Chronic Wound Care 4th Chapter 1
The Interprofessional Wound Caring Model
Diane L. Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN; George T. Rodeheaver, PhD; R. Gary Sibbald, BSc, MD, FRCPC (Med. Derm), ABUM DABD, M. Ed
Introduction
A person with a chronic wound often suffers from a
myriad of biopsychosocial problems, such as physical
disability, pain, social needs, and mental
anguish. Addressing these multiple issues properly requires
skilled help from knowledgeable wound care professionals;
however, wound care expertise and knowledge of the evidence
base for practice alone usually is not enough to heal
a chronic wound and improve the life of the person with
that wound.
In this chapter, the editors of Chronic Wound Care: A
Clinical Source Book for Healthcare Professionals present The
Interprofessional Wound Caring Model© (Figure 1; Plate 1,
Page 753). Our goal is to trigger you to think about your
own work environment and to reflect on whether it
enables you to practice wound care interprofessionally. We
challenge you to analyze how your current practice model
compares and contrasts with ours. Then ask yourself and
other members of your team if you can improve your
interprofessional wound caring practice model.
Additionally, we challenge you to complete your own personal
score card and to construct your personal learning
portfolio for your continuous professional development
and lifelong learning.
Patients, their families, and caregivers need the wound
care expert’s professional knowledge and skill, but they
also require the expertise of other members of the interprofessional
team, including generalist physicians and
nurses, physical therapists, dietitians, pharmacists, social
workers, discharge planners, and so on. The mix of professionals
that one patient needs will differ from another
patient’s through individualized patient-centered care.
Each individual healthcare professional’s caring behavior
is an essential dimension of our model.We sincerely
believe that without this commitment to the call to care
by all members of the team, wound care cannot be optimized.
The human touch—reaching out to patients, families,
and caregivers—builds the trust and the confidence
that heals wounds, patients, and lives.
Patient, Family, and Caregiver
The first dimension that is central to the model is that
of the patient, family, and care giver. Several key patient
factors often contribute to the development of chronic
wounds. People with chronic wounds are often older —
the average age is 70 years for venous leg ulcer sufferers
and 60 years for people with diabetic neuropathic foot
ulcers. These individuals frequently have co-existing
medical conditions that can impair healing. Oral drugs
prescribed for patients’ medical needs often interfere with
the wound healing process. Chronic wound patients often
experience pain that has not been addressed by their
healthcare team. Several international pain surveys have
demonstrated that pain is the third to fifth most important
component of care for healthcare providers and may be
the first priority for patients. 1 This disconnect emphasizes
the need to address individualized patient-centered concerns
as part of any chronic wound treatment plan. You
will find numerous chapters in this fourth edition of
Chronic Wound Care that focus on particular aspects of the
chronic wound experience that must be addressed for the
patient, family, and caregiver.
Chronic wounds usually interfere with a person’s quality
of life and activities of daily living. Imagine the social isolation
that a person with a leg ulcer feels when he or she cannot
eat with the rest of the family because the odor from the
wound is offensive. The person with a diabetic neurotrophic
foot ulcer can lay awake for hours because of burning and
shooting neuropathic pain in both feet at night. The chronic
pain, suffering, and diminished quality of life often lead to
depression. Depression is particularly common in persons
with diabetes due to multiple complications including neuropathy
but also ischemia, infection, and deformity.
Individuals suffering from chronic wounds often have
decreased capacity for the activities of daily living. They
often do not have the physical stamina for employment and
can have several absentee days or even can be trapped into
long-term disability. Frequent dressing changes may interfere
with employment opportunities, and the cost of supplies
may not be covered by the healthcare system. Affected
individuals often are unable to walk long distances or stand
for any prolonged period of time. They may have difficulty
sleeping and even maintaining an adequate level of self care.
We must address all of these patient-centered concerns.
Historically, patients often are given instructions on how
to treat a wound with minimal discussion to
explain the
cause(s) or address patient-centered concerns. They may not
comprehend the pathophysiology of their wound and the
importance of their cooperation (and their family and caregivers)
to promote wound healing. This is typical of the
concept of compliance defined as “to obey an order or command.”
This is very provider-centered care — not patient centered
care. Recent literature has emphasized the concept
of adherence or the ability of a patient to follow through on
a treatment or regime.
2 This shift in emphasis is away from
provider-centered care and refocuses on the patient’s perspective.To increase the collaborative network even further,
the term coherence refers to frank discussion between the
healthcare professional and the patient with both points of
view being considered and a negotiated treatment plan
incorporating both perspectives.
We must work toward collaboration with chronic wound
patients, their families, and caregivers. We must acknowledge
the fact that patients who have a social network of
caregivers, family, friends, and concerned acquaintances are
likely to have far better outcomes than those individuals
who are socially isolated.
Wound Care Expertise
Wound care expertise consists of evidence-based
wound care knowledge of the skills and expert knowing
gained from clinical experience and of the attitudes and
values that we bring to practice as individuals.
Knowledge of the evidence base for wound care can be
acquired by reading or attending formalized courses,
conferences, and seminars. Novice healthcare professionals
transition to expert practitioners with time and experience
as described by Benner and others.
As healthcare providers, we need to treat the whole
patient and not just the hole in the patient (Figure 2). Our
knowledge base should include expertise about the
cause(s) of common chronic wounds, such as venous leg
ulcers (Plate 2, Page 753), pressure ulcers (Plates 3 and 4,
Page 753), diabetic neurotrophic foot ulcers, and nonhealing
surgical wounds (Plate 5, Page 753).We also need to
know about uncommon chronic wounds, palliative
wounds, and deteriorating wounds. This knowledge needs
to be complimented with the ability to assess and treat
pain, other patient-centered concerns, and local wound
care core expertise.
Traditional wound care has often been delivered with
saline wet-to-dry gauze dressings. Removal of these
dressings can cause local bleeding and pain and the procedure is nursing time intensive. Since the classical work
of Winter, 5 several advantages for moist wounds have
been identified and include a faster healing rate with
occlusion and enhanced re-epithelization with removal
of eschar. To translate this into everyday practice, several newer, moist, interactive wound dressing classes have
been added to our therapeutic toolkit.
Local wound care expertise goes well beyond the selection
of the appropriate dressing to look at criteria to benchmark
healing and when to use advanced products, including
growth factors, skin substitutes, complimentary therapies, and
other procedures, such as skin grafting. We often teach the
principles of local wound care with the mnemonic: DIM
before DIME for adequate Debridement, Infection and
Inflammation control, and Moisture balance before the Edge
affect, signaling stalled healing and the need for active local
therapy. The optimal wound care practices outlined in the
preparing the wound bed algorithm are essential before
advanced and often expensive therapies are considered. 6 – 8 If a
wound with the ability to heal is not 30% smaller at Week 4,
despite optimal local wound care, it is unlikely to heal by
Week 12, and advanced therapies should be considered. 9
Clinicians are reminded that if a wound is unlikely to heal
(eg, due to inadequate vasculature or coexisting illness),
advanced therapies are seldom indicated and their chance of
success is minimal.
There is a need to link our new knowledge and research
findings in wound care to the improved outcomes of
patients with wounds worldwide. This process involves the
inclusion of evidence from 3 different perspectives: 10
• Efficacy—it works in idealized patients
• Efficiency—it works in usual patients
• Effectiveness—it has benefit at a reasonable cost.
The current organization of the evidence base for
wound care may not encompass all 3 perspectives. One of
the pitfalls of RCTs in wound research is the strict subject
selection, eliminating most “usual” patients, and the disadvantage
when attempting to extrapolate the RCT results to
the real world of clinical practice for patients that would
not meet the entry criteria of the study. Efficacy studies
compare strictly controlled patients without confounding
variables to a placebo. These conceptual studies are necessary
for proof of concept. These studies need to be complemented
with RCTs comparing the new treatment to usual
practices or evidence-informed practice in a clinic that
includes usual current treatment for all patients assessed
with wounds that have the ability to heal. This then must be
cost neutral or cost saving for the practice to be translated
into day-to-day care by obtaining reimbursement within a
healthcare system (effectiveness). There is a need to build
economic models to test the feasibility of integrating a new
treatment that may be expensive but have cost savings or
may be cost neutral to the healthcare system.
Sackett et al emphasized the importance of combining
clinical expertise and the best available external evidence
along with patient preference. Without clinical expertise,
practice risks becoming tyrannized by evidence—even excellent external evidence may be inappropriate for an
individual patient. Without current best evidence, clinical
practice rapidly will be out of date, to the detriment of
patients. This combination of the scientific evidence base
with expert opinion contextualized to local practice is
referred to as evidence-informed medicine. We also must
remember the central needs of the patient and the consultation
with patients to determine their preference for treatment.
The patient’s and his or her family’s experiences with
illness are often forgotten in the rush for RCTs and other
levels of evidence.
To translate the evidence-based paradigm, we can develop
a clinical practice guideline. However, all guidelines are
not created equal. The methodological quality of a guideline
can be assessed through the Appraisal of Guidelines
Research & Evaluation (AGREE) Instrument
(www.agreecollaboration.org). This instrument examines 6
domains: scope and purpose, stakeholders, rigor, clarity,
applicability, and editorial independence. Through this
process, we can identify high-quality guidelines and recommendations
for translation into practice without continually
creating new guidelines or reinventing the wheel.
The Interprofessional Team
Professionals involved in wound care come from diverse
professional backgrounds. Each professional brings unique
expertise, adding strength to the team. Team collaboration
helps fill knowledge gaps, broadens perspectives, and optimizes
patient care delivery. Many of the contributors to the
fourth edition of Chronic Wound Care have shared their collaborative
experiences working in teams. This teamwork has
presented both benefits and challenges that need resolution.
Teams are not created overnight. Individuals in a multiprofessional
network need to respect each other’s expertise
and work toward improving patient outcomes. The next step
is to form an interprofessional team with group care plans
and sharing of situational learning from experience. In some
cases, this may even evolve to a transprofessional team.
Advanced practice team members can often perform the
functions of more than one team member when required.
Highly functioning teams have a flattened structural framework
with shared care of patients and do not exemplify the
pyramidal structure of a dominant leader and followers that
have little to do with key patient care decisions.
Each of us as individuals requires a network of other
individuals with complimentary expertise in wound care.
Let’s conceptualize our team for this chapter. George
Rodeheaver, PhD, as the basic scientist, brings us new perspectives,
treatments, or diagnostic procedures from the laboratory
or clinical investigations for consideration. Diane
Krasner, RN, as a nurse and allied healthcare professional,
focuses on prevention, local treatment, and allied healthcare care issues across the continuum of care. Gary Sibbald, MD,
as the physician, evaluates innovative treatments or procedures
and trials them before identifying the strengths and
weaknesses as well as the advantages and disadvantages for
patient care before translating a new modality into every day
clinical practice. These 3 distinct professional perspectives
broaden our base and strengthen our team.
By practicing as a team, healthcare professionals are able
to balance the amount of responsibility and the workload,
particularly in challenging cases. It is imperative that all
team members share their knowledge and experience in
order to provide better care. Tuckman 12 has defined 4 stages
to team development: forming, storming, norming, and
performing. Several aspects are more likely to be found in
successful teams, including clear communication, flexibility,
adaptability, openness, shared leadership, and mutual respect.
Healthcare Professional’s Caring
Wound care experts must realize that working in a silo
even with individual caring cannot offer the patient, family,
and caregiver optimal treatment. Many individuals who have
become healthcare professionals do so because they truly
want to help others. The journey to successful healthcare
professional status requires a formalized training program that
often supplies the basics of nursing, medicine, podiatry, physical
therapy, occupational therapy, and other healthcare professional
disciplines. It is important to complement professional
knowledge with skills to work within a healthcare system.
Professionals in health disciplines need to develop skills of communication, collaboration, and management skills.
A caring healthcare professional must have a patient centered
approach. This can be exemplified by the Keller
and Carroll model 13 to patient communication
• Engage
• Empathize
• Educate
• Enlist.
For each patient, we should know something about him or
her other than the reason for the visit (engagement). This
information may include hobbies, important family events, or
milestones in their lives. We need to be good listeners and to
empathize with patients’ pain and suffering and not dismiss
their concerns with trivial sympathetic comments. Establishing
patients’ perspectives on their disease process allows healthcare
professionals to educate individuals from current beliefs to a
negotiated treatment plan, taking patients’ wishes into account
and having a consensus on the next steps. We then need to
enlist the patient to be an active participant and take personal
responsibility for the diagnostic and treatment process.
As individuals, healthcare professionals need to be in tune
with their own belief systems and have a balance with
attention to their physical, spiritual, psychological, and
social needs. Professionalism refers to the behavior of a professional
to uphold ethical and interpersonal values.
Healthcare professionals are expected to demonstrate
respect for others and uphold appropriate boundaries
between themselves, coworkers, and patients.
We should create a comfortable work environment with compassion for others and commitment to
improving illness but also promoting wellness. There is a
need to be a health advocate and promote a healthy living
style and wellness by setting a good example. Other
ways to advocate for health include developing newer
and better healthcare systems with universal access,
treating illness early, educating the general public, and
supporting wellness.
Continuous Professional Development and
Lifelong Learning
Continuous professional development (CPD) refers to lifelong
learning that is learner and work place centered. This is
also referred to as situational learning because it is determined
by practice and problems with patient care. Continuous professional
development relates to day-to-day activities. The
outcomes from CPD are more likely to change behavior and
improve patient care outcomes than an accredited classroom
event or traditional continuing education programs.
Single educational events without secondary enabling or
reinforcing strategies to bring the information back to the
workplace are often unsuccessful in changing practice.
Enablers, reference guides, and tool kits are examples of
products that can be utilized to change practice. An enabler
or quick reference guide is a 20-second to 2-minute summary
of relevant strategies for bedside or patient care. An
educational tool kit is designed for the implementation of
best clinical practices and may consist of educational materials,
measuring guides, monofilaments, and other useful aids
to clinical practice. Mentorship after an educational event or
small learning groups and educational outreach visits (where
an expert may come to translate the information learned in
the formalized setting for the workplace) can also facilitate
the integration of new knowledge into practice.
As healthcare professionals, we also must commit to lifelong learning through experience. We learn from the literature, but we also must learn from our experiences and dialogues with colleagues. The first step is to create a network of individuals who we can consult when we do not have an answer to a clinical question. We may need to involve a preceptor to learn a skill or task that is important to our job or clinical activities. Preceptorships are often time limited and driven by specific goals and objectives. Beyond preceptorships, we also may need a mentor. A mentor is an individual who in a nonjudgmental comfortable manner can provide guidance for job-related, personal, and other decisions to achieve life goals and balance as well as advance a career and promote wound care expertise. Some mentorship relationships have a time-limited spectrum, while others can evolve into a comentorship relationship. A younger mentee may be a computer “native” and can teach a computer “immigrant” mentor tricks of the new technologies. At the same time, the senior mentor can continue to add contextual knowledge from lifelong experience, solving difficult situational clinical problems for the younger mentee.
We often learn from relaying case studies or case series and
then discussing diagnoses and management. Another dimension
to a case history is storytelling. In storytelling, the emotional
and situational components of the history and the
sequence of events are related with a personal analysis or
honesty that may not be contextualized in the formal case
history dominated by facts in the sequential history, physical,
investigation, and treatment process. Storytelling and the personal
anecdote remain critically important methods—even
with the current trend to evidence-informed healthcare.
Knowledge Transfer into Practice
Knowledge transfer into practice refers to the link between scientific evidence and the need to change clinical practice. This is a conceptual framework of moving new knowledge from the laboratory bench to the literature/classroom and ultimately to the bedside in order to improve patient care outcomes. This concept requires the transfer of knowledge from efficacy or proof of concept RCTs in idealized patients to the trial of the same principles in usual everyday wound care clinics in order to demonstrate that the integration of the concept improves patient care outcomes.
Wikipedia, the internet free encyclopedia, describes 3 related
concepts in the health sciences: knowledge utilization,
research utilization, and implementation: These concepts
describe the process of bringing a new idea, practice, or technology
into consistent and appropriate use in a clinical setting.
14 The study of knowledge utilization and implementation
is a direct outgrowth of the movement toward evidence based
or evidence-informed medicine. Research to demonstrate
efficacy of a new treatment is often completed in idealized
patients, and this research needs to be repeated with usual
patients to confirm that the same treatment will make a difference
in everyday practice settings on usual patients.
Informal Communities of Practice
The concept of a community of practice (CoP) refers to the process of social learning that occurs when people who have a common interest in some subject or problem collaborate over an extended period to share ideas, find solutions, and build innovations. Do you have a wound care community of practice?
Wikipedia notes, “The term [community of practice] was first used in 1991 by Jean Lave and Etienne Wenger [to describe] situated learning as part of an attempt to ‘rethink learning’ at the Institute for Research on Learning. In 1998, the theorist Etienne Wenger extended the concept and applied it to other contexts, including organizational settings… Some of the aims and goals of a community of practice include: the design of more effective knowledge-oriented organizations, creating learning systems across organizations, improving education and lifelong learning, rethinking the role of professional associations and a design of a world in which people can reach their full potential…[a community of practice is] a group of individuals participating in a communal activity, and experiencing/continuously creating their shared identity through engaging in and contributing to the practices of their communities.”
Following are questions to ponder:
• Do you participate in one or more communities of practice?
• Can you describe their membership and essential components?
• How could you optimize your participation to maximize your social learning and improve your wound care knowledge?
• Could and should you foster a community of practice?
Conclusion
The fourth edition of Chronic Wound Care: A Clinical Source Book for Healthcare Professionals is a compilation of the evidence base for chronic wound care with expert opinion from key wound care leaders around the world. It is the starting point for your personal journey to improve outcomes for people with chronic wounds.
Figure 3, entitled Personal Score Card, presents a personal score card for you to copy and update on a regular basis for your personal self assessment and evaluation of the journey. This is also a way to identify personal needs and plan your future educational portfolio.
We challenge you to be:
More effective communicators and collaborators with
your patients, their families, and caregivers
Do you practice the 4 E model?
• Better distillers of knowledge of wound care through
examining the evidence base presented in this book,
reviewing guidelines with good methodological quality,
and seeking the opinions from others in your own
personal network in order to develop your wound
care expertise
Do you have or could you help form your own
wound care network or community of practice
within or outside your organization or workplace?
• More dedicated interprofessional team members by listening,
sharing, and collaborating with passion and commitment
Have you developed a knowledge translation
strategy for your workplace to improve the
efficacy, efficiency, and effectiveness of your care?
• More genuine in your personal caring
What is your current physical, psychological,
spiritual, and mental score card? Where are your
strengths and what weaknesses can you improve?
Do you have an action plan?
• More effective in your commitment to continuous
professional development and lifelong learning
Do you learn personally from a situational
continuous professional development model or
do you still rely on conferences and formal
education opportunities to obtain continuing
education credits as your major method of learning?
In closing, we challenge you to complete your own personal
score card and to construct your personal learning
portfolio. We urge you to reach out to patients, families, and
caregivers in order to build the trust and the confidence
that heals wounds, patients, and lives.
We wish you every success in Interprofessional Wound
Caring!
Diane L. Krasner
George T. Rodeheaver
R. Gary Sibbald
References
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