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The TVS Annual conference was held on May 4th in conjunction with the EPUAP meeting. Highlights included a review of Scottish Wound Care guidelines by Alison Coull and the NICE pressure ulcer treatment guidelines were presented by Elizabeth McInnes. Key international speakers including Italy's Marco Romanelli discussed consensus on wound classification. Other key papers included wound infection, diabetic foot ulcer guidelines, wound classification and principles of wound management. This was an excellent programme and proved very popular with all who attended.
The issues surrounding wound/pressure ulcer and leg ulcer education are not well understood. Very few studies report on the levels of knowledge which exist among practitioners across the various clinical areas where wound/ pressure ulcer and leg ulcer care are practised. Over the past two decades, the changes in wound care technology have been immense, and, coupled with a much greater understanding of the pathophysiology of wounds, the knowledge base had grown exponentially. The truth is, however, that there are few standards set relating to wound care education and training. Availability of courses is often dependent on the location of the individual and this then may involve the expense of fees and time off work to attend. Ideally what needs to be addressed is the lack of education at the grass roots level. As a tissue viability nurse I was constantly frustrated in the poor attendance at in house study days, this is not a unique phenomenon. In addition, within the private sector there is great difficulty in accessing staff for training purposes, yet we are aware that they look after a population of patients with many risk factors. Most of us will be involved in education as part of our everyday role, in some shape or form. This may be educating patients/clients, carers or colleagues. The key message within education at the moment is how can we ensure learning. My memory of wound care education has been one of 'presentations'. There is a time when presentations are required for information delivery, however, in many cases nursing education needs to be more 'hands on' to ensure learning has taken place. There is no point in delivering an hour long lecture if our attention span lasts only 15 minutes. Research in education has shown that the best way to encourage learning is to involve the student. This means that they need to take part in an interactive session which will allow feedback and encourage a two way dialogue. Problem based learning is a technique which is now widely used in Nursing and Medical education. The idea of students problem solving and seeking information mirrors, with reasonable success, the real world of clinical decisions and complex cases. Education which provides staff with these skills could prove extremely valuable, particularly in the field of wound care where often no two patients are the same, and in many cases there are so many variables which can negatively impact on the wound healing process.
Over the past decade, many of the top wound care companies have increased their profile in relation to education provision. Although this has been a central role of the companies' provision for those involved in wound care/pressure ulcer care and leg ulcer care, the main thrust is now to have the courses accredited through a University. Company held study days are for many nurses the only study days which can be attended, in many cases due to financial and time constraints. It is therefore essential that these days are well structured and meaningful learning experiences for the staff involved. In addition the companies involved have sought to employ a high level of expertise in the roles of Medical Educator or Clinical Education Specialist. This should herald a new era for corporate sponsored wound care education which moves away from the traditional didactic presentation styles, to one of interaction and participation.
The RCN have recently launched a campaign to help health workers combat the spread of MRSA. The "wipe it out" campaign aims to address the key issues involved in Hospital Associated Infection. The Royal College have set out a 10 point guideline which covers important issues such as staff training, protocol development and greater involvement of infection control specialists in the management of antibiotic resistant infections. For staff involved in wound care, this is obviously an issue which has to be monitored and the Government in conjunction with the RCN have reinforced the need to create a database of HAI in order to monitor patterns and strains of the specific bacteria.
Wound exudate is a key component in wound healing (Gray and White, 2004) and maintenance of a moist wound bed is widely accepted as the best environment to enhance wound healing (Eaglstein et al, 1988). Excessive amounts of wound fluid can however inhibit wound healing and cause maceration of the surrounding skin (Cutting and White, 2002). Additionally chronic wound fluid is known to differ from acute wound fluid and is more corrosive in nature with relatively high levels of tissue destructive enzymes - proteinases being present (Chen et al, 1992). From the patients perspective, smell and staining caused by exudate has a negative impact on Health Related Quality of Life (Hareendran et al, 2005) Modern wound dressings are designed to remove excess exudate while maintaining moisture at the wound bed (Bale and Jones, 1977). However, when considering the management of exudate in chronic wounds such as pressure ulcers and leg ulcers, there may be many variables contributing to the rise / alteration in the exudate levels. It is crucial to consider associated intrinsic and extrinsic factors before deciding on dressing choice. Increased exudate levels may be as a result of liquefying necrotic tissue that was once hard and eschar like and is now wet and sloughy, a process known as autolytic debridement. To maintain a moist wound bed, a moderate to highly absorbent dressing would be appropriate with additional debridement properties may be appropriate, such as Hydrofiber® dressing technology (AQUACEL®) In leg ulcers, if venous hypertension has not been addressed, exudate levels may be increased. A full leg ulcer assessment should be carried out. If appropriate (as dictated following the full assessment) compression therapy may be applied in conjunction with a moderate to highly absorbent dressing to manage the venous hypertension and exudate respectively. If clinical signs of infection are present such as pain, heat, erythema, spreading cellulitus, malodour, excessive purulent exudate, systemic antibiotics are indicated along with a dressing with absorbent and antimicrobial properties, such as Hydrofiber® technology with silver (AQUACEL® Ag) In conclusion, careful assessment and treatment of related factors along with appropriate dressing choice is the key to achieving moisture balance. In all cases an ideal exudate management dressing should have the qualities of absorption and retention especially under pressure as this will enhance wear time, improve cost-effectiveness and protect the peri-wound area. ® AQUACEL and Hydrofiber are registered trademarks of E.R.Squibb and Sons, L.L.C. ConvaTec is an authorised user.
References
This month I have decided to add some references from education related journals as well as some from wound care. Bryant-Lukosiosus D and DiCenso A (2004) A framework for the introduction of advanced practice nursing roles, Journal of Advanced Nursing, vol 48 no.5, pp530-540 Collier M and Radley K (2005) The development of a nurse led complex wound clinic. Nursing Standard Vol 19 No.32 pp74-84 Dowsett C (2005) Assessment and management of patients with leg ulcers, Nursing Standard Vol 19 No. 32 pp 65-72 Gray D, White R, Cooper P and Kingsley A, (2005) Understanding applied wound management, Wounds UK, vol 1 no. 1, pp 62-68 Hargreaves J (2004) So how do you feel about that? Assessing reflective practice, Nurse Education Today vol 24, pp 196-201 Mockridge J and Anthony D (1999) Nurses' knowledge about pressure sore treatment and healing, Nursing Standard, vol 13 no.29 pp 66-72 Quinn FM (2000) Principles and practice of nurse education 4th ed. Stanley Thornes UK. Race P (1994) Never mind the teaching feel the learning, SEDA paper 80 , Birmingham
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June 2005 |
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