Clinicians in the NHS are continually being challenged to provide high-quality care to patients despite decreasing resources (Health Foundation and Foundation Trust Network, 2014). The ageing population has led in an increase in people with long-term conditions, which are the primary cause of death and disability worldwide (Currie, 2013). One such condition is leg ulceration; according to Guest et al (2015), leg ulcers are the most commonly treated wounds in the UK, and are estimated to affect up to 1.5% of the population. Leg ulcers are painful, susceptible to infection and negatively affect quality of life and mobility (Green et al, 2014).
The annual cost of managing wounds within the NHS is estimated to be £5.3 billion (Guest et al, 2015). This cost may result in part from ineffective clinical practice such as inappropriate treatment and inaccurate diagnoses, which increase time to healing and the risk of infection or other complications (Han and Ceilley, 2017). Therefore, practitioners need to be knowledgeable about wound healing, assessment, diagnosis and care planning using clinically appropriate and cost-effective dressings (Stephen-Haynes and Greenwood, 2014; Browning, 2017).
The tissue viability nurses (TVNs) in the author's trust:
To achieve the different parts of the TVN role, many organisations, including the author's trust, have tissue viability link practitioners, also known as link nurses or champions, who liaise between their ward area/department and the clinical specialist (Legg et al, 2017). Link practitioners help to disseminate clinical and other information to their colleagues while developing their own knowledge and skills.
However, such roles have not been without problems; for example, Tinley (2013) found managers had negative attitudes towards them and some health professionals believed the role may deskill ward nurses rather than enhance their practice.
To address these issues in the author's trust, the innovative competency-based Wound Resource Education Nurse (WREN) programme was established; ultimately, this will support patient-centred care, effective nursing outcomes and staff satisfaction (Tully et al, 2007). A similar wound resource nurse group was established by Santamaria et al (2015) in Australia after a review of hospital-acquired pressure ulcers was carried out; the wound resource nurses are ward based and receive additional training in wound management and pressure ulcer prevention.
This article outlines how the WREN programme was developed and how it proved to be effective in one area. This programme is specifically for practitioners in the author's organisation and is not associated with the Tissue Viability Society's Wounds Research Network (WReN).
The programme
The WREN programme is open to health professionals, healthcare assistants and link practitioners who are enthusiastic and willing to develop their knowledge and skills within tissue viability.
The author acknowledges that the Tissue Viability Leading Change framework, developed by the University of Huddersfield and Urgo Medical (2020), is available. However, the WREN programme was developed to be adaptable; staff collaborated with the tissue viability (TV) team to identify their knowledge gaps and in accordance with Santamaria et al's (2015) ethos, so took ownership.
The aim of the WREN programme is that staff who have completed it will:
Once the programme was conceived, recruitment was organised by the TV team, and aimed at practitioners and link practitioners who had an interest in tissue viability and wound care. There were no exclusion criteria for attending the programme. Sixteen practitioners were recruited as the first cohort. Initially, the programme was implemented in the acute trust; a year later after, a local mental health trust introduced it, followed by the district nursing teams 6 months after that.
During the first ever introductory event, participants were asked to identify session content and topics that would update and increase their knowledge to achieve a greater buy-in and associated attendance.
The programme content and assessment methods are outlined in Table 1. The quizzes comprise multiple choice, true/false, fill in the blanks and matching questions, and are marked by the TV team. They are undertaken at the end of each session with a final quiz at the end of the programme, which tests participants on an amalgamation of the content of all sessions to confirm that learning has been retained. Staff who fail assessments are encouraged to retake the assessment or the session if they prefer. The TVNs also offer a 1:1 discussion where appropriate or necessary.
| Topic | Method of assessment |
|---|---|
| Skin anatomy and physiology | Quiz |
| Pressure injury prevention and management | Quiz |
| Moisture lesion prevention and management | Quiz |
| Skin tear assessment and management | Quiz and practical using tomatoes to show how to treat skin tears and the effect of wound closure strips on fragile skin |
| Wound assessment and asepsis | Asepsis practical and wound assessment/recording practical |
| Management of negative pressure | Quiz and practical (negative pressure specialist) |
| Oedema and lymphoedema | Quiz |
The programme comprises eight 3-hour sessions over the course of a year (24 hours); shorter sessions enable practitioners to leave their clinical area for a short, manageable period rather than having to take a full day out. Content is delivered by the TV team and, on some occasions, by wound management companies. The latter option supports the NHS's acknowledgement of the potential of partnering with healthcare industries to support and develop efficient, effective care pathways in its Best Practice Guidance on Joint Working Between the NHS and Pharmaceutical Industry and Other Relevant Commercial Organisations (Department of Health, 2008). The companies chosen had products on the organisation's formulary, and were forbidden from discussing any products that were not on it. Additionally, one of the TV team was present at the sessions to ensure the content agreed by the author was covered. These external resources provide variety for practitioners and give an insight into the business side of wound management, which is essential if they are to understand how resources are procured and used clinically.
The TV team realised that physically attending sessions is not always possible for a variety of reasons, so determined that aspiring WRENs must attend at least 80% of the sessions in person; if they are unable to attend because of work commitments or holidays, the session content is emailed to them to complete. This flexibility also presents opportunities to raise clinical or managerial issues and contribute to discussions when attending a session, and removes the pressure of having to be present physically when this is not possible.
A certificate of completion is given after each session for inclusion in professional development files or revalidation purposes. Successful completion of each session and competency in the programme entitles the practitioner to be identified as the WREN for their area or department.
During the course of the programme and for a period after completion, nurses from the TV team work with course participants to assess pressure injuries and moisture lesions and, where necessary, support them to complete incident reports. The post-course mentoring period is flexible according to the needs of the individual.
Following the success of the WREN programme in the acute trust, the programme was introduced to the mental health trust and is now in its second year of implementation. Before this, although there was a service-level agreement (SLA) between the two trusts, wound care education was not included, so patients often attended acute hospitals for wound treatment. The revised SLA focused on implementing wound care training and a review of the both the wound formulary and the pressure ulcer prevention and management policy. Table 2 outlines the topics determined through discussions with the staff and lead SLA contact
| Topic | Method of assessment |
|---|---|
| Basic anatomy and physiology | Quiz |
| Pressure injury/moisture lesion prevention and management | Quiz |
| Pressure-relieving equipment training | Quiz (by industry representatives) |
| Skin tear assessment and management | Quiz and practical using tomatoes |
| Aseptic technique | Practical |
| Management of self-harm wounds | Quiz |
| Burns | Quiz |
As the WREN programme is adaptable, the community-based aspiring WRENs revised the content to reflect their care setting and the types of wounds most commonly seen; for example, there were more scenario-based sessions pertaining to oedematous wet legs, leg ulcers and wounds requiring negative pressure.
Progress
To date, approximately 160 practitioners have completed or are continuing with the programme. The implementation of the programme across the three organisations is outlined below.
Acute trust
Within the acute trust, 60 WRENS have completed year 1 and are following year 2, in which sessions from year 1 are covered in more depth and new topics are introduced. Year 2 is not compulsory; after year 1, provided that all assessments have been passed, attendees are delegated as the WREN for their clinical area. Although attendance in year 2 is a personal choice, the majority of qualified WRENs choose to continue. As this is a continuous process, new year 1 practitioners are recruited while the year 2 programme continues. The target number of WRENS for the trust is two per ward area or department, accumulating to around 90–95.
Since the programme was implemented, a review of pressure injury incident data and patients' notes, coupled with the annual point prevalence audit, have demonstrated an improvement in the categorisation of pressure injuries and correct differentiation between moisture lesions and pressure injury. Before the programme, approximately 30% of pressure injury categorisations were incorrect; this has fallen to 5-10%. In addition, during the programme, a pressure injury reporting flow chart illustrating the success of the main principles of the programme was developed by the TVNs and cascaded down to clinical areas by the WRENS.
Mental health trust
The mental health trust now has 70–80 WRENs; they comprise registered nurses, healthcare assistants, doctors, physiotherapists and dietitians. At the end of the first year of the WREN programme, staff completed evaluations and identified topics they wanted for the following year, such as leg ulcers, oedema and how to complete wound care assessment charts. The programme was so popular after its first year that a waiting list had to be set up.
Before the programme was introduced, all 96 referrals from the mental health trust were for wound assessment and care planning. Wound assessment would often be delayed for 2–3 days, often longer, until a member of the TV team came to review, or patients were taken to accident and emergency review and assessment. In the latter scenario, visits required 2-4 members of staff to attend the patient. On completion of the WREN programme, staff were able to identify and treat wounds on the ward. After year 1 of the programme, referrals to the TVN for wound assessment and care planning dropped to 40% of the 191 referrals, with 60% being merely for reassurance that an appropriate wound management plan had been developed, rather than a need for a TV nurse to provide a care plan. The number of referrals roughly doubled as staff became more aware the trust had a TV service and were encouraged to refer patients with a wound to the TV service instead of transferring them to accident and emergency.
In addition, an evaluation after year 1 of the SLA showed that the updated dressing formulary and the implementation of the WREN programme had reduced spend on dressings from £26 000 to £16 000, a realised saving of £10 000.
District nursing
Twenty community WRENs from the district nurse bases attend the sessions regularly; as per the aim of the programme, new developments in the TV service are cascaded to the district nurse teams via the WRENs. Although not compulsory, the majority of the newly qualified community nurses attend the programme because they have a personal interest or their manager has designated them as the potential WREN for their geographical area; this has a dual benefit to the service:
In the 6 months before the programme was implemented, there were 663 referrals to the community tissue viability service; this fell to 545 (a 17% reduction) 6 months after implementation.
Across the community and acute trusts, the TV team were able to access both the district nurse (prescription) and ward ordering patterns for dressings. The team compared ordering data before and after the programme and found that adherence to the formulary increased by approximately 40% and that the only dressings ordered outside the formulary were on instruction from tissue viability or another specialist service.
Conclusion
The WREN programme has been well attended and received in the local acute, community and mental health trusts. Its success in terms of interest from staff is reflected in the fact that the TV team is preparing to deliver more sessions to accommodate those on the waiting list. The success of the WREN programme in the various organisations has been largely positive and, overall, the aims of the programme are being achieved.
The largest improvements in practice, care and cost savings have been at the mental health trust. Before the programme was implemented, staff had no or little knowledge of wound assessment or management. It has been demonstrated that significantly more patients with wounds are being treated in a timely and appropriate manner, and staff have the competence and confidence to manage wounds in their clinical area.
The community and acute trusts have both seen improvements in practice and in the percentage of appropriate referrals to the trust's acute and community TV services from areas that have a WREN. While at the time of writing audit data is not available, the programme has proved to be cost-effective as staff are using dressings more appropriately.
The author believes that the WREN programme, although developed initially for tissue viability services, can be used in any discipline as it is adaptable as the sessions and content can be tailored to the staff learning needs.