This article describes the context for and development of a tissue viability training programme in a low-to-middle income country setting: Uganda. The impetus for the project was the personal experience of the first author, a tissue viability nurse in the UK with family connections to Uganda.
Elizabeth's story
When I learnt that my grandmother was weak and was bedbound, I thought I ought to utilize my 18 years of knowledge and skills in pressure area care obtained from my studies here in the UK.
I took it upon myself to invest in preventive measures for tissue breakdown, including incontinence pads, barrier creams, guidance on nutrition, assessment tools etc, and shipped these over to my grandmother in Uganda. I thought I had played my part, but eventually, when I was able travel and visit my grandmother, I realised that my local colleagues in Uganda were not trained in these assessment skills because her skin had broken down. When I arrived, they informed me that ‘she has a “ekiwoundu!”’, which meant she had a chronic wound. They were preventing me from looking at it, but I insisted. I wanted to assess this ‘chronic wound’ personally to determine the appropriate management.
I knew my grandmother was not mobile and from my colleagues' feedback that her nutritional intake was deficient and had gradually deteriorated, but they had not accurately communicated this information. On assessment, I was heartbroken. My professional instincts kicked in and, as a nurse who has seen many of these stage 4 pressure ulcers, I know that management and treatment of such wounds have to be robust.
Having assessed the environment in which my grandmother was being nursed and, given her overall condition and comorbidities, the prognosis for managing the ulcer was not very good. She was frail, had problems with movement (immobile, requiring two people for transfers), had a low and inadequate diet and fluid intake, moist skin due to incontinence and suffered from early onset dementia. She was also living in a rural area with limited accessible health facilities.
But breaking bad news is an integral part of our job, so we hang on to hope, and away I went to search countrywide for the appropriate resources to treat this ulcer and create a care plan. I had an idea of what would be appropriate, if it were available. To my disappointment, I could not find any appropriate pressure ulcer dressing, nor any pressure-relieving device. I knew what would work but the only option was to source it from abroad, however, this would take many days to get to Uganda. I knew then that it would be too late.
My grandmother, like thousands of other vulnerable adults, continued to suffer as a result of inadequate skin assessments. I was her granddaughter who, in theory, could help alleviate her suffering, but, alas, I had no means to do this.
The experience challenged me to embark on a journey to find ways to share knowledge with my colleagues. It is a journey that involves equipping my colleagues with the skills, competencies and tools to appropriately manage their patients who develop pressure ulcers and those who present with complex wounds.
The workshop project
After meeting with the Chair of Wound Care Alliance UK (WCAUK), Professor Jackie Stephen-Haynes, at one of the wound care conferences in London, a sponsored tissue viability training workshop under the Alliance's remit of developing and promoting multidisciplinary education programmes was agreed. This was held on 17 October 2019 at Hoima Regional Referral Hospital in Uganda with the aim of enhancing tissue viability (TV) assessments. It was offered free to all nurses and midwives and held on-site in the hospital training room.
Although TV and wound care management is an area of health care that has synergy with many medical specialties (especially general surgery, vascular surgery, dermatology, care of older people, paediatrics, orthopaedics, lymphoedema, podiatry and diabetology), nearly all healthcare facilities in Uganda do not have wound care assessment tools in use. The tools required to assess and manage TV are not accessible, there is a lack of training, and there is not the comprehensive follow-up by a dedicated team of specialist TV nurses as would be the case in the UK.
It seems to be the case that many patients live with undiagnosed and untreated pressure ulcers in Uganda, but there are no hard data on the scale of the problem. High-quality care should involve TV training on best practice, and staff in every care establishment/care setting working within a robust prevention policy, with a commitment to ongoing education. However, this does not happen in Uganda, and this is due to various factors.
The main aim of the training was to address the nursing and midwifery curricula gap and limit practice for TV assessments and nurse-led interventions. The ultimate goal was to promote the role of a link nurse/champion for TV in each department, whose functions would include co-ordinating the patients' assessments in their area and taking the lead in evaluating TV.
The tools used for the training included presentation slides, scenarios and some pressure-relieving devices. A local chemist in London donated various dressing kits to simulate TV care and presented them to the hospital. Incontinence care and prevention of skin breakdown was identified as a particular issue to be addressed, so the kits included stoma/ostomy bags and flanges—to demonstrate ways of dealing with problems of leakage from the stoma and reducing damage to the skin—incontinence pads, hydrocolloids, and urology catheters.
There was relatively good representation as most departments from the hospital had a member of staff to attend. The training was not mandatory and a total of 65 nurses and some midwives attended. At the end of the training, a lead/champion for each department was identified for co-ordinating TV assessments and for capacity building.
We evaluated the training using printed questionnaire forms. Comments from the questionnaire evaluation included:
‘ It was beneficial information and a reminder to give holistic care and skin assessments.’
‘ More time for the training is needed.’
Conclusion
The diversity of nursing has evolved significantly over the past 20 years, with the development of many specialist nursing fields. The professional knowledge and expertise of modern nurses has expanded greatly, leading in some cases to advanced practice roles.
There is a great need to create and strengthen the champions to support pressure area care by offering them collaborative training, especially in low-to-middle income countries such as Uganda. With the appropriate training, skills, competencies and tools available for healthcare providers, Elizabeth's grandmother and many other vulnerable patients would not have to suffer in pain and die from pressure ulcers. These can be mitigated and improved.
Thank you to Wound Care Alliance UK for making this first training possible. On-site training to build the capacity of nurses in these settings is fundamental to enhancing care delivery in low-to-middle income countries. A further follow-up and evaluation workshop is required to monitor progress and promote the lead champions in TV assessments. We are requesting further support from WCAUK and other partners.