The Centre for Ageing Better (2022) reported there are almost 11 million people aged 65 and over equating to 19% of the total population in the UK. In 10 years’ this will have increased to almost 13 million people or 22% of the population (Centre for Aging Better, 2022). With an ever-increasing older population we can assume there will be an increase in people who have compromised skin integrity. Wicke et al (2020) argue ageing is associated with an impaired healing process and diseases that influence wound healing are more prevalent in the elderly. In relation to tissue viability and skin integrity stated the annual prevalence of wounds increased by 71% between 2012/13 and 2017/18 with annual costs rising from £5.3 billion a year to £8.3 billion each year (Guest et al, 2020). The National Wound Care Strategy Programme (NWCSP), developed as a response to this increasing burden of wounds, recognised there was inequitable care and unwarranted variations within wound care across the UK leading to elongated healing times, heightened patient suffering, escalation of costs and increased burden to wound care services (NWCSP, 2020). Educating all healthcare professionals surrounding management of skin, prevention of infection and evidence-based interventions to manage wounds is essential to improving patient outcomes, reducing length of stay, preventing readmissions and ensuring appropriate use of resources. However, shortage of nurses and other healthcare professional groups globally, can often prevent clinicians from attending face-to-face educational sessions to update both knowledge and skills. Added to this are minimal opportunities for mentorship and training in clinical areas due to time pressures. Accessible education of the workforce is key in maintaining standards and improving outcomes for the end-user, in addition to providing assurances to employers that staff have appropriate and up-to-date skills, which can enhance safe and effective practice. Here we present the results of a small survey exploring clinicians’ perspective of the necessary capabilities to care for patients with compromised skin integrity and wounds, presented in the updated Tissue Viability Leading Change (TVLC) Online Capability Framework.
TVLC Online Capability Framework is to assist healthcare professionals, and those aspiring to work in tissue viability/wound care, to understand the skills and knowledge required in this specialist area of care. TVLC Online Capability Framework includes 13 different capabilities (Table 1), with the online platform allowing users to choose which capability is important to their own learning and priorities within clinical practice. TVLC was originally introduced in 2016 as a paper document, but was relaunched in 2022 as an online portal offering complete flexibility and enabling the tool to be bespoke to the individual user and specific clinical area.
To ascertain which of the 13 capabilities was deemed most important to the user, a survey was distributed to a group of clinicians during the Wounds UK annual conference 2022 aiming to gain greater understanding of the needs and focus of clinical practitioners currently working within the field of wound care.
Participants who attended the Made Easy session “Assess, benchmark and improve: an introduction to the Tissue Viability Leading Change (TVLC) Online Capability Framework” held within the Wounds UK annual conference at Harrogate in November 2022 were asked to complete a survey questionnaire. Overall attendance across the two repeated sessions was 100 people with a background in nursing or podiatry, both generalist and specialists, including delegates from acute and community services. The overall objective of the TVLC Online Capability Framework is to provide a platform of ensuring skills and knowledge of the workforce meet the needs of the population served. During each Made Easy session attendees were given a short presentation introducing the TVLC Online Capability Framework, explaining how the platform is used, the ability to personalise this to specific learning needs highlighting potential benefits for the clinician overall workforce and how access to education and skills development can enhance outcomes for the patient. At the end of each session, delegates were asked to complete a short questionnaire, where they were asked to rank the capability domains, in order of importance. Completion of the questionnaires was voluntary and anonymous. Due to the methodology of the research, ethical approval was not required.
We received 75 responses, of which 3 were spoiled leaving a total of 72 included for the analysis. The top 5 ranking capabilities were:
1. Wound care
2. Pressure ulcer (PU) prevention and management
3. Lower limb ulceration
4. Health improvement
5. Leadership, management, and teamwork.
Lowest scored capabilities were:
- Research utilization and audit.
Wound care was the highest ranked priority, with 60/74 responders choosing this capability. It was unsurprising that this was one of the top 5 priorities as wound care is a core attribute of many healthcare practitioners including nurses and podiatrists. Guest et al (2020) highlighted that resources allocated to wound management in the UK included 54.4 million district/community nurse visits, 53.6 million healthcare assistant visits and 28.1 million practice nurse visits. Nurses and podiatrists are responsible for a range of wound types including acute, chronic and lower limb wounds, in addition to infected wounds. It is essential that all bands of staff, junior and specialist, are educated and upskilled to prevent, assess, manage and evaluate outcomes for all wound types.
The second highest priority with 58/74 responses was PU prevention and management. PU prevention and management continues to be a huge focus of many clinicians and health care organisations. Campaigns such as “React to red” and “Stop the pressure” combined with tools, such as model hospital data, incident reporting and root cause investigations, has ensured every organisation has developed a strategy for learning from this data. NHS Improvement (2018) concerns are that pressure ulceration development is mainly related to avoidable harm/lapse in care associated with healthcare delivery. They have raised the profile of the need for high quality skin inspection, attention on prevention, with clear organisational policy and a true quality improvement focus. Therefore is not unexpected that clinicians identified this capability as a priority.
It was reassuring to see that lower limb ulceration was identified as one of the 5 priority areas, with 54/74 choosing this capability. For many years the focus for clinicians, especially Tissue Viability Nurses has been directed to PU prevention and management, and in many organisations this was detrimental to early identification and management of lower limb ulceration, and while the incidence and severity of pressure ulcers has been declining, the number of patients with active lower limb ulceration has been increasing (NICE, 2014; Guest et al, 2020). The NWCSP clinical recommendations for lower limb wounds (NWCSP, 2020) and campaigns such as Legs Matter (Legs Matter, 2018) has empowered patients and challenged clinicians to ensure they are providing the right care at the right time. However, there continues to be a huge national need to improve outcomes for patients with lower limb wounds, particularly in ensuring patients have timely assessment, accurate diagnosis, and appropriate management. This is particularly important for patients with venous ulcerationI. It could be considered a crisis that national healing rates for patients with venous leg ulceration is only 37% after 12 months of treatment (Guest et al, 2020), especially when considering there is data to suggest that simply standardising care in line with the evidence base results in healing of 86% at 12 weeks (Gohel et al, 2018).
The next selected priority was leadership, management, and teamwork, with 53/74 indicating this was in their top 5 priorities. Over the past few decades, the requirement for effective leadership within clinical services has emerged more strongly than ever. Over the past 30 years or so, different governments have introduced measures to open up the NHS to market forces and competition with the creation of an ‘internal market’ in which the NHS was divided into those who provided services (e.g. hospitals) and those who purchased services from them. This has resulted in services having to generate their own income and compete for business. Service leaders need to be equipped with the skills to be able to lead their teams as a mini business, including strategic planning, business case development skills all aiding service-based development and effective implementation of strategy/change and to be able to demonstrate value for money in terms of clear outcomes. Leadership is much more than simple service management.An effective leader needs to be able to define what the future looks like, align people with that vision, and inspire them to make it happen despite any obstacles (Barrett and Robert, 2014). To enable effective leadership, individuals need the skills and capabilities to be able to develop a feasible business plan, be a visionary of what can be achieved, hold effective communication skills, motivate others, nurture talent and future leaders and be able to negotiate resources to support their goals. However, little education is provided for nurses and podiatrists via under-graduate or post-graduate curricula to teach and enhance business planning skills (Ousey et al, 2019). The need to develop these skills, leadership and talent management has never been more important as this will help protect and improve services for patients and staff both in the short term and in the future.
The final top priority identified in this survey was health improvement with 31/74 responders indicated this was in their top 5. Health improvement includes both improvement of health services and individual patient health improvement, both aspects are vital for the sustainability of the NHS. The NHS continues to be impacted by the COVID-19 pandemic, and there are growing concerns that the effects of this pandemic and social restrictions to control the virus are likely to exacerbate chronic conditions and create additional health needs to be managed over the long term (Bavli et al, 2020). It is essential the health service is fit for purpose but alongside this it is important all staff are empowered and supported to provide patients with personalised care.
The ‘generic capability’ came out as one of the lowest rankings of importance. Considering that the generic capability introduces aspects of maintaining skin integrity, holistic assessment, knowledge of skin and wound healing and the importance of working within scope/capability of practice, this was a surprising finding. The reason why this scored so low could simply be in relation to the sample, with the survey being undertaken within the Wounds UK conference there is an assumption that many of the responders already hold this generic level of capability, so this could have impacted on results.
It was interesting that only 2 of the 74 participants indicated that pharmacotherapy was in their top 5. This seems to be in opposition to the national focus on the need for health professionals to have a detailed understanding of pharmacotherapy and hold non-medical prescribing status. Increasing the number and focus on non-medical prescribing has demonstrated economic and patient care benefits. Investing in non-medical prescribing is seen as ‘an investment to save’ and encouraging non-medical prescribing capacity is understood to be a vital upskilling priority which features as a key enabler in the planning and delivery of new care models and transforming care (HEE, 2023). Additionally, non-medical prescribing training can support role and career development by enabling practitioners to take on greater responsibilities for managing patient care. Non-medical prescribing enhances patient care by supporting patients’ timely access to treatment with medicines, enabling choice while helping to reduce waiting times, reduce hospital admissions and maximising the wider skills of the healthcare team (HEE, 2023). Specific to wound care, non-medical prescribing has a potential to impact on inappropriate dressing use such as the use of antimicrobial wound dressings (Watret, 2016) and influencing antimicrobial stewardship strategies (Brett and Palmer, 2022). However, it is vital that when a healthcare professional gains non-medical prescribing status, that there is a mechanism for continued professional development and evidence of individual scope of practice (Armstrong, 2023), therefore it is interesting that none of the responders felt that pharmacotherapy was in the top 5 ranking.
Finally, research utilisation and audit were also in the bottom three results, with only 15 out of 74 practitioners placing this in their top five. Evidence-based practice is widely recognised as the key to improving healthcare quality and patient outcomes (Chien, 2019). To enable this we need all clinicians to embrace all manner of research from discovery to translation, from bench to bedside and from mechanistic to holistic (Pickler, 2018). For many years nursing, especially wound care, was considered more of an art than a science. Fortunately, through the emergence of research evidence, this view has evolved to recognise nursing and wound care as having a scientific underpinning. It is vital that all health professionals seek answers to clinical equipoise, to demonstrate effectiveness of established practice and seek evidence for emerging practices. Even more importantly, where evidence exists, it is crucial mechanisms are in place for all services and individuals to be able to change practice in a timely manner. It is imperative to recognise that clinicians leading Tissue Viability services often are the key decision makers for inclusion or exclusion of wound care products onto local formularies, so it is essential that they have the ability to critically appraise research evidence, ensuring that care provided is safe, effective and provides the patient with the best opportunity to improve their quality of life.
A major limitation of this survey is generalisability of the results found; this is due to the small sample size along with the environment in which the survey was undertaken. Using participants attending a national wound care conference could potentially impact on results, as participants attending may be perceived as already holding significant knowledge, awareness, and interest in wound care, compared with generalist nurses/podiatrists.
The methodology: The use of ranking, asking individuals to rank results provides only basic information. It does not explore the reasons why respondents’ believed something was important, more important, or non-important. Additionally, the reliability of results is uncertain due to items being ranked in relation to each other rather than individually. Therefore they may not provide fully accurate results as respondents cannot give the same rating to more than one item, even if they are of equal importance to them. The reliability of results tends to be stronger in the top and bottom three answers, with the middle ranges being mostly unreliable.
The analysis of the results was basic without any form of statistical analysis, but the authors believe this is justified as the aim of this work was to gain a snapshot of clinicians’ perspectives of which capabilities were perceived to be the most useful in practice.
This survey undertaken as a part of a made easy session held at the Wounds UK conference has provided a basis for further evaluation of the TVLC online capability framework. It has highlighted practitioners’ priority areas for skills and knowledge development but also identified areas where further work is required. This is particularly in relation to supporting healthcare professionals to develop critical decision making skills, encouraging clinicians to participate in research — while actively integrating research into clinical interventions — and to provide leadership and management skills for senior tissue viability and podiatry practitioners.