Pressure injury management: An exploration of current practice within New South Wales and Victorian Health Services

Abstract

INTRODUCTION Pressure injuries (PIs) are a multifactorial issue affecting those with complex chronic care needs. PI is also an important quality and safety issue, which presents challenges across all health service settings (Australian Commission on Safety and Quality in Health Care (ACSQHC), 2012a, 2012b). When PI occur they result in poor client and health system outcomes. Research in the area of PI has traditionally focused on acute and long-term aged care settings. The aim of the research project, which will be described in the present thesis, was to explore current practice in PI management, with a particular emphasis on PI management within community service settings. An enhanced understanding of current practice, captured across the main health service settings that comprise the Australian Health Care System (AHCS), informed new mechanisms to support the workforce in this challenging area of practice. METHODS A health services research approach was used to inform the current project. The aim of health services research is to improve health care through enhanced clinical and organisational practices and health care policy (Shi, 2008). All decisions regarding the research process were informed by a desire to influence outcomes of care through the application of the research findings in everyday practice. This applied approach was achieved through mixed qualitative methods, which were selected for there ability to address the research questions (Patton, 2002). Phase One involved two community based case explorations during which data related to the provision of PI services, experience of PI services and perceptions of real need for PI management were gathered. Phase Two involved five interdisciplinary group discussions with clinicians (n=38) from community based, hospital based and long-term aged care settings. These discussions were used to gather a range of perspectives and experiences regarding current practice. Phase Three involved peer validation processes including the provision of overall feedback to health services, two in-depth interviews and a series of presentations to clinicians and researchers at key conferences. All data were analysed using a thematic analysis approach (Braun & Clark, 2006). FINDINGS AND DISCUSSION Data collected over the course of this project were aggregated, synthesised and presented at the key levels of operation within health care: the system, client and clinician levels. This approach enabled consideration of the key issues influencing PI management, the capacity for change and the potential impact of innovations at each level of the AHCS. Participants discussed health systems as well as clinician and client behaviour at length. There were a number of issues occurring at the system, clinician and client levels that influenced PI management. The data suggested that participants were not convinced that the general approaches to PI were meeting the needs of all clients and services. Key issues relating to workforce development included skill-mix and organisation of services, along with education and training. Consideration of the key issues at the system, client and service levels of the AHCS, suggested that longer-term PI needs may be best met by supporting team-based approaches within primary health care. Most participants believed that increasing client and support care involvement in PI management was essential to meet increasing demands for these services. Additionally, the role of clients and their informal support care was found to be necessary in the early recognition of the signs and symptoms of PI, due to its natural history. Clients and their support care would thus benefit from clinicians, learning how to effectively educate clients as partners in their own care. SUGGESTIONS FOR PRACTICE AND RESEACH A new model of care is proposed and its necessary supports are described. This new model of care enhances client access to PI management by ensuring the best use of skills and local resources, toward team based approaches within community based care. By creating a ‘hub’ for PI needs within primary health care, this will better support the transition of PI management between hospital based and community based services, as well as facilitate improved continuity of care and co-ordination of care for those with longer-term PI needs. A necessary support for the model, amongst others, is a new role that works to address ‘gaps’ and the cross organisational boundaries that influence daily practice. This new role will also provide important support for clinicians in partnering with clients in their own care, by acting as an educative resource within community service settings. CONCLUSION As clients and their support care have the greatest opportunity to identify the early signs and symptoms of PI, the up-skilling of clinicians to effectively impartinformation to lay-persons isnecessary. The proposed new model of care and its accompany of supports may assist health services to enhance continuity ofcareandaccess to PI services, through the optimum organisationof skills at the local service level. Facilitating greater client and support care participation in PI management may assist health services to enhance preventative efforts, and assist in the earlier identification and expedited management of PI. KEYWORDS Pressure injury, Pressure ulcer, community, workforce, allied health, health services research.