worth

The participants in our study reported that they
suffered discrimination and oppression from their new
family. The women’s original culture was ignored,
suppressed, and even discriminated against by their
Taiwanese in-laws. Moreover, because most of the
women spoke Mandarin, they could easily be identified
as foreigners by their accent in the eyes of the Taiwanese
public. Consequently, the women remained silent and
were submissive to their in-laws.
The workshops used role-play activities, team pre-
sentations, and group discussions designed to increase
the women’s confidence in their ability to speak out
for themselves. After attending the workshops, the par-
ticipants described feeling more confident in problem-
solving and seeking better health care for themselves and
their family members. As one participant noted, “I had
a better understanding of taking care of myself and my
family.” Another participant said:
My mother-in-law won’t let my children get close
with me. They [in-laws and husband] say I am a
foreigner. They try to persuade the kids their mother
is an ignorant person, don’t ask me questions because
I know nothing. Now, I have learned lots of things. I
have more knowledge to manage my life. I can teach
my children.

Some of the participants experienced physical abuse by
their husbands and, in some cases, their in-laws. In the
special section workshop on domestic violence preven-
tion and management, participants learned about rescue
resources, their legal rights, and the hidden health prob-
lems related to abuse. After attending the workshop, the
women described feeling more self-empowered and more
confident in dealing with and overcoming domestic vio-
lence. For example, one participant mentioned:
Now I know my human rights, that nobody can beat
me. I can call the 113 protection hotline for help. They
[mother-in-law and husband] have no right to beat
me. Before attending the workshops, I thought I was
stupid. If I do something wrong, my mother-in-law
will slap me, and my husband will kick me when he
is drunk.
Building Psychological Resilience
The participants felt burdened with the stress of accul-
turation and its psychological effects, such as emotional
distress. This form of distress was reflected in the follow-
ing statement from one of the women:
I can’t sleep very well, and I often cry in the middle of
the night. I miss my home town. Immigration marriage
in Taiwan is a challenge and a bet. Our lives are filled
with hardships, such as no money in my pocket most
of the time. If I fight with my husband, I have nowhere
to go.
Attending the HEP, however, helped the participants
transform their life distress into a more positive outlook.
They resolved to make a greater effort to successfully
adapt to their new home in Taiwan. During the work-

shops, they discussed the need to increase their ability
to endure the difficulties in life by accepting the chal-
lenges as their destiny and focusing on their children’s
future. Successfully caring for and raising their children
became the women’s main purpose in life. For example,
one participant stated:
I have learned this for my children. I can bear the
hardships in life. Sisters, we must stay in Taiwan,
because this is our home, now we are mothers and
daughters-in-law. In the future, we will be other
women’s mother-in-law. So we keep going and take
care of our kids; they are our roots in Taiwan.
Discussion
The findings from our study not only confirm the
disadvantaged status of marriage immigrant women
in Taiwan and their vulnerability to health risks, but
also demonstrate the effectiveness of PAR as a useful
strategy to empower these women to make sustainable
and beneficial changes in their health and well-being.
The study participants had poor health literacy and
limited knowledge about medical care resources. This
finding is consistent with previous studies that found
immigrant women tend to have low levels of health
literacy, which acts as a barrier to seek out and access
appropriate health care (Kreps & Sparks, 2008; Lee
et al., 2013; Tsai et al., 2014). The women in our study
were unaware of such helpful resources as Taiwan’s
NHI, migrant welfare program, free services and medical
checkups provided by the local health centers, and
the telephone hotline number for domestic violence
protection. Findings from previous studies showed

that health literacy is vital for promoting health and
health-promoting behaviors (Speros, 2005; Von, Knight,
Steptoe, & Wardle, 2007). However, the health literacy
of the marriage immigrant women in our study was
poor. Therefore, we recommend that health promotion
strategies and interventions for migrant women focus
on improving their health literacy. Strategies can include
the development of comprehensive, translated health
information media for distribution to the women.
The study participants’ difficulties with language and
communication created another barrier to their ability
to effectively seek out and use Taiwan’s healthcare ser-
vices and resources. This finding supports similar results
from other studies that examined the health concerns of
marriage immigrant women (Hsia, 2010; Hung, Wang,
Chang, Jian, & Yang, 2012). Having difficulties in learn-
ing to speak and understand a new language often pro-
hibited the women from effectively communicating with
healthcare providers.
The study participants were further isolated by the ac-
tions of their husbands and in-laws who intentionally
prevented the women from going out alone and making
social contacts for fear the women might try to run away
and return to their homeland. This form of marginaliza-
tion and oppression is evident in other studies that focus
on health and social issues of marriage migrant women
in Taiwan (Yang & Wang, 2003). Our results are consis-
tent with previous studies in which PAR was found to
be a valuable strategy for developing a model of health

empowerment that promotes positive health behaviors,
improves access to community health services, and en-
hances healthcare policies that support the rights of indi-
viduals (Meyer, Torres, Cermeño, MacLean, & Monzón,
2003; Minkler & Wallerstein, 2010).
We also found that healthcare professionals can
play an important role in advocating for disadvantaged
women by participating in community advocacy orga-
nizations and serving as spokespersons for the needs
of immigrant women within the community and the
healthcare system. During the research process, we
collaborated with the local media to call attention to
the challenges that marriage migrant women face and
to arouse community concern. The local newspaper
published an article on the workshop activities, and
a reporter from a television program interviewed the
research team members who described the problems and
needs of migrant women in Taiwan.
Study Limitations
The study has some limitations. First, in our study,
convenience and snowball sampling was used to re-
cruit participants. The methods could have led to a ho-
mogeneous sample, resulting in findings that are not
representative of the entire population. Second, the in-
clusion criteria of the participants were limited to those
who had basic conversation ability in Taiwanese and
Mandarin. This would exclude those who could not speak
Taiwanese and Mandarin. A third limitation is that the
average length of residency in Taiwan was 8.3 years.
However, our participants live in a very remote area.

The social isolation is very severe, and health resources
and culturally appropriate education are limited. Even
though they have stayed in Taiwan for several years,
these women are still facing immigrant distress. And be-
cause recruiting was done in a remote area, transferability
of our findings may be limited to women who immigrate
into a remote area, and our findings may not reflect the
experiences of immigrant women in urban areas.
Conclusions
The study provides an example of a successful health
empowerment model for disadvantaged immigrant
women and offers a framework for using the PAR
approach to advance the efforts of community agencies
and healthcare professionals. The present study can
inform government agencies in making appropriate
healthcare policies and in shaping a comprehensive,
health-promoting program that improves marriage mi-
grant women’s well-being. It is also recommended that
primary care centers offer counseling and support groups
for migrant women. Increasing the women’s social par-
ticipation through women-to-women discussion groups,
conducted in an atmosphere of confidence and trust, can
reduce their isolation. Also, providing immigrant women
with the opportunity to meet and share experiences with
other migrant women, especially those from the same
native country, can improve their social support. The
findings of this study can be used not only to understand
the current situation of health empowerment among
marriage migrant women in Taiwan but also to advocate
for the health rights of all disadvantaged immigrant
women and their families. Health professionals are
encouraged to continuously emphasize the importance
of identifying and addressing immigrant women’s health

needs in practice, theory, research, and health policy.
Acknowledgments
The authors extend appreciation to all the research par-
ticipants and community partners for sharing their ex-
perience. This study was funded by the National Science
Council, Taiwan (NSC 96–2628-B-037–041-MY3).
Clinical Resources
� Bureau of Consular Affairs, Ministry of For-
eign Affairs, Republic of China (Taiwan): http://
www.boca.gov.tw/mp?mp=2
� Committee on the Elimination of Discrimi-
nation Against Women: http://www.un.org/
womenwatch/daw/cedaw/
� National Health Insurance Administration Ministry
of Health and Welfare: http://www.nhi.gov.tw
� National Immigration Agency: http://www.
immigrat-ion.gov.tw
� Lite-on Cultural foundation: http://liteoncf.org.
tw/wealth/a2.htm
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Reproduced with permission of the copyright owner. Further
reproduction prohibited without
permission.
NSG3029 Foundations of Nursing ResearchWeek 3: Discussion
Question 2 (Choose one article)
Study 1: Course content related to chronic wounds in nursing
degree programs in Spain.

Brief Description of Method Employed:
Study 2: Health empowerment among immigrant women in
transnational marriages in Taiwan.
Brief Description of Method Employed:
Data Collection Steps (add more steps if needed)
Study – describe the process of how data were collected
Comments about the data collection
Step 1
Step 2
Step 3

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