Paradigm shift: A clarion call for a holistic approach to chronic wound management

Advances in Skin & Wound Care,  Jan/Feb 2000  by Popoola, Mercy Mammah

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"Heating is a matter of time, but it is sometimes a matter of opportunity."

-Hippocrates

chronic wound is any disruption of the anatomic or physiologic funcdons of tissue, complicated by 1 or more chronic illnesses, and lasting more than 3 months. Such wounds can affect the whole person and lead to serious systemic and bone infections, resulting in costly treatment, amputation, and/or death.1

The prevalence and cost of managing chronic wounds continue to escalate, despite the availability of advanced wound care products, specialists and consultants, and the creation of risk assessment tools and wound healing centers. Because of the serious morbidity and financial costs precipitated by these wounds, a clarion call is made to health care providers, payers, and policymakers to revisit the way such wounds are managed today.

A multidisciplinary approach is critical for chronic wound management. However, economic costs to every system can be enormous, and lack of coordination or improper use of providers can lead to fragmentation of care and health complications. This prompts the need for an approach to wound management that will decrease cost, improve quality of care, and decrease incidence and prevalence of chronic wounds.

Healing, Not Fixing

During a recent presentation to 20 enterostomal nurses, I asked if they had been taught holistic approaches to patient care; all 20 had. When I asked their opinions on applying this approach to the management of chronic wounds, about 95% expressed approval. Later, I asked a group of 8 physicians the same question. Their debate centered on acupuncture, therapeutic touch, and other types of alternative medicine. Although alternative medicine has its place in practice, a holistic approach to patient care goes beyond these treatment methods.

Holism is an approach to care based on the premise that the whole is greater than the sum of its parts. In 1859, Florence Nightingale addressed this concept in the following statement: "In watching disease, both in private houses and in public hospitals, the thing which strikes the experienced observer most forcibly is this, that the symptoms of the sufferings generally considered to be inevitable and incident to the disease are very often not symptoms of the disease at all, but of something quite different."2

The holistic view of clinical practice, then, provides an opportunity to assess the patient as a whole, rather than focus on the illness or wound. It not only considers cost to the patient and health care system, but also strives for "healing" rather than immediate and/or temporary "fixing" or "curing" of the illness or wound.3,4 The clinician is required to consider the physiologic, sociologic, economic, psychological, and spiritual issues involved in the management of a patient's medical condition (Figure 1).

Beyond the Physical Wound

Applying this approach to chronic wound management allows clinicians to look beyond the physical presentation of a wound and assess the patient as a whole while combining treatment methods. For instance, a holistic approach helps a clinician see that a patient with a sacral pressure ulcer will not heal by simply turning him or her from side to side. Rather, healing will come from ongoing management and understanding of such patient concerns as incontinence, nutrition, mobility and pressure status, among others. This approach allows the clinician to see that a venous ulcer with drainage is already moist and does not require more wet-tomoist dressings. Instead, the wound requires ongoing compression therapy, proper skin care, and proper use of appropriate dressing products.

Simply put, the holistic approach allows clinicians to do more than "fix" a problem. It provides health care practiboners with an opportunity to educate patients and families (where appropriate) about continuing self-care and takes into consideration a patient's economic situation, insurance, employment, dressing needs and, if the patient is diabetic, offloading of the foot.

This clarion call is not limited to the health care professionals who care for patients with wounds. This call is intended to open the debate with policymakers, managed care organizations, wound care product manufacturers, and all others involved in the management of chronic wounds. In short, this call represents a paradigm shift from the present "fix it" curing model of practice5 to a more caring and healing approach.2,3

REFERENCES

1. Krasner D, Kane D. Chronic wound care: a clinical source book for healthcare professionals. 2nd ed. Wayne, PA: Health Management Publications, Inc; 1997.

2. Nightingale F. Notes on nursing: what it is and What it is not. London: Harrison; 1859 (reprinted by Lippincott,1946).

3. Anderson JM. Home care management in chronic illness and the self-care movement: an analysis of ideologies and economic processes influencing policy decisions. Advances in Nursing Science 1990;12(2):71-83.

4.Watson J. Nursing: human science and human care-a theory of nursing. New York: National League for Nursing; 1988.