A community-researcher alliance to improve chronic wound care
Ian D. Graham, Ottawa Health Research Institute, University of Ottawa
Margaret B. Harrison, Queen's University
Bob Cerniuk, Ottawa Victorian Order of Nurses
Sheila Bauer, Ottawa Community Care Access Centre
A partnership between health services researchers from Queen's University and the University of Ottawa, a community nursing agency and a home care authority in Ottawa led to major improvements in the quality of care for people with leg ulcers. The synthesis of both external and local evidence played a key role in the adoption of an evidence-based protocol and provided the critical context to support a significant reorganization of the existing service delivery model. This case demonstrates that, with a collaborative-partnership approach, systematic and transparent research processes can be rapidly developed to support policy change.
Leg ulcers are a chronic, debilitating, costly and neglected condition. In 1999, the annual regional expenditures for 192 individuals living in the Ottawa area and receiving home care for their leg ulcers was $1.3 million. This group of individuals accounted for only 6% of all home care clients, but consumed 20% of the total supply budget. Yet there is strong evidence from numerous randomized controlled trials that a thorough initial assessment and application of compression bandages is a very effective treatment for healing venous leg ulcers.1
Ottawa Community Care Access Centre (OCCAC), the home care authority in a region of approximately 750,000 people, became concerned about the growing demand for community care of wounds, burgeoning wound-care supply budgets, and a shortage of nurses. In 1999, the OCCAC partnered with a not-for-profit community nursing agency—the Ottawa Victorian Order of Nurses—and a team of health services researchers from Queen's University and the University of Ottawa to address their mutual concerns about care of individuals with leg ulcers. The objective of the partnership was to improve both the quality of care and health outcomes for individuals with leg ulcers.
This project involved both the community and tertiary sectors and was financially supported by the OCCAC, the Ontario Ministry of Health and Long-Term Care through career scientist research allowances, and CIHR through a grant to evaluate the effectiveness of home versus clinic care for leg ulcers.
The KT initiative
The partnership was formed with a common vision of developing a pragmatic, evidence-based approach to bringing about practice and service changes. We approached the research as a collaborative and participatory endeavour. The partnership has gone through a number of phases, each with a varying degree of knowledge translation (KT) activity. Sometimes occurring simultaneously and often impacting each other, the phases of the partnership included:
- The identification of the delivery of leg ulcer care as an important organizational issue by OCCAC, community nursing agency managers, and policy makers;
- Researchers reviewing the literature on the effectiveness of leg ulcer care and service delivery models and identifying best practices;
- Conducting a regional prevalence and profiling study, environmental scan and practice audit with OCCAC and the nursing agency to determine the magnitude of the problem and current practice;2,3,4
- Conducting surveys of care providers to determine provider concerns and issues;5,6
- Engaging OCCAC's board with evidence from both the literature and locally derived data to support their decision making;
- Forming an interdisciplinary group of providers and researchers which systematically reviewed the quality and utility of existing practice guideline recommendations and adapted them for local use by creating an evidence-based leg ulcer care protocol;7,8
- Managers, policy makers and researchers coming together to redesign the service delivery model to support best practice (a dedicated regional nurse led a leg ulcer team to provide care in home and clinic settings);
- Managers finding innovative ways to overcome organizational inertia and financial and structural barriers to make the redesign happen;
- Researchers, with the support of the agencies, creating opportunities for nurses to advance their wound care knowledge and skills through an exchange program in the UK;
- Conducting a pre-post study of the impact of the implementation of the evidence-based protocol;9
- Using the opportunity of preparing a grant proposal to seek peer-reviewed research funding to coalesce researcher-policy maker synergies;
- Securing research funding to conduct a randomized controlled trial of the effectiveness of the service model redesign.
Results of the KT experience
Arrangements have been made to ensure the leg ulcer service will continue to serve the region, even though the research study has ended.
Qualitative feedback indicated the partnership process had positive effects for all involved. A review of clients' health records also indicated that the quality of care improved.10 The results of the pre-post implementation evaluation indicated that the healing rate for leg ulcers at three months increased to 56% from 23% following introduction of the evidence-based protocol, coupled with significant reductions in nursing visits and supply costs.9 The randomized controlled trial evaluation of the effectiveness of home versus clinic care is in the last year of follow-up and the results are currently being analyzed.
Perhaps most importantly, arrangements have been made to ensure the leg ulcer service will continue to serve the region, even though the research study has ended. The methodology used to evaluate and adapt existing guidelines11 has been adopted by the nursing agency to develop protocols for other conditions. It also forms the foundation for best practice initiatives of the Canadian Strategy for Cancer Control, the Canadian Stroke Network, and the Registered Nurses Association of Ontario.12,13
We encountered some major challenges throughout the partnership, but also learnt a number of important lessons.
Change and commitment
Policy maker/manager partners changed frequently during the six-year period, meaning that we needed to continually foster new relationships. There were also numerous reorganizations and leadership changes within the regional home care and the home nursing agencies, making it challenging to keep the initiative on track.
While it can be frustrating to continually renegotiate and establish trust with new personnel, having access to policy makers and being able to influence decision making is ultimately very rewarding.
The end result of this partnership, however, was no less than the restructuring and reorganization of service delivery to support the provision of evidence-based care. This required a major organizational commitment from service providers as it involved altering staffing and remuneration arrangements and procuring additional provider education and training.
It was also labour intensive for the researchers. The research team was regularly and actively engaged in the day-to-day ups and downs of the service and, at times, took on an active role as implementation facilitators. The researchers who were perceived as credible and neutral often had to work between the OCCAC and the nursing agency to negotiate change. However, this direct contact helped to create the common understanding and trust needed for the partnership to succeed. While it can be frustrating to continually renegotiate and establish trust with new personnel, having access to policy makers and being able to influence decision making is ultimately very rewarding.
Making research evidence work for policy makers
As researchers, we had to develop methods of synthesizing and presenting external and local evidence that were useful, user friendly, and timely for policy makers. We also had to gain consensus on the value of "quick but good" research methods to meet the needs of the policy makers for immediate answers, while respecting researchers' concerns that the evidence be derived using rigorous methods.
The critical success factor for the adoption of the evidence-based protocol was the synthesis of external and local data.
The critical success factor for the adoption of the evidence-based protocol was the synthesis of external and local data. The external evidence from the literature provided the clinical direction for the care that "ought" to be delivered. However, the local data about current practice provided the critical contextual information to enable the delivery of effective and efficient care.
Peer-reviewed research funding can be used to leverage change with organizations that value research. However, it can also hold up things when resubmission to granting agencies is required and work cannot proceed without external funding.
Conclusions and implications
The initiative was driven by a common goal of improving care and making service delivery more efficient, using the best available evidence as the foundation. It demonstrates how policy making can become more evidence-based when researchers and policy makers adopt a collaborative-partnership approach, and how this approach can increase appreciation of each other's worlds and perspectives, build trust, encourage learning from each other and provide new opportunities to use research to improve decision making. It can be very rewarding when a visible difference is made to a population receiving care, and when that change creates additional successes.
It can be very rewarding when a visible difference is made to a population receiving care, and when that change creates additional successes.
The project also revealed it is possible to develop systematic, transparent and relatively quick (e.g. the guideline evaluation and adaptation cycle) research processes that can support policy making. As the results of the pre-post study validating the effectiveness of the locally-developed leg ulcer protocol have only just been released, it is premature to expect that it has been adopted elsewhere. However, the protocol was updated8 and formed the basis of an implementation study in three other regions of Ontario. Although the data have not been thoroughly analyzed, we do know that the protocol was adopted in two regions but not the third: this was likely due to the fact that organizational changes necessary to support delivery of the protocol were not made at the third site.
Important implications of this case study for future KT research include: the need to focus on researcher-policy maker relationships and the factors that promote or hinder the development of effective relationships; methods for synthesizing external and local data for policy makers; and the role of researchers as change agents and implementation facilitators.
1 Cullum, N., E. A. Nelson, A. W. Fletcher, and T. A. Sheldon. 2001. Compression for venous leg ulcers. The Cochrane Database of Systematic Reviews 2:CD000265.
2 Harrison, M. B., I. D. Graham, E. Friedberg, K. Lorimer, and S. Vandevelde-Coke. 2001. Regional planning study: Assessing the population with leg and foot ulcers. Can Nurse 97:18-23.
3 Friedberg, E. H., M. B. Harrison, and I. D. Graham. 2002. Current home care expenditures for persons with leg ulcers. J Wound Ostomy Continence Nurs 29:186-92.
4 Graham, I. D., M. B. Harrison, E. A. Nelson, K. Lorimer, and A. Fisher. 2003. Prevalence of lower-limb ulceration: A systematic review of prevalence studies. Adv Skin Wound Care 16 (6): 305-16.
5 Graham, I. D., M. B. Harrison, C. Moffat, and P. Franks. 2001. Leg ulcer care: Nursing attitudes and knowledge. Can Nurse 97:19-24.
6 Graham, I. D., M. B. Harrison, M. Shafey, and D. Keast. 2003. Knowledge and attitudes regarding care of leg ulcers: Survey of family physicians. Can Fam Physician 49:896-902.
7 Graham, I. D., K. Lorimer, M. B. Harrison, T. Pierscianowski, for the Leg Ulcer Protocol Tasks Force, Leg Ulcer Protocol Task Force Working Group, et al. 2000. Evaluating the quality and content of international clinical practice guidelines for leg ulcers: Preparing for Canadian adaptation. Can Assoc Enterostomal Ther J 19 (3): 15-31.
8 Graham, I. D., M. B. Harrison, K. Lorimer, T. Pierscianowski, E. Friedberg, M. Buchanan, and C. Harris. 2005. Adapting National and International Leg Ulcer Practice Guidelines for Local Use: The Ontario Leg Ulcer Community Care Protocol. Adv Skin Wound Care 18 (6): 307-18.
9 Harrison, M. B., I. D. Graham, K. Lorimer, E. Friedberg, T. Pierscianowski, and T. Brandys. 2005. Leg-ulcer care in the community, before and after implementation of an evidence-based service. CMAJ 172 (11): 1447-52.
10 Lorimer, K. 2004. Continuity through best practice: Design and implementation of a nurse-led community leg-ulcer service. Can J Nurs Res 36 (2): 105-12.
11 Graham, I. D., M. B. Harrison, and M. Brouwers. 2003. Evaluating and adapting practice guidelines for local use: A conceptual framework. In Clinical governance in practice, ed. S. Pickering and J. Thompson, 213-29. London: Harcourt.
12 Graham, I. D., M. B. Harrison, M. Brouwers, B. L. Davies, and S. Dunn. 2002. Facilitating the use of evidence in practice: Evaluating and adapting clinical practice guidelines for local use by health care organizations. J Obstet Gynaecol Neonatal Nurs 31 (5): 599-611.
13 MacLeod, F. E., M. B. Harrison, and I. D. Graham. 2002. The process of developing best practice guidelines for nurses in Ontario: Risk assessment and prevention of pressure ulcers. Ostomy Wound Manage 48 (10): 30-2, 34-8.
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