Abstract
Surgical wound dehiscence is a serious postoperative complication associated with a high mortality rate ranging from 10% to 44%. Older patients, as well as those with chronic conditions, are at a greater risk of the development of this condition due to the peculiarities of body mechanics. Renal transplantation operations are becoming more common, and the number of people undergoing this procedure is growing steadily. Although some surgical wound dehiscence prevention strategies exist, their effectiveness is limited. This project will involve the development of a pamphlet for renal transplantation patients at Saint Barnabas Medical Center. The pamphlet will include visuals addressing such aspects as surgical wound dehiscence prevention, appropriate posture and movements, and the importance of following these recommendations. The created visual aids will be aimed at all renal transplantation patients, irrespective of their demographic peculiarities. The pamphlet will be presented to the nursing staff, who will decide whether the proposed visual aid can be utilized in patient education.
Introduction
Postoperative complications are some of the most urgent challenges in the clinical setting to address due to the diverse negative consequences associated with this issue. Patient negative outcomes, longer hospital stays, a higher rate of re-operation, additional costs, and deteriorated quality of patient’s life are among the problems linked to various types of postoperative complications. Wound dehiscence remains a common condition despite the development of preoperative and postoperative care strategies and the improvement of suture materials (Levi et al., 2016). It has been estimated that the mortality rate associated with this complication can reach up to 44% (Chun et al., 2018). Surgical wound dehiscence can be defined as “a postoperative complication involving breakdown of surgical incision site” (Chun et al., 2018, p. 74). This condition is specifically common among abdominal surgery patients, including those who undergo renal transplantation (Boden et al., 2018). Due to the potential harm to patient outcomes, as well as other negative consequences, researchers and practitioners acknowledge the issue and try to develop effective strategies to address it.
The analysis of factors contributing to surgical wound dehiscence is one of the primary measures undertaken to create appropriate preventive methods. Some of the most influential risk factors are patient age, wound infection, hypoproteinemia, hypertension, anemia, obesity, emergency surgery, drain, suture material, as well as vomiting, constipation, and excessive coughing (Chun et al., 2018). In many cases, a set of factors lead to the development of the condition under analysis. Chun et al. (2018) noted that a combination of five risk factors increased the chance of dehiscence development considerably. Although factors causing dehiscence have been researched in detail, the exact body mechanics are yet to be explored (Levi et al., 2016; Strong & Smit, 2018). Only several studies have been implemented to describe the peculiarities of this process, which shows the need to continue the analysis of this aspect. The understanding of body mechanics will be instrumental in developing effective prevention strategies as researchers and practitioners will be able to concentrate on the most relevant problems.
In addition to the gaps in the knowledge base regarding the exact mechanisms of dehiscence, the existing prevention methods’ effectiveness is limited. The prevalence of the condition suggests that the employed strategies fail to address the issue. Patient education regarding wound care and self-management remain the basic approach aimed at dehiscence prevention. Patients are trained in various ways including clinically-set conversations, workshops, print materials, and digital-based training, among others (Liebner, 2015; Poole, Maslen, & Taylor, 2016; Woollen & Bakken, 2015). It is common to utilize a set of instruments to facilitate the training process.
Print materials are quite common tools and are often widely used to educate patients. Visual materials facilitate the learning process, and this technique has proved to be effective (Woollen & Bakken, 2015). At the same time, there is still no exact visual document that could be utilized in different healthcare facilities, which unveils a specific gap to be filled. Diverse visual aids in many forms (leaflets, posters, and other types) are introduced and evaluated in terms of their effects on patient self-care. For instance, Van Beusekom, Grootens-Wiegers, Bos, Guchelaar, and Van den Broek (2016) measured the efficacy of the use of leaflets at a healthcare facility and concluded that the developed visual aids were “discouraging” and ineffective (p. 1372). Therefore, the creation of visual aids that can be intelligible and useful for patients is an area of specific concern, specifically when it comes to nursing professionals who have little time to communicate with patients. This study will entail the development of a pamphlet with a number of visuals aimed at preventing dehiscence in renal transplantation patients at Saint Barnabas Medical Center.
Problem Statement
Surgical wound dehiscence is becoming a substantial healthcare burden for American healthcare facilities due to several reasons. One of the primary factors intensifying the severity of the issue is the aging population of the USA. As mentioned above, patient age is one of the major risk factors associated with the condition under analysis as tissue repair mechanisms are substantially deteriorated in aging people, which makes this population more vulnerable compare to younger patients (Chun et al., 2018). However, other patients at a high risk of dehiscence are also numerous as obesity, which is another cause of this surgery complication is still persistent in the country. In addition, hospital-acquired infections remain common and often have a negative effect on the healing process. Another serious aspect of the problem is the fact that dehiscence may occur 30 (or more) days after surgery (Chun et al., 2018). Patients tend to be less attentive and responsible one or several months after their discharge from the hospital. Therefore, effective prevention methods should be developed to minimize the occurrence of surgical wound dehiscence.
The use of pamphlet containing information regarding correct posture, movements, symptoms, as well as actions to be undertaken when they detect the sign of dehiscence can help patients to prevent this postoperative complication. Endla (2018) notes that nurses often lack knowledge and skills regarding body mechanics, so the development of visual aids can serve as educational materials for both nurses and patients. The created pamphlet will be distributed among nurses of the Saint Barnabas Medical Center, and an oral presentation will be provided to introduce a new instrument and discuss its usefulness. The leaflet will include visuals with textual clarifications related to the appropriate posture, movements, and activities. The depicted figures perform the tasks an average person has to fulfill on a daily basis, which can make patients more responsible and willing to follow the provided recommendations. Several discussions with the nursing staff will take place prior to and after the presentation in order to explore nurses’ opinions on the target health issue and the usability of the leaflets.
Background
The US health care is characterized by the use of advanced technology and innovative methods, as well as high costs and a high rate of readmission and adverse patient outcomes linked to numerous health conditions. Postoperative complications are also common, which increases costs (for the system and patients) and the overall dissatisfaction with the received services (Boden et al., 2018). Although healthcare professionals may utilize various technologies and methods to make incisions minimal, the occurrence of surgical wound dehiscence remains rather high. As mentioned above, some causes of dehiscence are associated with patients’ peculiarities (their age, skin, health status, lifestyle, and others). However, other factors contributing to the development of this condition are medical error (primarily, hospital-acquired infections), the use of certain materials (suture, drain, among others), and insufficient patient training (Chun et al., 2018). The aggregate of these causes reveals the vulnerability of the system and the need to take urgent actions to address the issue.
Renal transplantation is a procedure that may involve diverse populations irrespective of their features. The practice has been implemented for decades, but currently, kidney transplantation trends are changing. The process has become more complex and resource-intensive due to several reasons, including but not confined to shifts in demographics of recipients and organ quality decline (Axelrod et al., 2017). Thousands of people require transplantations, which is illustrated by the existing waiting lists. For example, according to the OPTN/SRTR 2016 Annual Data Report (chapter Kidney), in 2016, 30,869 candidates were added to the list while 33,291 were removed from it (Hart et al., 2018). It has been estimated that over one-fourth of 33,291 were removed from the list due to deteriorated health or their death (Hart et al., 2018). It is clear that kidney transplantation remains a frequent medical procedure that saves the lives of thousands of patients.
Another important trend related to renal transplantation is associated with the age of recipient patients. The increase of 250% of candidates on the waiting lists aged 65 or older at the time of the operation was identified in 2016 (Axelrod et al., 2017). This information is specifically relevant for the present project that is linked to dehiscence prevention as aging people are prone to the development of this postoperative complication. Due to the changing demographic characteristics of the US population, the rate of older patients requiring renal transplantation is likely to increase, which may be associated with the growth of the incidence of dehiscence. The need for effective dehiscence preventive measures is apparent, and it is clear that older patients may need particular attention.
The persistence of the incidence of dehiscence suggests that the existing measures are insufficient, and the increasing number of transplantations may result in a higher rate of this surgical wound complication. It has been acknowledged that the quality of self-management training has an influence on readmission rates including reoperations due to dehiscence (Schaffler et al., 2018). However, the effectiveness of such preventive measures is often limited (Van Beusekom et al., 2016). It is noteworthy that the reasons for the low efficacy of many prevention instruments remain unclear. The contributing factors can be patients’ low adherence to provided guidelines, lack of professional training provided to patients, and low-quality (low efficacy) of the educational materials given to patients. It is necessary to develop effective educational materials facilitating patients’ self-care.
Purpose
The purpose of this project is to develop a pamphlet aimed at preventing dehiscence though body mechanics in renal transplantation patients. As mentioned above, numerous interventions aimed at dehiscence prevention exist, but their efficiency and cost-effectiveness are limited or doubtful (Van Beusekom et al., 2016). At the same time, the use of visual materials as an effective alternative to costly programs is gaining momentum. Woollen and Bakken (2015) argued that visual aids were instrumental in assisting patients and their caregivers in addressing their health issues. Therefore, a pamphlet can assist renal patients in avoiding dehiscence and, as a result, readmission, reoperation, and other procedures that can be associated with additional health risks. The development of the visual aid for patients will improve patient outcomes and the quality of provided care, as well as reduce undesirable costs and losses for the hospital.
In addition to these outcomes, the utilization of discharge sheets can help nurses remain updated and provide training to patients. The discharge sheets can be used as checklists for nurses, especially those who work recently. Nurse leaders will be able to employ the sheets as training materials or visual aids during regular meetings. The distribution of discharge sheets will have a positive effect on the nursing staff because these healthcare practitioners will be less overloaded when discharging patients. Instead of repeating the information they provided during the stay and answering questions, nurses will provide discharge sheets, emphasize the need to adhere to the given instructions, and respond to questions that may arise.
The Nature of the Project
This project aims at the development of a tool aimed at preventing surgical wound dehiscence among renal transplantation patients. The project will be divided into several stages, such as the creation of the pamphlet, the discussion of surgical wound dehiscence with nurses, and the discussion of the potential use of the suggested pamphlet. Lewin’s model of change will be utilized during this project. The model includes such steps as unfreezing, changing, and refreezing (Bassot, 2015). During the first stage, the discussion of the incidence of surgical wound dehiscence among the patients of the Saint Barnabas Medical Center will be held. The unfreezing stage requires specific attention to the incidence of certain health issues and their outcomes. It is critical to make the stakeholders willing to change the status quo and bring new practices or norms to life (Bassot, 2015). If this phase is omitted or implemented ineffectively, nurses will be unwilling to change anything or the change will not be integrated into the daily practice of the staff.
The associated topics will be discussed during individual meetings and regular meetings of the nursing staff. Formal and informal communication channels will be utilized to identify the attitudes of nursing professionals to the problems and potential solutions. At this stage, the nurses will consider the urgency of the problem and the need to develop a sound solution within a short period of time. If the urgency of the problem is established, nurses will be more committed to change and will use the pamphlet to educate their patients, as well as gain knowledge and skills.
The suggested pamphlet will include several visuals and textual captions explaining them. Males and females will be depicted to make the leaflet appropriate for diverse populations. Each segment will include a correct posture or movement, as well as an incorrect one. The latter will be crossed to make the information more understandable. The pamphlet will include only the most relevant aspects to ensure that patients will look all the information through and follow the given recommendations. Part A of the pamphlet includes the most relevant information regarding the physical activity of renal transplantation patients after the surgery, as well as instructions and visuals concerning dressing, brushing teeth, toileting, doing laundry, and vacuuming. Part B highlights such activities as bending, making the bed, getting into and out of the car, as well as proper posture-standing and posture-sitting. At the bottom of Part B, the major symptoms of wound dehiscence are described, and the patients are encouraged to address medics if any of these signs occur.
The next stage implies the implementation of change, so the oral presentation of the pamphlet will be provided during a formal meeting. The focus will be on the need to educate patients regarding the prevention of surgical wound dehiscence. The benefits of the leaflet and ways to use it effectively will be highlighted. After the presentation, nurses will be encouraged to share their views on the pamphlet and its usability. Nursing practitioners will be asked to share their opinions and the possibility of distributing the visuals among renal transplantation patients. Endla (2018) stresses that educational programs for nurses aimed at raising awareness of body mechanics were instrumental in improving patient outcomes. Therefore, the created leaflet will be a good educational material for nurses, as well as patients.
During the refreezing stage, a new discussion will take place during a regular meeting of the nursing staff. The nurses will share their views concerning the pamphlet, their experiences associated with this tool, and their willingness to distribute it among renal transplantation patients. These healthcare professionals will discuss the effectiveness of the developed leaflet in patient education. This final stage will ensure the establishment of a specific norm as nurses will make the pamphlet a part of their work with patients.
Finally, the evaluation of the project implementation should be conducted in order to estimate its effectiveness. Discussions and interviews will be the primary method of data collection. During regular meetings, nurses will discuss the outcomes of their use of the pamphlets. The focus will be on the convenience and usability of the visual, patients’ response to the leaflet, and any concerns or challenges related to the use of the pamphlet. Several interviews may be held two months after the beginning of the project in order to understand the perspectives of nurse leaders and other nurses.
Research Question
The present project will be guided by a research question that was developed in terms of the PICO process. The target population of this project will be renal transplantation patients, and the use of visual pamphlet will be the intervention under analysis. The pamphlet will include information regarding dehiscence prevention strategies and related data. Visuals and textual information will be included in the leaflets. The new tools will be provided to nursing professionals who will discuss the effectiveness of the pamphlet and the possibility of their use at the Saint Barnabas Medical Center. The nurses will decide whether they will distribute the leaflets among renal transplantation patients. Hence, the research question can be formulated in the following way:
Will the distribution of visual pamphlet aimed at surgical wound dehiscence among renal transplantation patients improve their health outcomes?
Summary
In summary, it is necessary to state that surgical wound dehiscence is a serious postoperative complication. The aging population of the USA poses new challenges to the healthcare system as the number of transplantations is increasing and likely to grow considerably in the near future. Although various interventions have been developed, the rate of renal transplantation patients who develop this complication is still high. The purpose of the present project is to create pamphlet aimed at preventing dehiscence in renal transplantation patients.
This project involves the creation of a pamphlet where the most relevant recommendations will be provided in a visual form. This approach is gaining momentum in diverse spheres, and the use of visuals is regarded as an effective measure. The developed pamphlet will contain visual and textual information, providing the most relevant details regarding body mechanics, dehiscence prevention, and associated aspects. The implementation of the project will be guided by Lewin’s model of change. The project will involve an oral presentation, during which the pamphlets will be distributed among the nurses. Prior to the presentation, the incidence of surgical wound dehiscence will be discussed with nursing professionals during individual and group meetings. The research question that will be addressed within the scope of the present project is formulated as follows: Will the distribution of visual pamphlet aimed at surgical wound dehiscence among renal transplantation patients improve their health outcomes?
Future research may involve the focus on several aspects of the problem, including body mechanics and prevention. It is possible to continue exploring the body mechanics of surgical wounds after renal transplantation. Specific attention should be paid to body mechanics in different age groups, as well as the peculiarities of wound dehiscence in female and male patients, low-income and middle-class people, and other populations. These groups often have dissimilar lifestyles, which can become a significant factor contributing to wound dehiscence. Research aiming prevention may include the examination of specific physical activities and lifestyles preventing the occurrence of the problem. Patient training should also be further explored to develop effective educational programs for patients pertaining to different age, gender, cultural, and socioeconomic groups.
As for the future of this project, if the project proves to be successful, the corresponding protocols will be developed at the Saint Barnabas Medical Center. After its evaluation, it can also be refined and implemented with a larger population. The information regarding the project will be disseminated through the publication in a peer-reviewed journal, and the program will be implemented in other clinics across the city. The next section of the paper is Chapter 2 that includes a review of the current literature on the matter.
Literature Review
Introduction
This chapter includes an overview of the current literature regarding surgical wound dehiscence. The primary areas of concern researchers study involve the incidence and demographic peculiarities of the postoperative complication, patient literacy and education concerning their self-management, and the benefits of the information visualization approach. Primary studies and reviews are analyzed to explore the major findings that can be helpful to facilitate the present project. The number of studies aimed at evaluating training interventions is quite high, but it is also apparent that the effectiveness of the existing interventions is limited, or more research is required.
Incidence of Surgical Wound Dehiscence
The focus on the incidence and peculiarities of surgical wound dehiscence is justified as it is critical to understand the phenomenon in order to address the associated issues. Renal transplantation is a frequent procedure, and thousands of people require it in the USA (Hart et al., 2018). Hart et al. (2018) provided the data of the governmental report and noted that over 30,000 people were added to the list of patients waiting for the procedure. Axelrod et al. (2017) argued that the demographics of this procedure started changing substantially, and the number of elderly patients grew exponentially in 2016.
The mechanics of the health condition in question have also received sufficient attention among researchers. Strong and Smit (2018) reviewed the knowledge base on the specifics of tissue damage and concluded that force and the quality of tissue are major factors contributing to damage including dehiscence. Chun et al. (2018) added that the type of surgery (including its duration) and patient age were influential factors as well. The review of the existing literature regarding the peculiarities and incidence of wound dehiscence suggests that the rate of this postoperative complication can increase due to the growing rate of transplantations and the aging population.
Patient Education
Patient education has proved to be an effective strategy contributing to the improved health status of people. Nursing professionals focus on raising the awareness of patients and their close ones regarding disorders, prevention, treatment, self-management, and other areas (Liebner, 2015; Poole et al., 2016). Researchers pay attention to numerous aspects of patient education identifying existing issues and effective methods. Both quantitative and qualitative methods are employed to analyze various aspects of interventions and their efficacy. Kang, Gillespie, Tobiano, and Chaboyer (2018) found that the effectiveness of patient training depends on the frequency and duration of training sessions, as well as the use of diverse types of materials and technology. Boden et al. (2018) also suggested that education combined with exercise could be an effective preventive treatment for patients at a high risk of abdominal wound dehiscence. Endla (2018) also shed light on an important aspect of patient education, which is the provision of training to the nursing staff. The researcher found that educating nurses on body mechanics improved the provided care and patient training.
It has been found that the characteristics of patients should be central to the process of the development of educational interventions. Liebner (2015) emphasized that perioperative education should be characterized by the use of programs based on different learning styles. At that, Schaffler et al. (2018) found that income, age, and literacy had no significant impact on the effectiveness of self-management interventions. The authors added that the available literature suggested that the effectiveness of the interventions is limited. Boga (2019) stated that patients’ age and cognitive peculiarities are important features to consider when designing educational programs. It is also noted that more research is needed to evaluate the existing and upcoming programs and interventions.
Information Visualization
The form of training and materials provided to patients have also become the topics researchers investigate. Liebner (2015) claimed that visual aids given to patients to improve their self-management skills are often ineffective due to inappropriate design, including such details as ineligible texts and complex graphics. The author noted that the adherence to such recommendations is low since people are discouraged to use such materials. Woollen and Bakken (2015) reviewed the benefits of the information visualization (infovisual) approach and concluded that info visual could improve information dissemination and patient outcomes. Although visuals are more understandable for patients, Poole et al. (2016) stated that the materials provided to people should be consistent with their visual and cognitive abilities. People perceive visually facilitated information more easily, which can be specifically valuable with certain populations.
The utilization of visual aids is often accompanied by the use of other tools and strategies. Slota, McLaughlin, Bradford, Langley, and Vittone (2018) employed the concept of visual intelligence to evaluate interdisciplinary learning experiences stressing that learners benefited from using their visual intelligence. Van Beusekom et al. (2016) implemented a qualitative study and found that textual leaflets were seen as ineffective and frustrating while visual information improved patients’ motivation and literacy. The positive influence of visual aids in learning is apparent, so information visualization can become an indispensable element of patient education. At the same time, it is clear that visuals should be designed for specific populations due to their peculiarities. Moreover, healthcare practitioners may need some training to ensure the effectiveness of the use of visuals in patient education.
Conclusion
The review of the existing literature on the matter suggests that dehiscence is a common postoperative complication, and its incidence is likely to increase due to the demographic peculiarities of the U.S. population. Older patients are at a higher risk of developing this condition due to the peculiarities of body mechanics. Both quantitative and qualitative data are available, and diverse aspects of the problem have been analyzed in academia. Patient education is regarded as an important element of care provided to patients and their families that facilitates the healing process and contributes to the prevention of health deterioration. The visual information approach is becoming widely used to educate patients due to the effectiveness of this method. It is found that visual materials need to correspond to patients’ cognitive abilities and other peculiarities, which can ensure people’s adherence to the recommendations. This literature review suggests that there are no visual aids developed for older renal transplantation patients that have been evaluated and utilized in different clinical settings.
Summary
The implemented literature review shows that the incidence of surgical wound dehiscence among patients is increasing, which is becoming a considerable health concern. In order to avoid this health condition, patients receive training that is usually confined to the provision of certain guides and textual materials. However, the effectiveness of such interventions is limited due to the peculiarities of people’s perception, as patients prefer visual information with clear images. The use of visuals is becoming more common, but there is still no material developed specifically for renal transplantation patients. Therefore, it is necessary to develop the corresponding visual aids since the mechanics of dehiscence is rather specific in each case and requires quite particular preventive measures. These materials should be clear, usable, and consistent with the target group’s cognitive abilities.
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Appendix A
