Improving patient outcomes by coaching primary health general practitioners and practice nurses in evidence based wound management at on-site wound clinics

Abstract

Background

Wound management is frequently performed in the community and forms a large part of daily activities of General Practice health professionals. However, previous research has acknowledged a need for further education and training on evidence based wound management for these health professionals.

Aim

The aim of this project was to develop and trial a Cooperative Wound Clinic model of care in General Practices, using a nurse led, interdisciplinary, holistic approach; including training and coaching to increase the wound management expertise and capacity of health professionals working in the primary healthcare environment.

Methods

A longitudinal, pre-post design was used. Four Cooperative Wound Clinic pilot sites and nine wound clinics were established in General Practices across three Australian states with the intervention of the study being the model care and incorporating a local wound expert employed to provide the training and coaching. Pre and post survey data were collected on wound management practices, health professional confidence in evidence based wound management, patient health, wellbeing and healing outcomes. Longitudinal patient data were collected for 24 weeks.

Findings

Results included an increase in the confidence of health professionals to manage wounds. Utilisation of a repetitive coaching model over a six month period empowered the decision making process and assessment knowledge for a variety of wound types. A positive impact on patient outcomes for a variety of wound types was also observed.

Conclusion

The potential for expanding this model will bring many benefits including: empowerment of nurses’ confidence in managing wounds, promoting the role of nurse led clinics; improved wound related capability and confidence of health professionals; improved wound management, patient knowledge and better patient satisfaction and outcomes.

Introduction

The majority of wounds progress smoothly through the stages of healing, however, some wounds will remain unhealed for long periods of time. Wounds can occur as a disruption of skin integrity, as part of a disease process, or from intentional or accidental indications (Young & McNaught, 2011). Having a wound can be debilitating and patients often suffer multiple symptoms and effects, including pain, reduced mobility, lower limb oedema, venous eczema, wound exudate, decreased quality of life and depression (Jones, Barr, Robinson, & Carlisle, 2006; Parker, 2012). The effects of chronic leg ulcers involves 1–3% of the population (Briggs & Closs, 2003; Margolis, Bilker, Santanna, & Baumgarten, 2002) with many remaining unhealed for years or even decades. Caring for acute and chronic wounds is a multi-billion dollar burden on Australia’s health system with reported costs in excess of A$3 billion (The Australian Wound Management Association Inc & The New Zealand Wound Care Society Inc, 2011).

Wound management occurs primarily in the community with wounds being a common reason for admission to community nursing services (RDNS, 2008) and/or General Practice (GP), where patients are seen for frequent, on-going visits. One study investigating adults with leg ulcers who were visiting GPs for care of their ulcers, found that 82% attended 1–2 times/week for a median of 21 weeks (Edwards et al., 2014). The ageing of the Australian population, the increasing incidence of chronic illnesses and recognised inequities in access to health care have prompted governments to look for new ways to fund care that has more of a focus on prevention and ongoing disease management (Jolly, 2007). This has resulted in current health care policy that aims to transfer health services from the hospital sector to primary care where possible. With the number of nurses in GPs rapidly increasing from 7728 in 2007 to 10,683 in 2012 (Australian Medicare Local Alliance, 2012), nurses are well placed to play a lead role in redesigning care to meet these challenges.

Wound management is a large and important part of the daily activities for most primary health care nurses (Australian Medicare Local Alliance, 2012). The treatment of people with wounds is an important issue for nearly every GP in Australia (Britt et al., 2012). In 2011–12, a considerable proportion (33%) of Medicare claims were for wound management item numbers (Britt et al., 2012). Dressings accounted for 20% of all procedures performed by practice nurses and three of the five most common procedures in GPs involved wound management (Britt et al., 2012). An education and training needs analysis performed by the Wound Management Innovation Cooperative Research Centre indicated that primary health care was a high priority area requiring more education and training around evidence based best wound management practice (Innes-Walker & Edwards, 2013). There are many well documented barriers to nurses updating their evidence based wound management knowledge (Coyer, Edwards, & Finlayson, 2005), however, it has been indicated that significant social and economic benefits would be gained if resources and strategies were directed to facilitating implementation of these strategies in GP (Edwards et al., 2013; Graves, Finlayson, Gibb, O'Reilly, & Edwards, 2014).

This project implemented a Cooperative Wound Clinic (CWC) model of care which was underpinned by the principles of the “Leg Club^®” model of care, developed in the United Kingdom (Lindsay, 2004), and utilising a coaching model of education. The “Leg Club^®” model provides wound management for patients with an emphasis on social interaction, education, participation and peer support for patients (Lindsay, 2004). A randomised controlled trial in Australia that compared this model of care to in-home wound care reported significant improved outcomes in patient quality of life, morale, self-esteem, healing, pain and functional ability of the patient (Edwards, Courtney, Finlayson, Shuter, & Lindsay, 2009). It was proposed that a service delivery model based on the Leg Club^® model undertaken in a primary health care environment would also offer improved outcomes for patients and the health care system.

The CWC model of care also utilised coaching strategies designed to provide holistic, evidence based care and dedicated wound management clinic time to patients through the utilisation of a coaching model of education with a wound care expert. A coaching role in the delivery of education and clinical skills has been used effectively and has been noted to encourage communication, leadership and adaptability (Johnson, Hamilton, Delaney, & Pennington, 2011), while utilising skills in facilitation, practice development principles, adult learning strategies to support a person centred approach to care (Faithfull-Byrne et al., 2016). The successful utilisation of a coaching model has also been shown to increase documented assessments and knowledge in chronic conditions (Johnston et al., 2007) and health organisations (Faithfull-Byrne et al., 2016). The role of a practice nurse in today’s medical environment often occurs in rapidly changing circumstances and contemporary demands for workplace learning have been supported by coaching roles in teaching (Faithfull-Byrne et al., 2016). One-on-one or small group coaching allows for health professionals to be able to coach other staff through the wound assessment and management process, allowing for questions to be asked and critical decision making to be discussed throughout the process. This included staff development training, work integrated learning and the development of organised referral pathways for multidisciplinary care as appropriate.

Specifically, the expert attended the clinic and simultaneously led education to the health professionals and care to patients to facilitate the transfer of learning into practice. The wound expert used a patient centred approach incorporating holistic assessment and the development of plans with the health professional and patients and families while also encouraging the socialisation of patients and/or families and carers with other patients and/or families and carers in the wound clinic environment as per the Leg Club^® model of care.