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Wound Care: Improving Assessment and Management Practices in a Medical Unit

The Repercussions of Poor Wound Assessment and Management

Baringa Private Hospital is part of Ramsay Health Care located in the regional town of Coffs Harbour. It is a 78-bed hospital, with Surgical, Medical/Rehabilitation, Mental Inpatient, Intensive Care, and Day Inpatient Units. It provides advanced surgical procedures and interventional coronary angiography as well as endovascular, orthopaedic, and general surgery (Baringa Private Hospital, 2021).

Wound assessment and management are areas of poor practice, in particular on the Medical/Rehabilitation Unit at Baringa Private Hospital, which can be associated with a lack of competency and unwillingness to follow evidence-based practices on behalf of the Registered Nurse. This can lead to poorer patient outcomes, increased costs, and economic burden. Wound assessment tools and wound management is inconsistent and tends to avoid following best practice guidelines.

Patient Values

To provide the best patient-centred care, health professionals need to consider their patient's values in addition to the integration of scientific evidence (Bastemeijer et al., 2016). Bastemeijer et al., (2016), suggest that patient values can be categorised into three areas; personal values of a patient, the characteristics of the health professional that are valued by the patient, and the interactional relationship between the health professional and the patient. Despite evidence-based medicine [EBM] dedicating itself to the assurance that patient values and situations are well integrated with clinical expertise and evidence, there are inadequate methods to identify patient values and how to incorporate them into clinical decisions (Kelly et al., 2015).

Patient-reported experience measures [PREMs], have the potential to improve patient-centred care, improve the efficiency of care and generate data for the improvement of health care services (Squitieri et al., 2020). PREMs allow patients to impart feedback on the methods of clinical care they have received, and measure patient satisfaction (Squitieri et al., 2020). This has been shown to improve patient compliance and engagement of treatment, cultivate patient loyalty and retention, increase provider satisfaction and reduce medical malpractice (Squitieri, et al., 2020).

Patient's living with a wound may experience pain, reduced mobility, social isolation, anxiety and, low mood, which ultimately can affect overall wellbeing (Milne, 2014). Welsh (2018), states that those living with a wound negatively impacted their psychosocial health and overall wellbeing. Clinicians habitually focus on the management of the wound and cannot cope with the psychological effects on their patients (Milne, 2014). Clinicians should undertake a holistic assessment, incorporating shared decision-making for patients with a wound to improve their state of mind, their ability to cope with a wound, and overall health (Milne, 2014). By involving the patient in the treatment and management of their wound(s), listening to what patients want to discuss including decision-making, offering treatment choices, a sense of empowerment can be felt (Milne, 2014).

Professional Expertise

Wound care including assessment and management is complex, so to effectively treat chronic wounds the clinicians involved in the care of the patient and their wound(s) should be knowledgeable and possess the skills to improve and maximise patient outcomes (Welsh, 2018). Despite the increased focus on evidence-based practices and the advantages of following best-practice procedures, there is a reluctance for nurses to shift to evidence-based frameworks from practice-based experience (Welsh, 2018). Albeit wound care including assessment and management should include a combination of theoretical knowledge, contextual knowledge, and empirical knowledge to improve wound care practices (Welsh, 2018).

For health professionals to keep up with current wound management research, continuing professional development through education is crucial to ensure they are using best-practice to provide optimum wound care and patient outcomes (Martinengo et al., 2019). One barrier that health professionals have reported that limits their ability to attend educational courses for wound management, is that it is difficult to physically attend classroom lectures (Martinengo, 2019). Overcoming this barrier could include the implementation of digital education, which would enable the health clinician to improve and expand their knowledge on chronic wound management, practical skills, and behaviour changes within a more flexible environment (Martinengo, et al., 2019). Studies show that a combination of face-to-face learning in addition to digital education is essential and more effective than digital education alone, but digital education is far better than no intervention in respect to knowledge (Martinengo et al., 2019).

Health professionals make many decisions when looking after and treating their patients, and wound-care is one area where their decisions can affect the management of a wound and ultimately patient outcome (Gillespie, 2014). Wounds are not only a major source of morbidity to patients but can involve significant costs to health care organisations in the form of products, nursing time, and the utilisation of bed days (Gillespie et al., 2014). Clinical decision-making should include expertise, the use of accurate and relevant data, and the knowledge related to the presenting problem, but can be influenced by the availability of current technology, interpersonal relationships, and the presence or absence of experienced staff (Gillespie, 2014). To provide a balanced approach to wound assessment, there are three areas of decision-making processes that encompass both evidence-based knowledge and practice-based knowledge; utilisation of best-available information, consistent methods in wound assessment, and employing a multidisciplinary and holistic approach (Gillespie, 2014).

Wound care nurses have been recognised as playing a key role in the assessment and management of wounds and enhancing patient outcomes for individuals with a chronic wound, (Monaco et al., 2020). Studies involving the observation of wound care nurses' practices have been linked to improved outcomes such as healing and costs (Monaco et al., 2020). Wound care science is expanding and the need for highly qualified and specialised professionals is required to contribute to a multidisciplinary approach to the holistic management of patients with a chronic wound (Monaco et al., 2020). Wound care nurses would act as part of a team to provide care plans, participate in research, and play active roles in the assessment of new evidence-based products and/or technologies (Monaco et al., 2020).

Evidence-Based Research

The use of previous research systematically and transparently to develop a new study to answer questions is referred to as Evidence-based Research [EBR] and may focus on the consequences for stakeholders such as researchers, those who provide funds, and patients (Robinson et al., 2021). It is through knowledge that evidence can be attained, this evidence can then be utilised to inform clinical practice and comes from research and research methods (Liampittong, 2017). EBP in health care involves acquiring empirical evidence to support the claims of effectiveness of particular treatment options and establishing if they are relevant to the specific population/client (Liampittong, 2017).

By following evidence-based wound care along with coordinated care, improvements have been seen in regards to healing and lower recurrence rates, yet appropriate assessment of wounds is poor and is seen by significant gaps in the implementation of evidence-practice (Edwards et al., 2013). These evidence-practice gaps can be contributed to several factors, including a lack of skill and/or information, costs, limited access to specialists, and inadequate referral and treatment pathways (Edwards et al., 2013). By implementing best-practice pathways, not only are healing rates improved but as is reduced pain associated with wounds, improved independence in regards to activities of daily living, and psychological well-being (Edwards et al., 2013).

The use of evidence-based wound care products is important for all stakeholders involved in the treatment of wounds which includes patients, doctors, nurses, health care organisations, and manufacturers (Eskes et al., 2012). Eskes et al., (2013), believe that the choices various stakeholders make concerning wound care products are often not evidence-based regardless of the compelling evidence from research (Eskes et al., 2013). By using products that have been researched and based on evidence is pivotal in the quest for standardised and advantageous treatment options (Eskes et al., 2013).

Conclusion

Regardless of the extensive research, the proven benefits of evidence-based wound care practices for all stakeholders involved including patients, health professionals, and health care organisations, there is still a reluctance and/or lack of education on behalf of clinicians to combine evidence-based knowledge with practice-based knowledge. Improving wound care assessment and management practices can be improved by working with all stakeholders involved, and relevant parties should continue to update clinical guidelines when any new evidence has been researched and improvements in practices are discovered.

References

Baringa Private Hospital. (2021). About Baringa Private Hospital. https://www.baringaprivate.com.au/About-Us/About-Our-Hospital.

Bastemeijer, C., Voogt, L., van Ewijk, J., & Hazelzet, J. (2017). What do patient values and preferences mean? A taxonomy based on a systematic review of qualitative papers. Patient Education and Counseling, 100(5), 871-881. https://doi.org/10.1016/j.pec.2016.12.019

Edwards, H., Finlayson, K., Courtney, M., Graves, N., Gibb, M., & Parker, C. (2013). Health service pathways for patients with chronic leg ulcers: identifying effective pathways for facilitation of evidence-based wound care. BMC Health Services Research, 13(1). https://doi.org/10.1186/1472-6963-13-86

Eskes, A., Storm-Versloot, M., Vermeulen, H., & Ubbink, D. (2012). Do stakeholders in wound care prefer evidence-based wound care products? A survey in the Netherlands. International Wound Journal, 9(6), 624-632. https://doi.org/10.1111/j.1742-481x.2011.00926.x

Gillespie, B., Chaboyer, W., St John, W., Morley, N., & Nieuwenhoven, P. (2014). Health professionals' decision-making in wound management: a grounded theory. Journal of Advanced Nursing, 71(6), 1238-1248. https://doi.org/10.1111/jan.12598

Kelly, M., Heath, I., Howick, J., & Greenhalgh, T. (2015). The importance of values in evidence-based medicine. BMC Medical Ethics, 16(1). https://doi.org/10.1186/s12910-015-0063-3

Liamputtong, P. (2017). The Science of Words and the Science of Numbers. In P. Liamputtong (Ed), Research methods in health; foundations for evidence-based practice (3rd ed., pp. 3-26). Oxford University Press.

Martinengo, L., Yeo, N., Markandran, K., Olsson, M., Kyaw, B., & Car, L. (2020). Digital health professions education on chronic wound management: A systematic review. International Journal of Nursing Studies, 104, 103512. https://doi.org/10.1016/j.ijnurstu.2019.103512

Milne, J. (2013). 1: Improving wellbeing of those living with a wound. British Journal of Nursing, 22(Sup12a), 3-9. https://doi.org/10.12968/bjon.2013.22.sup12a.3

Monaco, D., Iovino, P., Lommi, M., Marano, G., Zaghini, F., & Vellone, E. et al. (2020). Outcomes of wound care nurses' practice in patients with pressure ulcers: An integrative review. Journal of Clinical Nursing, 30(3-4), 372-384. https://doi.org/10.1111/jocn.15583

Robinson, K., Brunnhuber, K., Ciliska, D., Juhl, C., Christensen, R., & Lund, H. (2021). Evidence-Based Research Series-Paper 1: What Evidence-Based Research is and why is it important?. Journal of Clinical Epidemiology, 129, 151-157. https://doi.org/10.1016/j.jclinepi.2020.07.020

Squitieri, L., Tsangaris, E., Klassen, A., Haren, E., Poulsen, L., & Longmire, N. et al. (2020). Patient‐reported experience measures are essential to improving quality of care for chronic wounds: An international qualitative study. International Wound Journal, 17(4), 1052-1061. https://doi.org/10.1111/iwj.13374

Welsh, L. (2017). Wound care evidence, knowledge and education amongst nurses: a semi- systematic literature review. International Wound Journal, 15(1), 53-61. https://doi.org/10.1111/iwj.12822