Wound management: Investigating the interprofessional decision‐making process

Abstract

Our aim is to develop a robust socio‐geographical transferable theory outlining the basic social process used by members of an interprofessional health care team when making decisions around wound care management. Using a qualitative multigrounded theory approach, three focus groups were held at the Royal Victoria Regional Health Centre in Barrie, Ontario, Canada, comprised of 13 clinicians who participate in wound care decision‐making. Data were analysed using an approach developed for multigrounded theory. A Critical Realist theoretical lens was applied to data analysis in the development of conclusions. Ten categories were identified before thematic saturation. Category interactions developed a perceived basic social process outlining how interprofessional clinicians determine how they approach wound care decisions: patient factors, scope of practice, equipment and supplies, internal clinician factors, knowledge and education, interprofessional team, assessment, wound care specialist consultation, and care plan, as well as documentation and communication. Understanding how wound care decision‐making is determined by interprofessional health care providers will assist clinical leaders and policy makers in creating a foundation for determining resource allocation, allowing clinicians to use evidence‐based practice to improve patient and clinician satisfaction, wound healing time, decrease costs, and prevent wound recurrence.

1. INTRODUCTION

The World Health Organisation has recognised wound management as a worldwide public health issue that is best managed by an interprofessional team.1 An interprofessional approach to the management of wounds has been shown to increase healing and decrease recurrence.1 A key concept in the wound bed preparation paradigm is meaningful input from both the interprofessional team and the patient.2 While this shared decision‐making model has been stressed as the preferred approach in health care, there remain many barriers to its use.3 With the potential benefits of patient adherence, knowledge, satisfaction, empowerment, and confidence, it is important to understand how decisions are made by the interprofessional team.3

Previous research conducted on wound care decision‐making has shown a lack of literature on this topic, noting that understanding this process could assist in the development of interventions to support the interprofessional team.4 The findings from a Grounded Theory study conducted by Gillespie et al provide a foundation for the development of a social process focused on wound care decision‐making by health care professionals.4 Unfortunately, traditional Grounded Theory does not allow for incorporation of established theories, reducing the potential further grounding of data.5 A more recent methodology, multigrounded theory (MGT), allows for both the development of a grounded theory based on a socio‐geographical perspective and also incorporates pre‐existing theories, reducing the risk of knowledge isolation.5 The use of MGT to build upon the Grounded Theory foundation developed by Gillespie et al, will provide a social process transferable to a broader range of locations and situations.4 The purpose of this study is to determine the basic social process used by members of the interprofessional health care team in an acute care environment when making decisions around wound management.

2. METHODS

A MGT design developed by Goldkuhl and Cronholm was selected to explore the decision‐making process of interprofessional team members who participate in wound management.5 A theoretical lens of Critical Realism was used during the study process, as previously described.6

2.1. Setting and sample

Purposive sampling techniques were used to collect data over three semistructured focus groups involving interprofessional health care providers who manage wounds at the Royal Victoria Regional Health Centre, a 319‐bed acute care hospital facility located in Barrie, Ontario, Canada. Only interested, consenting members of the interprofessional team that participate in wound care management were included in this study. Basic demographic information was collected from focus group participants, which can be seen in Table 1.

Table 1.

Participant demographics

Focus group	Number of participants	Mean focus group age	Focus group years of experience	Focus group years of wound care experience	Focus group levels of stated education	Focus group stated levels of wound care education
Focus group 1	Two occupational therapists; two physiotherapists; one registered nurse; one registered practical nurse	47	Two had 5 to 10 years of experience; one had 10 to 15 years of experience; one had 15 to 20 years of experience; one had 10 to 25 years of experience; one had 30 to 40 years of experience	Two had 3 to 5 years of experience; one had 5 to 10 years of experience; two had 10 to 15 years of experience; one had 10 to 25 years of experience	Two completed a diploma; two completed bachelor's degrees; and two completed masters degrees	Four completed a wound related course and one noted that in‐services have been attended
Focus group 2	Two dieticians; one occupational therapist; one physician assistant	41	One had 3 to 5 years experience; one had 5 to 10 years experience; one had 10 to 15 years of experience; one had 10 to 25 years of experience	Three had 3 to 5 years of experience; one had 10 to 15 years of experience	Three completed bachelor's degrees with one noting a postgraduate internship and one completed a masters degree	Two completed a wound care course
Focus group 3	One registered nurse; two registered practice nurses	42	Two had 5 to 10 years of experience; one had 10 to 15 years of experience	One had 2 to 3 years of experience; one had 5 to 10 years of experience; one had 10 to 15 years of experience	Two completed a diploma, and one completed a bachelor's degree	One attended a wound care certificate course

2.2. Data collection

Focus groups using a semistructured format were used in data collection. All focus group sessions were audio‐taped and transcribed. Focus groups were held over a 2‐week period in November 2016. Memos were incorporated during the data analysis phase. The second author conducted the interviews to minimise bias given the primary author's role in leading wound and ostomy care within the organisation. A modified interview guide developed by Gillespie et al was used in an attempt to remain congruent while incorporating different socio‐geographical perspectives.4 Initial questions were used from this interview guide to drive discussion and concept‐related questions were used if appropriate; however, clarifying questions were also used outside of the interview guide. Focus groups were held and data collection continued until it was believed by the interviewer that data saturation was achieved, as indicated by the presence of reoccurring thematic discussions.

2.3. Data analysis and theory generation

Data analysis and theory generation were completed using a previously described framework.5 The MGT approach is comprised of three tasks including theory generation, explicit grounding, and research interest reflection and revision.6 Theory generation is composed of inductive coding, conceptual refinement, pattern coding, and theory condensation.5 Use of inductive coding had the primary and secondary authors each independently review the transcribed focus group data and develop codes that included a property (theme of the text), as well as a value, (why the property is relevant to the participant). The primary and secondary authors then collaborated and agreed upon a singular set of codes based on both coders' properties and values. Categories were then developed and codes sorted into the categories. Conceptual Refinement was then carried out by reviewing generated concepts and determining their content, ontological position, context, function, origin, and its use of language. Each category was labelled with an ontological category. Ontological categories were chosen from a framework developed by Goldkuhl, as cited in Conholm.7 Pattern Coding was then completed using the action‐oriented paradigm model, which explains actions through conditions, actions, and consequences.7 A goal diagram was completed (Figure 1) with the conditions at the base of the diagram, actions in the centre, and consequences at the top. Theory condensation then occurred until ten categories remained that outline our process. An example of coding can be seen in Table 2.

Figure 1.

Elements of wound management

Table 2.

Example of data analysis

Transcripted text and external theories	Codes properties (values), (empirical data/external theory), (interview number)	Category (ontological category)
I find it scary sometimes when a patient comes with no wounds, but fell. And then they don't move and they start to develop, like they start with a stage one, right, and, you, you think, “oh my goodness.” and you're trying to reposition them every 2 hours or hour and a half or however long their plan is, and the patient is not compliant… so it's a little bit kind of scary think,” oh my goodness what if something happened now they blame me for, for this.”	Fear (of blame), (ED), (interview #3)	Internal clinical factors (Intrasubjective part)
Sometimes it's a resource aw, issue, or an equipment issue, so some information I might need is: Do we have any boots right now? Do we have an airbed? Might change the way that we treat that particular wound on that particular day. Um, it might not change the recommendation, but it might change the treatment that day.	Supplies (accessibility), (ED), (interview #2)	Equipment and supplies (artefacts)
“While diagnosis of wound aetiology and assessment were important, a systematic approach to assess the patient was also needed. ‘Understanding the goals of treatment’ encompassed using preventative strategies, managing complications and providing rationales” (Gillespie et al4 (p1244))	Assessment (understanding patient goals), (ET), (Gillespie et al4)	Assessment (intervention as action)

Explicit empirical validation was completed through the review and revision of data and codes to ensure that each property and value matched the appropriate category developed. Theoretical matching had the authors use the grounded theory study by Gillespie et al and divide the study findings into properties and values that were then sorted into the categories of our evolving theory to determine if further categorical change was needed.4 Finally, theoretical cohesion allowed the authors to review both theories to provide input on necessary modifications, criticisms, and observations to the evolving theory and develop a final process presented as a graphic illustration (Figure 2).

Figure 2.

Process of wound care decision‐making

2.4. Validation

Two validation strategies were used5, 8: (a) data triangulation, to ground the findings from both an Australian and Canadian context add to the study's validity; and (b) investigator triangulation, with both researchers coding the data separately prior to recoding the data together until agreed upon coding of the data was completed.

Reliability was addressed through the use of audio recording of focus groups, and direct transcripts of the focus group sessions. This study also addressed reliability through the use of intercoder agreement. Both the primary and secondary authors coded the research data separately and then reviewed codes and agreed upon a set of properties and values as well as concepts for each section of the transcribed text.

2.5. Ethical considerations

This study was approved by the Royal Victoria Regional Health Centre's Research Ethics Board.

3. RESULTS

Focus groups were conducted with a total of 13 interprofessional participants over three sessions and included Registered Nurses, Registered Practical Nurses, Occupational Therapists, Physiotherapists, Dieticians, and a Physician Assistant (Table 1). All participants were female aged 33 to 60 years old. Participants had 3 to 40 years of varying clinical experience, with 2 to 25 years of wound care management experience. Participants noted their care for patients with a variety of wounds including surgical, pressure‐related, chronic, skin tears, venous and arterial wounds, diabetic wounds, traumatic wounds, and disease‐related wounds. Demographic and education background is provided in Table 1.

In the tradition of MGT, a core category was not developed; rather, 10 distinct categories emerged. Each of the 10 categories, or elements of wound management, is able to be linked to one another while maintaining a distinct meaning of their own. Linkages between the categories discovered during the data collection are outlined in Figure 1. When comparing the previous grounded theory study on this topic with the results of the grounded theory developed during this study, similar elements emerged, with the addition of new elements, including: documentation/communication, scope of practice, and internal clinician factors.

During analysis, it was shown that positive and negative indications existed for each category. The authors believed wound care decision‐making was not simply a linear process, but rather a competing process that arose as a result of a multitude of obstacles and ideal situations (Figure 2). On either side of the Venn diagram, there are ten categories, one side from a negative context (“obstacles”), and the other from a positive context (“ideal situations”). In each instance of decision‐making, there were overlapping obstacles and ideal situations that were taken into account leading to a decision.

3.1. Patient factors (ontological category: Humans)

Participants believed that there were multiple patient‐derived factors that significantly affected the wound‐management plan. Patient history and their ability or their family's ability to inform the clinician of a wound history was believed to be very important. Knowing what had previously worked or what had been unsuccessful provided important insights into how decisions were made at the time of care. Participants noted that patients lead the goal of care, such as whether the focus was pain management, wound closure, or emotional health.

Participants discussed how patient refusal or lack of adherence to the plan of care greatly affected decisions around wound management. Nutrition was provided as an example where if a patient was not eating enough food but was refusing a feeding tube then it was believed that the wound may not heal. Participants discussed some of the challenges such as a patient requires off‐loading of a limb; including, patient continuing to walk on areas of pressure, not disclosing a wound to staff, and attempting to manage it themselves.

Some of the wounds, not very often, but some of the wounds can be like complicated to say and the patient is already like “don't touch me”, “don't do this”, and things like that so that makes it difficult too. (Registered Practical Nurse, Focus Group 3)

3.2. Scope of practice (ontological category: Artefacts)

Participants articulated a desire to work to full scope, but also understood the challenge of specialised mentorship availability. Working to full scope was believed to encourage full participation in many factors related to wound healing. For example, it was believed that all team members should play a role in encouraging proper nutrition, not only the dietician.

…the role of [the dietician] really shouldn't just be limited to us telling the patient you need to eat, like everyone can play a role in that, the wound care team. (Dietitian, Focus Group 2)

3.3. Equipment and supplies (ontological category: Artefacts)

Participants spoke to the importance of having easy accessibility to the supplies required to heal wounds, which meets the specific needs of each patient. Other participants noted issues obtaining the supplies they needed, impacting their ability to provide the care they wished to deliver.

…[determine if] there is any additional information that I could obtain subjectively from the person that we're assessing it for and then stratify it and then from there I'd decide what are our options in terms of treatment available in our particular facility… (Physician's Assistant, Focus Group 2)

While having multiple options for wound management is beneficial, this can lead to confusion determining the most appropriate dressing to use. The many names for products were found to be confusing, making choices around dressings difficult. Participants found that improper use of wound dressings leads to an increase in skin complications when trying to manage a wound. Furthermore, difficulty in understanding dressing types leads to a lack of adherence to the ordered treatment plan. Gillespie et al also noted how clinicians have a difficult time staying current in their knowledge regarding new wound dressings and management techniques.4

It was believed in some instances that certain dressings or methods would be more effective; however, other methods were tried first due to cost. Participants also noted that they considered staffing time and dressing cost when managing wounds. Gillespie et al also identified cost was considered an important factor when balancing costs with outcomes, ensuring that public funds were being used appropriately.4

Well if I would like to do this treatment, well it's quite expensive, is there something we can use before we get to that. Kind of a stepwise approach but always with cost in mind. (Physician's Assistant, Focus Group 2)

3.4. Internal clinician factors (ontological category: Intrasubjective part)

Participants expressed a lack of comfort and feelings of uncertainty, along with fear of blame during the wound care decision‐making process. Participants were concerned if the wound developed during a hospital stay, that they would be blamed for the occurrence. This leads to feelings of needing to protect oneself, placing more focus on documentation, and increased feelings of apprehension when a patient does not follow their treatment plan.

I find it scary sometimes when a patient comes with no wounds, but fell and then they don't move and they start to develop… a stage one… and you think ‘Oh my goodness.’ You have tried to reposition them every 2 hours… or however long their plan is, and the patient is not compliant… and you think they're going to develop a wound, it's under my watch, now I'm going to be at fault. (Registered Practical Nurse, Focus Group 3)

Participants also expressed that they believed there are no guarantees a treatment plan, even if appropriate, would be effective; however, noted that they experience feelings of hope when initiating a plan of care. When participants were asked how they would know a treatment plan would be effective it was stated:

You don't know! You hope! (Registered Practical Nurse, Focus Group 3)

3.5. Knowledge and education (ontological category: Human inner worlds)

Clinician knowledge and education on wound‐management principles had participants relying on a multitude of sources including prior experience, published guidelines, and peers and colleagues, as well as industry. Participants discussed how they would reach out to their colleagues or experts in the field to validate or guide them in their decision‐making process.

Participants noted that they would obtain wound care‐related education through both external and internal means. This included reaching out to organisational experts and reviewing organisation wound care resources such as easy to follow guides, specific wound courses, external experts, and industry representatives. As Gillespie et al found, however, education provided by industry representatives can be biased and this must be taken into account when making decisions.4

Participants believed due to the availability of a wound care specialist for consultation, there was a lack of accountability in gaining knowledge and education to later manage future similar wounds. Participants noted in some instances if they believe they have inadequate education to manage a wound they put off management and do not always apply the most appropriate dressing. Gillespie et al found that their study participants would base their wound‐dressing choices more on a product, their experiences with the product, and brand recognition rather than an understanding of the wound.4

When we only have one or two specialists within the building there's a take advantage kind of approach that we can refer and leave that up to that person so I don't think there's that transition in the education that's going on and filtered down to the proper people that need to be doing it… (Occupational Therapist, Focus Group 1)

3.6. Interprofessional team (ontological category: Reflection as action; natural environment)

Participants commented on the importance of interprofessional perspectives when assessing and treating a wound, how a lack of an interprofessional team approach is detrimental to patient outcomes, and assistance from team members is vital to patient outcomes and safety.

I think ultimately it's super important to have a team approach instead of one individual saying, okay this is what I think and not discussing it with other care members, because then someone else can end up probably doing something different or not following the treatment plan. (Dietitian, Focus Group 2)

Restrictions in occupational health and safety related to patient care and safe lifting for health care providers also highlight the need for interprofessional collaboration. For example, when repositioning a patient that is critically ill, more than one staff member is often required to maintain patient and staff safety.

…a lot of [patients] need two people to reposition, we are restricted for safety reasons how much we are supposed to pull, lift, carry as healthcare providers… I find it harder for the nurses to find that second person at times and I just worry about their safety when trying to reposition every 2 hours… (Occupational Therapist, Focus Group 1)

The results of Gillespie et al reiterate the importance of the interprofessional team.2 Their findings resulted in a similar category—“Utilizing a multidisciplinary and holistic approach” and noted that “collaborating with others' exemplified knowledge‐based decisions found on scientific rationales”.4

3.7. Assessment (ontological category: Intervention as action)

Across all focus groups, assessment was found to be a component of wound care that was vital in making decisions regarding patient care. Participants responded with the importance of a comprehensive wound assessment and how a lack of a complete assessment can affect patient outcomes and the overall decision‐making process.

Complete assessment prior to even looking at the wound, getting all the information historically, whether it is chronic, acute, where they're coming from… nutritional level, how much they're moving, how much they're involved in the community from a functional mobility point of view… I like to do a complete pre‐wound assessment. (Occupational Therapist, Focus Group 1)

Determining the cause of the wound through assessment was also found to be crucial in making decisions about a patient's wound. Gillespie et al also emphasise “being consistent” in assessment and documentation, with decision‐making accentuated by patient assessment and standardisation of practices.4 Gillespie et al continue to say that while diagnosis of the wound aetiology and assessment were important, a systemised and standardised approach to assess the patient was also required when making wound‐related decisions.4

3.8. Wound care specialist consultation (ontological category: Reflection as action)

Participants frequently discussed the benefits of a wound care specialist on the wound‐management team to assist in the decision‐making process. The wound specialist was discussed as a beneficial resource for whenever wound complications arise or staff are uncertain how to proceed with care.

Is there any microscopy associated with [the wound], is there any additional information that I could obtain subjectively from the person that we're assessing it for and then stratify it and then from there I'd decide what are our options in terms of treatment available in our facility and consult a wound expert. (Physician's Assistant, Focus Group 2)

It was believed that for clinicians to be truly independent in their decision‐making process they required the appropriate level of knowledge and education. Conversely, some clinicians believed that due to over accessing of this resource that it affected the ability of the wound care specialist to participate in program development, and provide education to staff. It was discussed how ease of access to the wound care specialist decreased feelings of accountability, and led to staff and physicians connecting with the wound care specialist before completing their own assessment and trying to determine the best course of action. The need for clarity of the wound care specialist responsibilities was discussed in order to more appropriately manage time, resources, and develop competency in wound management.

I find that as soon as there is a wound care specialist, as soon as there is a wound, the nurse consults the wound care specialist and doesn't want that on their things to do… (Occupational Therapist, Focus Group 2)

3.9. Care plan (ontological category: Interpretation as action)

Participants described the impact that the previously developed care plan can have on their decision‐making process. Factors such as which medications the patient has been prescribed, such as steroids, were noted to be a factor in determining how the wound should heal and the management needed. Physician orders were found to be helpful especially from the context of surgical wound; however, clinicians found orders to often be vague and further interpretation was required. This has led to clinicians noting an inconsistency in practice, with some clinicians interpreting an order differently than their peers.

I actually love it when there's actual orders of what to follow… but… it's so infrequent… most of the time it's just nursing (Occupational Therapist, Focus Group 2)

Also, consistency in following through on treatments, I find is a huge issue. Where you write an order and you will request a treatment but it may or may [not be] done or may not get done consistently. (Physician's Assistant, Focus Group 2)

Wound care orders and the patient care plan were also tied to scope of practice and wound care specialist consultation, in how when there were no orders present on the patient's care plan, clinicians were uncertain as to which dressings could be applied without a physician order. It was believed that when wound management was not included on the patient's care plan in a timely fashion it could be damaging to the wound healing process.

Along with the development of the treatment plan with input from the physician, nurse, and interprofessional team, and the many variables that impact patient wound healing, the patient's input on the care plan was believed to be extremely important. It was believed that if the patient was not adherent to their treatment plan or did not agree with the plan it was unlikely that the care plan would be effective.

Unless the patient has been found to be incapable then the patient has to be involved in all of these decisions because it's the patient that's going to have to live with the wound or live with the treatment, live with the pain, live with whatever. (Occupational Therapy, Focus Group 1)

Both on admission and at discharge, it was believed that proper management decisions had to be made should the treatment plan be effective for the patient. It was believed that due to short hospital stays, it was often difficult to assess if the current treatment plan is effective. Thus, it was noted that external outpatient services are considered when making wound care decisions, as some outpatient clinics may have modalities that could improve the patients wound at a faster rate.

I'll also look in the outpatient clinic if there is any modalities that can be used to assist in… speeding up or promoting wound healing. (Physiotherapist, Focus Group 1)

Follow‐up management was in some instances discussed as being difficult with patients discharged not understanding how to manage a wound, and being uncertain of management until their physician follow‐up weeks later. Similarly, it was expressed that with patients coming from home to hospital, clinicians are either having to try and substitute products from the community setting to continue the wound management in hospital, or are having to reassess the care plan from the community setting when they believed that there were more appropriate options within hospital.

3.10. Documentation and communication (ontological category: Intervention as action)

Participants resoundingly responded about the importance of accurate, timely, and consistent documentation and communication practices. Some of the challenges articulated specifically acknowledged a lack of communication and documentation, resulting in poor patient outcomes and potentially replying on “second‐hand information”.

…we need to be consistently talking the same language and making decisions together about how [the wound] is affected and how it's progressing… to ensure we are making the best decision for that patient. (Occupational Therapist, Focus Group 1)

Some of the challenges that I face from a nursing perspective is the sharing of information… it's not necessarily been shared through documentation… what you have from [the] previous assessment to where you are today, quite often you are always starting from the beginning… (Registered Practical Nurse, Focus Group 1)

Conversely, the participants recognised that optimal communication and documentation practices assisted patients in achieving their wound care‐related goals and interprofessional plans of care.

I find myself looking at the last charting … if it's charted that gives me a little bit of insight whether [the treatment] is actually working or not… (Registered Practical Nurse, Focus Group 3)

4. DISCUSSION

Understanding how interprofessional health care team members make decisions in wound care management led to a review of the current available evidence. This study, using a Critical Realism theoretical lens, has provided insights into the potential benefits of the MGT approach. The lens is more inclusive of a broader socio‐geographical context, allowing incorporation of insights from both a Canadian and Australian perspective. This lens complements the MGT design as both seek to identify causal mechanisms through the structuring of conditions, actions, results, and consequences. Through Critical Realism the in‐depth analysis yielded an opportunity to further explore the social process of wound care decision‐making. In this current search for the basic social process of wound care decision‐making among interprofessional team members, ten unique elements were discovered. These ten interrelated elements included: documentation/communication, equipment and supplies, assessment, care plan, wound care specialist consultation, internal clinical factors, patient factors, knowledge/education, interprofessional team, and scope practice. With the increasing costs associated with wound care, and the increasing demands on the interprofessional team, wound care management has been identified as a public health issue.1 Understanding the basic social process of decision‐making for wound management will assist future clinicians in implementing evidence‐based and patient‐centred care.

Study participants spoke to both ideal situations and obstacles faced within their clinical practice that affected their abilities to provide wound management to their patients. Supplies, resources, mentorship, accountability, training, and education were all discussed by participants as benefiting their ability to provide care to their patients but severely hindered their abilities when not available. Flanagan advocates for the recognition of these topics in the context of possible barriers to implementing best practice wound care.9 Flanagan discusses how with the constant changing and development of new wound care evidence, critical analysis of new research becomes ever more important, yet the ability to critically review literature is not a realistic expectation for all clinical staff.10 In many instances, personal experience and colleague opinions remain a key resource to clinicians when making a decision.9 Thus, Flanagan advocates for models based on expert and user driven guidelines.9 Study participants also discussed how they use their peers, guidelines, and prior experience when making decisions. Participants noted that when they were uncertain and in many instances because a wound care expert was available, they would not take on accountability for wound management. As Flanagan9 notes, wound expertise is sparse and cannot be relied upon, making the need for proper guidelines and practice tools of vital importance.

In recent years, research has increased in quality and along with the capacity for wound management in various professions, providing stronger evidence upon which clinicians may base their decision‐making.10 The advent of a higher quality of wound care knowledge has led to the development of the clinician wound care specialist internationally.10 As Madsen notes, this wound care professional takes on the role of change facilitator to encourage best practice use when making wound care decisions.10 Participants within the decision‐making study made note of the benefits of having an accessible wound care specialist; however, also stressed how the availability of this professional can lead to a lack of accountability. This demonstrates the importance of the wound care specialist's ability to develop strong leadership and management skills to encourage not only best practice use, but encourage accountability from clinicians to use the guidance provided to them.

Rose and Mackenzie previously highlighted how a single profession makes decisions related to wound care—specifically pressure‐related injuries.11 They conducted a grounded theory study in Australia with Occupational Therapists to further understand their perceived roles and decision‐making in pressure‐related wound care. As with this current study, knowledge and experience, resources, role perceptions and expectations, and client‐centred care were factors that contributed to how their study participants perceived their role in managing pressure‐related wounds. Along with the similar themes to this current study, Rose and Mackenzie also noted that study participants stated positive and negative factors throughout their findings.11 Ineffective team approaches, role tensions, broad but not deep knowledge, lack of confidence in their abilities, appropriate follow‐up with care plans, reliance on experience not evidence, cost effectiveness, patient‐driven choices, availability of resources, and using a wide range of assessments were areas highlighted through the focus groups with the Occupational Therapists as influences when providing pressure‐related wound care.

Making decisions in health care can come from different vantage points depending on the professional that is consulted as there are limitations in their practice in what they are legally entitled to perform. In certain settings, there are other limitations placed on professionals based on the priorities of the patient population. Scope of practice is an area that has been highlighted in this current study. Rose and Mackenzie found through their Grounded Theory study that there was a need for further investigation into an Occupational Therapist's role in pressure care management and further promotion of their scope of practice and expertise in this area.11 The current study findings also highlight a struggle within the interprofessional team related to varying scopes of practice and how those scopes of practice relate to the health care setting where wound management is occurring. Different professions may have a unique perspective when managing various health conditions, but also possess limitations to how they can treat a patient.

Recently, there has been a greater focus on interprofessional teams and their ability to provide multiple perspectives based on their individual expertise.12 Truglio‐Londrigan discusses shared decision‐making models and the importance of health care professionals understanding the roles and expertise of each professional involved in a patient's care.12 Participants of the wound care decision‐making study also discussed the importance of team work, both from the perspective of working collaboratively with other professions, but also between colleagues both for the safety and benefit of clinicians and the patient. In addition to the aforementioned literature, organisations such as the Registered Nurses' Association of Ontario (RNAO) have developed best‐practice guidelines for wound care, specifically pressure injuries, highlighting the evidence‐based recommendations for an interprofessional team approach to assessment and management of wounds.13

Patient factors and the inclusion of patients in the wound care decision‐making process were expressed as important should management be effective. With the increasing focus on patient‐centred care, sharing decisions with patients becomes a key task in wound management. Shared decision‐making has been shown to lead to positive health outcomes.12 Truglio‐Londrigan has outlined competencies for shared decision‐making to be effective within medical/surgical nursing practice, which includes: communication, assessment, teaching and learning, and the interprofessional team, among others.12 These same key factors to wound care decision‐making were discussed during participant interviews. Truglio‐Londrigan notes the importance of communication in development of a trusting therapeutic relationship.12 When discussing communication in wound care decision‐making, participants recognised that communication was important; however, they also stressed the communication between team members more so than with patients, as without an understanding of the patient's wound history it is difficult to determine proper management and determine if healing is occurring.

Understanding wound cause and completing a detailed wound assessment was a topic of great interest during participant discussion. The importance of determining wound cause and focusing on a holistic patient history and assessment rather than a focused wound assessment was made clear. A detailed assessment provides the information to guide decision‐making and prevents decision‐making based on assumptions.12 Current guidelines have recommended initial comprehensive assessments of a patient with a wound be completed by an interprofessional team, in partnership with the patient to determine the wounds ability to heal as well as intrinsic and extrinsic factors affecting wound healing.13

Although there remains a scarcity of literature regarding wound care decision‐making, there are a number of comparisons that can be made between this wound care study and previous published literature. The prior literature discussed assists in supporting the elements discovered in the analysis of these study data. It is clear, however, there remains much to be understood regarding wound care decision‐making. The theoretical lens used in this study has assisted with development of a basic social process that can further be developed building upon current understanding of this important phenomenon.

5. LIMITATIONS AND IMPLICATIONS FOR FUTURE RESEARCH

Although our focus group participant numbers were smaller in most cases than the ideal five to eight participants, Krueger and Casey note that focus group sizes should be based on study purpose and participant characteristics.14 Smaller focus groups provide greater opportunity for a more in‐depth discussion.14 They are also beneficial when participants have a great deal to share, which the authors believed would be the case in this instance given that discussion of behaviours over a wide variety of topics was being sought, which is in line with recommendations made by Krueger and Casey.14

This study did not include the patient perspective as part of data collection. Patients are part of the interprofessional team and as demonstrated in the analysis of this study, patient factors do play a role in the decision‐making process of others. Therefore, there is opportunity for future research to build upon the social process developed through this MGT study by including the patient perspective.

Although purposive sampling was used, theoretical sampling was not, as after three focus groups it was believed that data saturation had been reached. Krueger and Casey note that by three focus groups the researcher is often able to determine when data saturation may occur.14 Furthermore, Guest, Namey, and McKenna note that three focus groups have been large enough to identify all of the most prevalent data set themes.15

Given that participants of each focus group had a heterogeneous group of professions, this may have impacted group dynamics and discussion. A predetermined interview guide was used, however, for each group, to ensure that standardised questions were asked of each participant, while also allowing further discussion. In recognising this limitation, the second author conducted all interviews, noting recurrent themes discussed with each focus group, and data saturation achieved. As this study incorporated data from both a Canadian and Australian context, it continues to develop an ever‐evolving theory. As further socio‐geographical considerations are applied, it will continue to build upon our understanding of wound care decision‐making by the interprofessional team.

6. CONCLUSION AND IMPLICATIONS FOR PRACTICE

Wound care decision‐making by interprofessional team members is a complex and dynamic process that can be understood by acknowledging the key elements to wound management, as well as the positive and negative forces acting on them at any given time. Understanding the elements of wound management provides insights into how evidence‐based practice is used and what interventions can be implemented to affect change in the decision‐making process, thereby affecting patient care. The basic social process developed in this study describes how clinicians are influenced when providing wound care by the many intertwined environmental and social factors. These environmental and social factors have been addressed from both a Canadian and Australian context providing a more socio‐geographical transferable theory. Recognising the elements of wound management and how each clinician's environment affects these key factors may allow decision‐makers and leaders in health care the ability to influence change and allocate resources to best support evidence‐based, patient‐centred care.

Heerschap C, Nicholas A, Whitehead M. Wound management: Investigating the interprofessional decision‐making process. Int Wound J. 2019;16:233–242. 10.1111/iwj.13017