ABSTRACT

It has been suggested that there are approximately 2.2 million patients in the UK with a chronic wound (Guest et al, 2016). The cost of managing these wounds and associated comorbidities is approximately £5.3 billion (Guest et al, 2015), with this figure predicted to increase.

There are be a number of reasons why the NHS is faced with an increasing wound care management burden, with a contributing factor being the clinical competence of nurses caring for these patients. The NHS is facing a significant staffing problem, with recruitment and retention across England being a challenge for many healthcare trusts. This depleted workforce is bound to have a knock-on effect in terms of access to nurse training, professional development and clinical support. More recently, there has been an increase in skill mix introduced into nursing teams, with healthcare assistants, assistant practitioners and nursing associates now forming a significant percentage of the workforce (NHS England, 2013).

Although most would agree with the need to build an adaptable contemporary workforce that is responsive to the changing world of the nursing profession, these clinicians all come with their individual needs in terms of learning and clinical support. It is likely that everyone in this skill-mixed team will be delivering wound care, but, unfortunately, there is evidence that some of the factors associated with delayed healing can be attributed to lapses and inconsistencies in care and poor care planning by clinicians (Vowden and Vowden, 2016).

The wonderful quote ‘Wound care is everyone’s job, but no one’s responsibility’ (Evans, 2017) is worth some consideration. Unfortunately, this does appear to be the case, with nurses often undertaking task-orientated or ritualistic care based on what the previous nurse applied and possibly using skills that they may not be fully competent to deliver. If we are to improve care for our patients, nurses need to be given the time to properly evaluate their skills in order to acquaint themselves with any shortfalls or gaps. Once these have been identified or understood, the clinician can begin to improve, but unless you ‘know what you don’t know’ it will be difficult to take those first steps towards improvement.

---

The theory–practice gap

It is reasonable to suggest that the majority of nurses working in the NHS will have some access to woundcare training. The problem seems to be the ability of the clinician to apply learning to practice. This is known as the theory–practice gap.

The theory–practice gap occurs when practitioners struggle to integrate knowledge learnt (often in an academic or classroom environment) with real world clinical practice. Managing this gap can be overwhelming for many nurses, particularly those new to the profession or to a specific role. 
Much of the gap relates to a lack of awareness by nurses of the theory that guides their practice. However, it is not just about the lack of recognition, it is also about the lack of incorporation of evidence within clinical practice and the knock-on effect that this has on outcomes that is a concern. This disconnect is a problem because if clinical practice does not reflect best practice evidence, then it can result in sub-optimal or sometimes unsafe patient care (Meyer et al, 2007).

NHS England (2017) has highlighted that for many, the management of patients with lower leg ulceration is sub-optimal, with unwanted variations in practice responsible for increasing cost and prolonging healing times. The inadequate or incorrect use of compression therapy has meant that more human and financial resources are spent on care and treatments that may not aid wound healing (Mullings, 2018).

In wound care, it appears that there is little evidence on the barriers to incorporating evidence into clinical practice in the UK (Grothier, 2018), although there is much written on the difficulties of managing the theory–practice gap within the general healthcare domain (Donnellan et al, 2013). There have been many initiatives introduced over the years in an effort to bridge the theory–practice gap, many of them focusing upon the role of preceptors and mentors. In nursing, a mentor is a Nursing and Midwifery Council (NMC) registrant who will have completed an NMC approved mentor preparation course. They generally provide support and guidance to students (e.g. nursing students) in the practice area, and have the unique opportunity to role model the professional values, behaviours and professional integrity of nursing. Part of a mentor’s role is to assess competence, evaluate performance and provide constructive feedback. The goal of a preceptor is to provide valuable teaching and learning experiences and to role model safe patient care using evidence-based practice. Preceptors usually work alongside qualified staff, be that a nurse in his/ her first job, or a nurse with many years’ experience but new to the service. An example of this role in wound care would be the preceptor supporting a new nurse with their leg ulcer assessment and management skills. They would ensure the theory has been understood by using a competency framework and then allocate time in practice using a robust process of observation, feedback and assessment. Depending on the individual being supported, this process can be time-consuming, and unfortunately, unless preceptors have protected time to execute this role, they often get consumed in the general workload and therefore the new nurse does not get the support that is probably required.

---

Barriers to implementing theory into practice

Several barriers have been identified to putting theory into practice. These include:

• Insufficient mentorship/preceptorship roles
• The frequency of ritualistic and historic practice (Welsh, 2017)
• Insufficient clinical leadership/role models (Bradley et al, 2004)
• The individual’s skills, knowledge and attitude towards adopting and implementing the theory and the value they place on it (European Wound Management Association [EWMA], 2008).

• Nurses can often feel isolated and lack the skills to make a change within their clinical practice
• Nurses often lack the confidence to make key decisions (O’Brien et al, 2011)
• Nurses have insufficient time on the job to implement new ideas/new practice
• A lack of cooperation/support from managers/colleagues

---

Improving knowledge and skills in practice

It is important to point out that simply adjusting the components of a specific skill might not necessarily lead to success, nor will doing more of the same thing. Reading more or attending many courses might not lead to increased competency, as the scenarios in which specific skills are played out can be so individualised that nurses require a high degree of creativity to tailor the skill to a specific patient. This will come with experience, good mentorship, observing other practitioners and from reflecting on the skill that has been delivered.

Evidence shows that good mentorship, defined as ‘the art of influencing people to follow a certain course of action… directing them and getting the best out of them’ (Adaire, 2002) is essential for developing a skilled and competent workforce. A successful mentor needs the passion for staff development, enabling newly recruited or less experienced staff to test out their new skills in a safe and supportive environment (Frankel, 2008). An appropriate learning environment, relevant resources and an appropriate level of guidance and support is required if professional development and confident skill acquisition is to be achieved.

---

IDEAS FOR IMPROVING CLINICAL COMPETENCE IN WOUND CARE PRACTICE

The following ideas have been used within the author’s area of practice and offer some creative ways of supporting staff with their confidence and competence in wound care. This should not be seen as a one-off exercise. Sustaining competence is as important as developing competence, so there needs to be a strategy in place for ensuring that this happens.

Competency frameworks

Competency frameworks define the knowledge, skills and attributes needed for an individual (e.g. a nurse) working within an organisation. There will be an agreed set of competencies specific to that staff group, which are necessary for them to perform their role effectively.

In wound care, these are useful tools, as they set out the standard expected by the organisation and offer a framework to map improvement. Many competency frameworks are based on an initial self-assessment that helps to identify gaps in knowledge or skills. The individual would then work with their line manager or mentor/preceptor on a personal development plan for achieving full competence.

Some nurses, may find it difficult to self-assess and either mark themselves too high or too low. Protected time and commitment from both the mentor and the individual clinician is required to ensure that a SMART is in place for achieving competence, plus a process for assessing competence in practice. A SMART plan, incorporates five characteristics of a goal (Specific, Measurable, Achievable, Realistic, Timely). If a plan isn’t SMART, it may be less likely to succeed.

Setting of objectives — what is it you want to learn?

Many nurses go into a training session without actually thinking about what it is they want to learn.
Producing pre-course documentation that encourages the participant to think about their current knowledge and skills and to set themselves clear course objectives will help focus their mind on the topic and draw out any weaknesses or gaps. As a trainer, be clear about what you are setting out to achieve and keep checking with the participants that they have understood what is being taught.

At the end of the session, encourage reflection on the event and whether their individual objectives have been met. Nurses need to think about how they intend to consolidate the training, and this should be supported by an action plan. Managerial support in ensuring the action plan is implemented and completed is essential for gaining full competence.

Technology — iPads

Many nurses, particularly in the community have daily access to mobile technology such as iPads or iPhones. These devices can be used in several ways to improve clinical competence.

Clinical guidelines or treatment pathways can be downloaded onto the devices together with any local tools for assessing and managing wounds. Examples of this may be a tool designed for recognising wound infection, or a pictorial guide on the signs and symptoms of venous disease. Being able to remotely access this information provides clinicians with the opportunity to check their clinical decision-making against an evidence-based document, thus helping to alleviate doubt and uncertainty.

Video clips created either locally or by external companies can also be downloaded or saved to a device. An example where this may work well is the production of a video demonstrating the setting up of certain pressure-redistributing equipment. Having access to this increases the confidence and competence of nurses undertaking this task and reduces the risks associated with incorrect set up.

Skype/Facetime

As a consequence of the demands on nurses’ time, it is not always possible to be shadowed by your mentor. iPads can be used to provide ‘live’ clinical support while the nurse is with the patient. It is important that the patient is willing to participate in this process and some trusts suggest that signed consent is given. This is particularly useful for checking practical skills such as bandaging and ankle brachial pressure index (ABPI) measurement, as well as for the inexperienced nurse to check her decision-making has been correct/safe before she leaves the patient.

Recording a consultation

Having someone observe your practice (being physically present) can be a daunting and sometimes stressful experience, with many nurses admitting to developing a form of ‘stage fright’. Recording your consultation with a patient using a mobile device such as an iPad is a really useful way of reflecting on your practice with your manager or mentor. It is particularly helpful as a teaching/feedback tool when reviewing assessment and communication skills. Signed consent from the patient is generally required.

OSCE (objective structured clinical examination) type of scenarios

This approach is designed to test clinical skills and is a hands-on approach to learning that keeps participants engaged and allows them to understand the key factors that drive decision-making. An informal environment should be created with an emphasis on collective learning and peer support. This could be in a training room or the nurse’s office. Educational wound ‘models’, such as a leg with a wound or a bottom with a pressure ulcer can be purchased, allowing the scenario to be more realistic. These can be expensive though. If applying a practical skill, such as bandaging or taking an ABPI measurement, nurses can pair up with their colleagues.

Role play

Although this may cause anxiety for some, role play is a technique that allows participants to explore realistic situations by interacting with other people (e.g. their peers) in a managed way to develop experience and skills. Role play can be a really useful technique for practising communication or assessment skills.

Skills labs

Some organisations have developed skills labs that nurses/teams can book out for practising various skills. It provides a ‘protected space’ for learning, which might not otherwise be achieved in a busy/noisy office environment. Skills labs can be useful for practising practical skills such as ABPI measurement, bandaging, wound measurement and wound photography.

Competency and skills development nurses

Competency and skills development nurses are employed by some organisations to support new starters in developing core clinical skills and competencies. These nurses tend to be generalists with a wide range of skills and will have received additional training and support to be able to assess and sign off the competency of other clinicians.

Case study review/ clinical supervision

Using a process of reflection to critically analyse a case study or clinical scenario is a powerful tool for learning. This can either be done individually with your clinical supervisor or mentor, or as a group/ team. Talking through decision-making and the rationale for this provides assurance for safe and effective care. There may be times when your decision-making is challenged and from this further learning may occur. There needs to be an agreed contract with your peers as to how these sessions are conducted and the roles and responsibilities of each individual.

Working with industry

Many companies have clinical trainers or specialists who will work alongside tissue viability teams to support clinicians with both their theoretical and practical skills (e.g. bandaging, ABPI measurement or negative pressure wound therapy [NPWT]). They will also provide educational materials and support on the correct use of the treatment modalities they manufacture. Some companies have also developed generic e-learning programmes that can be accessed for free by nurses, and provide a useful adjunct to the education and training provided by NHS organisations.

Tissue viability link nurse/champion model

Link nurses or wound-care champions are a great resource for supporting other nurses locally and should be a first point of contact for day-to-day clinical queries. Time, however, should be ringfenced for these nurses if they are to fulfil their role adequately. Link nurses should receive additional training from tissue viability and be assessed as fully competent in all of the related skills. Link nurses are in a good position to work alongside new starters as they progress through their competency frameworks.

Daily huddles

Embedding a daily team ‘huddle’ for handing over patients with wound care needs is a good way of ensuring that everything that should have been done, has been done. Some teams use ‘Patient Status at a Glance’ (PSAG) as a visual check list against the standards required. This tool, often displayed on a white board, highlights any gaps in best practice and prompts the team to prioritise and allocate care.

Take 5 audit

Introduce audit as a way of checking that best practice is embedded into care. This should be a collective responsibility with all of the team being involved in the process. Pull five random sets of notes of patients receiving wound care (decide the frequency of doing this, e.g. every quarter). Use an audit tool to assess against specific criteria, e.g. Is there a wound assessment form in situ that is fully completed? Have risks for healing been identified? Is there a current care plan in place? Has the wound been measured? Nurses should audit somebody else’s notes. Results are shared and analysed. There should be action points drawn up after the audit which are agreed as a team.

---

CONCLUSION

Although many nurses in the NHS have access to wound care training, there appears to be a number of barriers for consolidating this learning into clinical practice. This results in sub-optimal care, increasing costs and lengthening healing times.

It is essential that nurses, new to a team or to a specific skill are adequately supported to ensure that their competencies are met. Although mentorship is crucial to staff development, there are also a number of creative and practical ‘tools’ that individuals and teams can use to monitor and assess the competence of staff.