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Received: 27 May 2018 Revised: 29 September 2018 Accepted: 6 October 2018
DOI: 10.1111/iwj.13017

ORIGINAL ARTICLE

Wound management: Investigating the interprofessional decision-

making process
Corey Heerschap | Andrew Nicholas | Meredith Whitehead

Interprofessional Practice Department, Royal

Victoria Regional Health Centre, Barrie, Ontario,
Canada
Correspondence
Corey Heerschap, BScN, MScCH, RN,
WOCC(C), Interprofessional Practice Department,
Royal Victoria Regional Health Centre,
201 Georgian Dr, Barrie, ON L4M 6M2, Canada.
Email: heerschapc@rvh.on.ca
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 multi-
grounded 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 doc-
umentation 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.

KEYWORDS

clinical judgement, decision-making, interprofessional team, wound care, wound

management

1 | INTRODUCTION Previous research conducted on wound care decision-

The World Health Organisation has recognised wound man-
agement as a worldwide public health issue that is best man-
aged 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
making has shown a lack of literature on this topic, noting
that understanding this process could assist in the develop-
ment 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 estab-
lished theories, reducing the potential further grounding of
data.5 A more recent methodology, multigrounded theory
(MGT), allows for both the development of a grounded the-
ory 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

Int Wound J. 2019;16:233–242. wileyonlinelibrary.com/journal/iwj © 2018 Medicalhelplines.com Inc and John Wiley & Sons Ltd 233

234
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 environ-
ment 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 interpro-
fessional team members who participate in wound manage-
ment.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 interpro-
fessional 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.
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 com-
prised of three tasks including theory generation, explicit
grounding, and research interest reflection and revision.6 The-
ory generation is composed of inductive coding, conceptual
refinement, pattern coding, and theory condensation.5 Use of
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HEERSCHAP ET AL.
Key Messages
• the process of wound care decision-making is best supported
by an interprofessional team; however, there remains a paucity
of information on the social process that underlies interprofes-
sional decisions around wound management
• using a multigrounded theory approach in an acute care hospi-
tal setting, a socio-geographical transferable theory was devel-
oped outlining the basic social process used in wound
management by an interprofessional team
• ten elements in the wound-management decision-making pro-
cess were identified: patient factors, scope of practice, equip-
ment and supplies, internal clinician factors, knowledge and
education, interprofessional team, assessment, wound care
specialist consultation, and care plan, as well as documenta-
tion and communication
• wound care management decisions are made based on the cul-
mination of positive and negative influences among these
identified categories
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' prop-
erties 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 con-
densation then occurred until ten categories remained that out-
line our process. An example of coding can be seen in Table 2.
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 devel-
oped. 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 cate-
gories of our evolving theory to determine if further categor-
ical 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).
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HEERSCHAP ET AL. 235

TABLE 1 Participant demographics

Focus group stated

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

FIGURE 1 Elements of wound management

2.4 | Validation
5,8
Two validation strategies were used : (a) data triangulation,
to ground the findings from both an Australian and Canadian
context add to the study's validity; and (b) investigator trian-
gulation, 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 ses-
sions. 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 interprofes-
sional participants over three sessions and included

236
TABLE 2 Example of data analysis
Transcripted text and external theories
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.”
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.
“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))
FIGURE 2 Process of wound care decision-making
Registered Nurses, Registered Practical Nurses, Occupa-
tional Therapists, Physiotherapists, Dieticians, and a Physi-
cian 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 man-
agement experience. Participants noted their care for patients
with a variety of wounds including surgical, pressure-
related, chronic, skin tears, venous and arterial wounds, dia-
betic wounds, traumatic wounds, and disease-related
wounds. Demographic and education background is pro-
vided in Table 1.
In the tradition of MGT, a core category was not devel-
oped; 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 mean-
ing of their own. Linkages between the categories discov-
ered 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 dur-
ing 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
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HEERSCHAP ET AL.
Codes properties (values), (empirical data/
external theory), (interview number) Category (ontological category)
Fear (of blame), (ED), (interview #3) Internal clinical factors
(Intrasubjective part)
Supplies (accessibility), (ED), (interview #2) Equipment and supplies (artefacts)
Assessment (understanding patient goals), (ET), Assessment (intervention as
(Gillespie et al4) action)
wound care decision-making was not simply a linear pro-
cess, 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

HEERSCHAP ET AL.
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 encour-
age full participation in many factors related to wound heal-
ing. 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 accessi-
bility 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 infor-
mation 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 Assis-
tant, 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 dress-
ings 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 under-
standing dressing types leads to a lack of adherence to the
ordered treatment plan. Gillespie et al also noted how clini-
cians 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
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237
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. (Physi-
cian'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 Practi-
cal 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,

238
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 account-
ability 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 interprofes-
sional 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 say-
ing, okay this is what I think and not discuss-
ing it with other care members, because then
someone else can end up probably doing some-
thing 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 reposi-
tion, 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
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HEERSCHAP ET AL.
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 simi-
lar category—“Utilizing a multidisciplinary and holistic
approach” and noted that “collaborating with others' exem-
plified 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 com-
ponent 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 histori-
cally, 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 com-
plete 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 con-
sistent” in assessment and documentation, with
decision-making accentuated by patient assessment and stan-
dardisation 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 dis-
cussed as a beneficial resource for whenever wound compli-
cations 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

HEERSCHAP ET AL.
facility and consult a wound expert. (Physi-
cian's Assistant, Focus Group 2)
It was believed that for clinicians to be truly independent
in their decision-making process they required the appropri-
ate level of knowledge and education. Conversely, some cli-
nicians believed that due to over accessing of this resource
that it affected the ability of the wound care specialist to par-
ticipate 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 special-
ist 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 spe-
cialist, 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 devel-
oped care plan can have on their decision-making process.
Factors such as which medications the patient has been pre-
scribed, such as steroids, were noted to be a factor in deter-
mining 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 differ-
ently 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 consulta-
tion, in how when there were no orders present on the
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239
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 damag-
ing 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 incapa-
ble 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 fas-
ter 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 manage-
ment 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 commu-
nication practices. Some of the challenges articulated specifi-
cally acknowledged a lack of communication and
documentation, resulting in poor patient outcomes and
potentially replying on “second-hand information”.

240
…we need to be consistently talking the same
language and making decisions together about
how [the wound] is affected and how it's pro-
gressing… to ensure we are making the best
decision for that patient. (Occupational Thera-
pist, Focus Group 1)
Some of the challenges that I face from a nurs-
ing perspective is the sharing of information…
it's not necessarily been shared through docu-
mentation… 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… (Reg-
istered 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 comple-
ments 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 cur-
rent 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, equip-
ment and supplies, assessment, care plan, wound care spe-
cialist 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
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HEERSCHAP ET AL.
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. Flana-
gan advocates for the recognition of these topics in the con-
text 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 impor-
tant, yet the ability to critically review literature is not a real-
istic 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, Flana-
gan 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 clini-
cians 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 interna-
tionally.10 As Madsen notes, this wound care professional
takes on the role of change facilitator to encourage best prac-
tice 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 lead-
ership 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 Thera-
pists 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 per-
ceived their role in managing pressure-related wounds.

HEERSCHAP ET AL.
Along with the similar themes to this current study, Rose
and Mackenzie also noted that study participants stated posi-
tive and negative factors throughout their findings.11 Ineffec-
tive 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 evi-
dence, cost effectiveness, patient-driven choices, availability
of resources, and using a wide range of assessments were
areas highlighted through the focus groups with the Occupa-
tional 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 con-
sulted 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 priori-
ties 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 Occupa-
tional Therapist's role in pressure care management and fur-
ther promotion of their scope of practice and expertise in
this area.11 The current study findings also highlight a strug-
gle 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 occur-
ring. 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 interprofes-
sional teams and their ability to provide multiple perspectives
based on their individual expertise.12 Truglio-Londrigan dis-
cusses shared decision-making models and the importance of
health care professionals understanding the roles and exper-
tise of each professional involved in a patient's care.12 Partici-
pants of the wound care decision-making study also
discussed the importance of team work, both from the per-
spective 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' Asso-
ciation 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 manage-
ment 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
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241
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 develop-
ment 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 man-
agement and determine if healing is occurring.
Understanding wound cause and completing a detailed
wound assessment was a topic of great interest during partic-
ipant discussion. The importance of determining wound
cause and focusing on a holistic patient history and assess-
ment 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 compari-
sons 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 | L IM IT AT IO NS A N D I M PLI C ATI O NS
F O R FU T U RE RE S E AR C H
Although our focus group participant numbers were smaller
in most cases than the ideal five to eight participants, Krue-
ger 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

242
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 sam-
pling 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 het-
erogeneous 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, not-
ing 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 | CO N CL U S I ON AN D I M P L IC A T I ON S
FOR P RA CT IC E
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 act-
ing 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 imple-
mented to affect change in the decision-making process,
thereby affecting patient care. The basic social process
developed in this study describes how clinicians are influ-
enced 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.
ACKNOWLEDGEMENT
The authors would like to acknowledge Meg Hawthorn, Jay-
nee McCann, and Breanna Magnoli for their work in
1742481x, 2019, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iwj.13017 by Nat Prov Indonesia, Wiley Online Library on [01/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
HEERSCHAP ET AL.
transcription of focus group data during the initial phases of
this study. The authors would also like to acknowledge the
author's time allocated to this study by the Royal Victoria
Regional Health Centre Interprofessional Practice Depart-
ment and managers Catherine Petch, Jeanette Johnson, and
Sarah Morris. The authors would also like to acknowledge
the external review of Dr. Giulio Didiodato and Dr. Jesse
McLean.
OR CID
Corey Heerschap https://orcid.org/0000-0001-7780-2528
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How to cite this article: Heerschap C, Nicholas A,
Whitehead M. Wound management: Investigating the
interprofessional decision-making process. Int Wound
J. 2019;16:233–242. https://doi.org/10.1111/iwj.
13017