Education is an important functional domain of enterostomal therapy nurses (ETN). Whether as a practice guideline document or as a distant education and consultation program, education has a tremendous influence on impacting positively care outcomes for our patients receiving wound, ostomy, and continence care. Evidence-based recommendations for conservative sharp wound debridement were recently published by the Canadian Association for Enterostomal Therapy (CAET).1 Authors Elise Rodd-Nielsen (project lead) and Jean Brown (Atlantic Regional Director and panel member) present the process used to develop this international consensus document. Our second article by Dorothy Phillips, past academic advisor for CAET Enterostomal Therapy Nursing Education Program (ETNEP) and CAET Certification Examination Committee member shares the impact of ETN on the development of a distant education program that uses educational technology and consultation to serve the First Nations and Inuit people in Alberta.2
CAET Evidence-Based Recommendations for Conservative Sharp Wound Debridement
Elise Rodd-Nielsen and Jean Brown
Conservative sharp wound debridement is recognized as an important intervention in the rapid preparation of the wound bed for healing, yet in North America there is a lack of standardization regarding policy, education, and practice guidelines. In 2009, as part of the Informatics and Research Core Program, the CAET sponsored the development of the evidence-based recommendations for conservative sharp wound debridement. This article summarizes the development process, challenges faced, and the Web-based technologies used in this national/international collaborative effort.
The document was developed over 20 months by a volunteer group of ETN who work in the domains of clinical practice, policy development, consultation, and education in wound care. The recommendations are based on a compilation of literature published between 1991 and 2010, focusing on the adult population with wounds for which conservative sharp wound debridement could be implemented as an intervention. The search terms used were conservative debridement, sharps injury, sharp wound debridement, sharp debridement, sharp debridement of wounds, curette debridement and clinical skills, diabetic foot ulcers, leg ulcers, and pressure ulcers. The following databases were accessed: Ovid EBM Reviews, Cochrane Database of Systematic Reviews (fourth quarter of 2009), HealthSTAR, PsycINFO, Medline Plus, Unbound Medline, and CINAHL.
Recommendations were derived through a consensus process that analyzed emerging themes from both the "soft" literature (expert opinion, case studies) and higher-level research. Levels of evidence were assigned to the recommendations. Validation of the recommendation headings and content was obtained from 29 volunteer national and international stakeholder reviewers from Canada, United States, United Kingdom, Italy, Brazil, Australia, and Mexico. The 10 recommendations encompass the domains of policy, clinical practice, etiology-specific wounds, and education.
One of the challenges encountered by the development authors was the lack of clear definitions and standardized terms for conservative sharp wound debridement. The definition used in this article is believed to encompass the gamut of conservative sharp wound debridement in nursing practice. Poston3 provided the basis of this working definition, to which the debridement of callous and hyperkeratotic tissue was added. Thus the definition of conservative sharp wound debridement used was the removal of loose, devascularized tissue, callous or hyperkeratotic tissue with the aid of a scalpel, scissors, or curette above the level of viable tissue.
The paucity of higher-level research related to conservative sharp wound debridement practice, policy, education, and outcomes posed a challenge in the development process. This paucity made the use of any content validation tool impractical and consequently certain recommendations are based on expert opinion. As research evolves, it is anticipated that future revisions of the recommendations will use a more rigorous approach.
The timeframe of 20 months for development also posed a dilemma. Literature and research in wound care is evolving at such a fast pace that it was necessary to repeat the literature search in late 2010 to reflect the most current evidence at the time of publication.
The practical challenges of a collaborative effort spanning a large country with 3 time zones were met by using remote servers (rather than desktop computers) to store, process, and manage data (cloud-based computing). Scheduling of teleconferences was done using a free Web-enabled scheduling site. The document was housed on an accessible Web site (GoogleDocs), which allowed development members to simultaneously work on their sections of the document and view the work of the other authors. This helped to decrease later formatting issues and reduced redundancies. Consensus was gained by the development members and from the stakeholders using an electronic survey site, which automatically sorted and compiled results facilitating feedback interpretation.
The CAET and the development authors are pleased to release this document to a world audience of wound care practitioners. We invite you to submit your feedback and share your use of this document with us. An electronic copy of these open source recommendations can be accessed at http://www.caet.ca.
Enterostomal Therapy Services in Health Canada, First Nations and Inuit Health, Home and Community Care Program
Dorothy E. Phillips
Health services in First Nations populations living on reserves in Canada are under federal jurisdiction and funded by Health Canada. Health Canada is divided into 7 regions. Alberta Region incorporates 45 First Nation communities in 3 treaty areas. The region's reserve population is approximately 65,000 with a combined total population of approximately 99,000. Geographical locations of the First Nations communities create challenges for patients who require expert clinical consult for wound, ostomy, and continence care. This results in increased costs due to frequent travel to urban centers and delay of required care due to lengthy wait times.
To ensure that patients living on reserve have equitable access to services as patients not living on reserve, it was necessary to develop a strategy to address this inequitable gap in service. In 2008, a position (15 hours/week) for an ETN was created in the First Nations and Inuit Health, Home and Community Care Program, Alberta Region. When asked how an ETN is able to facilitate the best possible outcomes for clients working only 2 days a week, I can only respond, "I couldn't do it without the help of the team I work with." Working only 2 days a week, it really is a balancing act." The current model allows the ETN to focus on the administrative aspects of clinical care such as policy and procedure development, the standardization of products, developing staff education, attending committee meetings for one of those days, and providing consultation services to nurses in the remote communities the other day on a case-by-case basis.
The model design of service delivery allows community nurses to access ETN services for clients in a timely manner without having to learn how to use new software programs or equipment. Nurses have access to computers, digital cameras, and videoconference equipment in all First Nations communities. Once the consultation is completed, an electronic consult form is forwarded to the community to include in the client's chart. The turn around time is usually less than 1 hour from the time the consult is received. This delivery model ensures that the patients is able to have access to a specialist and receive the right treatment at the right time, which facilitates positive outcomes.
Over the first year, a clinical education program was developed, which included the following topics: wound, continence, and ostomy care. All home care nurses (registered nurses and licensed practical nurses) were required to attend these sessions as part of their regional orientation. This education helps ensure that nursing staff demonstrate proficiency and mastery of clinical knowledge and skills beyond the basic level. The most rewarding aspect of this education is the growth seen in the nurses' knowledge and the pride shown when they achieve positive outcomes for their patients.
However, distant geographical locations of the First Nations communities also create challenges in accessing the education with minimal disruption to patients care and nursing practice. As a result, many nurses were not able to attend the education sessions. In 2009, a decision was made to explore the possibility of developing an e-learning program. An environmental scan was completed to identify platforms that could be used for e-learning. The platform chosen allows for both synchronous and asynchronous learning experiences. Each live e-learning session is recorded. The recording is edited and is converted to video format to be used for asynchronous learning. Following asynchronous learning, a live case study session is scheduled to provide the opportunity to practice skills learned, and clarify any misconceptions that might have occurred as a result of independent learning. To date there have been 51 live online sessions on 17 topics related to wound, ostomy, and continence management. The average number of participants per session is 10. Feedback from nurses has been positive. They view the online education as "a great time management tool" because it allows them to access education without having to leave the community.
This model of clinical and educational service delivery has proven to be so effective that funds have been allocated by Health Canada national office to implement similar services in other regions of the country. The hours of ETN services in Alberta region have expanded from 15 hours a week to full-time services, and ETN services for the First Nations population have been implemented in Manitoba region, and plans are underway to implement similar services in the Ontario region. The ETNs in Health Canada have established a community of ETN practice and collaborate on development of policies and procedures and education programs to standardize services across the country.
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