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

Abstract

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.

1. INTRODUCTION

Venous leg ulcers (VLUs) are painful lower limb wounds that have been present for more than 4 weeks.1 The most common cause of VLUs is an underlying aetiology of chronic venous insufficiency (CVI).2 VLUs have been identified as a growing silent and costly epidemic in Australia.3 Though VLUs are the most common chronic wound seen in Australian community practice,4 they are frequently under‐detected and under‐treated.3 The social and personal impacts of VLUs are significant. Up to 7% of people with VLUs remain unhealed after 5 years of treatment due to variability in clinical practice.5 Once healed, the likelihood of VLU recurrence is between 40% and 70% within 12 months.6 This has serious ramifications for patient's quality of life7 due to reduced mobility, pain, social isolation, loss of self‐esteem, anxiety, and depression.8, 9

Furthermore, management of chronic wounds, particularly VLUs, in Australia and other developed countries, is costly.10, 11, 12, 13, 14, 15, 16 In Australia, the estimated overall health care costs relating to chronic wound management, where the greater proportion of wounds are VLUs, exceed AUD3 billion per year.3 The VLU burden and cost is expected to rise dramatically due to the ageing population and projected increased incidence of diabetes,17 chronic cardiovascular disease,18 and obesity.19 The cost savings related to reduced health service utilisation as a result of timely management have been calculated at AUD1.2 billion in recent economic modelling estimates.6, 12, 20, 21

Early diagnosis and appropriate management are paramount to optimise the health and healing outcomes for patients with VLUs.22 Clinical practice guidelines (CPGs) allow practitioners to access the most up‐to‐date evidence on disease states to enable the highest quality of standardised care to patients.23, 24 The current CPG relevant to Australia and New Zealand is the Australian and New Zealand Clinical Practice Guideline for Prevention and Management of Venous Leg Ulcers (VLU CPG).25 Both full and abridged versions of the VLU CPG25 and the flowchart for assessment of VLUs are available cost and subscription free on the Wounds Australia and the New Zealand Wound Care Society websites: https://www.woundsaustralia.com.au/Web/Resources/Publications/Publications.aspx and https://www.nzwcs.org.nz/resources/publications/10-guidelines-and-protocols.

Compression therapy is crucial in the management of underlying CVI26; it increases healing rates compared with non‐compression and prevents VLU recurrence.27 The Early Venous Reflux Ablation (EVRA) randomised controlled trial28 reported early (2 weeks from randomization) endovenous ablation as adjunct intervention to compression therapy was more effective for promoting healing and preventing recurrence of venous leg ulceration compared with the delayed ablation (in 4 weeks from the time of randomization).28 However, the evidence of effectiveness of endovenous ablation (subfascial endoscopic perforator surgery) for the treatment of VLUs is uncertain due to small sample sizes and risk of bias in the included studies, producing low‐quality and very low‐quality evidence as a recent systematic review29 concluded. The evidence of effectiveness of most adjuvant therapies including endovenous ablation in VLU healing and recurrence is of low quality.30 Although a useful option for some people with VLUs, these procedures are invasive and of high cost. Most people with VLUs are elderly and unable to afford or tolerate surgery.

A range of non‐invasive diagnostic investigations are used to support the diagnosis, including venous duplex scanning to determine the presence and severity of CVI, and Ankle Brachial Pressure Index (ABPI) measurement to exclude arterial insufficiency.23 The exclusion of arterial insufficiency indicates that application of compression is safe. Currently, many patients with active ulceration have no formal investigations to diagnose the severity of CVI and VLU.4, 31 The decision to apply compression is made predominantly on clinical assessment, which may inadequately assess the presence or severity of CVI and VLU.4 In the absence of formal investigations to exclude arterial involvement, compression therapy is often delayed.4, 5 Despite VLU CPGs recommending the use of compression therapy, it is estimated that 40% to 60% of patients with VLUs in Australia do not receive adequate compression therapy.20 To our knowledge, there are no published data to demonstrate whether all patients in primary care are offered compression and decline as VLU patients' health, social, health literacy, and financial needs are often overlooked.20, 32, 33

The VLU CPG recommendations assist general practitioners (GPs) and practice nurses (PNs) in accurate diagnosis and decision making, improve patient‐professional communication, and improve patient outcomes.5 Although the VLU CPGs are available and accessible to all health professionals in Australia and New Zealand, the quality of services provided to patients with VLUs is suboptimal.3, 5 Identification of factors that influence the awareness of CPGs and their uptake by health professionals can highlight the areas of educational need and inform the interventions that can aid health professional CPG use in clinical practice.34, 35

The aim of this study was to identify health professional perspectives about using VLU CPGs to guide the management of people with VLUs in primary care in Melbourne metropolitan and rural Victoria, Australia. Findings of this study will inform intervention development aimed to increase the uptake of the VLU CPGs by GPs and PNs and to reduce the evidence‐practice gap in VLU management. These interventions have the potential to improve health outcomes of the VLU patients and reduce health care costs relating to VLU management.

2. METHODS

2.1. Study design

We conducted a qualitative research project. The selected methods were semi‐structured face‐to‐face and telephone interviews with health professionals, GPs, and PNs from primary health care settings located in Melbourne metropolitan and rural Victoria. The interview guide for this study (Appendix S1) has been developed using the Theoretical Domains Framework (TDF) questionnaire.36 It allowed us to obtain the behavioural domains and corresponding constructs. Additional potential interview questions/probes were adapted from the questionnaires,36, 37, 38 assessing the barriers and enablers to target behaviours, using the TDF (refer to Appendix S1 to see the questions).

2.2. Ethical issues

The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in the approval obtained from the Monash University Human Research Ethics Committee (reference number 2018‐9823‐20 337).

2.3. Recruitment strategies

We employed convenience and snowball sampling strategies to recruit the participants. GPs and PNs from the researchers' (CW, VT, LT) professional networks were contacted and a brief explanation of the aim and the methods of the project were provided. If they accepted the invitation to participate in the interview or to receive more information about the project, contact details of the study coordinators (VT, LT) were provided. Upon contact, the study coordinators provided additional information, answered their questions, and offered to email the participant the explanation statement. Face‐to‐face interviews were arranged with the potential participants at a convenient time and place. If telephone interviews were preferred, these were arranged at the participant's convenience. At the end of the interview, all participants were asked to nominate other GPs and PNs from their professional network who may have an interest in participating in this study. We were guided by the maximum variation sample technique.39 We recruited health professionals from different geographic proximities in Victoria to ensure that participants had variance in clinical practice duration and frequency of managing VLU patients. LT kept a database of all potential participants.

2.4. Data collection

Data collection took place from March 2018 until August 2018. Two researchers (VT and LT), both experienced in conducting semi‐structured interviews, conducted 15 face‐to‐face and 20 telephone interviews with 15 GPs and 20 PNs.20 Interviews lasted approximately 35 minutes. Face‐to‐face interviews took place either in the vacant room in the general practice or in the University office. All interviews were audio recorded. At the time of the interview, the participants were briefly reminded the main points from the participant information statement and asked if they have had any questions, which were then answered. After signing the informed consent or providing their verbal agreement over the phone (it was audio recorded with the participants' prior permission), the participants were invited to share their experience of the current practices of the VLU management and to discuss factors that influence evidence‐based practice (EBP). We conducted data analysis concurrently with data collection. We stopped recruitment once we reached data saturation and informed the remaining health professionals who wished to participate that we had stopped recruitment.

2.5. Data analysis

All audio records were transcribed, using professional transcription services. All transcripts were compared with the voice files by VT to ensure data quality. Transcripts were uploaded in NVivo 12 software for qualitative data management and coded by three researchers. To ensure interrater reliability, three non‐randomly selected transcripts were coded by researchers from clinical (VT and CR) and non‐clinical backgrounds and codes were compared.

We used a contemporary theory‐driven conceptual analysis, using the TDF,36 in an analysis of GPs' and PNs' uptake of an evidence‐based CPG to guide management of people with VLUs in Victoria. This theory helps to elucidate the theoretical basis for behavioural change in implementing new EBP through the identification of factors, influencing research translation and implementation.40 The TDF integrates 33 behaviour change theories and includes associated tools, which assist researchers to better understand the implementation challenges and to address these challenges through behavioural change interventions.40 The TDF consists of 14 domains, including Knowledge, Skills, Optimism, Emotion, Behavioural Regulation, Reinforcement, Beliefs about Capabilities, Beliefs about Consequences, and other. Each domain has a few specific constructs. For example, the Reinforcement domain has seven specific constructs, including Rewards, Incentives, Punishment, Consequents, Reinforcement, Contingencies, and Sanctions.40

Data were coded, using three‐level coding. Our first level nodes were the TDF domains, such as Skills, Knowledge, Optimism, and so on. Our second level nodes were the TDF constructs, such as skills development, competence, and ability (in the Skills domain). Our third level nodes comprised the field‐specific codes, such as skills in selecting the VLU dressings/compression and competence in performing and calculating the ABPI. These codes were assigned through reading the transcripts and labelling the segments of text. Furthermore, the codes with similar meaning were merged in the main themes, which were then allocated in the relevant theoretical domain and matched with a specific construct. For example, codes “the lack of time” and “not a priority” comprised the main theme “busy clinical practice.” This theme was allocated in the Environmental Context and Resources Domain, and further matched with the Organisational climate/culture construct. Furthermore, we identified all domains considered relevant to the behaviours under investigation. This was achieved by identifying domains containing a large proportion of the coded data that indicate that this domain is relevant to the clinical practice behaviours.

During the analytical process, the transcripts were checked frequently to verify the interpretations and the application of the codes. Regular face‐to‐face and Skype meetings were held with the principal investigator (CW), researchers (VT, CR, LT), other investigators and their collaborators to ensure consistent application of the codes, and the relevance of the identified codes and themes to the TDF domains. Member checking, also referred to as participant validation after data analysis,41 was not used in this study.

3. RESULTS

3.1. Study participants

We interviewed 15 GPs (43%) and 20 PNs (57%), including two Aboriginal health nurses (6%), who worked in primary health care settings located in Melbourne metropolitan 21 and rural Victoria 14. The average number of years participants had been in clinical practice was 19 years, ranging from less than a year to 50 years. The average number of years participants worked in their current clinical practice was 8 years, ranging from less than 1 year to 26 years. The number of VLU patients assessed per week varied between 0 and 20 with the average number of 8 patients per week. Twelve participants (34%) reported that they had attended a recent course on wound management and dressing selection, while 23 (66%) had not attended any recent courses on wound management and dressing selection.

3.2. Knowledge

Only 11 participants (31%) were aware of the VLU CPGs, and of these, only five (14%) used the CPGs to guide VLU management. Twenty‐four out of 35 participants (69%) reported they were not aware of the VLU CPGs. Nine out of 20 PNs (45%) and two out of 15 GPs (13%) were aware of the VLU CPGs (Table 1). Many participants who did not know about VLU CPGs relied on previous knowledge and training and, sometimes, on “a gut feeling” to manage people with VLUs instead of accessing the VLU CPGs. Knowledge of the VLU CPG recommendations on VLU management varied with participants who were aware of the VLU CPGs, demonstrating better knowledge of recommendations and increased confidence in managing people with VLUs.

Table 1.

Theoretical domains framework: knowledge domain

Participants mentioned	No of references	Main construct(s)	Main themes	Sample quotes
PN18 GP12 Total30	151	Knowledge	Awareness of Venous Leg Ulcer Clinical Practice Guidelines (VLU CPG)	Q: Are you aware of venous leg ulcer management guidelines? A: No, I wasn't until you mentioned the other day actually. [30 GP]   Q: Are you aware of venous leg ulcer management guidelines? A: No. I've only looked up on different websites what the best management is and all that sort of thing. I didn't know there are actual guidelines. [22 PN]
			Reliance on own knowledge and training	Look, a lot of times we also look and listen to specialists… I mean if we refer a patient onto a specialist, you follow what they do, and we look at and try and remember what they do, what the wound looks like and their reasoning behind it. And you learn from previous patients too. [24 GP]   “I think because we all know our patients pretty well we have an instinct… yeah it's more of a gut feeling.” [01 PN]   Q: So, you are really relying on your experience? A: Absolutely. And, because you have done it that many times, it is just an automatic… Q: So, you wouldn't feel the need to go looking for something more like that like a chart or something? A: Probably not. No, I probably wouldn't. [10 PN]
		Procedural knowledge, Knowledge of task environment	Knowledge of the + recommendations related to VLU diagnosis	I would be moderately confident in saying this is a venous leg ulcer. But perhaps if it's not healing at all, then I would start thinking twice and say could this be a malignancy, that needs a biopsy and especially if you've been doing all the right things, the dressing and stuff. Trying to reduce the edema and it's still not healing like after months… [33 GP] Q: How confident would you feel in making a venous leg ulcer diagnosis? A: Pretty confident. In most cases, is this venous or it is arterial, in some cases you get mixed up scenarios… This is what we will observe; and I am fairly confident. [29 GP]
			Knowledge of dressings and compression	We actually had a nurse come out. It is quite some time ago, probably about 3 years ago, who went through all of that compression bandaging things with us [10 PN]. Q: As you said you've done a workshop about venous leg ulcer going to the [Title] Wound Clinic. Was that just for a morning? A: I wouldn't call it a workshop, one of our patients here who was saying why don't you come down and let them show you how it's done. We called up the wound clinic and they were happy to actually accommodate us and show us and teach us how to actually get things done, different ways of treating a leg ulcer. So, that's how we actually learnt it. [06 PN]

Knowledge of compression therapy and application varied. A few participants reported attending a recent workshop; some participants attended workshops in past; one participant learned from fellow nurses who shared compression application knowledge and skills. Two participants reported that they usually use compression bandages that were available in their clinic, regardless of their knowledge. Two participants were concerned about the wound industry‐delivered seminars and workshops: “I would say that the content was utterly… biased by dual interests in the sense that a lot of the products that were recommended were of a particular brand” [05 GP]. One PN [12 PN] reported that taking into account skin allergies and dressing tolerance, dressing selection is always a matter of “trial and error.”

3.3. Skills

In this study, we focused on ABPI calculation, compression application, shared decision making, and referral to specialist if the VLU was not healing. Although a few people, particularly those who previously worked in a hospital ward and wound clinics, said that they were competent and confident in their skills related to ABPI calculation, a greater proportion of nurses and doctors said that they had limited skills in measuring ABPI. Compression application skills varied across PNs; most GPs said that they had limited skills and usually relied on PNs to apply compression (Table 2). One of the main messages to encourage patients to wear compression as recommended in the VLU CPG was underutilised. Both GPs and PNs reported they usually discussed basic wound care, leg elevation, pain management, and continuity of care. All participants said that they would usually refer patients to a specialist, if the wound does not heal. They were unaware of the VLU CPG 3‐month timeline recommendation to refer to wound specialist and relied on their own decision about referral times.

Table 2.

Theoretical domains framework: skills domain

Participants mentioned	No of references	Main construct(s)	Main themes	Sample quotes
PN17 GP14 Total31	304	Ability, competence, practice	Competence and skills related to wound dressings and compression	Q: [How confident do you feel in] applying graduated [compression] or compression? Are you happy with that?A: I usually go with the duty nurses. They have huge passion with probable venous ulcer. [29 GP] I would probably say I'm not as confident as I'd like to be about applying compression because I'm somebody who's very over‐cautious about over‐compressing. I can do bandaging, but if they're getting to the point where they need compression, I'll offer to refer them to the [hospital‐based] Wound Clinic where I can have a really proper assessment done. [08 PN] Q: But as a nurse do you feel confident measuring ABPI? A: Absolutely. [17 PN]
		Competence, interpersonal skills	Involving patients in decision making	Q: And do you know what recommendations you might give to a patient with a venous leg ulcer when they're leaving? A: We always tell them to elevate, to try and stay off it as much as they can and to make sure they come back to get the dressings changed. [15 PN]   Q: And what sort of things might you tell them?A: Usually keep the wound dry, basic wound care management you'd say. If there's any signs of infection, wetness, pain around the area come back to us. [06 PN]   Q: So, you don't usually suggest to use the compression? A: No, I rely on the ‐ well, they bring the wound consultants, the RDNS, so I rely on their expertise. [04 GP]
		Ability, competence	Referral skills	So, the difficult ones [patients] I would refer on to them [specialists], and they can do Doppler ultrasounds. [16 GP] You do [refer] I guess if you've got worries that their circulation is not good. [17 PN]

3.4. Social influences

Teamwork, collaboration, and shared decision making on VLU management were the main social influences identified by participants (Table 3). GPs generally reported they shared the VLU management decision making with PNs, specifically related to dressings selection and compression application. GPs usually contacted PNs who, they believed, were more aware of current dressings, more up to date with the latest approaches, and more experienced in wound management.

Table 3.

Theoretical domains framework: social influences domain

Participants mentioned	No of references	Main construct(s)	Main themes	Sample quotes
PN17 GP15 Total32	211	Social support	Teamwork	It's very much a team effort, which actually works quite well here, because there's only four of us, four nurses and we all have a different area of interest, so it works quite well. [01 PN] Yeah, I think recognising that we can't be an expert in every single thing, so that supporting team members to upskill. For example, the practice nurse taking a more leading role for wound management. [14 GP]
			Collaboration	So, it's easy to go to somebody else as well and go: “Have you seen this? Do you know? What would you do with this/in this instance?” That sort of stuff. So, it's a collaborative approach to the wound care here as well. [23 PN] I think I sometimes do rely on my colleague whoever it may be more experienced in wound management, and also the nurse that I told you about is very good, so we do take opinion from the nurse as well. [31 GP]
			Shared decision making with other clinicians	We had a very capable nurse practitioner; and she is updated with all the new guidelines. If we have any issue, we go to her. [32 GP] So, if there is anything that I'm not aware of I can just go up to any of the doctors and go what is this, how is this. And then they have their own resources and they will just look up their resources, print me out the paper and then go here have a read… They have their own guidelines. [06 PN]

Almost all participants reported that they relied on social support from their colleagues and sought their VLU management advice rather than referring to the VLU CPGs. Participants reported that other team members had better knowledge and skills, which were regularly updated, particularly if wound management was an area of their professional interest. However, this was not always the case. One GP reported she relied on PNs because “one has a long‐standing experience in wound care and the other had recently completed a workshop on VLU management.” However, when we interviewed PNs, the one with long‐standing experience said that she did not complete any courses on wound management in the immediate past, and the other said that she has completed dressing selection course and had limited knowledge of VLU management and compression application skills. A few GPs reported they lacked knowledge in VLU management.

Participants provided other reasons why they prefer to consult a team member rather than read or use the CPGs. These included time pressure, ease of access, perceived better awareness of CPGs, and collegial trust. Team functions included peer‐to‐peer education, performing quality assurance, reviewing patient cases, identifying health problems, and diagnosing and determining the management plan for the patient. One participant reported they “trusted a colleague more than they did the information included in the VLU CPG.”

3.5. Environmental context and resources

The nature of clinical environment, busy clinical practice, was one of the most frequently discussed issues that interfered with the health professionals' ability and motivation to search for and read CPGs (Table 4). Many participants reported they have a limited number of patients with VLUs and, therefore, they focused on the CPGs of the most frequent illnesses and health conditions managed in their practice.

Table 4.

Theoretical domains framework: environmental context and resources domain

Participants mentioned	No. of references	Main construct(s)	Main themes	Sample quotes
PN 18 GP 15 Total 33	165	Organisational climate/culture, environmental stressors	Busy clinical practice	It's constant, pretty busy. Particularly in the mornings when we see most of our dressing patients, it's one to the other to the other to the other. And I suppose with a concern like, if you don't feel that you are not progressing or a wound isn't healing as quickly as you'd like it to, there isn't the need to go and seek extra information. [01 PN] Yes, don't have time to be running around looking for guidelines and reading guidelines. To be really honest just over the years you build up enough experience and you read enough of the GP journals that it's in your head. [16 GP]
			Lack of patients with VLUs	Q: What is the main reason that you do not refer to guidelines, particularly about venous leg ulcer management? I know, people have different reasons, but referring to your practice. A: I think it is just lack of patients. I mean, we have only seen one or two with venous ulcers which have been quite small and easily manageable. [02 GP]   Q: May I ask you a question about other guidelines? If you use any guidelines in your practice related to other diseases? A: Yeah, probably COPD, asthma, hypertension, diabetes. They're the big ones. I guess it's probably because we don't see as many venous ulcers and we don't get as much education about. [24 GP]
		Resources/material resources	The guidelines are not easily accessible	This is our library… and, basically, we have boxes here there and everywhere with information. When people leave us lots of information we try and find somewhere to store it, but we have no storage. We're about to have renovations, which is going to create some storage for the nurses, but essentially there is no storage; we're really encouraged not to keep a lot of paperwork because there is nowhere to put it. [01 PN] I don't really have any guidelines, that's probably the simple answer. I don't have, as far as I know I don't have any access to any guidelines. [16 GP]
			Lack of resources in our clinic	Q: So, you do not have the equipment there to do [ABPI]? A: No, we don't; and the equipment would be about half an hour way. [27 PN] Q: Do you have a Doppler to exclude arterial involvement? You said that you're not so confident if it is a venous leg ulcer? A: Yeah, unfortunately we don't. Not here, yeah. We haven't got one. [17 PN] We have a small selection of basic venous ulcer dressings which I tend to use. [16 GP]

Lack of access to print and electronic versions of the VLU CPG was a common theme. Many participants, particularly PNs, reported they do not keep print versions of the VLU CPGs due to the lack of physical space and difficulty with managing multiple print resources that they collected after attending professional development workshops and courses. Some GPs reported subscription is required to access CPGs, and some clinics might not be able to access with relative ease. Due to lack of awareness of VLU CPG and perceived access fees, some GPs and PNs reported they would usually “google” the information they need to manage people with VLUs.

Some participants reported that they were unable to follow individual recommendations in the VLU CPGs due to the lack of resources in their primary care. For example, in the absence of handheld Doppler ultrasound, they were unable to measure the ABPI. Some of health professionals reported they usually refer VLU patients to other services for ABPI measurement, while others reported they proceed with dressings and refer for ABPI measurement if the wound does not heal. Two PNs from rural care reported that they lack plain language VLU educational resources that would suit the needs of patients with Aboriginal background. They reported that the absence of plain language educational resources made it difficult to explain to patients why particular tests are needed and what they need to do to facilitate VLU healing.

3.6. Beliefs about capabilities

Recently graduated health professionals, who were in clinical practice for less than 5 years, reported they frequently referred to the CPGs because they were educated in a culture of EBP and acknowledged their lack of experience (Table 5). Most health professionals relied on their successful past experience in VLU management with some reporting the approaches that worked in past. One PN reported that CPGs are simply recommendations/guidelines and not the rules, and that the main aim is to heal the ulcer rather than to follow the guideline.

Table 5.

Theoretical domains framework: beliefs about capabilities domain

Participants mentioned	No of references	Main construct(s)	Main themes	Sample quotes
PN 18 GP 15 Total 33	165	Perceived competence, self‐efficacy, and professional confidence	Professional confidence and experience	I think that younger professionals such as myself, there would probably be a greater uptake in guidelines due to lack of experience, perhaps confidence, or wanting to double‐check, as well as being, perhaps, brought up in a culture or educated in a culture of best practice and referring to evidence‐based treatment. [02 GP] In this practice, what my experience is, our treatment of venous ulcers is very successful. We've only had probably one or two, possibly there might be one I don't know of that have been referred elsewhere. So, whatever we're doing, and the expertise we've drawing on what is working. [01 PN] To be really honest just over the years you build up enough experience and you read enough of the GP journals that it's in your head. [16 GP] We treat them as guidelines, not rules. Some products that we've tried, I haven't seen it anywhere else, but it works. That's the aim of the game, is to heal the ulcer. [12 PN]

3.7. Social/professional role and identity

GPs, particularly in rural areas, viewed their role in VLU management as very important because GPs were the first point of contact for patients (Table 6). However, many GPs and PNs believed that general practice is “just general” and “broad” and deals with many health conditions; and health professionals do not need to know the specific details of VLU management. They reported that it would be overwhelming for them to read the CPGs for all health conditions as every GP and PN has a particular area interest and an expertise. Although some of them may have an interest in wound care, others have interests in other medical conditions.

Table 6.

Theoretical domains framework: social/professional role and identity domain

Participants mentioned	No of references	Main construct(s)	Main themes	Sample quotes
PN18 GP12 Total30	134	Professional role, identity, and group identity	Practice is “general” and we cannot be expected to know everything	General practice as you know is really broad and so we know a little bit about lots of things and then we know a lot about our particular area of interest. And they draw on me for my area of interest around women's health, and I draw on their expertise for wound care. [01 PN] Just looking at it is overwhelming to have that many pages for one medical condition and in general practice we deal with hundreds, so I wouldn't be able to read that [the guideline] for every condition we have. [11 PN] I think my role is very important in terms of managing venous ulcers. Often, GPs are the first port of call for patients. [02 GP]

3.8. Intentions

The participants who reported they were not aware of the VLU CPGs reported the lack of their awareness influenced their intention to use VLU CPG (Table 7). In addition to the factors discussed in other domains, such as a belief that general practice is “general” and “broad” and health professionals did not need to read all available CPGs, some health professionals had a feeling that their patients would not follow the recommendations included in CPGs. Two PNs said that some patients just do not want to talk about the VLUs, some could be careless and do not follow the instructions, and older patients may be forgetful due to cognitive decline. One of the GPs reported that the concept of “EBP” does not make any sense to most of his patients and, thus, he had no intention of discussing the CPG evidence recommendations with his VLU patients.

Table 7.

Theoretical domains framework: intentions domain

Participants mentioned	No of references	Main construct(s)	Main themes	Sample quotes
PN18 GP11 Total29	103	Stability of intentions	I have never thought to use the guidelines	To be honest, I've never thought that there should be [VLU] guidelines, yeah. And we should—it's just because we don't deal with any [VLU patients]so it's just something that we've not [been aware of]. I personally haven't thought of. [07 PN]
			Patients would not follow the guidelines	Some of the patients we know very well, and the last thing they want to talk about is their ulcer. And others are very interested and very keen to know what next, what's the long‐term likelihood of this dressing, how long am I going to be coming, how often am I going to come. Patients mostly are concerned about how long it's going to take to heal. [01 PN] Q: Are there reasons why you think they [patients] do not follow the recommendations that you could just briefly list today? A: I think sometimes they forget. Sometimes they (the patients) may have a degree of dementia, so they become a bit careless. I think it could well be a nuisance. [12 PN]

3.9. Memory, attention, and decision process

The participants could not remember the CPG‐based recommendations for all the different health conditions they manage in primary care (Table 8). They reported there are too many guidelines; the guidelines are wordy and difficult to understand and apply in practice. In busy clinical practice, the participants reported that they would not usually read or use CPGs, except perhaps CPGs in the field of their clinical interest and most common illnesses. One of the PNs [08 PN] reported CPGs were written in “academic‐speak,” and the levels of evidence are difficult to comprehend. She identified the need to have brief, straightforward guidelines that are easy to comprehend and apply in practice.

Table 8.

Theoretical domains framework: memory, attention and decision process domain

Participants mentioned	No of references	Main construct(s)	Main themes	Sample quotes
PN14 GP9 Total23	35	Memory, attention, attention control	There are too many guidelines Some guidelines are too long and difficult to remember	A lot of the guidelines are very pointed, you know, like they say Evidence‐base C and blah, blah so they can be a bit wordy at times rather than just let's get to the point and tell you what's important. I found that a bit annoying about reading them when I read them the first time. It was just the way they were written in academic‐speak [inquiry] whereas if you want to get to practice nurses you have to talk about it in a quick, easy manner that's easy to assimilate, if you like, and to practice. Something that's practical. [08 PN]
				A: Well, to me, just looking at it [the guideline] is overwhelming, to have that many pages for one medical condition; and in general practice we deal with hundreds, so I wouldn't be able to read that for every condition we have. Yeah, it's not like, if that was my only area, then yes, I would go through it and with a fine‐toothed comb, but because we have so many different conditions, there's just no time; and I don't like reading, truth be told. [13 GP] There is just a limit to what our brain can hold with everything. [04 GP]

4. DISCUSSION

In this study, we applied the TDF to understand the uptake and use of VLU CPGs among GPs and PNs from primary health care. Our findings indicate that the lack of participants' awareness of VLU CPGs resulted in limited adherence to the evidence‐based recommendations, which is consistent with findings from previous studies.3, 42, 43, 44 Our research highlights important clinicians' perspectives on the use of VLU CPGs that will inform and guide future studies in chronic wound care to optimise the uptake of CPGs in the future. The lack of awareness of the CPGs and the lack of the familiarity with their recommendations are not unique to the field of wound management. These are the most common individual‐level barriers to guideline implementation.45 Recent Australian studies have indicated that some GPs were lacking familiarity and knowledge of various other CPGs, including obesity,46 osteoarthritis,47 type 2 diabetes,48 and antibiotics prescribed.49 Given the huge financial burden that VLU places on the health system,20, 50 primary care clinicians should be more aware of the existing VLU CPG.

Although the development of effective dissemination tools and strategies is one of the first important steps in guideline implementation,51 there are various other individual‐level barriers related to health professionals' attitude to a particular CPG need to be identified and addressed, including the lack of agreement, the lack of motivation, the lack of self‐efficacy, and the lack of skills.45 The domain most frequently referred by clinicians in our study was Skills (referred 304 times by all participants). Specific skills that were described by participants included competence in performing ABPI, wound dressings, and compression; providing health information to patients; and referring them to external providers. Though not as frequently referred, Knowledge domain (referred 151 times) was closely related to Skills, particularly in discussions surrounding the participants' knowledge of evidence‐based CPG recommendations related to managing VLUs. The overlap between the Knowledge and Skills domains was also observed by other researchers.52 Participants in our study discussed their knowledge (or the lack) of the VLU CPG recommendations related to VLU management, and described that they are more likely to rely on their previous acquired experiential knowledge. They experienced marginal shortfalls in their knowledge in certain areas of VLU management. Although they were able to provide the basic CPG recommendations in relation to VLU management, they were unable to recall specific recommendations or lacked confidence to complete certain aspects of VLU management. For example, even though many participants understood the importance of compression application in VLU management as outlined in the VLU CPG,25 they were not confident to apply compression hosiery/bandages, and they acknowledged they had limited ABPI measurement skills that may impact on timely wound healing. Thematic parallels can be drawn with the studies that identified the main factors related to the CPG implementation in Knowledge and Skills as relevant domains. For example, in United Kingdom, aged care nurses52 and community wound care providers53 had limited knowledge and skills in wound management.

Other frequently discussed topics were in Social Influences (referred 211 times) and Social/professional Role and Identity (referred 134 times) domains. Acknowledging their professional role in primary care, the participants reported that they see patients with hundreds of various health problems across a complex interplay of medical, social, and psychological issues and believed that they do not need to read the CPGs for all conditions unless it is one of the commonly presented health problems, such asthma, diabetes and hypertension, or a health issue of their professional interest. Although VLUs are the most common chronic wound managed in primary care in Australia,4 they are not as common as the other chronic illnesses that are seen in primary care;54 and participants felt that this made them less compelled to access the VLU CPGs. This finding was congruent with the study conducted in South Africa, which found that CPG implementation should be more inclusive of participants that accurately represent primary care facilities.55 This finding demonstrates a link between the subjective beliefs of clinicians about the frequency and severity of certain illnesses, and the subsequent need to access the CPGs and enrol in training courses.55 Previous studies have found that practitioners are less likely to implement EBP when they do not have ample exposure to certain patient groups in their care56 or do not believe the illness is very serious.57

A common belief, also confirmed in our study, is that CPGs are seen as being too long for casual access in primary care.47 Our participants reported the VLU CPG was too long, and this hindered uptake. The participants expressed a need for a short and easy CPG for clinical practice. Many participants were unaware that the abridged version of the VLU CPG and the flowchart for assessment of VLUs were available online and free of charge.

Although GPs and PNs collaboration and shared decision making in team environments are imperative,58 in our study, these approaches interfered with the use of the VLU CPG. Most health professionals reported they rely on teamwork, collaboration, and shared decision making instead of using VLU CPGs. In particular, GPs described that though they are responsible for diagnosing the VLU, they are appreciative when PNs take a more active role in VLU management. GPs reported that they relied on PNs' knowledge in skills in dressing selection and compression application. PNs also relied on GPs to aid their decision making in VLU care and reassure that they are on the right track. Effective communication among primary care practitioners can improve decision making59 and lead to better patient outcomes60 when it is underpinned by the CPG recommendations. Teamwork and social influences themes and constructs have been pertinent across other studies that have used the TDF,61, 62, 63 including in wound research.52, 53

Environmental factors were frequently discussed (referred 165 times). Participants revealed that they did not always have access to equipment required to perform EBP recommendations consistent with the VLU CPGs; for example, conducting the ABPI measures in the absence of the handheld Doppler ultrasound. In practices where they see very few VLU patients, participants explained that practice owners are often reluctant to purchase this equipment or provide funding for staff to access VLU‐related training. Many participants said that busy clinical environment, infrequent visits of the VLU patients, the lack of printed, easily accessible CPGs, in addition to insufficient clinicians' knowledge on where to locate the CPGs, and their perceived subscription fees to access the VLU CPG have influenced their usage. A wider dissemination of guidelines, including The Royal Australian College of General Practitioners (RACGP), Royal District Nursing Service (RDNS), Department of Health—Primary Health Networks (PHN), and General Practice Network were suggested. It would be beneficial to include the VLU CPG in the NHMRC Australian Clinical Practice Guidelines (https://www.clinicalguidelines.gov.au/) and the Medical Journal of Australia (MJA) Guidelines (https://www.mja.com.au/journal/guidelines) portals.

An additional factor identified in our study is patient‐professional communication, which was considered under the domain Intentions. Most PNs and GPs wanted to ensure their practice, including the CPG, was patient‐centred, which has been highlighted across the literature that GPs and PNs feel a great responsibility to respect the unique circumstances of their patients64 and maintain an effective patient‐clinician relationship.55, 65 In our study, some health professionals reported that VLU is not a priority when compared with the patient's other chronic illnesses, such as diabetes and hypertension. Other believed that their patients either do not understand the concept of “evidence‐based care” or did not want to discuss wound management except clarifying the date for their next appointment and, therefore, they did not discuss with them the importance of compression as the evidence‐based approach in VLU management.

Overwhelmingly, there were many factors that influenced the uptake of the VLU CPGs in primary care. In general, CPGs should be developed in consultation with primary care facilities in order to facilitate their translation into clinical practice.55 However, evidence‐based research is often conducted outside of primary health, leading to poor translation across clinical environments.55, 66 Although increasing health professionals' awareness of the VLU CPG is the first step in guideline implementation,35 to change clinicians' attitudes and organisational practice, it is not sufficient to only provide information about the required change. The behaviours and underlying factors influencing behaviour are also need to be modified. Behavioural modification could be achieved through the addressing of underlying social and environmental factors and health professionals' attitudes towards the use of CPGs.40 These beliefs and attitudes include beliefs that in primary care, which is also called “general practice,” GPs and PNs need to have only basic “general” knowledge and skills, also that patients do not understand the concept of “EBP” and, thus, do not require explanation of the latest evidence. These beliefs in addition to a misconception that VLU CPGs require subscription fees influence health professionals' intention to use the CPG.

Furthermore, health professionals will need access to and be upskilled in the use of handheld Doppler ultrasound to measure ABPI prior to compression application. In the absence of handheld Doppler ultrasounds in smaller primary care settings, a policy to refer to other settings for ABPI measurement is needed. New implementation models have been developed to improve the use of compression therapy as the gold standard for VLU management, which can be implemented among other interventions; for example, the ABC model of VLU management,67 where A stands for assessment and diagnosis, B—for best practice in wound and skin management, and C—for compression therapy for active treatment and for prevention of recurrence. Finally, given that findings of our study suggest that PNs are taking a leading initiative in the selection of dressings and compression application, the model of the VLU care may need to be revised; and PNs' skills updated to take on leadership roles in primary care for people with VLUs. Findings from a systematic review68 on implementation of doctor‐nurse substitution strategies in primary care reports acceptance of some doctors' leadership roles by nurses and nurse‐led care are possible, subject to nurses having access to resources, equipment and supplies, adequate training and supervision, and clearly defined roles. A detailed list of proposed interventions to tackle the barriers to the VLU CPG recommendations was developed and published in our other work originated from this project's findings.69

4.1. Limitations and suggestions for further research

We acknowledge that there may be limitations to applying these findings to other clinical settings where VLUs are managed as the data were collected in selected primary care settings across Victoria. Although we have applied maximum variation sampling,39 study participants may not represent the population of health professionals in Victoria. We would encourage a state‐wide and a nation‐wide survey of health professionals to be conducted to elicit GP and PN awareness and use of VLU CPG. Findings of our study, however, can be used to guide further research, such as TDF‐informed survey questionnaires, controlled evaluation studies, and audits where implementation of the guidelines can be formally assessed in other wound management clinical settings.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.

AUTHOR CONTRIBUTIONS

All persons designated as authors in this manuscript qualify for authorship. Each author has contributed sufficiently to take public responsibility for the content. C.W. developed the study proposal and secured the grant. V.T. and L.T. conducted the interviews. V.T. and C.R. coded the interview transcripts. All authors contributed to data analysis and article writing. The final version was approved by all authors.

Supporting information

Appendix S1 Supporting information

Weller CD, Richards C, Turnour L, Team V. Understanding factors influencing venous leg ulcer guideline implementation in Australian primary care. Int Wound J. 2020;17:804–818. 10.1111/iwj.13334