The client and family experience of attending a nurse-led clinic for chronic wounds

Introduction

Nurse-led models of care are reshaping conventional health care by filling the gap in areas where there is an increased demand for services and workforce shortages. The benefits of nurse-led care include reduced waiting times, more cost-effective care, advanced nursing practice and offloading workload pressure on medical-led services (Allan 2018). However, there is minimal research available on the lived experience of attending a nurse-led model of care for chronic wounds, and whether current practice reflects the literature.

Chronic wounds have a significant impact on the health and wellbeing of an individual and their family (Wellborn and Moceri 2014). There are approximately 400 000 people in Australia living with chronic wounds, and it is estimated to cost the government 2% of national health care expenditure (Graves and Zheng 2014). The financial burden is also placed on the individual and their family, because there are minimal reimbursements for the cost of wound care. In Australia, the lack of reimbursement for wound care consumables may be seen as a disincentive for health care providers to provide evidence-based care (Kapp and Santamaria 2017). The literature has identified that individuals with chronic wounds spend approximately 10% of their disposable monthly income on wound care (Kapp and Santamaria 2017). Pain makes it increasingly difficult to complete day-to-day activities, and heightens the risk of developing anxiety and depression (Wellborn and Moceri 2014). The result of a combination of financial stressors and declining health leads to a poor quality of life in people with chronic wounds (Kapp and Santamaria 2017; Walker et al. 2023).

Living with a chronic wound is a difficult experience to face, and having a strong support network is fundamental towards being able to cope. The majority of people with chronic wounds are older adults, because they are more susceptible to age-related changes that have a negative impact on wound healing (Woo 2012). Older adults are at a greater risk of loneliness and social isolation, causing them to be more likely to develop negative health outcomes (Coyle and Dugan 2012). In the community, the majority of wound care is performed by nurses (Edwards et al. 2009). Leg ulcers are one of the most common chronic wounds, and approximately 80–90% of leg ulcers in Australia are treated by general practitioners and practice nurses (Norman et al. 2016). The literature has also demonstrated that nurse-led interventions have a positive impact on wellbeing and fill the gap of social support (Edwards et al. 2009; Van Hecke et al. 2011; Clark 2012; Upton et al. 2015).

Nurse-led care is guided by evidence-based practice to provide advanced nursing care that is innovative, easily accessible and cost-effective (Allan 2018). Within the community, nurse-led clinics are beneficial, because they provide continuity of care, reduced waiting times, high levels of client satisfaction and social support (Allan 2018). The positive outcomes of nurse-led clinics in wound care have been demonstrated in the literature; however, there is minimal research available on the lived experience of attending a nurse-led clinic for chronic wounds (Dhar et al. 2020). Therefore, the aim of this study was to evaluate the experience of the client and family attending a community-based nurse-led clinic for people with chronic wounds.

Methods

This study used a descriptive qualitative design to evaluate the client and family experience of attending a community-based nurse-led clinic for chronic wounds.

Results

A total of 14 participants completed the interviews; 12 clients and two family members and participants’ ages ranged from 41 to 98 years (M = 66, s.d. = 15.72; See Table 2 for demographic data; see Fig. 1 for participant recruitment). The interviews were approximately 20 min in length. One family member was the client’s spouse, and the other family member was a parent.

Fig. 1.

Participant recruitment.

One-third of clients (n = 5) attended the clinic on less than three occasions and continued their wound care in the home after receiving an initial consultation. Some clients (n = 4) attended on a regular schedule over a period of 3–6 months. One client was referred by the hospital, and four clients were referred internally within the community nursing agency. The remaining clients (n = 7) were referred by their general practitioner.

Discussion

The demographic data in this study found that the majority of people were older adults and retired, reinforcing the common demographic of people with chronic wounds (Gould et al. 2015). Older adults experience longer wound healing times due to increased comorbidities and age-related changes that make them more susceptible to chronic inflammation and infection (Woo and Sibbald 2008; Gould et al. 2015). Wound pain was mentioned in every interview completed for this study, demonstrating the significant impact that pain has on daily life. The client and family explained that the nurses in the clinic acknowledged and considered their pain during wound care. This supported Frescos (2018) work, which found that nurses working within a range of areas (e.g. hospitals, community health, aged care facilities) were more likely to conduct a pain assessment in comparison with other health practitioners. However, pain was not always adequately managed within the nurse-led clinic, and the family had a greater desire for nurses to be able to provide better pain management. Woo and Sibbald (2009) found that pain impaired wound healing, and suggested using a framework where a comprehensive pain assessment guide is conducted prior to determining a wound care plan.

Chronic wounds have a negative influence on the ability of people to complete their basic activities of daily living (Wellborn and Moceri 2014). In this study, the two family members had a major role in being able to provide this level of support by assisting their family member with showering, transportation and managing health care needs. Due to the small sample size of family members in this study, it cannot be concluded that family always has a major role in supporting people with chronic wounds. For those with minimal social support, receiving practical support becomes increasingly difficult (Kouris et al. 2016). The nurse-led clinic was able to provide practical support through community transport and in-home care. To provide holistic care, the psychosocial wellbeing of the person with the wound has to be taken into consideration. In the study by Edwards et al. (2009) with 67 participants, they found improved quality of life, self-esteem, morale and wound healing within a group of people who received care in a nurse-led clinic that promoted peer support and socialisation, where a group of people with chronic wounds were able to communicate with each other in a communal setting. There is minimal research available on specifically improving the mental health and psychological wellbeing of people living with chronic wounds, and future research is warranted to improve health outcomes.

In this study, the majority of participants attended the nurse-led clinic because they were wanting to receive expert advice from a specialist wound nurse. Adderley and Thompson (2016) found nurses specialising in wound care had more post-graduate qualifications, and were more likely to make accurate judgements regarding the diagnoses and treatment of venous leg ulceration in comparison with general community nurses. This finding was based on the reasoning that community nurses had less exposure to complex wound care, as specialist wound nurses were the primary clinicians. However, the majority of care provided by a community nurse encompasses chronic wounds, and is one of the most common procedures in general practice (Innes-Walker et al. 2019). Interestingly, only 66% of community nurses attending a series of study days identified having no specialised training in wound care (Mahoney 2019). Participants in this study have experienced negative encounters regarding their wound care from previous health care professionals. Therefore, specialised training is required to prepare the workforce for increasingly complex wounds in the future within the ageing population (Pacella 2017).

The nurse-led clinic in this study was able to provide expert advice based on the comments provided from participants. The analysis revealed that the nurse’s knowledge and expertise in wound management influenced the client’s trust in the nurse. Multiple studies investigating nurse-led wound care have reported high levels of satisfaction with care provided by nurses, and the results of this study reinforce the current research (Edwards et al. 2009; Woo and Sibbald 2009; Van Hecke et al. 2011; Clark 2012; Wellborn and Moceri 2014; Upton et al. 2015). This highlights the important role nurses have in providing safe, quality care, and positions the nursing discipline at the forefront of wound management (Pacella 2017).

Current research highlights that nurse-led clinics in the community provide an accessible service, and this was reinforced based on the participants’ feedback (Randall et al. 2017). The World Health Organization (2020) outlines three categories to describe accessibility in health care, including: physical accessibility, economic accessibility and information accessibility. The nurse-led clinic provided community transport, simple referral processes and a safe environment for its participants; however, economic accessibility was not easily achieved based on the participants comments.

Chronic wounds cost the Australian healthcare system A$3 billion annually; however, the majority of cost is placed on the individual (Pacella 2017). Kapp and Santamaria (2017) found people with chronic wounds in the community spent approximately A$2475 on wound dressing products since the beginning of their wound. The participants in the current study reported that wound care products were expensive and often not suitable once purchased, adding extra costs to their personal health budget. The government fails to provide adequate funding to reimburse health care providers for the cost of wound care. Therefore, there is less incentive to provide this service. There are <200 people who receive subsidised wound care dressings from the federal government (Medical Technology Association of Australia 2020). This demonstrates a large disparity in the allocation of funding, because there are up to 400 000 people living with chronic wounds in Australia (Graves and Zheng 2014).

Nurse-led clinics have been shown to reduce costs in the hospital sector by providing an outpatient service for wound care; however, the individual is still left to bear the cost (Bergersen et al. 2016). This study was able to provide a real-world perspective on the client and family experience of managing the cost of wound care. The majority of studies investigating the outcome of wound care provide their services at no cost as part of the investigation. Therefore, it is not known whether this model of care would be sustainable without knowing whether the individual could afford the service (Shelton and Reimer 2018). Therefore, it is imperative for policy makers and government sectors to increase funding allocated to wound care to facilitate the provision of evidence-based care and better health outcomes (Pacella 2017).

To provide an accessible service, information accessibility ensures health care consumers are able to make informed decisions regarding their care at a level that is understandable to them (World Health Organization 2020). Some participants in this study expressed a greater desire to know more about their treatment. Through tailored education, nurses can provide individuals and families with the knowledge and skills required to self-manage their chronic illness, and make the most effective use of the healthcare system (Harris et al. 2008). Nurses can also encourage individuals to work collaboratively with their peers and general practitioners’ to build a stronger support network (Harris et al. 2008). Margolis et al. (2015) found providing education in the first month of wound care can significantly improve wound-related outcomes. Therefore, it is important for nurses to consider health literacy and provide education to empower people to make the best possible decisions regarding their own care.

Conclusion

This study explored the client and family experience of attending the nurse-led clinic, and the findings demonstrated a strong emphasis on the impact of chronic wounds on daily life, and the benefits and challenges of attending the nurse-led clinic. Through the participants’ stories, it was highlighted that comprehensive pain assessments, improved social support, better client education and cost-effective care is required to optimise the experience for people attending the nurse-led clinic.