A nurse-led tissue viability service in Malta

24 June 2021
Volume 30 · Issue 12

This article discusses the key issues I personally faced in setting up and running a nurse-led tissue viability service in Malta. I will highlight relevant areas that helped in the process: gaining knowledge and experience, developing an accessible service, working with professionals who are interested in working with you, creating a national and international network of support, being politically astute and taking hold of any opportunity to increase awareness of the service. I thought it is important to write about this experience because often these vital nurse initiatives are not documented and nothing is available for new nurses to go back to in order to learn about their predecessors' journey. My hope is that this will not only shed light on some important elements that helped me in the development of a national service on Malta, but also will encourage other nurses who might be thinking about pursuing a similar journey.

In recent years, both locally and internationally there has been a marked increase in the number of nurse-led clinics in a variety of specialties. Across Europe this has been brought about by, among other factors, a shortage of doctors (or the changes to working hours), advancing and expanding nursing skills and filling the gaps in the healthcare service. However, the development of specialist nursing positions seems to be related to the culture and advancement of nursing in the specific country. For example, in Malta there is no shortage of doctors, nurses do not have prescribing powers and the role of the advanced nurse practitioner or physician's assistant is still not realised. Therefore, the roles of nurses in Malta seem to expand and develop in areas that are considered to be the nurse's domain such as wound, stoma and incontinence care.

From a dream to reality

In 1994-1995 during my follow-on degree course, I worked for a few months as a community nurse in our capital city of Valletta. It was like a baptism of fire. I think 50% of my time was dealing with wounds of all sorts including diabetic foot ulcers, venous leg ulcers, pressure ulcers, fungating wounds, and dehiscence surgical wounds. I immediately knew this was the area I needed to specialise in, but had no idea from where I had to start. As a junior nurse and just having qualified with the first 4-year diploma course at the University of Malta, I grasped that I had no understanding of wound care. Although we were taught that hydrogen peroxide and EUSOL, the two most and only used products in wound healing at the time, were considered to be outdated and not to be used, I had little knowledge of what products I should use. I also became aware that GPs were in a similar boat to me and could not suggest anything better.

Knowledge and experience

I started seeking courses to pursue in the UK or around the globe but could only find undergraduate certificate courses of a few weeks' duration, although I was told that the School of Medicine at Cardiff University was planning a postgraduate course leading to a master's degree in wound healing. However, my journey in wound healing had begun.

As part of the undergraduate course in nursing I had to undertake a small study and I chose leg ulcer care—this project led me to the dermatology department at the hospital where my study population was found, who were only too pleased to help me and who became my second home for the next decade. The need was evident there too but my colleagues were eager to teach, learn and support the idea of a specialist wound care clinic. Within the dermatology department there was a leg ulcer clinic that soon became a clinic dealing with more wounds of different aetiologies. This further re-enforced the need for more in-depth knowledge for me to be able to argue and make the necessary changes.

Following my degree, I worked at the dermatology department for over 8 years until I started the first nurse-led tissue viability (TV) service in Malta but I attended at least two international conferences a year and also participated in short courses. Together with a couple of colleagues, I had also organised the first educational event on wound care in Malta and we had our first international guest speaker. In 1999 I started the master's degree in Cardiff and also started building a network of international colleagues, who gave me an opportunity to visit their clinics and start shaping the service in my head. Knowledge is power and the more I learnt the more I had the chance to make the necessary changes needed. Having a good foundation in skin care and now pursuing a master's degree I needed to start lobbying for the future service. I had convinced my director of nursing to support me to go to the UK and The Netherlands to visit and work in clinics for a few weeks and to my surprise the hospital had also supported me financially to undertake the degree in Cardiff. This was not common in those times and I was breaking new ground as a nurse.

Setting up the service

Although many articles describe the role of various nurse-led clinics, few address the key issues underpinning setting up a clinic and achieving a sustainable service. Beginning with a broad definition of the nurse-led TV service was paramount. This was the first service of its kind on the island and it couldn't be so specific, we didn't have a role model to follow or a mentor to rely on, we just had our instincts, knowledge and determination. Although this might be frowned upon, it was the way we developed. We started working with people who wanted our service. Although I started out alone, after a couple of months another nurse arrived and we were joined by another nurse a year later. Nothing was clear and we took each day as a win and the more we started receiving referrals we knew we were on the right track.

We were aware that we might be perceived as a threat by some healthcare staff because the service represented a change to the usual pattern of working. Nurses were not used to being consulted by patients, we were not allowed to refer to other health professionals and request investigations such as a simple wound swab. Making sure all staff were kept informed, valuing their opinions, and incorporating suggested ideas did smooth the way for change. We feared doctors initially since we thought they would be the ones who would oppose this service but to our surprise it was other nurses who initially shunned us. It was apparent that nurses did not understand our role so our first task was to increase our visibility and provide information.

Memos and walkarounds were the norm of the day—the office was in the general hospital and the outpatient clinic was on another site in a tertiary hospital. Our first clinic was on a Sunday as there were no other available slots for us. Although this meant we did not have any support stuff we accepted the slot and never looked back. The physiotherapy department was the next department to welcome our services and we used to spend a day in their outpatient clinic following up with patients who had amputations.

From there on we planned to meet with managers and directors of other hospitals and also had meetings with GPs since we started offering a domiciliary service. The aim of our nurse-led service was to allow the same nurse to see the patient over a prolonged period of time and in this way a highly therapeutic relationship was offered, but we still needed a team. The concept of a nurse-led clinic suggests increased autonomy, but staff should not work in isolation. Liaison with, and support and advice from, other nursing and multidisciplinary colleagues will assist in developing an effective service.

Having worked in the dermatology department I had my roots and connections, but we started seeing more patients with diabetic foot problems and thus needed a podiatrist. Finding allies was key and the team started on a volunteer basis for a couple of hours on a Sunday. After lobbying, a podiatrist was sent to work with us full time and the team started building. Our next vital team member was a vascular surgeon who had just arrived from Scotland and who understood and valued specialist nurses. The next step was having multidisciplinary ward rounds and clinics and this was the first arrangement of its kind in the acute general hospital.

Being politically astute

Good publicity was essential so whenever we were asked to see patients, we did this even on our day off. We had an open-door policy also for patients and this took off within a few weeks. In the first year and following the introduction of larval therapy and negative pressure wound therapy, I was on call 24/7. I knew that this was not going to last forever but I needed to prove that the need was there and that we were offering a much-needed service. The first couple of years were tough but we had to prove ourselves before we could ask for more staff and help.

A lot of lobbying took place and meetings were held and we developed a strategy to meet all health professionals including pharmacists, physicians, hospital management and heads of departments, including podiatry and the laboratory, GPs and community nurses. This process was replicated for our neighbouring island of Gozo, but that involved a direct meeting with the Minister of Gozo since everything was channelled through the Ministry. I devoted at least one session a week to bringing others on board, whether it was via meetings, media appearances on the radio or television, or through educational events I was invited to. We then decided to organise conferences and strategically invite members of parliament and the health minister to open the conference—we also invited key international people and invited the media for coverage and quickly noticed that when state-level politicians are invited, more media representatives show up.

The TV service started from a makeshift office that was converted from a veranda, we had no pagers, no phone, practically nothing but we started going around the hospital and meeting nurses and other health professionals. It quickly became obvious that we needed to invest in equipment such as pressure-relieving mattresses and moving and handling aids such as lifters and slide sheets. Trying to convince managers that these were needed was going to need numbers so we organised a point-prevalence study on pressure ulcers and also while going around the hospital we took an inventory of what was available. This was the beginning of the biannual pressure ulcer audit and it was also a way of sending the facts to the authorities.

We then needed to invest in equipment such as a hand-held doppler and dressings. Procurement was a new area for me and this meant understanding the lengthy process of opening files, getting people to support your application and writing a business plan or a cost:benefit proposal. Again, this meant looking for people who were ready to help us and these were found in the engineering department and in theatres. It was valuable to create a business case and this came after 1 year of operation. Following the first year the annual report was rigorous—this included a detailed outline of all the patients we visited or cared for, what was needed in terms of resources (clinics, admin support, a car or a transport service) and something as basic as being recognised for the position we held, because at this time I had no official position or title. This came a few years down the line when in 2003 a handful of specialist nurses were officially appointed.

The aim was to produce a professional and detailed report and to send it to top administrators and managers. This was not only sent to the nursing hierarchy but also to the medical one. Moreover, I did not just send it to them but asked for a meeting with them in order for me to explain what was in the document. The same was done with the medical superintendent of the hospital and the Director General for Nursing and Doctors at the Ministry of Health. We needed them all to understand what we were doing and what our vision was—and we also knew that these professionals are often too busy to read detailed reports so we presented the document but also discussed our priorities. This seemed to have worked. This was also important since Malta was in the process of building a new state-of-the-art hospital and we were in time to get our voice heard. In fact, when we moved to the new hospital in 2007, we had one of the best outpatient clinics with a large office and secretarial support. We were also given the opportunity to train and employ interested nurses to work with us on an overtime basis—so a pool of around 15 nurses were chosen and trained to help us. Today most of them run their own TV clinic or service.

Conclusion

Nurse-led services can be highly challenging, but also very rewarding. I think one of the most important things is to self-reflect in assessing and achieving competence. Although this may be gained through certification from a university, it is important to remember that professional development is an ongoing process. The creation of clear aims and objectives, a business case and discussion with those who will use the service and those who can offer support, will highlight potential difficulties at an early stage, but it will also allow time to problem solve. Performing reviews and evaluations can help to identify factors that are promoting or hampering progress of the service. Although this was never done officially, we used to have regular meetings with colleagues and service users to listen to how we could improve. Notwithstanding this, following nearly two decades of the TV service in Malta a clinical audit is well overdue to seek to improve the quality and outcomes of patient care.