Nurses' experiences of hospital-acquired pressure injury prevention in acute healthcare services in Victoria, Australia: A qualitative study using the Theoretical Domains Framework.

We investigated nurses' experiences of hospital-acquired pressure injury (PI) prevention in acute care services to better understand how PI prevention may be optimised. We used the Theoretical Domains Framework to systematically identify barriers and enablers to evidence-based preventive practices as required by the International Guideline. This study was one element of a complex capacity building project on PI surveillance and prevention within the acute health service partners of Monash Partners Academic Health Science Centre, an accredited academic health partnership located in Melbourne, Australia. We adopted a qualitative descriptive design. We interviewed 32 nurses that provided care in intensive care units, general wards and COVID wards of four acute care services. Nurses were recruited from four large acute care services (three public, one private) located in Melbourne. Most of them worked with patients who were at high risk of hospital-acquired PI on a daily basis. Interview transcripts were coded and analysed using thematic analysis guided by the Theoretical Domains Framework. The domains referred to most frequently by all participants included: Knowledge, Skills, Social/Professional Role and Identity, Beliefs about Capabilities, and Environmental Context and Resources. The key barriers discussed by nurses included gaps in nurses' knowledge and skills related to identification and staging of PI, heavy nursing workload and inadequate staffing levels, stigma and self-blame related to PI identification, and exacerbating impacts of the COVID-19 pandemic. Main facilitators discussed were training programmes, nursing audits and feedback, and teamwork. Participants suggested improvements including accessible and tailored training, visual reminders, and addressing heavy workloads and emotional barriers nurses face. Investing in tailored training initiatives to improve nurses' knowledge and organisational changes to address low level staffing and heavy workloads are urgently needed to support nurses in delivering optimal care and preventing hospital-acquired PI.

A conceptual framework of patient-reported outcomes in people with venous leg ulcers.

Venous leg ulcers (VLUs) are a common chronic often undertreated condition, which affects individual's health-related quality of life (HRQoL). Numerous patient-reported outcome measures (PROMs) have been validated to capture HRQoL in patients with VLUs. However, available instruments contain many items, are hard to use in clinical practice, and present with weak responsiveness. This study aims to determine clinical utility of an existing VLU-QoL instrument and to develop a comprehensive PROs assessment framework to guide clinical practice treatment in people with VLUs in Australia. Semi-structured qualitative interviews were conducted with VLU patients (N = 13) and their managing clinicians (N = 6) in Victoria, Australia. Interview topics covered content and face validity, appropriateness, and acceptability of the VLU-QoL instrument to determine suitable and appropriate for use in clinical practice. Clinicians and patients agreed that a VLU-QoL instrument was needed in clinical practice. Both clinicians and patients agreed it would be appropriate to answer PROMs questions prior to consultation with clinicians every 3-6 months. However, patients considered that some of the questions are ambiguous and too technical. Patients reported that it would be useful to include additional items relating to daily wound care, compression bandaging, and dressings. Clinicians reported that the VLU-QoL instrument was too long and required restructuring to facilitate utility in practice. A conceptual framework for HRQoL in VLUs included traditional HRQoL components and VLU-specific issues. Overall, the VLU-QoL was well accepted, although changes to make it more concise, comprehensive, and to clearly reflect consumers' perspectives were lacking. The proposed conceptual framework will inform the development of a new PROM for use by clinicians and patients in clinical settings.

Vascular assessment in venous leg ulcer diagnostics and management in Australian primary care: Clinician experiences.

AIM: In this article, we focus on primary health clinicians' experiences of vascular assessment in venous leg ulcer (VLU) diagnostics and management, including ankle brachial pressure index (ABPI) measurements using Doppler ultrasonography. METHODS: We conducted semi-structured face-to-face and telephone interviews with general practitioners [15] and practice nurses [20] from primary health care settings in Australia. Twenty-one participants were recruited from practices located in Melbourne metropolitan settings and 14 from rural Victoria. We used the theory driven thematic analysis as a method of data analysis. The Theoretical Domains Framework informed this analysis. RESULTS: Five domains were identified as relevant, including Environmental Context and Resources, Motivation and Goals, Skills, Knowledge, and Beliefs about Capabilities. Although the Australian and New Zealand clinical practice guideline for prevention and management of venous leg ulcers recommend that vascular assessment is conducted for all patients with suspected VLUs, findings from our study indicate vascular assessments are not routinely performed in many primary care settings. Our study also found that a lack of awareness of clinical practice guidelines among clinicians might be one of the main issues for not following the latest clinical recommendations for vascular assessment in venous leg ulcer diagnostics and wound management practice. CONCLUSION: We recommend development of theory-informed interventions for clinicians in primary health care settings to optimise VLU management and healing outcomes for patients with VLUs. Implementation and evaluation of these interventions have the potential to reduce the evidence-practice gap in VLU management and optimise healing outcomes.

Rationale for participation in venous leg ulcer clinical research: Patient interview study.

Recruitment to wound care clinical trials is challenging and a better understanding of patient decisions to participate has the potential to influence recruitment success. We conducted 31 semi-structured telephone interviews of patients who participated in the Aspirin in Venous Leg Ulcer (ASPiVLU) randomised controlled trail (RCT) or ASPiVLU cohort study. Data were coded and analysed using thematic analysis. We identified four key themes: (a) "I participated to help others"; (b) "I participated in research to thank those who cared for me"; (c) "I participated to receive better care"; and (d) "I participated to have a say on what works." These themes became basic elements for the Rationale for Research Participation Framework that we have developed to improve the participant recruitment process for clinical trials in wound care.

Understanding factors influencing venous leg ulcer guideline implementation in Australian primary care.

The aim of this study was to gain a better understanding of the venous leg ulcer (VLU) management in primary health care settings located in Melbourne metropolitan and rural Victoria, Australia. We explored health professionals' perspective on the use of the Australian and New Zealand Venous Leg Ulcer Clinical Practice Guideline (VLU CPG) to identify the main challenges of VLU CPG uptake in clinical practice. We conducted semi-structured interviews with 15 general practitioners (GPs) and 20 practice nurses (PNs), including two Aboriginal health nurses. The Theoretical Domains Framework guided data collection and analysis. Data were analysed using a theory-driven analysis. We found a lack of awareness of the VLU CPGs, which resulted in suboptimal knowledge and limited adherence to evidence-based recommendations. Environmental factors, such as busy nature of clinical environment and absence of handheld Doppler ultrasound, as well as social and professional identity factors, such as reliance on previous experience and colleague's advice, influenced the uptake of the VLU CPGs in primary care. Findings of this study will inform development of interventions to increase the uptake of the VLU CPG in primary care settings and to reduce the evidence-practice gap in VLU management by health professionals.

Patient education materials on pressure injury prevention in hospitals and health services in Victoria, Australia: Availability and content analysis.

Pressure injuries (PIs) are a common quality indicator for hospital care, and preventing PIs often requires patient engagement; as such, Australian consensus research has recommended that high-quality education materials be made to patients for PIs via hospital networks. The purpose of the present study was to assess the availability and accuracy of patient education materials on PIs in publicly available hospital websites in Victoria, Australia. Two independent coders assessed 212 websites for content on PI prevention and management, analysing availability and accuracy of PI definitions, risk factors, preventive strategies, referral, visual tools, consumer endorsement, information for family/carers, and translation on community languages. A greater proportion of hospitals did not have any patient education materials on PI prevention publicly available, with private hospitals (compared with public) and metropolitan hospitals (compared to rural) more likely to have materials available on their sites. The available materials contained accurate messages on PI defining characteristics and risk factors for PIs, although there was considerable variability on the availability of other information. Our findings suggest a significant deficit in the availability of educational materials for acute care patients and their families. There is a need for evidence-based, consumer-endorsed, uniform materials on all hospital websites to prevent PIs in acute care.

Clinical Coders' Perspectives on Pressure Injury Coding in Acute Care Services in Victoria, Australia.

Pressure injuries (PIs) substantively impact quality of care during hospital stays, although only when they are severe or acquired as a result of the hospital stay are they reported as quality indicators. Globally, researchers have repeatedly highlighted the need to invest more in quality improvement, risk assessment, prevention, early detection, and care for PI to avoid the higher costs associated with treatment of PI. Coders' perspectives on quality assurance of the clinical coded PI data have never been investigated. This study aimed to explore challenges that hospital coders face in accurately coding and reporting PI data and subsequently, explore reasons why data sources may vary in their reporting of PI data. This article is based upon data collected as part of a multi-phase collaborative project to build capacity for optimizing PI prevention across Monash Partners health services. We have conducted 16 semi-structured phone interviews with clinical coders recruited from four participating health services located in Melbourne, Australia. One of the main findings was that hospital coders often lacked vital information in clinicians' records needed to code PI and report quality indicators accurately and highlighted the need for quality improvement processes for PI clinical documentation. Nursing documentation improvement is a vital component of the complex capacity building programs on PI prevention in acute care services and is relied on by coders. Coders reported the benefit of inter-professional collaborative workshops, where nurses and coders shared their perspectives. Collaborative workshops had the potential to improve coders' knowledge of PI classification and clinicians' understanding of what information should be included when documenting PI in the medical notes. Our findings identified three methods of quality assurance were important to coders to ensure accuracy of PI reporting: (1) training prior to initiation of coding activity and (2) continued education, and (3) audit and feedback communication about how to handle specific complex cases and complex documentation. From a behavioral perspective, most of the coders reported confidence in their own abilities and were open to changes in coding standards. Transitioning from paper-based to electronic records highlighted the need to improve training of both clinicians and coders.

Patient Explanation of Adherence and Non-Adherence to Venous Leg Ulcer Treatment: A Qualitative Study.

The aim of this study was to understand which factors influence patients' adherence to venous leg ulcer treatment recommendations in primary care. We adopted a qualitative study design, conducting phone interviews with 31 people with venous leg ulcers in Melbourne, Australia. We conducted 31 semi-structured phone interviews between October and December 2019 with patients with clinically diagnosed venous leg ulcers. Participants recruited to the Aspirin in Venous Leg Ulcer Randomized Control Trial and Cohort study were invited to participate in a qualitative study, which was nested under this trial. We applied the Theoretical Domains Framework to guide the data analysis. The following factors influenced patients' adherence to venous leg ulcer treatment: understanding the management plan and rationale behind treatment (Knowledge Domain); compression-related body image issues (Social Influences); understanding consequences of not wearing compression (Beliefs about Consequences); feeling overwhelmed because it's not getting better (Emotions); hot weather and discomfort when wearing compression (Environmental Context and Resources); cost of compression (Environmental Context and Resources); ability to wear compression (Beliefs about Capabilities); patience and persistence (Behavioral Regulation); and remembering self-care instructions (Memory, Attention and Decision Making). The Theoretical Domains Framework was useful for identifying factors that influence patients' adherence to treatment recommendations for venous leg ulcers management. These factors may inform development of novel interventions to optimize shared decision making and self-care to improve healing outcomes. The findings from this article will be relevant to clinicians involved in management of patients with venous leg ulcers, as their support is crucial to patients' treatment adherence. Consultation with patients about VLU treatment adherence is an opportunity for clinical practice to be targeted and collaborative. This process may inform guideline development.

Health literacy in people with venous leg ulcers: a protocol for scoping review.

INTRODUCTION: Chronic venous leg ulcer (VLU) healing is a complex clinical problem. It requires intervention from skilled, costly, multidisciplinary wound-care teams, working with patients to manage their care. Compression therapy has been shown to help heal venous ulcers and to reduce recurrence, with some evidence suggesting the value of exercise as well. These activities require health education and health literacy (HL) as patients must process, understand and consistently apply health information for successful self-management. Research suggests that those most vulnerable to VLUs also tend to have limited HL, but there have been no reviews examining the state of HL in patients with previous or active VLUs. This scoping review aims to examine the level of HL in VLU patients and how HL may link to self-management behaviours (particularly exercise and compression adherence), and their VLU healing generally. METHODS AND ANALYSIS: We will use Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Review guidelines and the Levac methodology framework to explore eligible papers that examine the effect of HL on their exercise and compression adherence. Electronic databases will be searched (MEDLINE, EMBASE, the Cochrane Library, PsycInfo and Health, OpenGray), examining for all papers on these subjects published between 2000 and 2020. All studies describing compression and or exercise during VLU management will be included. Study characteristics will be recorded; qualitative data will be extracted and evaluated. Quantitative data will be extracted and summarised. ETHICS AND DISSEMINATION: We will disseminate results through peer-reviewed publications. We will use data (ie, journal articles) from publicly available platforms; so, this study does not require ethical review. The consultation step will be carried out with patients, carers and health professionals as part of an established wound consumer group.