SW Regional Wound Care Framework Initiative ENVIRONMENTAL READINESS ASSESSMENT SURVEY FOCUS GROUP RESPONSES SUMMARIZED Updated January 2010 Environmental Scan from Focus Group Meetings Six focus group meetings were conducted in Owen Sound (GBHC), Parkhill (Chateau Gardens), London (ComCare), Woodstock (Carressant Care), Stratford (SWCCAC) and Tillsonburg (Valleyview LTC) in September and October, 2009. There was a focused agenda to provide information about the SWRWCF and to conduct an envirionmental scan looking at Barriers and Facilitators to the implementation of Best Practice Guidelines. One person recorded the discussion during the session using paper and pen format, and each participant was given a blank form to write down any comments that they were unable to express during the session, or to elaborate. These were collected at the end of the sessions. An evaluation form was also distributed post-sessions. Structure 1. To what extent does decision-making occur in a decentralized manner? Structure of Organization: o Front Line staff participation: A majority of respondents identified front line staff as integral to a team approach. o Committee/Team participation: Staff sit on wound care committees for wound care product evaluation, and education. Team membership - All sites represented on Wound Care Team. o Participants noted size of the organization, politics and funding, and networking across sites as factors impacting decentralized decision- making. E.g. Larger organizations have access to more resources as noted by a newer Family Health Team. Building Strategy: o The need to start small, take baby steps and build trust and support was identified. o Networking and strong partnerships key to process. Communication: o Gather facts and present to develop support. o Document and share the good stories. o Use technology. o Monthly meetings especially in LTC. Education: o ETs are accessible for nurses to consult re protocols, procedures, product selection, etc. Front line staff make immediate decisions re wound care, in conjunction with ET nurses & wound care consultants where available. (This appears to differ according to setting/organization and resources. E.g. hospitals and LTCHs) o Wound Care product companies provide lunch and learn opportunities which in turn become networking opportunities. Knowledge: o inconsistent knowledge r/t wound care of front line nurses o understanding or lack thereof of various roles of health care team members Wound Care Products: o differ across system o difficulty getting supplies preferred products not always available; costs a factor? SW Regional Wound Care Framework Steering Committee: Environmental Readiness Asses Summary Updated January 2010 1
o difficulty obtaining wound care products without jumping through CCAC hoops. ; need authorization. Time: o inability to access ET nurse consultant in a timely manner o length of time to realize change Communication: not all staff are aware of options Workload: o workload makes it difficult to get to education sessions No incentives to attend inservices Attitudes: o attitudes and lack of interest of bedside nurses o nurses frustrated with process and want change o physicians are the hardest to change ; want easy, quick ; not all are technologically current; handful of surgeons & family Drs who do not collaborate with ET nurses & insist on OD visits & saline. Funding: o availability of funds for equipment recommendations 2. Is there enough staff to support the change process? Among the facilitators/enablers noted and/or suggested by participants: Education o provide staff with incentives, time and choices for education participation E.g. attempt to have nurses work 4 hrs to cover patient assignment so nurse can attend team meeting o provide one on one time for staff with consultants o time management team building development of consistent wound care policy, products Staffing & Workload: o Without exception, the respondents felt there was not enough staff (or time) to allow all staff to attend education o insufficient staff to do the teaching- ETs really busy not always able to follow up within 2 wks o a considerable amount of staff turnover Knowledge: o a sense that inconsistent scope of practice exists in the community need education and policy Inconsistent Policy o there needs to be a consistent wound care policy. Environment/ Workplace Culture 3. What previous attempts have been made to implement wound care best practices or clinical pathways? Were they successful? Various attempts have been made across the SW Region to implement better practice including: electronic/preprinted orders, ordersets, and clinical pathways. o E.g. LHSC has had some successes. SW Regional Wound Care Framework Steering Committee: Environmental Readiness Asses Summary Updated January 2010 2
o Currently, CCAC as well as nursing agency (CP) pathways prompt nurses to specific items & teaching topics so assessment and teaching practices are standardized & complete Suggestions made include: keep pathways short set schedule for wound care focus, education E.g. Wednesday is Wound Care Day ensure electronic connections between sites Best Practice Guidelines re ordersets E.g. Best Practice Guidelines: LTC - pressure ulcer BPG; Falls BPG - standardized product cards with protocols BPG. ETs are instrumental in orientation programs and some shadow on home visits use of conferences with Dr K. from LHSC point of care for PSWs allows them to sign for interventions which have been implemented as a result of completion of Braden Scale provide product suggested retail cost information to staff and clients nurses suggest need keeping wound care front and foremost in Drs minds. awareness and knowledge must be emphasis to sustain best practices. Lack of success was attributed to: wound care products differ and may not be available pathways may be too lengthy and cumbersome therefore Drs. are not apt to participate or work with nurses re their recommendations charting methods may differ and some are still paper-based some staff attitudes are negative workload (staffing/hr) time funding different charting, documentation forms and methods when emphasis & awareness not sustained, knowledge level decreases. 4. To what extent are the wound care best practices or clinical pathways consistent with the values, attitudes and beliefs of the practice environment? Some respondents were able to articulate that attitudes, values and beliefs are consistent with their practice environment. Others were able to speak to the enablers put into place by management that are consistent with the values of the agency/organization. Enablers in place and/or suggested include: having a champion with whom the staff can identify wound and skin care best practices at orientation for new staff\ monthly (self) audits free inservices wherever possible College of Nurses use of the same charting system across the continuum I.e. poor flow of clinical information across sectors - patients who come to LTC who have been in community are arriving at LTCH & staff have to start all over unable to access information from hosp/community safer health care now initiatives get physicians on board SW Regional Wound Care Framework Steering Committee: Environmental Readiness Asses Summary Updated January 2010 3
Among barriers expressed by participants were: staffing and workload issues - a significant barrier to management s ability to really walk the talk lack of funds not enough money to carry out education, best practices electronic charting systems not in place across the LTCHs up to individual therapist to seek out further educational opportunities lack of comprehensive knowledge of best practices evident among nurses and doctors therapists felt that their care pathways need to be integrated with the multidisciplinary care pathways (e.g. pressure risk assessment, non-healing wounds, e-stim etc) 5. To what degree does the culture support change and value evidence? Education funded o several participants stated that their attendance for education, conferences, and books/texts etc is paid for by their organization teams embrace change and evidence to support change; nursing goal is healing of wound and d/c of patient/client. Buy-in of practice is the same in LTC and community consistency of person providing (wound)care is the same in LTC monthly program audits are in place for falls, infection and pressure ulcers in some organizations Funding/Budget: o little or no money for education, and budget restraints do not support the best practices direction management wishes to take. They are unable to walk the talk due to insufficient budget, heavy workloads/caseloads, etc. Facilities (LTCHs) are not budgeted to send staff to education sessions o whether LTC or Community care, the buy-in of the practice is the same; dollars just aren t enough and education is often the first thing to be cut from budget. Communication 6. Are there adequate (formal and informal) communication systems to support information exchange relative to the wound care best practices or clinical pathways and the implementation processes? The majority of respondents felt that although informal communication is the most prevalent means of communicating, technological advances definitely support better communication across the health care continuum (team members in the community with those in LTC, telehealth, conference calls etc), the use of education tools such as clinical ordersets/pathways support consistent approach to care best practice evidence is available on the computer; good communication and use of technology (intranet and internet) keeps everyone in touch and involved. Respondents also noted that knowing who to contact, having accessible contact information, making joint visits to see and talk through best practices, involving the entire team, and using all the means made available to team members (e.g. bulletin boards, policies on desktop, charting forms, etc) are all important. Barriers cited include: shortage of time to document electronically or to pass along the information due to heavy caseloads limited resources different communication systems SW Regional Wound Care Framework Steering Committee: Environmental Readiness Asses Summary Updated January 2010 4
different levels of useage of technology (some paperless and others still very paper-oriented systems) within and across disciplines and settings wound care education and knowledge differs among individuals/nurses, impairing bpg implementation (feel they are not all on the same page) nursing education materials are not standardized. Leadership 7. To what extent do the leaders within the practice environment support (both visibly and behind the scenes) the implementation of the wound care best practices or clinical pathways? Within the limitations of available resources, respondents felt that leadership does support the implementation of wound care best practices or clinical pathways. Participants felt that staffing and budget are key influences. Where resources are available, staff receives video conferencing, have experts in the field in for inservices, send front line staff to conferences, provide on line accessuses an edu-cart for mini inservices on each unit, uses a web site to put policies and procedures on line for easier and timelier accessibility for staff. Leaders are on board! Those barriers cited Include: Staffing/budget: o staffing shortage means fewer staff able to get to inservices, conferences etc). o staff does not want to come in on days off or without pay for education. o may only be funded for one hour even though it lasts for two hrs. Transdisciplinary approach: o there needs to be more coordinated work across disciplines especially in the community with therapies such as OT, Dietitians etc no recognized wound care job/role funding is inconsistent across the different facilities, community, etc for pressure relief surfaces, OT support 8. What is the availability of wound-specific policies/ procedures/ protocols/ resources? From the focus groups held across the SW Region, it is clear that availability of wound-specific policies/procedures/protocols/resources varies. Some organizations have on-site ETs while others have an ET/wound care resource person. Suggestion was made to use PDAs (RNAO project). Staff has access to both the internet and intranet use of picture board with protocols; for many, on-line policies and procedures are available and for some policy manual and clinical textbook is on the computer desktop. Some agencies appear to use product companies to provide education in which case they also have wound care policies and procedures from product companies. Perceived barriers are: Time - (and lack of sufficient time) Technology: o poor electronic capacity (i.e. not all have high speed internet therefore difficulty downloading policies and procedures o on line access not always available SW Regional Wound Care Framework Steering Committee: Environmental Readiness Asses Summary Updated January 2010 5
o nursing receives NO compensation for internet access, printing costs, or time accessing information Policies: o policies and procedures not standardized E.g. different policies for length of stay which impacts education (i.e. leg ulcer LOS 7 days) o different policies E.g. compression hose which requires assist of PSW through CCAC. Changing products - would be beneficial to have standard products. Resources: o not all wound care resource persons are wound specialists (Ed. note: Editor believes the reference is to formal qualifications ) 9. How is best-practice evidence used within the organization? Respondents variously reported that they used the best practice evidence in building care maps and ordersets. Staff had a better sense of when to seek help, when to call on ET. Best-practice evidence also supports: o the expectations of management, and the modification of expectations o education and conferences o gap analysis - currency and updating of education, policies, procedures and products (e.g. Braden Scale use) o joint visits of RN and ET specialist also rehab. o Best Practice Guidelines (RNAO) agency (CP) is now a BPSO (Best Practice Spotlight Organization) o point of care, prevention o need for standardized wound assessment tool Quality indicator tracking when research involved, resulted in increased funding. For some respondents there appeared to be no clear process of how wounds are to be assessed and treated - when do we bring in the experts? Some felt that it would be good support for budget, and for conferences. Therapists thought it would be beneficial to bring OTs together from different agencies to develop best practice guidelines for wound management in the community. Some felt there was limited availability to (conduct) research NCPs may not be current; based on bpg Others felt there is inconsistent knowledge re research use and scrutiny or inconsistent use of wound assessment tools. Industry tries to sway staff. 10. What does the current wound care educational program consist of? Who delivers the education? Who evaluates the content? What is the background of the person? SW Regional Wound Care Framework Steering Committee: Environmental Readiness Asses Summary Updated January 2010 6
Although some responded that their wound care programs are sporadic, most wound care education programs appeared to be continuous and at the outset, consisted of an orientation program which varied from 1 hr to 2 hours plus a variety of other educational elements. These included: video conference opportunities lunch and learns nursing rounds on-line learning conference attendance joint visits with ET on line education prepared by ET education by wound care product reps (E.g. 3M) Annual education fair The Amazing Race component for orientation package orientation x 1 day with skin + wound nurse at the bedside time is worked into hours which are already allotted to/for orientation compensation for mandated on-line education modules (SEHC) Braden Risk Scale new flow sheets/wound assessments wound care assessment tool wound care team MD HEAL inservices (CCAC) Occasional inservice based on wound care orientation to new staff re: wound care flow sheet BWAT photographic booklet, created by Connie some agencies have the tools in place champions in-house measure of best success use in-house staff i.e. pharmacist, ET, Drs wound care binders on each floor access to resource person (ET, etc) evaluated by Patient Care Manager/charge nurse who gathers information from ED inconsistent attendance (not all nurses attend HEAL or other inservices due to workload, time management and funding) not all RN students receiving wound care education 11. Who delivers the education? Education appears to be delivered by a variety of persons and health care professionals including: wound care nurses, ETs, nurse clinicians, educators, CNEs (Clinical Nurse Educators), professional practice facilitators, RN to RN, and wound care product company reps. telehealth may be utilized yearly certification with VAC, compression therapy educator will use resources that are available; monitored on line by CRN; post test must get 80% Respondents stated that where there are multi sites in an organization there may only be 1 ET for the entire corporation. SW Regional Wound Care Framework Steering Committee: Environmental Readiness Asses Summary Updated January 2010 7
(Most) nurses are not paid to attend education therefore do not attend and in another organization, seasoned staff do not take the time to attend, while others noted staff shortages, nurses paying out of pocket and lack of time for nurses to share what they have learned at conferences. Also noted was the comment that a CNE is not a wound care expert and that access to ETs is limited. no formal evaluation process seasoned staff not taking time to attend to new material wound product company bias 12. Who evaluates the content? Respondents identified the following: wound care nurse; ET; clinical resource nurse; flex clinic (?); wound care team (nursing, dietitian, physician, others who meet 1/4ly). Also noted by respondents was the evaluation of the presenter by attendees on an evaluation form after each inservice, then forwarded to the Director of Nursing and or the speaker. It was noted that some staff may not want education on wound care; that there is no formal evaluation process and that it is difficult to keep information up to date as it changes so rapidly. One respondent noted that they have difficulty finding courses for regulated and unregulated staff to attend. Some were unsure that content was evaluated other than by presenter and that the attendees fill out the evaluation form of the educator. ( Ed. Note: Query the quality and risk management, checks and balances of content/course material and value of evaluation). Knowledge, skills and attitudes of target group 13. What is the background of the person who delivers the education? Most respondents identified an ET nurse, or a stoma ET nurse and wound care specialist BScN nurse as professionals who are wound care specialists WCS should be at least IIWCC trained one identified a recent BScN graduate in second semester of the CAET course. Some agreed that it depended on the area within the region. noted by one person that a CNE is not a wound care expert. varies according to (geographic) area and size (of organization). 14. Does the staff have the necessary knowledge and skills? Comments and suggestions include: precepting is available for new skills that need to be taught visits are coordinated with ET, nurses that have higher skill level there are free wound care courses (through ETs, etc) SW Regional Wound Care Framework Steering Committee: Environmental Readiness Asses Summary Updated January 2010 8
orientation includes wound care educational resources are available on line and in print It was noted that therapists have specialized skills but that their role is not well known in the community and that the focus seems to be predominantly on dressings Increase Education o include aides opinions in education o provide more intensive PSW education (all levels of provider team need to be excited) Barriers noted include: there isn t always sufficient knowledge and skill and some expressed concern about influence by sales reps from commercial wound care/product companies who seem to be promoting their products. time for education and resourcing insufficient funds not all staff have same knowledge base nor the same interest in wound care (and the same appears to be the case among physicians) many physicians appear to be unwilling to learn/change their practice the learning curve is great doctors seem to be a barrier they need to be aware of what is best practice and product awareness although some felt it wasn t a resistance to change but just that they don t have the information the wound care nurse is not a dedicated role so some pts are unable to be seen in a timely manner again it was noted that the PSW is a front line worker and are the eyes and ears (of the team) 15. Which potential target group is open to change and new ideas? Respondents felt that most are open to suggestions re change however, nurses (especially front line staff, newer staff, new grads) are most open also pharmacy, infection control, and (many) doctors Suggestion: workload, human resources, funding, time need to be addressed first in order for staff to truly embrace change and new ideas Suggestion: historically communication not great between hosp/community, therefore need to use synergy & build on it. some new grads seem less open to change primarily doctors (most especially surgeons) are the barriers Some also identified the client as resistant and posed the question how do we get the client to buy in and follow what they are taught? staff skeptical that management interested in change primarily to save money (decreasing dressing supply costs and nursing visits). 16. To what extent are they motivated to implement the wound care best practices or clinical pathways? when (one) sees success, more likely to continue and remember (e.g. empowerment) Cost Impact: SW Regional Wound Care Framework Steering Committee: Environmental Readiness Asses Summary Updated January 2010 9
o the majority felt that the most convincing evidence to support change is the cost impact o litigation also a motivator Education: o staff and management need to be aware of costs o inform clients re retail cost of wound care as funding for wounds is limited. The groups also felt that the GPs are greatly motivated. Food is a motivator! Build trust with teamwork and results Sustain the impetus of wound and skin care team implementation provide time, resources, technology and other tools to enable staff have more than one champion who could sustain the enthusiasm for change insufficient time to educate and implement change workload and funding issues all need to be taken into account staff are not aware of the costs, as is the case with clients. Commitment to quality management 17. Do quality improvement processes and systems exist to measure results of implementation? CQI is in place o chart audits physical and electronic are undertaken regularly o audits of documentation o performance assessments o care maps, pathways o RAI assessments (LTC and Hosp) o consistent check of lists o reviews of product use o quality indicators available from electronic documentation o use of Braden Scale o BWAT (and the BWAT booklet by C. Harris) o CCAC wound prevalence study o also cited was the PT/OT/Dietitian/FNM, RC program. o prevalence study in LTCH (Spruce Lodge) time and staffing (workload and HR issues) were cited as primary barriers techniques vary and are inconsistent - not all nursing is using the BWAT consistently and that some note inconsistency in wound measurement and assessment techniques. unable to obtain baseline data from CCAC/nursing Availability of resources 18. Are the necessary human resources available to support implementation? clinical nurse specialist in wound healing, advanced wound/ostomy specialist on Brussels/Listowel team SW Regional Wound Care Framework Steering Committee: Environmental Readiness Asses Summary Updated January 2010 10
2 ETs contracted to one specific area a number of participants felt this multi disciplinary team approach/communication and networking would be very helpful. In several focus groups respondents felt that putting a process in place would be beneficial. A number of the barriers are noted below - primarily lack of availability of resources and insufficient access to resources were cited as significant barriers. Focus Group participants felt that they had an opportunity to help fix the problem in terms of process and communication, but noted that fundamentally, in their opinion, the problem goes back to funding. Respondents in one area of the SW region felt that budget restraints and a hiring freeze played a significant part in their assessment that there is not sufficient staff to support implementation. Some noted that the system is reactive not proactive and that there are limited resources forthcoming from the Ministry. Others cited workload, lack of access to wound care specialist, and the fact that the record in the home is not always filled out. Respondents also noted that all providers in the community are unable to get together; they saw this as a missed opportunity as there is a willingness to communicate across disciplines. 19. Are the necessary physical resources available to support implementation? Technology: o respondents did note that they have on-line access to information and access to an ET through Voice Mail. Chart audits audit tools Respondents felt that, generally no, not all areas have the necessary physical resources to support implementation. In LTC, funding is available only for Stage 3 or greater ulcers. There appears to be no funding for prevention. Respondents noted the shortage of special surfaces/new beds as well as the inability to order a bed due to funding shortages. In a number of focus groups it was noted that there was also inability to access OTs and Dietitians as there were none available in smaller sites; also noted was the fact that there are no adjunctive therapies (except VAC) available in some community settings and that because it may take a week to obtain supplies from their CCAC, they try to keep many products on hand. 20. Are the necessary financial resources available to support implementation? No enablers were cited in any of the 6 SW Region Focus Groups. Respondents felt that funds are very limited; approximately $41.50/resident/day is budgeted in LTC but that is all there is for supplies such as gloves, masks, gowns etc; high needs clients wounds must be a stage 3 before there is (Ministry) coverage for supplies, while budgets for wound care supplies for stage 1 and 2 come out of the nursing budget. SW Regional Wound Care Framework Steering Committee: Environmental Readiness Asses Summary Updated January 2010 11
Among other barriers related to funding are monies for education. Respondent reported that they are compensated for 1 hr of education even if the session is lengthier. e.g. two hr session, paid for 1 hr education. Respondent felt that because nursing is unfairly compensated in community (wages) it is perpetuating (the) shortage, resulting in high turnover, resulting in knowledge gaps. Mileage compensation is also lacking. Interdisciplinary relationships 21. Are there positive relationships and trust between the disciplines that will be involved or affected by the wound care best practices or clinical pathways? Generally, there is a sense of trust among team members and across disciplines with the exception of the physician group. Respondents felt that better relationships exist in LTCHs, Hospitals, Health Care Teams than in the community care sector where there have not been enough opportunities to build relationships but that good communication exists and is there to build on. Suggestions include: seek opportunities to build relationships o utilize regular monthly sessions and one on ones with wound care experts o conduct regular caseload reviews o participate in rounds - interdisciplinary rounds (hospital setting) o meet weekly on complex continuing care o review and define roles of team members clearly to enhance knowledge, relationships, trust and respect. o conduct annual sessions and recertification which will help to develop relationships. o develop education tool collaboratively It was noted that time constraints greatly impact the ability to meet, to communicate and build relationships and that this needs to be regular. Comments also included: Not all surgeons, GPs respect knowledge, skills, and recommendations of ET nurses. Also noted was that there is no team approach in the community e.g. case conferencing ability and use whereas there is pt. focused care in hospitals, wound care teams in LTC and interdisciplinary rounds with hospital teams in the hospitals. Education of Staff 22. What type of educational interventions have been the most successful in changing practices in the past? Among the educational interventions seen to be most successful are: lunch and learn one on ones paid education monthly inservices paid, short inservices E.g. 15 minute at change of shifts use of on-line learning tools lecture yearly skills fair language usage with all team members, especially physicians SW Regional Wound Care Framework Steering Committee: Environmental Readiness Asses Summary Updated January 2010 12
standardized NCPs and clinical pathways sharing resources education related to wound care prevention Respondents felt that there needs to be something ongoing to sustain best practice, that there needs to be regular reviews of material E.g. Braden Scale every 3 weeks as seeing is better than talking. Respondents did identify learning what language to use with Drs as beneficial along with listening to peers and reviewing the literature. Also cited was learning who the contact persons in one s area are e.g. who is the OT you would contact? Funding for staffing and education was raised. Perception by some that change is forced on staff ( we don t have a choice ). SW Regional Wound Care Framework Steering Committee: Environmental Readiness Asses Summary Updated January 2010 13