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10 Steps for Writing a Wound Care Case Report

Writing up a case report is an important professional activity in not only wound care, but in any other field as well. A case report records the details of the presentation of signs and symptoms, assessment, diagnosis, treatment and outcomes of a patient case or series of cases. Case reports typically describe an unusual presentation or complication relating to the patient's condition, or a new clinical approach to a common problem. The publication of a case report in a peer-reviewed journal, if that is your intent, is a great addition to your CV, especially if you are new to the profession.

Following are general steps to take in creating a patient case report.

1. Talk to Colleagues:

If you encounter a striking or unique patient case in your clinical practice that seems worthy of a case report, talk to your colleagues and senior clinicians to determine if the patient case is of interest for further research and documentation in the form of a case report. Also, determine what protocol you must follow within your facility to gain permission and access to take on the composition of the case report.

2. Conduct Research:

Once you have determined the viability of a patient case for a case report, conduct research to ensure this case will present new and/or unique findings to the wound care community. Use online medical databases to research peer-reviewed journal articles to review similar cases and/or the condition(s) presenting in your patient. Conducting this early stage of research will not only validate your case by allowing you to see what's already been published on the subject, it also help you compile your research for inclusion in the case report.

3. Seek Permission:

Gain the permission of the patient(s), or in the case of a deceased patient, the next-of-kin. You may also need to seek permission from the patient's primary case manager depending on your position and facility protocol. Many journals require patient consent in order for a case study to be considered for publication, and may have their own permission form requirements. Receiving clearance from the patient is essential to the presentation of your patient's case, especially if it is your intention to submit the case report for publication.

4. Compile the Patient Background and History:

Create the presentation of the patient case and wound care treatment. Include the clinical background of the case. It is in this section that you will describe the case and start with the basics:

• Who is the patient?
• What type of wound is it?
• Describe the medical history of the patient

Example: TJ is a 55 year old woman presenting to the wound clinic with a venous ulcer to her left lateral lower leg. TJ has a history of anemia, medication controlled hypertension, and varicose veins that initially presented six years ago.

5. Document Wound Assessment:

Once you have set the stage, follow up with the wound assessment . Describe the location, etiology, wound history, size, and appearance of tissue, exudate and periwound skin. Remember to incorporate any information that is relevant to potential barriers to healing such as co-factors, patient compliance issues or other complications that arise during treatment.

Example: Ulceration to the left lateral lower leg with a history of being present for 45 days. The wound is partial-thickness, 3x4cm with a depth of 2mm. Explain tissue type, amount of tissue by type, exudate characteristics and amount.

6. Describe Treatment Protocol:

The next section should address and explain the treatment protocol that was implemented. Describe your wound management approach here. List what treatment intervention and/or product(s) were used, how much, frequency of dressing change and any other pertinent information.

Example: Using an alginate dressing 4x4 to the wound bed followed by applying a skin barrier ointment to the periwound area, cover wound with a foam dressing and secure with a four-layer compression system . Change the wound covering and compression every four days.

7. Document Results:

Describe and detail what wound changes you observed and at what time intervals during the treatment process. Discuss how many days transpired until closure was observed.

Example: Protocol initiated and on day four of the treatment the wound had decreased in size to 2x1cm, depth 1mm. Periwound erythema and maceration resolved. The protocol was continued for 20 days. On day 24 the wound had closed, the periwound skin was intact and without evidence of maceration. Compression was continued on a weekly change schedule.

8. Include Photo Documentation and Clinical Data:

Include any photo documentation that you have taken. It is a good idea to show a comparative "before" photo taken at the beginning of the wound care intervention, allowing you to demonstrate the wound healing in progress, and the wound closure on your patient's last visit.

Provide graphic data in the form of charts, graphs and other visual depictions to support your case findings and/or treatment outcomes.

9. Product Name Citation:

When using the product's name, use the service or trademark that you can find on the package, insert or user information. List any of the product's trademarks at the end of your discussion.

10. References:

Include any literature citation that you reviewed in developing or evaluating your protocol. It is permissible to list Instructions for Use (IFU) information.

Now you are on your way to sharing your wound care experiences with your colleagues through professional wound care case reports.

Editor's Note: This article was originally published on November 11th, 2010 and has been updated and expanded for comprehension.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.

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Wound Care: A Comprehensive Guide for Nurses

This article was written in collaboration with Christine T. and ChatGPT, our little helper developed by OpenAI.

Wound care is the process of managing and promoting the healing of various types of wounds, such as surgical incisions, pressure ulcers, and traumatic injuries. It involves assessment, treatment, and prevention strategies tailored to the specific needs of each patient, with the goal of minimizing pain, infection, and complications while optimizing healing.

Related Terms

• Debridement: The removal of nonviable tissue, debris, and foreign materials from a wound to promote healing and reduce the risk of infection.
• Pressure ulcer : A localized injury to the skin and/or underlying tissue, usually over a bony prominence, resulting from prolonged pressure or pressure combined with shear and/or friction.
• Wound dressing: A sterile material applied directly to a wound to protect it, absorb exudate, and maintain a moist environment conducive to healing.

Synonyms, Definitions, and Examples

Assessment techniques and tools.

Wound assessment techniques and tools include:

• Visual inspection of the wound, noting its size, depth, color, and presence of exudate or necrotic tissue.
• Palpation to assess for pain, tenderness, warmth, or induration, which may indicate infection or other complications.
• Measurement of the wound dimensions, using a ruler or wound measurement tool, to track changes in size over time.
• Evaluation of the surrounding skin and tissue for signs of inflammation, maceration, or other abnormalities.
• Assessment of the patient’s overall health, including nutritional status, comorbidities, and risk factors that may impact wound healing.
• Documentation of the wound assessment findings using standardized tools or forms, such as the Pressure Ulcer Scale for Healing (PUSH) Tool or the Bates-Jensen Wound Assessment Tool.

Assessment Frameworks

Several wound assessment frameworks are used by healthcare professionals to guide the evaluation and management of wounds. Some of these frameworks include:

• TIME: Tissue management, Infection or inflammation control, Moisture balance, and Epithelial edge advancement. This framework helps guide the assessment and treatment of chronic wounds.
• Wound, Ischemia, and foot Infection (WIfI) classification system: This system is used to classify the severity of diabetic foot ulcers and guide treatment decisions.
• Wound bed preparation: This concept involves assessing and managing the wound environment, including debridement, bacterial balance, and moisture management, to optimize healing.

Assessment Documentation

Proper documentation of wound assessments is essential for monitoring healing progress, guiding treatment decisions, and facilitating communication among healthcare providers. Key aspects of wound assessment documentation include:

• Describing the wound’s location, size, depth, and appearance, including the presence of exudate or necrotic tissue.
• Documenting the patient’s pain level, using a standardized pain assessment scale.
• Recording any interventions performed, such as wound cleansing, debridement, or dressing application, along with the patient’s response to these interventions.
• Noting any patient education provided regarding wound care, prevention strategies, or self-management techniques.
• Updating the patient’s care plan as needed based on the wound assessment findings and the patient’s overall health status.

Legal and Ethical Considerations

Legal and ethical considerations in wound care include:

• Adhering to evidence-based practice guidelines and professional standards for wound assessment, treatment, and prevention.
• Respecting patient autonomy and obtaining informed consent before performing any wound care interventions.
• Maintaining patient confidentiality and adhering to privacy regulations, such as the Health Insurance Portability and Accountability Act (HIPAA) , when documenting and sharing wound assessment information.
• Advocating for patient needs, including appropriate resources and referrals for specialized wound care services if needed.
• Continuously updating knowledge and skills related to wound care through ongoing education and professional development.

Real-Life Examples or Case Studies

Case studies in wound care provide valuable insights into the complex process of wound assessment and management, highlighting the importance of a comprehensive and individualized approach. Examples include:

• A patient with a chronic venous leg ulcer that improves with compression therapy, wound cleansing, and moisture-retentive dressings.
• A patient with a diabetic foot ulcer requiring debridement, offloading, and close monitoring of blood glucose levels to promote healing.
• A patient with a pressure ulcer that resolves through a combination of repositioning, pressure redistribution surfaces, and appropriate wound dressings.
• A patient with a surgical wound experiencing delayed healing due to infection, which is successfully managed with antibiotic therapy and wound care interventions.
• A patient with a traumatic injury requiring a multidisciplinary approach to wound care, including surgical intervention, nutritional support, and psychological counseling.

Resources and References

For further learning and professional development in wound care, consider the following resources:

• Wound, Ostomy, and Continence Nurses Society (WOCN): https://www.wocn.org/
• WoundSource: https://www.woundsource.com/
• Journal of Wound, Ostomy, and Continence Nursing (JWOCN): https://journals.lww.com/jwocnonline/pages/default.aspx
• Wound Care Education Institute (WCEI): https://www.wcei.net/

Wound care is an essential aspect of nursing practice, requiring a comprehensive and patient-centered approach to assessment, treatment, and prevention. By staying up-to-date on the latest evidence-based practices, adhering to legal and ethical principles, and utilizing available resources, nurses can play a vital role in optimizing patient outcomes and promoting healing.

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• v.15(1); 2018 Feb

Wound care evidence, knowledge and education amongst nurses: a semi‐systematic literature review

1 School of Health, Nursing and Midwifery, University of the West of Scotland, Paisley Scotland

The aims of this study were to determine the knowledge and skills of nurses involved in wound care, to provide a critical overview of the current evidence base underpinning wound care and to determine the extent of utilisation of existing evidence by nurses involved in the management of wounds in practice.

A semi‐systematic review of the literature was undertaken on Cinahl, Medline Science Direct and Cochrane using the search terms: wound, tissue viability, education, nurse, with limitations set for dates between 2009 and 2017 and English language.

Shortfalls were found in the evidence base underpinning wound care and in links between evidence and practice, prevalence of ritualistic practice and in structured education at pre‐ and post‐registration levels.

The evidence underpinning wound care practice should be further developed, including the conduction of independent studies and research of qualitative design to obtain rich data on both patient and clinician experiences of all aspects of wound management. More structured wound care education programmes, both at pre‐registration/undergraduate and professional development levels, should be established.

Introduction/background

The presence of a wound represents a considerable burden in terms of economic cost to health and social care providers and impact on patient quality of life (QoL). This is notably so for chronic wounds, the definition of which has not been universally agreed upon but is generally accepted to refer to wounds that do not follow the normal stages of healing and in which healing is consequently delayed 1 . Whilst chronic wounds were previously estimated to cost the National Health Service (NHS) between £2·5 and £3 billion p/a 2 , more recent data propose that the annual cost to manage wounds and associated comorbidities is between £4·5 and £5·1 billion 3 . In addition, Augustin et al. 4 found living with a wound to have a negative multifactorial impact on psychosocial health and well‐being. This impact is recognised to be worsening with changing demographics and a population that is living longer with multiple comorbidities and chronic conditions 5 . In the UK, the increasing decentralisation of health and social care means that the majority of the burden lies within the community setting where district nurses (DNs) and other community health and social care providers are responsible for wound management 6 . Indeed, wound care represents between 35% and 65% of community nurses' caseloads ( 7 , 8 ), which has significant implications for an increasingly overstretched and pressurised DN work force 6 , 9 , 10 .

The effective management of chronic wounds is complex, and in order to maximise outcomes for patients, it is recommended that those involved in their care and treatment should have the appropriate knowledge and skills (European Wound Management Association 11 , 12 . This includes an understanding of the anatomy and physiology of tissue repair and aetiology and also knowledge pertaining to the selection of appropriate products and interventions to support the achievement of positive outcomes. The most obvious of these is wound closure, which is reflected in the frequency with which it is measured in studies 12 ; however, those relating to patient QoL are increasingly regarded with equal importance as wounds negatively impact all aspects of an individual's life, and complete closure is not always the ultimate goal of care (e.g., in palliative care patients for whom maximisation of comfort and dignity often takes precedence over healing) 13 . Despite this, little is known about nurses' knowledge and skills in wound care, both in relation to formal evidence and education and that which is from gleaned from experiential learning and clinical practice 14 , 15 . There is also debate surrounding the quality of evidence, which seeks to confirm the proposed effectiveness of particular types of wound treatments and products and factors influencing their selection 5 , 16 . A significant shortfall of this evidence is that it is largely driven and funded by industry, which may have potential methodological and ethical implications. It is therefore crucial that a more developed understanding of the evidence base underpinning the care of wounds and its role in shaping nurses' knowledge, education and clinical practice is achieved so that outcomes can be maximised.

The aim of this literature review is to provide a critical overview of the current evidence base underpinning wound care and the extent of utilisation of existing evidence by nurses involved in the management of wounds in practice. It will also seek to determine the knowledge and skills of nurses in relation to wound care and the sources from which it arises, including those that are formal (i.e. empirical evidence and structured education) and those that are informal (i.e. experiential, clinical practice and knowledge gleaned from colleagues).

Search strategy

An initial literature search was carried out in February 2017 on health care and scientific databases, including Cinahl, Medline, Cochrane,; Science Direct and PubMed, with the following key words singularly and in various combinations: Wound*, knowledge, nurs*, tissue viability, evidence, education.

Inclusion criteria were as follows: original research studies with no restrictions on design or methodology, English language, date of publication between 2009 and 2017 to source contemporary literature and all age groups.

Exclusion criteria were as follows: review papers, publications in languages other than English, date of publication before 2009, publications not fitting specified methodologies, publications focusing upon specialist or novel approaches to wound management, studies published with industry support and funding and studies focussing on specific or specialist wound care skills and practice.

The original search yielded 201 papers, which were filtered to 193 with the removal of duplicates; 193 papers were screened, with 104 excluded by title and abstract, and a further 84 excluded following review of full text and reference lists. An additional search on Google Scholar was carried out, but no further studies were identified. Saved searches were re‐run on a weekly basis until March 2017, but no new studies were identified, leaving a final total of five papers that fit the inclusion criteria (Figure ​ (Figure1 1 ).

Search strategy algorithm. PRISMA 35 .

To assist with structured methodological appraisal, a summary table was used (Table ​ (Table1). 1 ). An appraisal tool was adapted from the Critical Appraisal Skills Programme (CASP) for quantitative studies to support the critique of each study using the checklist approach that is recommended by the Centre for Reviews and Dissemination 17 .

Summary appraisal table

Key findings

The findings of the literature review highlighted a number of shortfalls and limitations pertaining to wound care knowledge and practice, with the following common sub‐themes emerging:

• Limitations in the evidence base pertaining to wound care, including the domination of studies published for corporate interest;
• Poorly developed links between evidence and wound care in practice;
• Recognition of insufficient wound care knowledge amongst nurses;
• The frequency of ritualistic and historic practice;
• Recognition of the need for more structured wound care education programmes for nurses at pre‐ and post‐registration levels.

A number of generic ontological and methodological limitations were identified with the evidence sourced – most notably that all studies took a similar post‐positivist approach, adopting descriptive and quantitative methodologies. A key and significant flaw is, therefore, the absence of studies underpinned by a constructivist or interpretivist paradigm and an overlooking of knowledge formation from contextual, individualistic and socially developed perspectives 18 . This might be contested to particularly misalign with the ethos of the nursing profession, which is embedded in person centeredness and holism 19 . The absence of studies adopting a qualitative design also overlooks the importance of rich contextual data, for example, that pertaining to nurses' views on their wound care knowledge and patients' lived experiences of having a wound 18 . The uniform choice of questionnaire and survey design methods considerably limit the variety of data that shape the resulting evidence base and may not accurately represent wound care in the practice setting, particularly because all studies relied upon data that was self‐reported.

In terms of methodological weakness, only one study utilised a validated tool to collate data, whilst a number of the sample sizes were small, with only one study completing a power calculation and others having relatively poor participant response rates. For the majority of studies, the approach to sampling was convenience, which may not have led to results reflective of wider nursing practice. No studies declared whether researchers had been previously known to participants and in what capacity, which could have contributed to a researcher effect 20 . This is considered to be an important factor in maintaining reliability in studies of positivist, realist and, to a lesser degree, post‐positivist ontology as contextual factors, including relationships between researchers and participants, should be highly controlled 20 . Finally, four of the studies used participants from only acute clinical settings, which limits the generalisability of the findings to wider areas of practice. This is particularly relevant in the UK where the majority of wound care is carried out in the community setting and may consequently account for community nurses having more developed skills in wound management 6 . However, the representation of wound care practice in a variety of geographical settings might be argued to shape a global perspective and enable useful comparisons to be made.

Each of the emergent themes will now be explored in succession.

Evidence in wound care

Nursing has been historically criticised for the absence of a distinct profession‐specific evidence base, instead borrowing on those from professions such as medicine and the social sciences 21 . To some extent, the academisation and move from an apprenticeship model to a higher education model has raised the profile of the profession in this capacity; however, there is still a reluctance amongst nurses to fully embrace evidence‐based practice (EBP), most notably within the clinical context 22 . This trend has been particularly visible within wound care, which has been argued to lag behind other areas of practice due to the lack of robust empirical evidence 23 . All five of the publications reviewed acknowledged this shortfall and the need to establish a more scientific evidence base 23 , 24 , 25 , 26 , 27 . Whilst national clinical guidelines, such as those produced by National Centre for Health and Care Excellence (NICE) in the UK, employ strict criteria for development (e.g., the underpinning of empirical evidence that is high on the hierarchy of evidence such as clinical trials), it was also recognised that, within wound care, nurses often rely upon evidence that is lower on the traditional hierarchy to shape practice 26 . This was particularly noted in relation to a lack of evidence supporting the efficacy of specific dressings 26 . However, although empirical evidence was widely agreed to be a crucial component of EBP in relation to wound care, additional types of knowledge, such as that gleaned from informal sources (i.e., experience, clinical practice and learning through colleagues), were also recognised to be important 23 , 24 , 25 , 26 , 27 . Indeed, the Centres for Disease Prevention and Control [CDC] in the USA applies a combination of empirical evidence, theoretical knowledge and contextual knowledge to shape each of its recommendations 26 , which supports an increasing awareness of the role of informal sources of knowledge in EBP. Dugdall and Watson 23 additionally recognised shortfalls in evidence pertaining to the management of wounds for specific patient groups (e.g. paediatrics and neonates) and a subsequent need to adopt evidence from studies conducted on adults to shape practice. However, it should be noted that this challenge is not unique to wound care as it is ethically problematic to carry out trials using paediatric and neonatal participants in all areas of practice 28 . A final factor is that much wound care research is supported by industry, leading to potential conflicts of interest in relation to overall corporate aim and the opportunity for ethical misconduct.

Poorly developed links between evidence and practice

All five of the studies either directly or indirectly identified poor links or barriers to the implementation of EBP. Although McCluskey and McCarthy 27 recognised the importance of informal sources of knowledge, such as experiential learning and intuition, in shaping competence in wound care practice, the lack of a structured approach and barriers to the implementation of EBP were also identified. As such, nurses' knowledge was, in some cases, found to be sufficient, but poor application negatively affected competence in practice. Gillespie et al . 26 also recognised the role of experiential knowledge but found gaps between knowledge and practice and a failure of nurses to apply recommendations made by national clinical guidelines, whilst a high number of respondents in deFaria et al . 24 and Ferreira et al . 25 reported a lack of awareness of the existence of local protocols or guidelines pertaining to wound care in their clinical area at all. Dugdall and Watson 23 found statistically significant correlations between positive attitudes to EBP and a specific tissue viability role ( P = 0·002), a first degree ( P = 0·001) and a formal tissue viability qualification ( P = 0·001), which suggests that EBP is more positively received by those with structured education. However, shortfalls in partnerships and integration between higher education/academic institutions and clinical sectors were also noted, which are also recognised to negatively affect the implementation of EBP in the practice setting 23 , 24 .

Inadequate wound care knowledge amongst nurses

Nurses' knowledge in wound care was addressed by five of the studies, all of which acknowledged an insufficiency to some degree. deFaria et al . 24 and Ferreira et al . 25 noted a clear deficit in knowledge in a number of areas pertaining to wound care (e.g. pressure ulcer grading, awareness of clinical guidelines/protocols, dressing selection etc.), although it should be noted that both studies were conducted in the same acute hospital in Brazil, which may identify shortfalls pertaining to the particular setting rather than to nursing in the wider sense. McCluskey and McCarthy 27 found that whilst wound care knowledge was sufficient to inform practice overall and somewhat better than reported in a number of previous studies, this was distinct from competence, which was often negatively affected by nurses' poor application of knowledge in the clinical setting. This was supported by Gillespie et al . 26 who found that despite having a good theoretical knowledge of wound assessment, Australian nurses working in the acute sector demonstrated similar poor links between knowledge and practice and poor application of clinical guidelines. Dugdall and Watson 23 was the only study that did not explicitly explore knowledge; however, they did identify a link between higher and specialist wound care education and a positive attitude to EBP, which subsequently led to better wound care practice. Although findings from some of the studies also suggested that nurses often lack product‐specific knowledge, which is required to make evidence‐based decisions in the selection of dressings 24 , 26 , in other studies, some participants reported a degree of confidence in product selection 25 . deFaria et al . 24 found that 70% of respondents attested that there were no wound care guidelines or standards in their area of practice, whilst a further 6% were unable to respond due to lack of information. When questioned about their level of professional autonomy in the selection of wound care products, 63% also stated that authorisation from the doctor was required in this capacity. This is in contrast to the UK where nurses historically take the lead in the management of wounds; however, although this might be argued to be reflective of differences in the organisational and professional hierarchies in health care, nurses from those studies carried out in other areas also reported some lack of knowledge, which reveals a potential deficit in a range of geographical settings 26 , 27 . Finally, only McCluskey and McCarthy 27 explored the nature and types of knowledge nurses apply to shape wound care practice, including those that are empirical, formal and explicit and also those that are tacit, informal and contextual, the latter of which were perceived to be linked to competence and experiential learning in practice.

Ritualistic and historic practice in wound care

Four of the studies attributed much wound care practice to derive from historic and ritualistic practices ( 23 , 24 , 25 , 26 ). Ferreira et al . 25 reported that wound care practice was rooted in tradition and myth; with Gillespie et al . 26 using the concept of the “sterile field” as an example of wound care practice, which is ritualistic rather than underpinned by evidence. Gillespie et al . 26 and McCluskey and McCarthy 27 both acknowledged the contextual and individualised nature of knowledge applied to wound care practice and a lack of standardisation that varied both within and between organisations. Dugdall and Watson 23 attributed this partly to the increasing availability of wound care products and nurses' reluctance to change the types of dressings used in case it appeared that they were challenging colleagues, whilst Gillespie et al . 26 attested that the selection of product can also be limited by contextual factors such as senior clinician preference and stock availability. McCluskey and McCarthy 27 also recognised the increasing complexity of wound aetiologies as a potential factor affecting ritualistic practice, whilst Ferreira et al . 25 and deFaria et al . 24 acknowledged challenges associated with accessing updated information about wound care and reliance upon colleagues' knowledge and experience as a means to address this. This was echoed by Gillespie et al . 26 , who reported that 75% of respondents obtained wound care information from informal sources, such as local specialists, rather than from scientific journals. Although learning from colleagues may be argued to present an opportunity for the maintenance of historic and ritualistic practice, in contrast, McCluskey and McCarthy 27 found that wound care competence in practice improved in accordance with length of clinician experience, which supports a positive link between contextual learning and competence in wound management.

Shortfalls in wound education

Dugdall and Watson 23 acknowledged the need for better education in EBP and research and also specifically recognised shortfalls in tissue viability content in undergraduate nursing education. This was echoed by Ferreira et al . 25 and deFaria et al . (2016) 24 , who found that 71·4% and 67·3% of respondents, respectively, reported to having insufficient formal wound care education, and McCluskey and McCarthy 27 , who recommended the implementation of better wound care education programmes for nurses working in acute setting. Gillespie et al . 26 did not specifically comment on the existence or effectiveness of formal wound care education or that accrued in practice but did acknowledge the existence of a positive relationship between higher education or specific tissue viability training and favourable attitudes towards EBP, which suggest that education improves practice. This may be argued to be of particular importance within the primary care sector as in a number of areas (e.g. across the UK), complex care is increasingly delivered in the community, and ineffective wound management would have a significant impact 6 .

It is clear from the findings of this review and from additional studies that the existence of high‐quality evidence pertaining to wound management is limited. This was found to be the case both in the generic sense but also in more specific areas of wound care practice (e.g. paediatrics) and was particularly notable in relation to the perceived effectiveness of specific products. This has been proposed to be related to a number of potential factors, notable of which may be that wound care practice has been traditionally led by the nursing profession rather than the medical profession, the latter of whom are historically regarded as the dominant health care professional 29 . As such, this may lead to their domination of competing research activity and resources but also to a failure to prioritise wound care and continually regard it as being of lesser importance than many clinical activities traditionally associated with doctors. It may also be linked to the lesser overall production of nursing research as nurses are recognised for their lesser engagement and reluctance to participate in scholarly activity in comparison to their medical counterparts. All of the publications acknowledged the need to establish a more scientific evidence base; however; despite attempts to gain legitimacy by aligning itself with the post‐positivist approach favoured by medicine 20 , nursing might be argued to be more ontologically in tune with the interpretivist/relativist/constructionist paradigms, which continue to be regarded with lesser scientific value amongst academic and research bodies than both the positivist and post‐positivist paradigms 30 . A further consideration is the links between wound care research and industry, although this has been addressed to some extent by the development of ethical codes of conduct for those employed by public sector and industry 31 , 32 .

Although empirical evidence was recognised to be a key component of practice [e.g. shaping national clinical wound care guidelines, such as those produced by the Scottish Intercollegiate Guidelines Network (SIGN) in the UK], nurses were also found to rely on evidence that is lower on the traditional hierarchy, with additional types of knowledge gleaned from informal sources (i.e. experience, clinical practice and learning through colleagues) also being recognised as important in all five studies. However, all studies also identified barriers to the implementation of EBP, including poor application of knowledge, failure to apply recommendations made by clinical guidelines or lack of awareness of protocols and guidelines altogether. Shortfalls in partnerships and integration between higher education/academic institutions and clinical sectors were also recognised to negatively affect the implementation of EBP in the practice setting 23 , 24 .

One of the shortfalls pertaining to the application of wound care theory to practice was the deficit in structured tissue viability education, both at an undergraduate level and that accredited by continuing professional development, which may be linked to the lack of prioritisation of wound care in comparison to other areas of practice and a consequential failure to organise and deliver sufficient education programmes. A further issue may be the increasing complexity of health demographics, which has led to a call in some circles for the preference of the term complex wounds rather than chronic wounds as the latter is defined by an association with time whilst the former recognises the growing underlying comorbidities that have a more multifactorial impact on wound healing 33 . This highlights an additional challenge for clinicians who are ultimately accountable for ensuring correct diagnosis, treatment pathways and responsible use of resources; however, this may be further limited by local systems and protocols impacting product availability in particular clinical areas (i.e. local wound care formularies). Additionally, the reduction of funding in CPD courses by NHS England in the UK may have a detrimental impact on access for those nurses wishing to undertake tissue viability courses, a development that is likely to filter out to other areas of the UK over time 34 .

A final point to note is that the majority of research pertaining to wound care is of quantitative design, and there is a noted absence of qualitative studies exploring either patients' or nurses' views, experiences and knowledge surrounding wounds and their management. Although the formal evidence base pertaining to wound care is unwaveringly limited, evidence and knowledge from less formal sources were more challenging to define. This was reflected in mixed evidence amongst the studies supporting the use of experiential and tacit learning in the practice setting and the conflicting results that emerged (i.e. learning from colleagues but also passing on ritualistic practices); however, experiential knowledge has been long recognised to be an important component of nursing practice, and there is no theoretical reason to believe this to be any less so in the field of wound care 14 , 15 .

This work reviewed literature pertaining to wound management to determine the current evidence base underpinning wound care, the extent of utilisation of existing evidence by nurses involved in the management of wounds and the knowledge and skills of nurses in relation to wound care. The evidence base pertaining to wound care practice was found to be limited, with weak links between EBP and practice‐heavy reliance upon industry support and funding, which may have potential ethical implications. Nurses were found to rely upon both formal and informal sources of knowledge to shape wound care practice; however, this contributed to the culture of ritualistic practice that withstands the clinical setting. A further impacting factor was found to be the inadequacy of wound care education at all levels.

Recommendations for practice

• The commitment to the conduction of independent studies in an effort to build the evidence base on all aspects of wound management;
• The commitment to the conduction of wound care research of qualitative design to obtain rich data on both patient and clinician experiences of all aspects of wound management;
• The development of more structured wound care education programmes at both pre‐registration/undergraduate and professional development levels;
• The commitment from nurse leaders and managers to support innovation and best practice through ongoing governance and audit activity.

Acknowledgements

The authors acknowledge Professor Ruth Deery, School of Health, Nursing and Midwifery, University of the West of Scotland, Dr Stephen Day, Assistant Dean, School of Education, University of the West of Scotland, Dr Vivian Crispin, Lecturer, School of Health, Nursing and Midwifery, University of the West of Scotland.

No conflicts of interest declared.

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Compassionate leadership in district nursing: a case study of a complex wound

Shirley Willis

Lecturer, School of Healthcare Sciences, Cardiff University

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Sally Anstey

Senior Lecturer, School of Healthcare Sciences, Cardiff University

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This article encourages nurses to explore leadership in district nursing practice and community teams. The challenges faced by district nurses are discussed in relation to the current health policy agenda in Wales and the increasingly complex care demands being placed on district nursing services because of the aging population and the rise in numbers of individuals living longer with multiple long-term health conditions. The concept of compassionate leadership is presented and discussed using a case study approach. The article explores compassionate leadership in the context of caring for a patient with a complex malignant wound needing palliative care. A framework for practice is developed to illustrate compassionate leadership in action to meet the needs of both the team and of the nurses delivering person-centred care.

The current health policy agenda in Wales and across the UK emphasises the value and importance of providing care closer to the patient's home or community. Healthcare services will need to change and adapt to meet this policy agenda ( Welsh Government (WG), 2018 ), with the result that community nurses in particular will need to lead and deliver care in an increasingly challenging environment. Investing in the development of a skilled community workforce is imperative if these challenges are to be overcome. In Wales, there is an ever-increasing healthcare demand associated with an aging population, where individuals are living longer with complex coexisting long-term health conditions ( WG, 2014 ). In achieving the aim of providing care closer to home, district nurses (DNs) may be seen as key players, reflecting their role as providers of care for patients within their own homes ( Welsh Assembly Government (WAG), 2009 ). This view is supported by the Queen's Nursing Institute (QNI) (2009) , which identified DNs as the main providers of care in the home and community setting. It is suggested that one in four people over the age of 75 years and one in two people over the age of 85 years require care from a community nurse at home.

Positive and demonstrable leadership within DN teams is key in supporting this provision of effective care for patients in the community setting ( QNI, 2012 ). Leadership has been identified as one of the key skills, alongside governance and accountability, as essential to the sustainable delivery of safe, effective and person-centred care ( WG, 2015 ). Similarly, it is recognised as one of the four pillars supporting advanced nursing practice ( National Leadership and Innovation Agency, 2010 ), and leadership education is a key requirement within the district nursing Specialist Practice education programme ( QNI, 2015 ). The relationship between nurse leadership and positive patient outcomes has been well documented ( Wong et al, 2013 ; Carragher and Gormley, 2017 ). Similarly, the Francis Report (2013) and the Keogh Report (2013) highlight the consequences of failed leadership, both at an organisational and clinical level, on patient care.

Historically DNs have been identified as the ‘glue’ that holds together the complexity of the care interventions frequently required to support patients at home ( Audit Commission, 1999 ), and it would appear that this continues to be the case today ( QNI, 2014 ; Maybin et al, 2016 ). Maybin et al (2016) consider how quality in district nursing services might be determined and argue that it can be achieved in part if the disctrict nursing ‘leadership voice’ is heard at a strategic level in order to articulate DNs expertise and knowledge. Kumar (2013) suggests that effective leadership by health professionals is essential in modern healthcare settings, where the effectiveness of clinical leadership is measured through patient outcomes. However, there would appear to be little evidence exploring the nature of leadership in DN teams ( Cameron et al, 2012 ), making the case for exploring clinical leadership within district nursing practice compelling.

The aim of this paper is thus to consider through a case study approach the importance of compassionate clinical leadership in district nursing practice in caring for patients with complex chronic wounds requiring palliative care. A leadership framework for clinical practice is developed, based on an anonymised case study ( Nursing and Midwifery Council (NMC), 2018 ).

Defining leadership

While we might intuitively know what ‘leadership’ looks like, definitions are often coloured by the perspective of the individual and the context in which ‘leadership’ is being defined, with the result that we all have our own view of the concept of leadership ( Kumar, 2013 ). Northouse (2016) describes how early definitions of leadership reflected the importance of the personal traits of the leader as an individual, with the followers remaining largely invisible. As the study of leadership developed through the 20th century, trait theories fell out of favour and leadership became defined in terms of the skills and behaviours of the leader and the effect of these behaviours on the followers. Northouse (2016) offers the following definition:

‘Leadership is a process whereby an individual influences a group of individuals to achieve a common goal’.

The strengths in this definition lie in the fact that leadership is acknowledged as a process and it recognises the relationship that needs to exist between the leader and their followers. It is the recognition of this relationship that has supported the development of more contemporaneous leadership theories during the latter part of the 20th century, such as servant leadership, authentic leadership and transformational leadership ( Gopee and Galloway, 2017 ) ( Table 1 ). The contribution of effective leadership to the delivery of quality and safety in healthcare service provision has been recognised ( Wong et al, 2013 ). More specifically, transformational leadership has become widely advocated within the healthcare setting, with transformational leaders aspiring to effect significant positive change in services and organisational culture through their relationship with their followers ( Fischer, 2017 ; Gopee and Galloway, 2017 ).

Despite Sarah's deteriorating condition, her wish was to remain at home with her children, and a key aspect of compassionate leadership is this person-centred approach, which is particularly relevant when caring for patients like Sarah, where wound healing is not the primary goal of care. Political and organisational agendas frequently present DNs with ethical dilemmas, where scarce resources and budget limitations require DNs to take a utilitarian approach of doing the most good for the greatest number of patients. As a consequence, there is a risk that the person-centred approach to care is lost, to the detriment of patients with complex health and social care needs like Sarah.

Wound management has been identified as a key area of the district nursing practice ( Friman et al 2010 ; QNI, 2013 ), with clinical responsibility for assessment and subsequent wound management decisions falling firmly within the district nursing role. It is evident that DNs are caring for patients with increasingly complex and chronic wounds, including malignant wounds and those requiring palliative care. The challenges faced by DNs in providing care for this particularly vulnerable group of patients are significant and exist on a number of levels. Patients with complex wounds present with very unique problems, requiring solutions that might lie outside of normal service provision. However, DNs can feel unsupported, which generates a culture of fear and lack of compassion and results in care that may be less than optimal. On a more personal level, addressing the professional issues of meeting the requirements of the code ( NMC, 2018 ) when providing care that is constrained by the political and organisational agenda can add to the high personal burden for DNs providing care for this particular patient group ( Table 2 ).

Alvarez et al (2007) define palliative wound care as ‘strategies that prioritise symptomatic relief and wound improvement ahead of wound healing’. Palliative wound care is not an excuse for poor care or for withdrawal of treatment options. Indeed, no specific therapies should be excluded if they could improve the patient's quality of life ( Langemo, 2006 ; Ferris et al, 2007 ; Grocott and Grey, 2010 ). In Sarah's case this was a particularly important element of her care, in that active interventions in the form of palliative radio-therapy were effective in managing some of her distressing symptoms, including spontaneous bleeding and high levels of exudates. Because of the chronic nature of these types of wounds, much of the care will be provided in the home setting with the DN being the main care provider. It is also clear that the care and management of patients presenting with this type of complex chronic wound requires a multi-disciplinary approach, with the role of the DN as a leader in facilitating this care being key in achieving the principles of palliative wound care ( Willis and Sutton, 2013 ).

The notion of compassionate leadership fits well with this scenario and addresses many of the challenges faced by DNs in caring for Sarah and her family. Ali and Terry (2017) suggest that compassionate leadership fosters the effective team working that is so important within the district nursing practice. In achieving this, compassionate leadership can ensure that the value of staff wellbeing is acknowledged and, more importantly, that patients felt that they are being cared for and not ‘just treated’. Compassionate leadership would also work well within the ‘quasi-family’ model of leadership identified by Cameron et al (2012) as existing within district nursing teams, with staff needing to feel cared for, nurtured and supported. The framework for compassionate leadership ( West et al, 2017 ) explored in relation to the clinical scenario allows the DN as a clinical leader to demonstrate clearly the actions that address the needs of patients with malignant and palliative wounds ( Table 3 ). These not only relate to addressing Sarah's particular needs, but also demonstrate how the compassionate leader can support team members to develop new and transferable skills for the benefit of the wider patient population.

The compassionate leader is well placed to recognise and nurture the strengths and talents of every member of the team, acknowledging the value that each member brings to the team for the benefit of the patient. Taking the democratic and inclusive approach inherent within compassionate leadership allows the leader to support individual team members to develop their skills and confidence in caring for the patient. As a result of this, team members are supported in developing transferable skills, which will allow community nurses to meet the needs of all their patients while still allowing for a patient-centred approach to underpin the nurse-patient relationship. This represents a cultural shift away from the utilitarian, task-focused approach and reflects the ethos of contemporary healthcare outlined within the principles of prudent healthcare ( Bevan Commission, 2013 ), where the patient lies at the heart of care.

The actions taken by the compassionate leader were key in this scenario, both for Sarah herself and for the team members caring for Sarah, and they demonstrate how the compassionate leadership framework can be used to support and inform patient-centred care in practice ( Table 3 ). Sarah wanted to continue with treatment, as she held the view that her condition was still being treated and would get better, a view shared by her mother. Sarah continued to be cared for at home and the district nursing team worked collaboratively with community tissue viability specialist nurses, the community palliative care team and the oncology service to optimise Sarah's quality of life as well as support her family. Sarah was admitted to a specialist secondary care unit for management of her symptoms, but despite every effort being made to bring Sarah home, she died a few days later in hospital.

Conclusion and recommendations

Clinical leadership is complex and can be difficult to articulate. Drawing on a palliative wound care patient scenario, the role of compassionate leadership in district nursing practice has been explored, and a framework for practice has been developed based on the key elements of compassionate leadership. It is clear that compassionate leadership is well suited to developing community nursing practice more widely. The inclusive nature of compassionate leadership fosters the development of a safe and nurturing environment so that community nurses can learn both new and transferable skills for the benefit of the wider patient population, while providing individualised patient-centred care. The value of this approach cannot be underestimated when viewed in the context of diversity of the district nursing practice.

The health policy agenda continues to move the focus of the provision of care increasingly towards the community setting and away from secondary and tertiary inpatient care facilities—a move that is likely to continue given the pressures on resources and rising levels of demand. DNs are going to be the key health professionals who will be called upon to deliver these services. It is clear from the literature that along with a desire by clinicians to provide a more patient-focused service, there is a strong link between effective clinical leadership and positive patient outcomes. The contribution that leadership can make to the innovative development of community services within the present climate needs to be recognised and acted upon if DNs are to be able to address the challenges of care delivery in their daily practice.

Recommendations

• Further research is needed to explore the nature of leadership within community nursing teams
• Innovative strategies for delivering leadership education as part of the specialist practice programmes need to be explored to ensure that the clinical element of leadership is recognised and valued
• Clinical portfolios and clinical learning contracts need to be used within specialist practice education programmes to support students to apply evidence to practice and to articulate their leadership activity
• Students should undertake the specialist practice education programme to have the opportunity to participate in structured reflective discussions with an experienced mentor
• Using the four domains of the compassionate leadership framework to facilitate performance development review will allow DNs to map their clinical role and clearly identify leadership activity and areas for further professional leadership development.
• Clinical leadership is complex and often difficult to articulate
• Robust, effective leadership within district nursing teams is key in the delivery of safe, effective and person-centred care
• Compassionate leadership advocates a person-centred approach, which is particularly important in caring for vulnerable groups of patients and their families, where innovative solutions are often required to meet the complex needs of patients with malignant wounds
• The compassionate leader is well placed to recognise and nurture the strengths and talents of every member of the district nursing team for the benefit of all patients
• Effective team work, essential in the delivery of care in the community setting, is achieved through the democratic and inclusive nature of compassionate leadership

CPD REFLECTIVE QUESTIONS

• Reflecting on your clinical practice, which leadership theory do you feel best describes your own leadership style and why?
• Within the district nursing team, what might be the facilitators and barriers in relation to supporting a culture where compassionate leadership can be embedded within clinical practice?
• How can a compassionate leadership approach help you to support informal carers providing palliative and end-of-life care for a family member in the home setting?

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Case Studies

The NWCSP and First Tranche Implementation Sites have gained valuable learning through implementing the NWCSP recommendations for lower limb care. Putting the recommendations into practice in organisations of different sizes with different structures is helping the programme to develop a good understanding of best practice that can be applied to other healthcare settings to help improve lower limb care on a wider scale.

We have created a series of case studies to present the learning and achievements of the sites who have been implementing the lower limb recommendations. These case studies show a range of adjustments to working practices to help improve care for people with leg and foot ulcers.

• Clinical pathway changes
• Patient involvement
• Wound care education
• Funding new services
• Supported self-management
• Piloting new clinics

Hull City Health Care Partnership (CHCP) carried out work to create a comprehensive, streamlined clinical pathway for leg and foot wounds. They also redesigned their existing services to offer a dedicated service for leg and foot ulcers.

If you work in or for health and social care, you can find further information on this case study via the FutureNHS Case Study Hub.

Case Study: Establishing ‘First Assessment Clinics’ to improve lower limb wound care

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Manchester University Foundation Trust (MFT) developed, piloted and implemented a patient survey to ensure that a new co-designed leg ulcer service would meet patients’ needs.

Case Study: Conducting a patient survey to inform the co-design of a leg ulcer service

Mid and South Essex Community Collaborative established wound care education resources as mandatory learning to give staff relevant wound education for their role. These resources were developed by NWCSP and Health Education England.

Case Study: Improving wound care knowledge and skills in the workforce: mandating online wound care education   

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Wye Valley NHS Trust successfully redirected vacancy funding to support dedicated Lower Leg Ulcer Nurse Specialist roles. These roles spanned the ambulatory and housebound population, increasing patient access to specialist advice and releasing nursing time.

Case Study: Creating Lower Leg Ulcer Nurse Specialist (LUNS) roles from unfilled community nursing vacancies to improve Leg Ulcer Service provision within Wye Valley

Kent Community Health NHS Foundation Trust adapted the local process for empowering patients and enabling supported self-management to ensure a consistent approach to lower limb care across the Trust. This included the adaption of NWCSP resources for local use and the use of the NWCSP Assessment for Shared Care to create the criteria for new resources.

Case Study: Designing an approach for Supported Self-Management in Wound Care – Download

Livewell Southwest piloted nurse-led vascular diagnostic clinics in the community. It was agreed that a Leg Ulcer Specialist and the Vascular Nurse Specialist would be present for each clinic, with rotation of the community Leg Ulcer Nurse Specialists to develop relationships, skills and knowledge.

Case Study: piloting nurse-led vascular diagnostic clinics in the community – Download

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