There was a total of eighteen participants in this study. Four yarning circles were conducted, one at each AMS. Two circles had four participants and two circles had five participants. There were four AHP, seven AHW with four of these currently training to be AHP. There were also four RNs and one EN participants. There were 14 females and four males, and the participants had a range of experience in working in AMS or working with Indigenous communities ranging from two weeks - 28 years. Table 2 provides the number of participants at each site, gender and role designation. Two themes were constructed from the yarning circles: Knowledge and Experience with Wound Management and Barriers and Enablers for Wound Management.
Table 2. Participants in Yarning Circles
Setting
|
Participant number
|
Role
|
Gender
|
Site 1
5 Participants
|
P1
|
AHW
|
Male
|
P2
|
RN (non-Indigenous)
|
Female
|
P3
|
EN (Indigenous)
|
Female
|
P4
|
AHP
|
Female
|
P5
|
AHP
|
Female
|
Site 2
4 Participants
|
P6
|
RN (non-Indigenous)
|
Female
|
P7
|
AHW (trainee AHP)
|
Male
|
P8
|
AHW (trainee AHP)
|
Female
|
P9
|
AHP
|
Female
|
Site 3
4 Participants
|
P10
|
AHW (trainee AHP)
|
Male
|
P11
|
AHW (trainee AHP)
|
Male
|
P12
|
AHW
|
Female
|
P13
|
RN (Indigenous)
|
Female
|
Site 4
5 Participants
|
P14
|
AHW
|
Female
|
P15
|
RN (non-Indigenous)
|
Female
|
P16
|
AHW
|
Female
|
P17
|
AHP
|
Female
|
P18
|
AHW
|
Female
|
Total
|
18 participants
|
AHW- Aboriginal Health Worker; AHP- Aboriginal Health Practitioner; RN- Registered nurse;
EN- Enrolled Nurse.
Knowledge and Experience with Wound Management
Participants in this study had varying levels of hands-on experience in wound care and wound management. AHW and AHP identified that their exposure to wound care mostly involved working alongside and /or being guided by the doctor or the RN if they were available and/or onsite.
When I first started, I didn’t really know what to do in the role [AHW role]. And often we will just open up the wound, have a look at it and then the doctor will come in and have a look and they’ll make a decision what they want to do with it or if they need to refer it (P4 AHP).
Reviewed by doctors and depending on the doctor who we have here at the time, they all have different ideas with wound management (P14 AHW).
The types of wounds that participants experienced having to manage included surgical wounds, chronic wounds, wounds from scabies, and abscesses (that involved using wound packing techniques) and some wounds resulting from injuries and accidents.
We do all different types of wound care. Mostly in diabetic and post-surgery wounds (P14 AHW).
By far the most common wounds managed were those arising from clients with diabetes who sought help with managing diabetic ulcers. Participants discussed how some clients had been receiving long term wound management for what is considered chronic diabetic ulcers: I see them coming in and they’re just ongoing, ongoing because they’re chronic disease (P17 AHW) and one we have been dressing for 7 years (P18 AHW).
Many of the AHW and AHP were frequently required to manage the wound care for clients without what the participants feel is the requisite knowledge or skill. These expectations that the AHW and AHP manage wounds often arose because of staffing within the services as one participant states:
Might have had the one experience with the dressing – wound management, but the expectations of “Oh, well you’re in clinic today so you’ll do the dressing.” (P6 RN).
Participants noted that nurses within their services have largely been the ones to receive and undertake formal training for wound assessment and management practices. However, the knowledge and skill were often not shared because of nursing staff attrition.
One person trained up there in wound management. You know, she went away, done the training. Well, she’s no longer here so she took those skills with her (P9 AHP).
However, the AHW and AHP participants were actively seeking skills and knowledge in wound management because they were not provided wound assessment and management care in their AHW training packages and there were expectations by their workplaces that they will provide wound care.
I didn’t know that as soon as I clean it starts bleeding that means it’s healthy, it’s growing, like I didn’t know that (P11 AHW).
The AHW and AHP felt that they missed out on training opportunities to enhance their clinical skills in wound care because there was no regulatory body requirement for AHW to be completing professional development as is required with nurses.
As an Aboriginal health worker, I think the training probably falls back because a nurse has to do training [professional development] where a health worker doesn’t (P17 AHW).
Barriers to Providing Wound Care
Participants described the barriers for them in providing wound care such as a lack of documentation and communication for transitioning client care, skill of the staff, model of care being used and the cost of the wound care products.
Participants identified that within the AMS there was often a lack of documentation in clients’ medical records about any wounds a client may have, and how and if the wound/s were being managed. This lack of information in patients records about the wound posed barriers to being able to manage the wound and participants recognised did not provide for a consistent approach to management of the patient’s wound.
We had a shortage of staff, so I went into the notes, had a look, it just said “wound care”, nothing else, nothing else. So, yeah, of course there’s going to be wound care, that’s the reason … but then, you know, normal saline wash whether it was a foam or packing gauze or cream that was used, you know, melolin and a crepe bandage applied. There was nothing. So, I went in blind … (P6 RN).
During the yarning circles there was concern for the transition and continuity of care between health service providers and much discussion around the relationships with other providers and how wounds were managed. Participants described a lack of communication with other health service providers within the community and a need for different models of care.
You don’t really see the referrals. We just do the wound care if that makes sense. Like we don’t know really know much about like what’s going on and all that ... (P12 AHW).
Supervised by the GP because there’s nothing documented in the patient’s chart (P9 AHP)
Case management was suggested as a model of care with respect to clients that have wounds because clients would present to an AMS for care of a wound and the participants experienced that it took some time for them to sort what needed to occur for the client in the absence of any documentation or communication from previous service providers or indeed from their own service around history and management of the wound.
I think it’s on case management on the wound. That way everyone’s involved …Trying to sort of get back with the hospital because the hospital doesn’t speak to the clinic type thing…if you’ve got a chronic wound that’s going to be longer you do need to case manage because there’s more than just the wound. It’s not just the wound so case management should be happening more, and we don’t either get time or we can’t organise it (P6 RN).
Participants all felt that this lack of communication prolonged the wound management unnecessarily for the client and meant that there could be inconsistency between staff or service providers in terms of management of the wound. Participant experiences with liaising with other local health service providers around clients with wounds was not consistent. Some were able to narrate positive experiences where there were collegial supportive relationships with local health service providers in managing and transitioning the care of clients and their wounds.
We’re building… Yeah, we’re building on that now, because [uses name here] from the hospital, every two weeks she comes down and we do patient conferences…. And [names person here] up there, she’s the community nurse, she emails me on clients that may have come back. So, we’ve got that link together then, yeah, because you know, on the weekends or whatever, after hours, yeah, she [community nurse] will fill me in… there’s never/ hardly any discharge summaries (P4 AHP).
Other participants described needing to develop better relationships with other health services. They were concerned for the welfare of their clients particularly when clients sought out of hours care for their wounds from mainstream health services and subsequently were then referred by that health service back to the AMS to continue the care during office hours.
Case conferences because some of our patients do care share, you know, as we shut at five and we don’t open on the weekends, so there’s clients that use both facilities, well [names person here] you know, she fills us in on what they’ve done (P5 AHP).
I’ve spoken to them on the phone. But it depends on who’s there. Sometimes I’ll try and contact them, [local health service] and I can’t get anyone and then other times I’ve had a couple who have been really good, and I’ve been able to discuss over the phone… I think they’re always short down there [local health service] as well. So yeah, they don’t really have any one particular [person] dedicated, you know, clinician to their clinic, which makes it difficult. Occasionally you will get some, but the wound clinic is only Monday to Friday. If clients need dressings over the weekend, then they just have to present to ED to get their dressings done. And they can sit up there for 6 hours waiting to get them (P15 RN).
Yet for other participants they could not identify any relationship with other service providers in the community around supporting and managing clients who required ongoing wound care/management. There was a perception that more could be done for their clients when they present to other health services.
So, if they’re Indigenous they will automatically [discharge to the AMS]. The hospital isn’t very helpful sometimes in taking those clients (P16 AHW).
This situation was a cause of frustration because participants felt they were often not being included in what should occur for clients in management of the wound particularly when clients were referred to them, they had little knowledge of how the wound was to be treated and what else might be occurring for the client and this was preventing them from caring holistically for their clients.
People jumping between us doing it and Blue Care are doing it then the hospitals are doing it, then back to us doing it and everyone’s got different ways of doing it that can leave the wound not progressing (P6 RN).
Participants expressed concern for their clients who came to the AMS for wound care because after presenting at other health service providers for wound care they were often referred directly back to the AMS with no attention to the wound as one AHCW stated They don’t want to go to the hospital, it slows the healing process (P18 AHW). Participants experienced that client referrals to the AMS would frequently not be accompanied with discharge plan or clinical care notes indicating type of wound and the management.
It’s just a huge, big gap. So, it’s a bit difficult – like we’ll send somebody up, we’ll say “we can’t – this wound is past what we can do”, you know, “we need more specialised services”. And usually, they will bounce back within 24 hours usually. So, they’ll go up, the hospital will have a look and go “No you’re GP can do this”, because that’s a standard response to everything. And they will get bounced back to us again and to be reviewed by your GP within the next two to three days, and no correspondence whatsoever (P15 AHW).
This shared experience highlighted what can be a difficult strained relationships between the health service and the Aboriginal medical service. In this context the HHS was not always prepared to manage a client wound but would rather quickly refer to the AMS regardless of the staff's ability to manage and assess a wound.
Discussions focused on models of care, highlighted that the way the participants wanted to practice needed to allow them to provide a more wholistic view of caring for the client who has a wound. Recognising that the role of the AHW was an all-encompassing holistic view of the client the participants did not want to just focus on the wound. They recognised that wound management was not just about the wound but also needed to extend and consider what was happening with the individual.
In the community we’ve had a few clients who have had diabetic ulcers. It was pretty much raw skin from the knee to the ankle, on both legs. We would get him to a point where there wouldn’t be dressings anymore and then all of a sudden, they would be back, they’d all broken down again. That’s just non-compliance with diet, medications, self-care, hygiene. They just get there, and they think all done, and throw everything out the window and it just slowly breaks down. They have to continue to keep coming. Because they get a cup of coffee and a yarn and socialise and… (P15 AHW).
It all becomes about the wound and so then you’re not looking at the bigger picture and you need to look at the bigger picture because you’re not going to heal that wound unless you deal with the bigger picture of what’s happening the wound is like the starting point in that… (P9 AHP).
Further to this there was a perception that clients were not managing their wounds appropriately at home causing long delays in healing which added to the bigger picture of how they enacted their role-not just managing the wound but also helping to effectively manage and consider cultural aspects.
In the community we’ve had a few clients who have had diabetic ulcers but they’re deliberate intentions to keep those wounds breaking down…I’ve noticed that probably three out of my four of my diabetic ulcer people were doing that (P15 AHW).
A barrier to what participants thought was effective wound care was the continuity of care and the consistency in wound care management. For example, the limited availability of staff who are trained in providing wound care and the availability of wound care dressings and products. Participants identified that if in their service the RN was the only one to perform wound care, then that often acted as a barrier for their clients because it reduced the client’s choice of who provided the care. If the RN was busy or not available, then this often resulted in long wait times for clients or inconsistent management of the wound and delayed outcomes for the healing of the wound. For example, the below is from an AHW who explains
If [mentions name here] is who’s doing their dressing every second day but they are on leave so someone else takes over the dressing, well you’ve got clients who then don’t like the person that’s going to be taking over the dressing so don’t come back so when [mentions name here] comes back the wound has gone backwards...But, yeah, it’s just a lack of staff that’s available and choices (P6 RN).
As well many of the products used on the clients’ wounds by other health service providers may not be available to the AMS and this was also thought by participants to influence the consistency of wound management and subsequent wound outcomes for the client.
The biggest thing for us is with the hospital, so if people get discharged from the Wound Clinic for the hospital, the stuff that they are using we don’t have. So, then we have to alter whatever’s been done. Most of the time they’re reviewed by doctors and depending on the doctor who we have here at the time, they all have different ideas with wound management (P14 AHW).
Only two participants from two of the four AMS were able to identify professional development opportunities directed on wound management as an enabler for their wound care management practices. One AHW had received online education and one AHW had attended face to face workshops at another health service.
The online one, [education program] was actually by a podiatrist who’s a specialty wound diabetes educator as well. So, she was really good and gave us a really good overview of what to look for and didn’t highlight any particular dressings, you know, like brand name dressings, just the type of thing that you would need to help control that wound. So, it was really good, that online one … was really thorough with what she taught us (P14 AHW).
AHW participants who had opportunities to attend and or complete education on wound management all agreed that this training for them was very beneficial.
Training over [mentions health service name here] that was pretty good. We got to see – I think for a week or so and see a number of different people and like different types of wounds (P10 AHW)
An enabler for management of wound care in the absence of formal support or education was the mentoring support from more experienced nurses in wound care.
I never got taught, I was getting taught by another nurse of ours, she showed me a lot of stuff and there were a few clients coming in with wounds and so she said, “Come and watch what I have to do.” And she’s just teaching me some stuff she’s also one that was like giving me more knowledge (P1 AHW).
Participants described seeking knowledge and using self-support strategies for enabling their wound care skills.
We learn from each other…. there should be enough wound clinics around the area where the health worker or everyone, when they’re doing their training, should be able to say, okay, “we’re going to put you down there now for a month because it’s part of your training where you learn”, you see, you look, you hear, you know (P 4 AHP).
But we usually have a standard sort of approach to what we use on particular wounds… If one person’s doing a dressing and they think “something is not going right, we need to try something”, so well everybody usually talks between each other to decide what we’re going to do if we need to change the dressings (P14 AHW).