nursing dissertation wound care

Nursing School Theses, Dissertations, and Doctoral Papers

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Management of wounds in the community: five principles

Affiliations.

• 1 Specialist Registrar in Plastic Surgery, St George's University Hospitals NHS Foundation Trust, London.
• 2 Lead Nurse for Plastic Surgery, St George's University Hospitals NHS Foundation Trust, London.
• 3 Consultant Plastic, Reconstructive and Aesthetic Surgeon, BMI Hospitals.
• 4 Consultant Plastic and Reconstructive Surgeon, St George's University Hospitals NHS Foundation Trust, London.
• PMID: 31166795
• DOI: 10.12968/bjcn.2019.24.Sup6.S20

The care of any wound in the community requires multidisciplinary working between healthcare professionals. In this article, the authors offer five generalisable principles that colleagues providing community care can apply in order to achieve timely wound healing: (1) assessment and exclusion of disease processes; (2) wound cleansing; (3) timely dressing change; (4) appropriate (dressing choice; and (5) considered antibiotic prescription. High-quality wound care is an essential aspect of healthcare practice but lacks an evidence base and standardised practice at present. The practice and teaching of wound care should be more greatly emphasised in healthcare training for all disciplines.

Keywords: Antibiotic stewardship; Dressing change; Dressing choice; Wound assessment; Wound cleansing.

Publication types

• Case Reports
• Community Health Nursing
• Patient Care Team*
• Practice Patterns, Nurses'*
• Skin Ulcer / nursing
• Skin Ulcer / prevention & control*
• Surgical Wound Infection / nursing
• Surgical Wound Infection / prevention & control*
• Wound Healing*

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Adderley U, Evans K, Coleman S. Reducing unwarranted variation in chronic wound care. Wounds UK. 2017; 13:(4)22-27

Being patient with EBM. ‘Just because we can does not mean we should’—supporting informed decision-making Evidence for Everyday Health Choices series. 2018. https://tinyurl.com/yarpxwkh (accessed 1 March 2019)

Antibiotics and antiseptics for wounds: evidence and ignorance. Evidence for Everyday Nursing series. 2016. https://tinyurl.com/yxa22lcz (accessed 1 March 2019)

Chapman S. Venous leg ulcers: an evidence review. British Journal of Community Nursing. 2017; 22:S6-S9 https://doi.org/10.12968/bjcn.2017.22.Sup9.S6

Coleman S, Nelson EA, Vowden P Development of a generic wound care assessment minimum data set. J Tissue Viability. 2017; 26:(4)226-240 https://doi.org/10.1016/j.jtv.2017.09.007

Dealey C. The care of wounds: a guide for nurses, 4th edn. Chichester: Wiley/Blackwell; 2012

Fletcher J, Anderson I. Tissue viability and managing chronic wounds, 4th edn. In: Brooker C, Nicol M, Alexander MF (eds). Edinburgh: Churchill Livingstone/Elsevier;

Guest JF, Ayoub N, McIlwraith T, Uchegbu I, Gerrish A, Weidlich D Health economic burden that wounds impose on the National Health Service in the UK. BMJ Open. 2015; 5:(12) https://doi.org/10.1136/bmjopen-2015-009283

Joint Formulary Committee. Wound management products and elasticated garments. British National Formulary online. 2019. https://bnf.nice.org.uk/wound-management/ (accessed 1 March 2019)

Lindsay B. Understanding research and evidence-based practice.Exeter: Reflect Press; 2007

NHS England. Leading change, adding value: a framework for nursing, midwifery and care staff. 2016. https://tinyurl.com/h45wu74 (accessed 1 March 2019)

National Institute for Health and Care Excellence. Leg ulcer – venous. Clinical knowledge summaries. 2017. https://cks.nice.org.uk/leg-ulcer-venous#!topicsummary (accessed 1 March 2019)

National Pressure Ulcer Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP), Pan Pacific Injury Alliance (PPPIA). Prevention and treatment of pressure ulcers: quick reference guide. 2014. https://tinyurl.com/yck2mmr6 (accessed 1 March 2019)

Norman G, Westby MJ, Rithalia AD, Stubbs N, Soares MO, Dumville JC. Dressings and topical agents for treating venous leg ulcers. Cochrane Database Syst Rev. 2018; 6 https://doi.org/10.1002/14651858.cd012583.pub2

Scottish Intercollegiate Guideline Network (SIGN), Healthcare Improvement Scotland. Management of chronic venous leg ulcers. A national clinical guideline 120. 2010. https://tinyurl.com/y8wfh964 (accessed 1 March 2019)

UK Sepsis Trust, Royal College of Emergency Medicine. Toolkit: emergency department management of sepsis in adults and young people over 12 years. 2016. https://tinyurl.com/yylxdytw (accessed 1 March 2019)

UK Sepsis Trust. Community nursing sepsis screening and action tool. 2018. https://tinyurl.com/y3ljl63o (accessed 1 March 2019)

Worley L. Wound management, 9th edn. Student edition. In: Dougherty L, Lister S, West-Oram A. Chichester: Wiley-Blackwell;

Xiaoli Z, Ryan K. ‘When can I be free from my miserable leg?’ A qualitative study of patients' experiences of chronic leg ulceration in primary healthcare. International Archives of Nursing and Health Care. 2017; 3:(3) https://doi.org/10.23937/2469-5823/1510073

Current thinking on caring for patients with a wound: a practical approach

Sarah H Annesley

Senior Lecturer, Adult Nursing, Faculty of Health and Life Science, Northumbria University, Newcastle-upon-Tyne

View articles · Email Sarah H

Wound care is increasingly nurse led. This article describes the types and causes of wounds, the six domains needed for systematic wound assessment and the principles nurses can apply to ensure evidence-based wound care. The author argues for the importance of a patient-focused approach in the care of people with chronic and acute wounds. It highlights, when specialist referral may be needed and presents a case study explaining the difficulties of managing a patient with a wound at the end of life. Nurses care for people with wounds in a broad range of clinical settings and it is a real challenge to provide optimum patient outcome (wound healing) and a positive patient experience.

Patients requiring wound care can belong to any age group and are found across all areas of health care: in nursing homes, health centres, inpatient services or at home ( Guest et al, 2015 ). Holistic wound care draws on the skills of a broad range of healthcare disciplines but depends most on nurse-led assessment and treatment ( Guest et al, 2015 ). Nurses are central to ensuring optimal patient outcomes, positive experiences and the best use of resources for people with wounds ( NHS England, 2016 ). To deliver on these triple aims nurses are required to understand types and causes of wounds and their assessment ( Adderley et al, 2017 ), the evidence base which supports nursing care, and the physiology of wound healing ( Fletcher and Anderson, 2013 ).

For nurses, wound management can be challenging: wound healing consists of a series of interrelated processes dependent on several factors that impact on the rate of healing. Wound care should be evidence based but, as Chapman (2016) states, reliable clinical evidence to support best practice is lacking.

Healing of an open wound is defined as a ‘process by which damaged tissue is restored to normal function’ ( Worley, 2015: 746 ). Three physiological processes are involved:

• Primary intent, such as in the excision and removal of a mole, where the skin margins are brought together aseptically and closed with sutures or skin adhesive
• Secondary intent, where there is no clear incision, the wound is open and the margins of the wound cannot be brought together. In wounds such as leg or pressure ulcers secondary healing uses dressings to promote granulation of the wound bed. This healing process can take longer than primary or tertiary intent because there has been significant tissue loss, resulting in a large chronic wound and the risk of infection
• Tertiary intent, when a wound has resulted in a large amount of tissue loss and the skin margins cannot be brought together. In this case a skin graft is used to further wound healing ( Worley, 2015 ).

Types and causes of wounds

A wound is defined as any injury or damage to the integrity of the skin ( Dealey, 2012 ). This damage can be a consequence of traumatic injury by mechanical, physical and/or chemical impact, either intentional, as in a surgical incision, ischaemic due to a lack of sufficient blood supply (e.g. an ischaemic diabetic foot ulcer) and/or pressure, as in a sacral pressure ulcer ( Dealey, 2012 ).

The nursing assessment of a wound should include identification of its underlying cause(s). Some wounds result from a combination of factors. For example, an arterial leg ulcer may start as a traumatic physical injury to the lower leg that does not heal due to mechanical damage and which might include narrowing or occlusion of the peripheral femoral arteries. The reduced blood supply to the tissue means that the injured area receives inadequate oxygen and nutrients, so that the wound does not heal: a combination of physical trauma, mechanical issues and ischaemia has caused the wound.

Wounds may, consequently, be classified as either acute or chronic ( Worley, 2015 ). An acute wound is associated with trauma, immediate injury or surgery, with the resulting skin damage progressing through the healing phases. In a chronic wound the skin remains open and does not progress through the healing phases as expected.

Four interrelated phases in wound healing ( Box 1 ) commonly progress in a continuous rather than a discrete manner ( Fletcher and Anderson, 2013 ).

Awareness of the time periods associated with each phase is important, since they are dependent on a patient's overall state of health. If that is compromised by underlying morbidity, poor nutrition and/or infection, the healing process will be prolonged and the individual healing stages may take longer.

Phase I: haemostasis (a process that lasts minutes)

At the time of injury, the wound bleeds and the cavity fills with blood. Plasma proteins initiate platelet aggregation and the formation of a platelet plug. The clotting cascade in turn initiates a fibrin clot that strengthens the platelets' clot formation to establish haemostasis ( Worley, 2015 ). If a patient is on anticoagulation therapy, such as aspirin or low molecular weight heparin, then bleeding may be prolonged and the first requirement is to stop the bleeding by applying direct pressure.

Phase II: inflammation phase (lasts 4–5 days)

Inflammation is an important part of the body's natural response to injury. It is characterised by symptoms that we associate with acute injury, such as pain, swelling, heat and redness ( Dealey, 2012 ). Healing is delayed when there is a disruption to the inflammatory response, which may be caused by factors including, for example, ongoing foreign material in the wound, wound cleansing causing disruption to the wound bed and/or the presence of infection. In addition, poor nutritional status will delay healing because of the energy and nutritional resources needed to drive the inflammation phase on to the next healing stage. Effectively, wounds can become stuck in the inflammatory phase: an acute wound may become chronic and disabling for patients, as in venous leg ulceration.

Phase III: proliferation or reconstructive phase (lasts 3–24 days)

Phase III is marked by evidence of granulation tissue in the wound, which appears as visibly pink tissue, or by a change in wound shape. Often this phase can overlap with phase II; or, different parts of the wound may display different phases, so that some parts show evidence of granulation tissue and others sloughy tissue. An example of this may be a patient with a sternal incision after coronary artery bypass graft (CABG) surgery. Often, by day 10 to 14, the proximal aspect of a wound will be showing signs of proliferation and reconstruction, whereas the distal portion can appear inflamed, red and exuding serous fluid—all signs of continued inflammation.

Phase IV: maturation or remodelling phase (last from 21 days onwards)

Potentially lasting for more than a year, phase IV marks the return of the skin to normal function. It is characterised by epithelialisation and maturation ( Dealey, 2012 ). For maturation to commence we have to see granulation tissue in the wound and, in the case of a wound healing by secondary intent, this commonly happens from the wound bed upwards and may take a prolonged period, perhaps years. As epithelialisation is established the wound tissue is remodelled by the deposition of collagen fibres ( Worley, 2015 ).

The process of wound healing is not linear and, as illustrated in Box 1 , different parts of a wound might be at different stages. A wound may progress from phase II to phase III only for an infection to result in the wound returning to phase II. Determining which phase of healing a wound has reached is an important aspect of its ongoing assessment.

Wound care assessment

Wound assessment helps determine baseline wound information to support decision-making on the selection of appropriate dressings ( Worley, 2015 ). However, currently there is no agreed approach to assessing wounds in the UK ( Coleman et al, 2017 ) and consequently there is concern about unwarranted variation in chronic wound care ( Adderley et al, 2017 ).

As part of NHS England's (2016) nursing and midwifery strategy Leading Change, Adding Value there is ongoing work to develop a wound assessment minimum data set ( Coleman et al, 2017 ). Current thinking on the data needed for a wound assessment is a consideration of six domains:

• Information on the patient's general health
• Baseline wound information, including wound location, duration and type
• Wound assessment, including size (maximum length, width and depth)
• Wound symptoms, including pain, and amount of exudate
• Signs of local or systemic infection
• Further investigation or referral for specialist tissue viability support ( Adderley et al 2017 ; Coleman et al, 2017 ).

Delivering evidence-based wound care

The real world of practice demonstrates that, commonly, wound care is a nurse-led discipline ( Guest et al, 2015 ). Therefore nurses need to make informed choices about treatments in partnership with their patients. In wound care this is not as straightforward as it may at first appear, with a plethora of available treatments and dressing options ( Chapman, 2017 ). When faced with this confusion it is good to reflect on a few basic principles and be aware that evidence-based practice (EBP) is not solely dependent on the best available research evidence. EBP in nursing includes patient experience and preferences, and the experience and knowledge of the nurse, to ensure delivery of the most effective care ( Lindsay, 2007 ).

Cleansing the wound

The function of wound cleansing is to prepare the wound bed and create an optimum healing environment ( Worley, 2015 ). It should not be assumed that cleaning a wound is always required and, indeed, in certain circumstances it can be detrimental, damaging newly formed granulating tissue and precipitating a drop in wound bed temperature, both of which may set back healing ( Dealey, 2012 ; Worley, 2015 ). If a wound is to be cleansed the recommended products are 0.9% saline (common for surgical wounds) and tap water (common for chronic wounds). The use of topical antiseptics, such as povidone iodine in pressure ulcers and leg ulcers, is not supported by research evidence, with no benefit demonstrated despite the persistent use of these products in practice ( Chapman, 2016 ).

A practical approach, therefore, is to advocate careful wound cleansing in acute wounds using sterile 0.9% saline, as part of a nurse's overall assessment of the wound; and, in chronic wounds, with body temperature tap water. This provides an opportunity to assess the wound close up and support patient comfort and relief (for example, if a patient is anxious about wound odour or exudate).

Dressing a wound

Deciding on what topical dressing to apply to a wound bed is another area of much debate and discussion in the nursing literature, with little research to support practice. The lack of EBP leads to wide variation in practice between individual nurses and to inconsistencies in wound dressing over the course of treatment. A recent review by Norman et al (2018) was unable to demonstrate that dressings or topical agents offered any beneficial effect on healing, highlighting the challenges of clinical decision-making. Since the evidence base is so poor, some basic principles of wound dressing provide the best guidance on what to use, and when.

Table 1 provides some principles to adhere to when dressing a wound to act as a guide to decision-making.

Psychological support for people with wounds

Wounds have a psychological as well as physical impact on people and as part of a patient-centred assessment nurses should consider the impact of living with a wound, irrespective of the length of healing time. In turn, being aware of the psychological impact of a wound helps nurses to provide more sensitive care. Nurses should particularly assess for:

• Aspects of anxiety
• Any possible impact of the wound on body image
• Fear or fear of loss
• Grief, perhaps for loss of function or because the wound causes disfigurement ( Dealey, 2012 ).

Frustration and depression have also been associated with the experience of living with leg ulceration ( Xiaoli and Ryan, 2017 ). Overall, the negative impact of a wound on an individual's psychological wellbeing is significant and, potentially, as oppressive as the wound itself.

One positive approach to promoting awareness of psychological wellbeing in our daily practice is to consider flipping the conversations nurses have with their patients from ‘What's the matter with you?’ to ‘What matters to you?’ and ‘who matters to you?’ ( NHS England, 2016 ). These questions help to support a patient-centred approach to decision-making; patient involvement in care is an important element in evidence-based care ( Byatt and Chapman, 2018 ).

This article has highlighted some key considerations in the care and support needed for patients with wounds, both chronic and acute. Using an evidence- and practice-informed approach, it has drawn together current ideas that can inform our knowledge base. It has highlighted current research and gaps in evidence but also areas where new ideas, such as those promoting an agreed UK minimum data set on wound assessment, are being proposed.

Finally, the author argues that nurse-led wound care would benefit from asking, listening to and doing what matters to patients, providing care sensitive to the priorities, hopes and fears of people living with a wound.

LEARNING OUTCOMES

• Understand the importance of wound care as a nurse-led skill
• Know the different types and causes of wounds
• Understand the physiology of wound healing
• Know how to conduct an evidence-based wound assessment and the treatment options available
• Be able to identify the signs of infection in acute and chronic wounds
• Know when to seek specialist help
• Understand the importance of providing psychological support when caring for a patient with a wound

CPD reflective questions

• What can you do to enhance your understanding of the physiology of wound healing for the wounds you encounter most commonly in your clinical setting?
• Consider the six domains of wound assessment and how these could be used to improve patient assessment and documentation of wound care in your clinical setting
• Reflect on a patient who you have recently cared for and consider how their acute or chronic wound impacted on their everyday life

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• Volume 9, Issue 7
• What factors influence community wound care in the UK? A focus group study using the Theoretical Domains Framework
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• http://orcid.org/0000-0002-8088-0698 Trish A Gray 1 , 2 ,
• http://orcid.org/0000-0002-2657-5780 Paul Wilson 2 , 3 ,
• Jo C Dumville 1 , 2 ,
• Nicky A Cullum 1 , 2 , 4
• 1 Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health , University of Manchester , Manchester , UK
• 2 NIHR CLAHRC Greater Manchester , Salford Royal NHS Foundation Trust , Manchester , UK
• 3 Alliance Manchester Business School , University of Manchester , Manchester , UK
• 4 Research and Innovation Division , Manchester University NHS Foundation Trust , Manchester , UK
• Correspondence to Dr Trish A Gray; trish.gray{at}manchester.ac.uk

Objectives Research has found unwarranted variation across community wound care services in the North of England, with underuse of evidence-based practice and overuse of interventions where there is little or no known patient benefit. This study explored the factors that influence care in community settings for people with complex wounds, to develop a deeper understanding of the current context of wound care and variation in practice.

Design Qualitative focus group study using the Theoretical Domains Framework (TDF) to structure the questions, prompts and analyses.

Setting Community healthcare settings in the North of England, UK.

Participants Forty-six clinical professionals who cared for patients with complex wounds and eight non-clinical professionals who were responsible for procuring wound care products participated across six focus group interviews.

Results We found the TDF domains: environmental context and resources, knowledge, skills, social influences and behaviour regulation to best explain the variation in wound care and the underuse of research evidence. Factors such as financial pressures were perceived as having a negative effect on the continuity of care, the availability of wound care services and workloads. We found practice to be mainly based on experiential knowledge and personal preference and highly influenced by colleagues, patients and the pharmaceutical industry, although not by research evidence.

Conclusions Our study provides new insight into the role that experiential learning and social influences play in determining wound care and on the limited influence of research. Workforce pressures and limited resources are perceived to impede care by reducing patient access to services and the ability to provide holistic care. Participative collaboration between university and healthcare organisations may offer a supportive route to addressing issues, implementing sustainable changes to practice and service delivery and a resolute commitment to research use among clinical professionals.

• qualitative research
• focus group
• wound management
• healthcare professional
• healthcare quality
• theoretical domains framework

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/bmjopen-2018-024859

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Strengths and limitations of this study

This focus group study is the first to explore the factors that influence wound care and the reasons for known variation in practice.

Employing a qualitative methodology provided new insight into the role experiential learning and social influences play in determining clinical and procurement choices.

The focus group design stimulated discussion allowing participants to examine their own and others’ views and experiences.

The Theoretical Domains Framework provided a theoretical structure for developing a deeper understanding of wound care delivery.

The sample was taken from community healthcare organisations in the North of England, inclusion of participants from a larger geographical population may have provided different views.

Introduction

People with complex wounds (open wounds, such as foot, leg and pressure ulcers, burns, open trauma and surgical wounds that are difficult to heal), 1 2 are more likely to be elderly and living with multimorbidity. 3 In the UK, the management of people with complex wounds 1 2 is mainly carried out in patients’ homes or community clinics by community nurses with advice and support from specialist teams (nurses and medics with expertise in tissue viability, burns, vascular medicine or dermatology). Podiatrists also play a vital role in managing complex foot wounds, often working in conjunction with community nurses.

Care of complex wounds in community settings normally includes a comprehensive assessment of the person and their wound (involving demographics, risk factors for wound healing, quality of life measures, wound status, wound parameters and symptoms), specific wound-related assessments such as Ankle Brachial Pressure Index (ABPI) for people with venous leg ulcers and implementation of appropriate interventions. 4 Interventions may involve wound cleansing followed by dressing to manage exudate and protect the wound. While dressings are used widely across wound types, with many different options available, there is currently no evidence that one dressing type is more clinically or cost-effective than another, even in the case of relatively expensive antimicrobial dressings. In contrast, there are effective first-line treatments which should be widely used, such as the use of compression therapy for venous leg ulceration which is known to reduce time to wound healing. 5 6

As part of a wider programme of wound care research funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Greater Manchester (NIHR CLAHRC GM) , we conducted a survey to assess how healthcare professionals managed wound care across five community healthcare organisations in the North of England. 7 The findings are discussed in more detail elsewhere 7 but in summary the survey revealed unwarranted variation in clinical practice, with general underuse of Doppler-aided measurement of ABPI, 8 underuse of compression therapy and 9 potential overuse of antimicrobial dressings. 6 In the UK, variations in wound care are being recognised and addressed with initiatives such the Leading Change, Adding Value Nursing and Midwifery Framework 10 11 ; however, there has been little formal exploration of drivers for this variation in the delivery of wound care and barriers to implementing the findings from current research evidence. In turn, there is little intelligence to guide further research implementation and bring about meaningful practice change with the aim of maximising patient benefit.

Our aim was to identify and explore factors that influence care in community settings for people with complex wounds. We wanted to better understand the current context of community wound care and how research evidence informs care delivery.

We conducted six focus group interviews to explore the factors that influence the care of people with complex wounds in community settings. The Theoretical Domains Framework (TDF) was used to structure the questions, prompts and analyses. 12 13 The TDF provides a theoretical lens through which to view cognitive, affective, social and environmental factors that could potentially influence behaviour. 14 It has been used extensively across a range of clinical areas. 15–17 Its constructs are grouped into 14 discrete domains. 12 The TDF is presented in table 1 showing the domains, definitions and examples of behaviours related to wound care and wound product procurement.

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The Theoretical Domains Framework: domains, definitions and examples of behaviours related to wound care and wound product procurement

Participants and settings

Purposive sampling was used to ensure that we recruited participants with relevant clinical and/or procurement experience. Eligibility included community-based clinical professionals who cared for patients with complex wounds or non-clinical professionals who were involved in the procurement of wound care products. Clinical professionals included community nurses, podiatrists, tissue viability or burns specialist nurses, wound research nurses and clinical nurse managers (who had a clinical role, managed a team of community nurses and were responsible for wound product procurement decisions). Non-clinical professionals included: medicines optimisation pharmacists, procurement leads, procurement advisors and medicines management leads. There were five multidisciplinary focus group interviews for clinical professionals; one for each participating provider organisation. Four were drawn from provider organisations in one defined geographical area with a fifth conducted in a different geographical area but similar urban conurbation in the North of England. The latter was chosen for its well-established links with university researchers as a comparison to the other organisations where collaborative partnerships with university researchers were in their infancy. A separate focus group interview was held for non-clinical professionals. As the themes for clinical and non-clinical focus group interviews differed, we chose to separate clinical from non-clinical professionals to maintain focus and create an optimum environment for free flowing discussions. Potential participants were identified through contacts developed as part of the NIHR CLAHRC GM wound care programme and were approached via email, telephone or face-to-face meeting. Focus group interviews were held locally to participants’ work place in a healthcare setting or conference centre.

As participants were drawn from a relatively homogeneous population and the interview schedules were focused on specific aspects of wound care and wound product procurement, we anticipated that we would reach data saturation within three to four focus group interviews; however, to incorporate all partner provider organisations using the format described above we needed to recruit 50–60 participants in total across the six groups (to allow for 8–10 participants per group), based on recommendations from existing literature. 18–21

Data collection

The format was similar for all focus group interviews; they were facilitated by a lead (TAG) with one or two co-facilitators (PW and JCD). All facilitators were experienced researchers and familiar with the evidence base for wound care. A fourth member of the research team took field notes. Before the session began, participants were asked to complete a brief demographic questionnaire to clarify their academic and professional qualifications and wound care/product procurement experience as relevant; these data were used to describe the participants involved and were not linked to particular responses or quotes. Each session was audio-recorded with recordings deleted following verification of anonymised transcripts.

The discussion explored specific behaviours linked to the TDF domains and reactions to site-specific, regional and national procurement data using the questions and prompts outlined in online supplementary appendix 1 . Clinical professionals were encouraged to think about factors that from their experience, enable or hinder the delivery of wound care, relating their answers to their own experiences. Through prompts we probed further, allowing participants’ reactions to unfold, giving them the opportunity to explore their own and others’ views. We continued to prompt if responses were not spontaneously offered to encourage full participant engagement. The focus group interview for non-clinical professionals followed an identical format with the questions more related to procurement systems and procedures (online supplementary appendix 2 ). Interview schedules were piloted by specialist nurses, clinical managers and a procurement lead, after which minor amendments were made. Respondents validated the accuracy and completeness of the findings 22 following a verbal summary (taken from the field notes) at the end of each focus group interview and a post-analysis report sent via email.

Supplemental material

Patient and public involvement.

Views expressed by members of the NIHR CLAHRC GM Wounds Research PPI Forum about their experiences with healthcare professionals and wound care services were used to inform some of the questions and prompts for the focus group interviews.

Data analysis

Quantitative data were stored in SPSS (IBM v.22). Demographic variables are expressed in frequencies, means and SD where distributions are normal, and medians and range when skewed. Qualitative analysis followed a seven-step process in line with the framework method ( figure 1 ). 23–25

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Qualitative analysis using a seven-step framework method.  

Participant characteristics

Sixty participants were invited to attend one of six focus group interviews (mean duration: 106 min). Fifty-four participants attended while nine invited participants could not attend due to other clinical commitments or annual leave (three of whom nominated colleagues to attend in their place). Participants comprised 46 clinical professionals (10 specialist nurses (19%), 25 community nurses (46%), 7 podiatrists (13%), 3 clinical managers (5%) and 1 research nurse (2%)) and 8 non-clinical professionals (15%). Wound care experience was extensive (mean 14.6 years, SD 8.8) among clinical professionals ( table 2 ).

Participant characteristics (n=54)  

Key themes identified within relevant domains

Five TDF domains dominated: environmental context and resources , knowledge, skills, social influences and behaviour regulation . The domains of knowledge and skills were closely linked and frequently overlapped, therefore, we combined these. We did not code any source data to the domains of emotion and intentions and found the remaining six domains to overlap with the five dominant domains. We have therefore, focused on the five key domains which best explain the variation in wound care and the underuse of research evidence. The coding tree ( figure 2 ) demonstrates the relationships between domains and subthemes.

Coding tree showing the four salient domains with connected subthemes.

Environmental context and resources

Delivery of care.

Clinical professionals across all groups expressed feeling the pressure of increased workloads. Some participants said they were working more intensely and without breaks, constantly feeling anxious that they may have missed something as time was limited between patient consultations. They reported that there was an increase in sick leave, experienced colleagues were leaving and their roles were left vacant.

You haven’t got the same skill base any more. We haven’t got the same expertise, we’re losing our experienced link nurse this week, and we haven’t really got anybody with that level of skill in wounds to take her place…we’ve got 30 vacancies at the moment that haven’t been filled. (Clinical manager)

Community nurses reported that specialist clinics were being cut, and patients previously seen in dedicated leg ulcer clinics by nurses with specialist knowledge, were now visited at home by understaffed community nursing teams.

Physically running the clinic was based on when there was about six or seven (leg ulcer specialist) staff. …when it was a leg ulcer service. There’s only two of us so we haven’t got the capacity to cover those let alone do all the home visits. (Community nurse)

Community nurses and podiatrists voiced concern that undue time was spent gathering required patient information due to poor referral information supplied by hospital staff.

You constantly are ringing because they’ll (ward staff) put (on the referral) ‘care of wound’, but… what wound have they got? What operation have they had? What would you like me to do with it? It’s very, very poor. (Community nurse)

Variation in care and services

Many clinical participants attributed variation in the patterns of care delivery to realignment of services due to reduced funds. The majority of clinical professionals reported that specialist leg ulcer clinics had been cut resulting in a greater number of home visits for community nurses. Participants from the research active organisation reported that practice nurses (nurses based in a general practitioner practice providing primary care for a local population) managed mobile patients with wounds, while community nurses cared for housebound patients with more complex health needs. This changed model of service delivery was felt by the community nurses to have eased their workload.

Participants from organisations that managed both hospital (acute) and community services felt that resourcing prioritised the acute service at the expense of the community service. Participants made reference to the differences between resources available in acute care that were limited or unavailable in the community; this included wound care products and digital technology.

I just don’t feel the acute side has got a grip at all on community services in terms of what we do…I mean, I do a specialist (acute) clinic on a Tuesday morning and have access to all sorts of dressings. And I come back into the community….and we’re very limited, we’ve got one foam (dressing) that we can use. (Podiatrist)

Clinical participants viewed access to photographic equipment as a valuable resource that allowed images of wounds to be sent to a podiatrist or specialist nurse for rapid diagnosis and care planning, however, only healthcare professionals with access to hospital photographic equipment could make use of this service. One specialist nurse apologised for using photographic equipment that the community nurses within her organisation did not have access to.

I do (take photographs of wounds). I’ve got a camera. Sorry. It is downloaded onto a programme at the hospital. So that’s probably why (I have access to it). (Specialist nurse)

Variation in product procurement

Participants reported a variety of wound care product procurement processes; some (across two provider organisations) obtained all products via prescription, others (across two provider organisations) used a combination of prescribing and stock purchase and one group (one organisation) operated a total stock purchase system. All participants noted the local use of wound care formularies (a locally developed list of recommended products), to guide prescribing or purchasing decisions, 26 however, through discussion it was recognised that the products listed and the number of product available varied across formularies. One organisation had a very restrictive formulary and monitored use closely; participants found this restrictive formulary enabled them to choose appropriate products.

I think it’s an enabler, … there are so many (dressings to choose from) you can go completely for something that costs so much and something that wouldn’t be right … but having that formulary means that we know what we can choose. (Community nurse)

Knowledge and skills

Education and training.

All nurse participants agreed that there was a limited amount of wound care education for student nurses and that most wound care knowledge and skills were gained through community placements rather than in the classroom. Only specialist nurses had attended a university-based post-registration wound care course. In contrast, podiatrists received regular undergraduate and postgraduate wound care education. All clinical professionals viewed wound care knowledge across other services (hospital, primary care and nursing homes) to be poor, which increased their workload if aspects of care, documentation or prescription information were incomplete.

Specialist nurses reported that due to workforce pressures, in-house courses they offered were often cancelled or attendance was poor. Due to these difficulties, specialist nurses relied on the pharmaceutical industry to provide wound product training sessions. Concerns were raised particularly by the non-clinical professionals that the educational contributions of industry representatives were highly likely to favour their own products.

But then at the same time they’d spy the competition and they’d basically suggest that their products are equivalent to those products that were already on the shelf …….and then we were inundated with requests for new products. (Non-clinical professional)

Use of research evidence

Only participants from the provider organisation with a history of collaborative wound care research indicated that they actively sought to keep up to date with research. Specialist nurses from this focus group talked about their established links with university researchers and their involvement in co-producing wounds research with academics. They discussed disseminating relevant research findings through electronic newsletters, workshops and meetings with community staff and where capacity allowed, staff were supported to implement research findings. Participants reported that their organisation was highly research active in wound care; clinical professionals had participated in research that found compression stockings to be more cost-effective than compression bandages for people with venous leg ulcers 9 and they subsequently implemented the findings into practice. The remaining participants viewed research with caution, they found very little time to search for evidence or be involved in research. 6 27 28

I can’t know everything about all dressings, and therefore you often stick to what you know and you don’t often have time to look at research. (Non-clinical professional)

And as healthcare professionals it’s not built into our contracts to do research…there’s no time put aside. (Specialist nurse)

Social influences

The importance of good teamwork was frequently emphasised and acknowledged by all participants. Much of the sharing of experiences was conducted informally. Clinical professionals reported that team support alleviated some of the current workload pressures and shared care was viewed as a valuable method for joint decision making. Participants from one focus group only reported the existence of wound care link nurses whose role was to cascade new information, new research evidence and product updates from specialist nurses to their colleagues. However, capacity issues were affecting the scope of this role.

Industry and patient influence

As referred to above, all participants were concerned about the influence that the pharmaceutical industry had on product choices. It was felt that this influence varied depending on how closely pharmaceutical representatives’ access was monitored. Non-clinical participants were particularly and negatively vociferous about the influence of pharmaceutical representatives yet viewed the role of policing any promotional activity as a specialist nurse responsibility.

You can police this a little bit more in acute, can’t you, but in the community we were fighting a losing battle with the reps when they’re just given free range to provide training.(Non-clinical professional)

Participants were very aware of the influence that patients have on wound care, which at times caused difficulty finding a suitable dressing that met patients’ expectations. Participants reported that some patients removed dressings earlier than necessary if minor staining appeared. Participants were mindful that careful assessment and monitoring patients’ adherence to therapy was necessary when making product choices. Participants also found that patients searched for information on the internet in an attempt to influence product decisions.

She (the patient) read that honey was good and she thought I’ll go and buy my own…. and swore it did the trick, so who are we to argue with her? (Community nurse)

Behaviour regulation

Community nurses reported that antimicrobial dressings (particularly silver-impregnated dressings) were used for individual patients for a 2-week trial period and then reviewed, however, they acknowledged that if use was not closely monitored there was potential for overuse. Non-clinical professionals and specialist nurses were aware of the high expenditure on antimicrobial dressings but acknowledged difficulties in monitoring effectively and providing adequate training and support due to capacity issues.

Silver spend is still a problem and it’s a long-term……I think there’s still habitual use, district nurses having the time to stop and think and review and stop a treatment rather than continue. (Specialist nurse)

Specialist nurses reported that general practitioners regularly prescribed high cost antimicrobial dressings for nursing home residents. The prescription for these dressings would often be repeated without review unless the resident was referred to a specialist nurse. There was an opinion among participants that some prescribing of silver dressings may be accidental because dressings are listed alphabetically in some prescribing platforms and silver dressings appear first (as they are denoted by the chemical symbol for silver, ‘Ag’).

We believe this is the first study to explore factors influencing care in community settings for people with complex wounds while seeking to understand the reasons for known variation in practice. Overall, participants described a challenging working environment, with influences such as workforce shortages and diminishing treatment resources having a marked effect on continuity of care, patient access to services and workload. Clinical practice seemed to be predominantly based on experiential knowledge, personnel preference and to be highly influenced by colleagues, patients and the pharmaceutical industry.

Workforce pressures and diminishing resources

Wound care services were described by participants as a working environment characterised by increasing time pressures and diminishing resources. Roles were perceived as becoming task orientated which was felt to dilute the quality of care. Participants reported there was a rise in sickness, colleagues were leaving for less pressured roles and vacancies were not being filled. UK surveys of community nursing services have found similar results. 29–31 The UK has fewer nurses relative to the population than many EU countries. 32 The number of community nurses is falling, with an estimated vacancy rate of 9.4%. 33 Forty per cent of experienced nurse positions are vacant. 34 Championing flexible career pathways, integrated care and the introduction of combined hospital and community posts (to standardise practice, improve care coordination and vary work experiences) have been proposed by UK governing bodies to improve retention rates. 35–38

Participants reported that specialist clinic sessions had been cut, resulting in increasing workload pressures for community nurses. A systematic review of 27 studies found improved information technology, including remote specialist consultations, to improve access to specialist input, provide educational support for the referrer, shorten referral time and avoid unnecessary travel and inappropriate visits. 39

Experiential learning and social influences

All nursing participants agreed that there was a lack of wound care education in basic nurse education. Wound care skills were learnt during community but not hospital placements. This was verified by participants’ reference to insufficient information from hospital nursing and medical staff on referral forms and via telephone calls which cause delays in assessment and frustration for community nurses. While all specialist nurse teams offered ongoing wound care training to community nurses, cancellation or poor attendance frequently occurred due to staff shortages. By contrast, podiatrists’ viewed their wound care education to be strong before and after qualification.

In the light of the current workforce issues and the difficulties community nurses had updating their wound care knowledge, other strong influences played a significant role in wound care choices such as personal, colleague and patient preferences as well as the influence of pharmaceutical company representatives. This influence can drive variation in dressing and treatment choice depending on the amount of access pharmaceutical representatives have to healthcare settings and clinical professionals’ attitude to the information they provide. 40 The ongoing cuts to continued professional development funding in the UK since 2015 may lead to greater dependence on the pharmaceutical industry for training and ‘education’, which is problematic due to companies’ vested interests in the use of specific products. 41 42 Interprofessional education may break down professional boundaries and provide opportunities for mutual learning and joint solutions across professional groups and specialties. 43 Further investment into evaluated training interventions that are of high quality and independent is warranted to ensure education is consistent and effective; providing healthcare professionals with the confidence to make the right decisions to improve continuity and quality of care. 36 44–46

The influence of research on wound care

Using research to guide product choice.

There is a plethora of wound products available for use but, as several Cochrane systematic reviews have shown, there is a paucity of research evidence showing that products are clinically effective. 6 47–52 Despite this, product use and expenditure have grown; particularly antimicrobial dressing use, where no compelling evidence or guideline recommendations exist to support routine use (Hussey et al , 2018, manuscript submitted for publication).

We found that a restrictive formulary was viewed as enabling better patient management, particularly if guidelines accompanied the formulary. Community nurses found a formulary and guidance gave them more assurance that they were making the right decisions and specialist nurses found formularies reduced inappropriate product choices and assisted in standardising product use across their service. For the majority of organisations, however, the formulary acted as guidance only and ‘off-formulary’ prescribing could occur without restriction unless resources were available to monitor prescribing behaviour closely. National guidelines exist to guide the use of specific products, 4 6 27 28 however, national standards to guide choice across the range of wound care products would reduce variation of product use and guide more rational prescribing. 53

Engagement in research

Research was raised as a factor influencing wound care in only one, highly research-active provider organisation. In this site, well-established links with university researchers had been highly influential. Current evidence suggests that there is an association between the engagement of individuals and healthcare organisations in research and improvements in healthcare performance. 54 In the other sites, where collaborative links with university researchers were more newly established, research informed decision making was more limited and research generally was viewed with caution. Much of the discussion around acquiring knowledge and skills to inform wound care decisions was related to experiential influences; day-to-day wound care experience, watching others and consulting with more experienced colleagues and specialists. This finding is in line with other research showing that experiential learning and the social influence of peers rather than research knowledge are major influencers on nursing practices. 55–57

If evidence obtained from research is to inform management and practice, robust, long-term strategies to support and facilitate its use will be required. In England, the NIHR funded research that incentivises co-production of research, for example, NIHR CLAHRCs represent an ongoing nationwide experiment to close the distance between research production and research use.

Limitations

The main limitation is the sample which was taken from community healthcare provider organisations in the North of England and included only one research-active organisation. Inclusion of participants from a larger geographical population may have provided different views, however, we captured many of the issues affecting healthcare (such as work pressures, staff shortages and limited resources) across the UK 30 58 59 and further afield 60 61 due to the financial healthcare crisis worldwide. We would have preferred to include more than one research-active organisation but due to the limited number of research-active organisations within our geographical area as well as funding and time limitations we could not recruit more. We were able to recruit the recommended number of participants for each focus group but work pressures dictated the range of clinical professionals and for one group there were no podiatrists which may have reduced the diversity of views, for that particular interview. However, there was good representation from podiatrists across the other groups ranging from senior management to junior positions. Only one research nurse was able to participate and as the research-active organisation was the only organisation to employ a small team of wound research nurses it is not surprising that we could only recruit one. 30 58–61

A challenge of using the TDF was the overlap across domains such as knowledge and skills , beliefs about consequences and social/professional role and identity. Other authors have reported similar issues. 17 62 The recently published guide to using the TDF addresses these and other challenges to promote the use of the TDF to a wider audience. 14

Finally, our aim in this study has been to surface factors that could potentially explain variations in the delivery of wound care. We of course recognise that wound care is complex and multifaceted involving a wide range of behaviours. Given this, we recognise that any formal attempts to develop strategies to modify existing practices and behaviours will require a level of granularity beyond what is available in the data presented. Our study does shed light on those domains where those future efforts should focus.

Conclusions

Our study provides new insight into the role experiential learning and social influences play in determining management and treatment choices and on the limited influence of evidence obtained from research. Workforce pressures and limited resources were perceived by the participants to impede care by reducing patient access to services and the ability to provide holistic care. Co-production of research evidence through participative collaboration between university and healthcare provider organisations may offer a supportive route to addressing issues, implementing sustainable changes to practice and service delivery and a resolute commitment to research use among clinical professionals.

Acknowledgments

The authors would like to thank many colleagues within the NIHR CLAHRC Greater Manchester Wound Care Programme, who have assisted with and supported this work. The authors would like to thank all participants for giving their time, sharing their views and for their enthusiasm throughout.

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Contributors NAC, JCD and TAG conceived the idea and design for the overall project. PW contributed to further development of the study design. TAG, PW and JCD collected the data. TAG and PW were responsible for data analyses. TAG created the original draft of the manuscript. All authors contributed to the interpretation of study findings, critical revision of the manuscript for important intellectual content and approval of the final manuscript.

Funding This project was funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester. The NIHR CLAHRC Greater Manchester is a partnership between providers and commissioners from the NHS, industry and the third sector, as well as clinical and research staff from the University of Manchester.

Disclaimer The views expressed in this article are those of the authors and not necessarily those of the NHS, NIHR or the Department of Health.

Competing interests None declared.

Ethics approval Ethics approval was sought and granted from the University of Manchester Research Ethics Committee (Refs 15272, 15327 and 2017-0559-1767) and HRA approval was sought and granted (Refs IRAS 174691, 184865 and 219918). Written informed consent was obtained from all participants

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement Requests for access to data should be addressed to the corresponding author.

Patient consent for publication Not required.

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In a First, an Orangutan Healed His Own Wound Using a Known Medicinal Plant

The primate named Rakus chewed up yellow root and applied it to an open facial wound, closing the sore within days

Christian Thorsberg

Daily Correspondent

In June 2022, a team of researchers observed a behavior never before witnessed in the animal world: A Sumatran orangutan named Rakus self-treated an injury using a medicinal plant.

At Gunung Leuser National Park, a rainforest reserve on the western Indonesian island of Sumatra, scientists heard from the treetops a series of “long calls,” a behavior that usually preempts assertions of male dominance or aggression. The next day, they saw Rakus with an open wound on his right cheek, just below his eye.

Days later, the team watched Rakus get to work—picking and chewing the stems and leaves of Akar Kuning ( Fibraurea tinctoria ), or yellow root. The plant is a climbing vine native to the region that local people use for its medicinal qualities to treat conditions such as diabetes, dysentery and malaria.

While hardly a staple of the orangutan diet—the team noted that yellow root is eaten only 0.3 percent of the time—Rakus consumed it anyway. He also chewed it, without swallowing, then spread its juices and poultice on his wound, where some flies had begun gathering. Rakus came back to the plant and ate it the next day, and soon, his wound was fully healed. This week, an analysis of the orangutan’s behavior was published in the journal Scientific Reports .

“[This] is the first observation of a wild animal actually treating his wound precisely with a medical plant,” Isabelle Laumer , a primatologist at the Max Planck Institute of Animal Behavior in Germany and the lead author of the study, tells National Geographic ’s Daryl Austin.

It took five days after treatment for the wound to close, and scientists saw no signs of infection after one month. Research on yellow root’s chemistry has shown the plant to have “antibacterial, anti-inflammatory, anti-fungal, antioxidant, pain-killing and anticarcinogenic properties,” the Guardian ’s Nicola Davis reports.

Sumatran orangutans are a critically endangered species—only 14,600 remain across the world, and the area surrounding Gunung Leuser’s Suaq Balimbing research station is home to Earth’s highest density of the creatures. But in 21 years of observing orangutans at this park, scientists have never seen an individual self-heal a wound using Akar Kuning.

Perhaps the primates do not get injured enough in the wild to need its healing properties, writes  Nature News ’ Gayathri Vaidyanathan. Or maybe Rakus, who is now 35 years old, is simply the only individual aware of the technique.

Whatever the reason, scientists agree the observation offers new insights into natural medicinal practices. 

“We often lose sight of the fact that modern medicine is derived from a very ancient system of knowledge that began millions of years ago in a variety of habitats about which our knowledge is only beginning to expand,” Mary Ann Raghanti , a biological anthropologist at Kent State University who was not involved in the study, tells National Geographic . 

Past research has shown Bornean orangutans self-medicating by rubbing their limbs with chewed plants, perhaps to alleviate sore muscles . And chimpanzees have been known to spread chewed insects over their wounds , though the effectiveness of this treatment is uncertain. Other animals engage in similar practices: Several species of birds rub themselves with ants—a technique called “anting”—to rid their bodies of parasites or feather mites, the New York Times ’ Douglas Main reports.

But the novelty of Rakus’s behavior comes both from his treatment of an external wound and Akar Kuning’s known healing qualities, which scientists have acknowledged as unique.

“It shows that orangutans and humans share knowledge,” says study co-author Caroline Schuppli , a primatologist at the Max Planck Institute of Animal Behavior, to Nature News .

The incident could shed light on the origins of self-medication for wounds, which was mentioned by humans in a medical manuscript dating to 2200 B.C.E., the Guardian writes.

“The fact that this has only been observed once in the study population leaves many questions unanswered about the origin of the behavior, but it adds to the idea that self-medication may have very deep evolutionary roots in our lineage,” Anne Pusey , an evolutionary anthropologist at Duke University who was not involved in the study, tells National Geographic.

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Christian Thorsberg | READ MORE

Christian Thorsberg is an environmental writer and photographer from Chicago. His work, which often centers on freshwater issues, climate change and subsistence, has appeared in Circle of Blue , Sierra  magazine, Discover  magazine and Alaska Sporting Journal .

• Victor Mukhin

Victor M. Mukhin was born in 1946 in the town of Orsk, Russia. In 1970 he graduated the Technological Institute in Leningrad. Victor M. Mukhin was directed to work to the scientific-industrial organization "Neorganika" (Elektrostal, Moscow region) where he is working during 47 years, at present as the head of the laboratory of carbon sorbents.     Victor M. Mukhin defended a Ph. D. thesis and a doctoral thesis at the Mendeleev University of Chemical Technology of Russia (in 1979 and 1997 accordingly). Professor of Mendeleev University of Chemical Technology of Russia. Scientific interests: production, investigation and application of active carbons, technological and ecological carbon-adsorptive processes, environmental protection, production of ecologically clean food.   

Title : Active carbons as nanoporous materials for solving of environmental problems

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