As a clinical nurse specialist in wound care for the Southern District Health Board, MANDY PAGAN provides a consultation role in residential aged care (RAC) facilities in Southland. To complete her clinical masters, she conducted a systematic review investigating wound programmes in RAC facilities. Here is an overview and summary of this review.
Residential aged care facilities are faced with significant challenges when caring for the frail older person. These can include high patient dependency, inadequate funding and resources, care provided mostly by unregulated workers, high staff turnover, and reduced opportunities for staff education and training.
Wound prevention and management practice demands ongoing knowledge and education to ensure best practice treatment and cost-effective care is delivered.
Healthcare professionals require knowledge and skill to prevent and manage wounds and reduce the risk of chronic wounds developing.
A systematic review was conducted to determine the effect of wound prevention and/or management programmes in RAC facilities. Objectives included establishing the composition of wound-related programmes, implementation strategies, and resident and clinical staff outcome measures.
Of the 51 appraised studies, 11 observational or descriptive studies met the grading process. Due to methodological heterogeneity across studies, statistical pooling of data could not be performed. The data was then analysed to identify recurring findings. From this process, three key syntheses and nine categories were developed (Figure 1). Ten studies implemented pressure injury programmes. In addition, education was included for leg and diabetic foot ulcers in two studies and skin tears in one study. A single study implemented a skin care programme and regime solely for residents with incontinence to prevent incontinence-associated dermatitis and pressure injuries.
The available evidence indicated that pressure injury programmes based on practice deficits can improve staff knowledge and care processes to reduce pressure injury rates. The data is limited to providing conclusions for wound programmes rather than for pressure injuries and is an area for future research. The review included observational or descriptive studies that provide lower levels of evidence for intervention effectiveness and were of low methodological quality; hence caution when generalising findings must be taken. The use of randomised controlled trials applying process evaluations using qualitative and quantitative approaches would provide more rigorous study data and is appropriate for evaluating quality improvement interventions.
Recommendations for practice from the studies analysed
- Increase programme success, pre-assess facilities to determine the readiness for change, the organisation’s culture, and potential programme barriers and facilitators.
- Evidence-based pressure injury programmes in RAC are recommended in order to increase staff knowledge and skills and thereby improve residents’ care and reduce pressure injury rates.
- Continuous quality improvement methods provide an adjustable and effective process to plan, implement, evaluate and sustain programmes in RAC facilities. Audit and feedback is an essential element to motivate staff and monitor adherence.
- Allow a sufficient period of time for programmes to be implemented, measured and evaluated.
- Engage, involve and update relevant RAC key stakeholders, including administrators, managers, nurses, healthcare assistants, doctors, residents and family before, during and after implementing programmes.
- The use of multiple programme interventions is recommended to increase the success of programme implementation and outcomes.
- Increase staff engagement, use staff incentives when developing, implementing and evaluating programmes.
- Plan flexible, realistic and achievable programmes in anticipation of staff turnover, and resident and administrative work demands.
- Project teams and/or champions are recommended to build staff confidence and skills, leadership and facilitate self-sufficiency and programme ownership. Enrolled nurses and healthcare assistants should be considered in these roles to work alongside registered nurses. These roles need to be supported by managers and staff alike.
- Use expert external mentors to assist facilities and staff to identify practice issues, develop programmes and model and guide best practice.
- Programmes implemented into compulsory staff training schedules ensure evidence-based updates are routinely provided for current and new staff.
Applying research to practice
Within my clinical nurse specialist role I have begun working with nurses and managers to develop the ‘wound champion’ role in one RAC facility. An important part of this role has been to help the facility to identify their practice deficits. One of these deficits included the under-reporting of stage 1 pressure injuries and the need to better educate healthcare assistants on reporting these. My role included providing and/or developing resources, including a 10-minute PowerPoint presentation to help the ‘wound champions’ to provide this training to all the healthcare assistants.
The next identified issue is to investigate a skin moisturising regime to reduce the risk of skin tears. I am now in discussion with other RAC facilities to provide the same support and resources. My objective is to provide a mentoring role and to empower the ‘wound champions’ to administer programmes in their facilities.
For further information of the review process, data synthesis, and for references, the full article can be accessed: Pagan, M., Trip, H., Burrell, B., & Gillon, D. (2015). Wound programmes in residential aged care: A systematic review. Wound Practice & Research, 23(2), 52-60.
Meet wound champion Bianca
Bianca Lawrence graduated as a registered enrolled nurse in 2012. She has worked in aged care since graduation, and more recently, has become the wound champion at Bupa’s Ascot Care Home, which has 104 beds over three levels of care: hospital, residential and D3.
In her role Bianca sees multiple wounds in the elderly, some due to the usual causes like falls, skin tears and so on. With the assistance of wound care specialist Mandy Pagan, the facility has a very high recovery and healing rate.
Bianca says she is passionate about finding the path to increasing the healing rate.
“Being able to access great products in conjunction with ongoing education shows we can heal and add to each resident’s quality of life,” she says. “Without a chronic wound everything is easier for the resident and it is much easier to achieve the best possible quality of life.”