Developing a Model of Care for Healing Pressure Ulcers With Electrical Stimulation Therapy for Persons With Spinal Cord Injury

This initiative is a collaborative effort between Western University, South West Community Care Access Centre (CCAC), and Parkwood Institute. The South West CCAC is one of 14 regionally based CCACs in the province of Ontario and coordinates publicly funded home care providers to seniors, individuals with disability, and/or individuals requiring assistance to live independently in the community.32 They provide community-based services including supportive care, nursing, and/or rehabilitation. Parkwood Institute is a large tertiary rehabilitation center in Ontario that specializes in the rehabilitation of individuals with SCI.

To improve the uptake of practice change and facilitate implementation, it is critical to engage local stakeholders. Community-based participatory research (CBPR) or participatory action research (PAR) was an approach to facilitate involvement and create a partnership and mutual trust among researchers and community.33 Studies suggest that it can enhance the quality of the research and the potential for addressing major concerns in the community.34–37 Therefore, the researchers at Western University convened a representative panel of 11 individuals, including other researchers, administrators, regional managers, program coordinators, a clinical nurse specialist, and an SCI consumer. The panel (ie, the Steering Committee) was drawn from public and private health sectors and from the community (ie, South West CCAC and contracting agencies) in London, Ontario. The group appreciated and valued the importance of this initiative to improve the local management of pressure ulcer care, and thus it was very receptive in engaging in a research-clinical partnership. The group was mandated to review the perceived “facilitators” of and “barriers” to EST implementation, make key decisions around the model of care, and seek approval from administrative leaders within their organization/institution. The principal investigator and study coordinator facilitated each of the meetings and distributed minutes following each meeting. The meetings were held monthly between April and October 2014.

Members of the Steering Committee identified and engaged key stakeholders who were willing to contribute their thoughts, perspectives, and attitudes about EST. Direct invitations via e-mail were made to these individuals. There were 3 types of stakeholders interviewed for this phase of the project: (1) hospital and community administrators and practice leaders; (2) hospital and community frontline care providers including registered nurses, occupational therapists, physiotherapists, social workers, physicians, and a registered dietitian; and (3) SCI consumers with recent or prior experiences with pressure ulcers. The study coordinator met with 29 stakeholders face-to-face or via telephone to examine the potential facilitators of and barriers to implementing EST. The interviews were semi-structured with a set of open-ended questions to facilitate discussion, but they remained focused and organized. The coordinator recorded key descriptions and concepts that emerged during the conversations. There was no audio recording during these conversations.

Following the stakeholder interviews, the study coordinator followed a qualitative method for data analysis; the notes were repeatedly reviewed, and concepts related to the stakeholders' perceived facilitators of and barriers to implementing EST were identified. The responses were then collated and categorized into implementation drivers according to the NIRN framework.31 These drivers are part of a structured process to inform and facilitate implementation action planning.38 There are 9 key drivers divided into 3 categories: competency, organizational, and leadership. Competency drivers are activities that develop, improve, and sustain one's ability to put a program into practice. The 3 competency drivers include selection, staff training, and coaching. The skills that are achieved in the selection criteria, taught in training, and supported in the coaching process are monitored using performance assessments. Organizational drivers are activities that help develop the supports and infrastructure needed to create an environment for the new practices. The 3 organizational drivers include decision support data systems, facilitative administrative support, and systems interventions. Leadership drivers focus on providing effective leadership strategies for challenges that arise when the program is put in place. The 2 leadership drivers include technical and adaptive leaderships.31,39 To achieve effective implementation, it is important to achieve a balanced approach by ensuring that the activities (ie, the barriers and facilitators) are distributed across several drivers. The drivers are integrated, complementing one another, but also compensate when challenges arise.

These findings were presented to the Steering Committee and reviewed thoroughly. The Steering Committee noted that the majority of the stakeholders lived in urban areas, and it recognized that these findings may not be consistent with persons living in the rural areas. The Committee discussed the potential facilitators and barriers to implementing a new program in rural areas with less access to resources. Any differences of opinion about aligning the facilitators or barriers with the implementation drivers were openly discussed and edits were made.

The perceived facilitators of and barriers to EST implementation were later provided to a working group. This group, comprised of researchers, frontline providers, and administrators, and a few members of the Steering Committee, focused on developing a model of care for treating pressure ulcers with EST. The goal was to incorporate EST as a treatment method for managing pressure ulcers, while also addressing the key themes that were discovered during the stakeholder interviews.

The working group met 3 times for 2 hours between June and September 2014. Following the first meeting, the working group developed a preliminary model of care, which was presented to the Steering Committee by the study coordinator. The Steering Committee reviewed the model in detail and provided their feedback. The model of care went through 2 more revisions until a final model of care was reached, with the endorsement from the Steering Committee.

Figure 1 outlines the perceived facilitators of and barriers to implementing EST for treating pressure ulcers in individuals with SCI living in the community categorized into the implementation drivers. There were 3 key barriers that emerged from all of the interviews: (1) lack of interdisciplinary collaboration and communication; (2) inadequate training and education; and (3) the lack of funding, time, and staff.

The stakeholders frequently reported ineffective interdisciplinary collaboration and communication as a barrier. Individuals with SCI often have a number of underlying issues associated with their pressure ulcers including comorbidities, nutritional deficiencies, prolonged sitting and immobility, and psychosocial concerns. The stakeholders familiar with EST identified the importance of addressing these concerns with the appropriate providers prior to or concurrently with receiving EST in order for the treatment to present positive healing benefits. Therefore, the stakeholders reported the significance of having interdisciplinary collaboration amongst providers such as nurses, occupational therapists, physiotherapists, social workers, and dietitians, which is often missing or infrequent in community care. Lack of communication at all levels across the organization and between organizations was cited. Specifically, providers in the community identified that there is a lack of consistent and available means to communicate basic information about a client's care plan and health status to the client's circle of care, especially if they are from a different provider agency. The stakeholders also described that there were frequent conflicts and power struggles between providers in the community and those in the hospital regarding what the best and most appropriate treatment plan would be for the client. For example, one community stakeholder indicated that they sometimes did not follow dressing instructions provided by wound specialists or physicians. The stakeholders highlighted the importance of creating a trusting environment amongst members of the client's circle of care, including the client.

Many stakeholders stated that there was lack of awareness, knowledge, training, and skills surrounding the use of EST in managing pressure ulcers across the continuum of care. They emphasized that prior to implementation of this therapy, it is important to incorporate improvement strategies, such as education and training sessions that are focused on introducing EST as a feasible therapy for improving pressure ulcer healing. Stakeholders expressed a preference for open educational resources that would be freely accessible online and available in print, in addition to hands-on demonstrations on how to use EST. They also indicated that not every provider would be receptive and willing to participate in the training sessions offered to them.

The most commonly reported barriers expressed by providers, particularly those working in the community, were the lack of funding, time, and staff for implementing strategies that may result in a change in practice. To obtain funding for EST delivery, the stakeholders stressed the importance of acquiring complete buy-in and ongoing support and feedback from administrators and/or practice leaders. When interviewing the stakeholders, many were unfamiliar with the EST literature to date and, therefore, were unaware that EST with standard wound care can be more cost-effective compared to standard wound care alone.40 All community stakeholders reported the issue of high turnover, resulting in fewer staff, higher workloads, and lack of time to consider learning a new practice. Many providers felt overloaded and burdened as a result of concurrent projects or competing initiatives. Self-management by the client was identified as a possible solution. However, the need to recognize family/caregiver “burnout” was emphasized, resulting from highly complex care needs of their loved ones and high stress levels.

Figure 2 illustrates the model of care that was developed with consideration of the facilitators of and barriers to implementing EST in treating pressure ulcers in individuals with SCI living in the community. To summarize, referrals for individuals meeting the inclusion criteria would be sent to a local EST coordinator. The coordinator would schedule an appointment for the client to meet with a specialized interdisciplinary pressure ulcer team at a rehabilitation center to address the wound and its underlying causes. A treatment recommendation with EST protocol (if appropriate) would be developed and shared with the patient's care team including both public and private providers. A community care coordinator or champion in the private or public sector would coordinate any additional care and order necessary equipment and resources to execute the patient-specific treatment recommendation. The client's care team in the community including regulated and unregulated care providers would lead the care plan at the client's home. If the wound had not reduced by 50% after 3 months, then the client might need to be reassessed by the specialized team. Specific details within the model of care are given below.

There are 3 features to this model that make it unique within the context of the current practices that occur in this region. These include (1) a specialized SCI pressure ulcer team that provides consultation and specific recommendations about feasibility of EST therapy, (2) provision of tools that enable ongoing collaboration and communication between community and rehabilitation providers, and (3) a focus on capacity-building and enhancing expertise in the community.

The model proposed that there be a specialized interdisciplinary team located within a tertiary SCI rehabilitation center (ie, St. Joseph's Health Care London, Parkwood Institute), where community-dwelling individuals with SCI with a new or existing pressure ulcer may be referred. Members of this specialized team should have collective knowledge and expertise in preventing and managing common conditions in persons with SCI as well as a firm understanding of best practices in wound care. The Canadian best practice guidelines23 recommend that the team consist of a physician (preferably a physiatrist specialized in SCI), a nurse specialized in wound care, an occupational therapist, a physiotherapist, a dietitian, and a social worker or psychologist. It was also suggested that each discipline would contribute to a comprehensive assessment and that the team would develop a preliminary interdisciplinary treatment plan, including recommendations for EST, if appropriate. These recommendations would be shared with the client and community care providers.

Ideally, successful implementation and effective care delivery occur when all stakeholders caring for a client share a sense of collaborative team, despite representing different organizations or settings. Although not clearly evident in the figure, one of the key aspects of this model is the need for ongoing collaboration and communication among the client's care team. This includes communications between the specialized SCI team and the providers in the community caring for the client. Ideally, successful implementation and effective care delivery would be facilitated by a shared sense that all stakeholders are part of the collaborative team approach for a given client – no matter if they represent different organizations or settings.

Before the treatment plan is initiated in the community, the specialized SCI team negotiates it with the client and/or their caregiver, the care coordinator, and community care providers. It is important to determine whether the treatment is acceptable and feasible within the community environment. Once finalized, the community providers would execute the treatment plan. They would then share the client's progress with the entire care team through follow-up care conferences. The unregulated care providers involved in the client's care should also be part of the care team, as they tend to interact with the client most frequently.

Another primary component of the model of care was to build capacity and enhance expertise in both the community and the rehabilitation setting. Therefore, it was felt that the specialized SCI team should also have an outreach component in which they would support community providers by providing education and training. On the other hand, the community providers have a clear understanding of home care and can educate the specialized SCI team on community processes and practices. By creating this 2-way flow of knowledge, we hope to strengthen the relationship between organizations and improve the quality of care we provide individuals with SCI.

To our knowledge, this is the first study to develop an adapted pressure ulcer model of care for healing pressure ulcers with EST by initially understanding the perceived facilitators and barriers to implementation. A significant number of perceived facilitators and barriers emerged following the stakeholder interviews, highlighting the complexities involved with implementing EST in the community. Several barriers identified in this study are comparable to other studies investigating implementation of evidence-based practice in health care, such as lack of time, problems with staffing including workload and understaffing, inadequate training and education, lack of resources, ineffective communication among team members, poor attitudes and beliefs toward practice change, incongruent polies and procedures, and difficulties reaching rural areas.41–47 This initiative did find some facilitators that could help foster implementation, including a clinical champion who could advocate for EST and obtain complete buy-in from all team members including rehabilitation, community, and the patients. These have been confirmed as necessary factors by other SCI-related implementation studies.48,49 

By classifying these items within the implementation drivers outlined by the NIRN model, we were able to visualize that changes are required not only at the individual and patient levels, but also at the organizational and system levels in order to successfully implement and sustain a practice change.41,42 This is noteworthy, as these implementation drivers are part of a structured (ideally facilitated) process to inform implementation action planning as part of the NIRN framework.38 These issues can be carried forward into the implementation action planning, with the success of these approaches assessed during the testing phase of this initiative.

When developing the model of care, the Steering Committee and Working Group agreed that not every barrier to implementation could be addressed. However, there were many discussions about possible options to manage the major barriers such as lack of communication and inadequate training and education. Improving communication amongst providers between or across setting and organizations may be achieved via teleconferences, videoconferences, and perhaps existing or newly developed electronic platforms. Once communication strategies are in place, it is likely that providers from rehabilitation and community can share their skills and expertise with one another to build capacity for pressure ulcer management. Alternatively, knowledge and skills related to EST can be gained through online resources and hands-on experiences provided by experts within the field.

As the model of care was being created, the Working Group proposed different models for integrating rehabilitation and primary care that would benefit persons with SCI, including a clinic approach, self-management program, outreach services, and a case management approach. These different approaches to care were combined to create our pressure ulcer model of care. Although each of these approaches has its advantages and disadvantages, together these models create a unique program to treat pressure ulcers in individuals with SCI living in the community. Interestingly, these models have all been previously shown to be feasible when managing persons with disabilities and chronic illnesses.50 Therefore, this SCI pressure ulcer model of care or aspects of the model is an exemplar for persons with other conditions, especially those with movement disorders who are at risk for developing ulcers.

This article also described in detail a method for gathering key initial implementation processes outlined by the KTA and NIRN framework. Using a CBPR approach seemed to be a good tactic given that the issue of pressure ulcers in the community was important to the team members and the assurance of collaboration resonated with the Steering Committee. More importantly, as researchers, we gained valuable insight into the advantages of using a CBPR approach, including the ability to create a trusting partnership with community members with diverse backgrounds, to achieve an understanding of the culture and dynamics of different communities and how a practice change such as implementing EST may not apply to other local circumstances, and to use community members as a primary resource to gain insight into how practices are run in different settings and organizations.

There are limitations that need to be addressed. When interviewing the stakeholders to gather the barriers and facilitators, the conversations were not audio recorded. Therefore, the meetings were not transcribed word for word, and appropriate coding could not be performed to complete a qualitative analysis. However, this phase of the initiative is intended to be exploratory and only requires an understanding of the issues that may be faced as the therapy is implemented into practice.

Another limitation was that there was poor representation from personal support workers, community dietitians, and occupational therapists in the stakeholders group who were interviewed. Fortunately, an administrator and clinical leader from a local nonprofit organization that provides attendant care services to individuals with disability participated in the Steering Committee and Working Group, respectively.

This article outlines a structured plan and collaborative approach between researchers and community members in developing a pressure ulcer model of care while taking into account perceived facilitators and barriers to implementing EST for managing pressure ulcers in the community-dwelling individuals with SCI. Using a similar stakeholder engagement approach, the next phase of the implementation planning will include further adapting the recommended practice in a 2-day ADAPTE workshop,51 where frontline providers will operationalize the model of care by taking into account the barriers to create process maps detailing steps needed to initiate EST in the local community. This will be followed by a field test using iterative Plan, Do, Study, Act (PDSA) cycles52 on a sample of community-dwelling individuals with SCI and pressure ulcers.

The authors declare no conflicts of interest.

This work was supported by the St. Joseph's Health Care Foundation (#078-1314). Deena Lala received support from Ontario Graduate Scholarship and the Siskinds Studentship in Spinal Cord Injury Research (grant #017-1516). Dr. Wolfe was supported by a collaborative mentorship agreement from Ontario Neurotrauma Foundation and Rick Hansen Institute (grant #2011-ONF-RHI-MT-930).