Implementing Wound Care Guidelines: Observations and Recommendations from the Bedside
- 0 Comments
- 16379 reads
Abstract:The successful implementation of wound care guidelines requires an appreciation for the frustrations experienced by nurses trying to incorporate these tools into clinical practice. These frustrations or barriers to best wound care practice implementation are examined from the perspective of: 1) the practice environment, which must be understood; 2) the potential adopters, predominantly nurses seeking the best fit between evidence and their clinical practice setting; and 3) the evidence-based innovation created to change wound care practice at the point of care. Barriers identified include lack of available resources, time constraints, prescriptive guidelines that incorrectly assume details of the practice environment, and wound care product confusion. Recommendations to facilitate implementation from the bedside are discussed and include expanding guidelines to incorporate detailed educational content and dissemination strategies that serve to increase relevancy to everyday practice. Additional suggestions include decreasing wound care product confusion by developing standardized, function-based product nomenclature and improving the quality of wound care research to increase nurses’ confidence in the evidence and resultant recommendations. Resources currently used to develop guidelines also should be utilized to create accompanying educational material to support the transfer and uptake of knowledge.
Key Words: wound care, guidelines, implementation, barriers, nursing
Ms. Lloyd-Vossen is a member of the faculty, Nursing Education Program of Saskatchewan. Please address correspondence to: Jan Lloyd-Vossen, NEPS SIAST Kelsey Campus, PO Box 1130, Saskatoon, Saskatchewan S7K 3R5 Canada; email: firstname.lastname@example.org.
Tracey is a 30-year-old registered nurse who graduated from a baccalaureate program 5 years ago. She recently accepted the only clinical nurse educator position in her 100-bed hospital. Tracey’s manager asked her to create an effective in-service to remedy “all the confusion the nurses have about those new dressings.” Tracey investigated the value-added educational programs offered by the wound care manufacturers. The facilities in the region recently standardized the wound care product formulary, awarding products to six manufacturers, each with independent programs and company-specific product information. Tracey contacted the regional wound care specialist, who suggested that rather than focusing only on dressing selection, a comprehensive education program consistent with the province’s skin and wound care guidelines should be planned. After studying the regional guidelines, Tracey attempted to assemble a multidisciplinary team to organize and facilitate guideline implementation. Unfortunately, although most clinicians thought wound care standardization was a good idea, only two people attended the initial meetings. After several unsuccessful attempts to elicit support from the stakeholder and countless attempts to “chunk down” the guidelines to a series of short educational events, Tracey put the wound care product in-service on hold.
To the expert wound care provider, it may seem implausible that something as simple as creating a product in-service can become difficult. How hard can it be to plan and implement wound care educational sessions when nurses have access to a wealth of wound care resources, including specialist journals and textbooks, conferences and educational courses, numerous websites, clinical guidelines, care maps, implementation checklists, wound care specialists, and associations dedicated to the advancement of wound care?
Research-based practice is a hallmark of professional nursing. Although this example is specific to wound care, it typifies the frustration experienced by nurses trying to incorporate practice guidelines into clinical practice.
1. International Council of Nurses. Position Statement: Nursing Research. Geneva: International Council of Nurses. 1999. Available at: www.icn.ch/PS_B05_Nsg%20Research.pdf. Accessed June 5, 2009.
2. Burrows C, Miller R, Townsend D, et al. Best practice recommendations for the prevention and treatment of venous leg ulcers: update 2006. Wound Care Canada. 2006;4(1):45–55.
3. Saskatchewan Health Quality Council. Saskatchewan skin and wound care guidelines. Available at: www.hqc.sk.ca. Accessed May 2, 2007.
4. Sibbald G, Orsted H, Coutts P, Keast, D. Best practice recommendations for preparing the wound bed: update 2006. Wound Care Canada. 2006;4(1):15–29.
5. Valente S. Research dissemination and utilization: improving care at the bedside. J Nurs Care Quarterly. 2003;18(2):114–121.
6. Hicks C. A study of nurse’s attitude towards research: a factor analytic approach. J Advanced Nurs. 1999;23:373–379.
7. McCaughan D, Thompson C, Cullum N, Sheldon T, Trevor A, Thompson D. Acute care nurses perceptions to barriers to using research information in clinical decision making. J Advanced Nurs. 2002;39:46–60.
8. Jones V. The use of gauze: will it ever change? International Wound J. 2006;3:79–86.
9. Pearson C, Care W. Meeting the continuing education needs of rural nurses in role transition. J Continuing Educ Nurs. 2002;33(4):174–179.
10. Bolman L, Deal T. Reframing Organizations: Artistry, Choice, and Leadership. San Francisco, CA: Jossey-Bass;1991.
11. Bolman L, Deal T. Leadership and management effectiveness: a multi-frame, multi-sector analysis. Human Resource Manage. 1991;30(4):509–526.
12. Logan J, Graham I. Toward a comprehensive interdisciplinary model of health care research use. Science Communication. 1998;20(2):227–246.
13. Foy R, MacLennan G, Grimshaw J, Penney G, Campbell M, Grol R. Attributes of clinical recommendations that influence change in practice following audit and feedback. J Clin Epidemiol. 2002;55(7):717–722.
14. Logan J, Harrison M, Graham I, Dunn K, Bissonnette J. Evidence-based pressure-ulcer practice: the Ottawa model of research use. Can J Nurs Res. 1999;31(1):37–52.
15. Shields M, Wilkins K. Findings from the 2005 national survey of the work and health of nurses. Available at: www.statcan.ca/cgi-bin/imdb/p2SV.pl? Function=getSurvey&SDDS= 5080&lang=en&db= IMDB&dbg=f&adm=8&dis=2. Accessed June 2, 2007.
16. Hutchinson A, Johnston L. Beyond the barriers scale: commonly reported barriers to research use. J Nurs Admin. 2006;36(4):189–199.
17. Davies B. Sources and models for moving research evidence into clinical practice. JOGNN. 2002;31(5):558–562.
18. Tryssenaar J, Gray H. Providing meaningful continuing education in a changing long-term care environment. J Nurs in Staff Development. 2004;20(1):1–5.
19. Young K. Where’s the evidence? Am J Nurs. 2003;103(10):11.
20. Registered Nurses Association of Ontario. Educator’s resource: integration of best practice guidelines. Available at: www.rnao.org/Page.asp?PageID=924&ContentID=822. Accessed May 15, 2007.
21. Registered Nurses Association of Ontario. Toolkit: implementation of clinical practice guidelines. Available at: www.rnao.org/Page.asp?PageID=828&ContentID=823. Accessed May 15, 2007.
22. Schultz G, Sibbald G, Falanga V, et al. Wound bed preparation: a systematic approach to wound management. Wound Repair Regener. 2003;11(2):S1–S28.
23. Biala K, Cervantez K, Hadrian D, et al. Building the foundations of wound care training. Home Healthcare Nurse. 2004;22(5):304–311.
24. Queen D, Orsted H, Sanada H, Sussman G. A dressing history. International Wound J. 2004;1(1):59–77.
25. Bolman L, Deal T. Looking for leadership: another search party’s report. Educational Administration Quarterly. 1994;30:77–96.
26. Hunt J. Guest editorial. Barriers to research utilization. J Advanced Nurs. 1996;23:423–425.
27. Towler J. Influencing clinical practice: evidence-based wound care. Br J Nurs. 2001;10(11):S44–S58.
28. Bradley M, Cullum N, Nelson E, Petticrew M, Sheldon T, Torgerson, D. Systematic reviews of wound care management: dressings and topical agents used in the healing of chronic wounds. Health Technol Assess. 1999;3(17):1–35.
29. Vermeulen H, Ubbink D, Goossens A, de Vos R, Legemate D. Dressings and topical agents for surgical wounds healing by secondary intention. Br J Surg. 2005;92:665–672.
30. Ativeh B, Ioannovich J, Al-Amm C, El-Musa K. Management of acute and chronic open wounds: the importance of moist environment in optimal wound healing. Curr Pharmaceutical Biotechnol. 2002;3(3):179–194.
31. Helberg D, Mertens E, Halfens R, Dassen T. Treatment of pressure ulcers: results of a study comparing evidence and practice. Ostomy Wound Manage. 2006;52(8):60–71.
32. van Rijswijk L, Beitz J. The traditions and terminology of wound dressings: food for thought. J WOCN. 1998;25(3):116–122.
33. Altman D, Schulz K, Moher D, et al. The revised consort statement for reporting randomized trials: explanation and elaboration. Ann Intern Med. 2001;134(8):633–694.
34. Moss L. The CONSORT statement: progress in clinical research in pediatric surgery. J Pediatr Surg. 2001;36(12):1739–1742.
35. Bennett J. The consolidated standards of reporting trials (CONSORT). Nurs Res. 2005;54(2):128–132.
36. Mills E, Wu P, Gagnier J, Devereaux, P. The quality of randomized trial reporting in leading medical journals since the revised CONSORT statement. Contemp Clin Trials. 2005;26:480–487.
37. McDiarmid S. Continuing nursing education: what resources do bedside nurses use? J Continuing Education. 1998;29(6):267–273.
38. Clarke C, Wilcockson J. Professional and organizational learning: analyzing the relationship with the development of practice. J Advanced Nurs. 2001;34(2):264–272.
39. Winch S, Henderson A, Creedy D. Read, think, do! A method for fitting research evidence into practice. J Advanced Nurs. 2005;50(1):20–26.
40. Buonocore D. Leadership in action: creating a change in practice. AACN Clinical Issues. 2004;15(2):170–181.
41. van Rijswijk L. Ingredient-based dressing classification: a paradigm that is passé and in need of replacement. J Wound Care. 2006;15(1):11–14.
42. Ovington L. Wound care products: how to choose. Advances Skin Wound Care. 2001;14(5):259–266.
43. Teot L, Cherry G, Denis C, et al. Reimbursement of dressings: a WUWHS statement. International Wound J. 2006;3:296–301.
44. Bolton L, Monte K, Pirone, L. Moisture and healing: beyond the jargon. Ostomy Wound Manage. 2000;46(1 suppl A):51S–62S.
45. Jones V, Harding K. Moist wound healing. In: Krasner D, Rodheaver G, Sibbald RG (eds). Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. Wayne, PA: HMP Communications;2001:245–252.
46. Ovington L. Hanging wet-to-dry dressings out to dry. Advances Skin Wound Care. 2002;15(2):79–86.
47. van Rijswijk L. Bridging the gap between research and practice. Am J Nurs. 2004;104(2):28–30.
48. Smith S. Successful outcomes with the h.e.a.l. program. Ostomy Wound Manage. 2006;52(30):40-53.
49. Grol R. Successes and failures in the implementation of evidence-based guidelines for clinical practice. Medical Care. 2001;39(suppl 2):II-46–II-54.