A dissertation on Wound Assessment in Diabetic Foot Ulcer.

A dissertation on

Wound Assessment in Diabetic Foot Ulcer.

Diabetic foot ulcer is a complication that results from diabetes mellitus. The aim of this paper is to address how to assess the wounds that are formed as a result of foot ulcers. The assessment of the wounds involves a physical examination, dermatological examination, and many other observations. The aim of the assessment is to find a solution and to find ways of classifying and treating the wounds.

I would have expected a little more detail in your abstract to inform the reader of the scope of your work.

 

 Removed to ensure privacy

TABLE OF CONTENTS

TITLE                                                                                                                            PAGE

Chapter One: Introduction …………………………………………………………………………. 5
………………………………………………………………………………………… 5
Dissertation Aim…………………………………………………………………………………… 7
Dissertation Question……………………………………………………………………………. 8
Search Strategy…………………………………………………………………………………….. 8
Chapter Two: Literature Review…………………………………………………………………….
Introduction …………………………………………………………………………………………..
Causes of Diabetic foot ulcer…………………………………………………………………..
Wound assessment of diabetic foot ulcer…………………………………………………..
Treatment of the wound…………………………………………………………………………..
Summary of the literature review………………………………………………………………
Recommendation for local service improvement………………………………………….
Leadership and service improvement………………………………………………………………
Service improvement in the healthcare sector………………………………………………
Leadership in healthcare and service improvement ……………………………………..
Leadership theories………………………………………………………………………………….
Leadership styles…………………………………………………………………………………….
Introduction of the best wound assessment tools in local practice…………………
Conclusion…………………………………………………………………………………………………..
References………………………………………………………………………………………………… 9
Appendix…………………………………………………………………………………………………….
Chapter One.
Introduction
The cases of diabetes type 2 are increasing worldwide. It is widespread, but can also be prevented. Among all the adults diagnosed with diabetes, 90-95% of them have type 2 diabetes. You need to support factual statements with references

Additionally, about 29.1 million people in the US have diabetes. Up to 9.2% of pregnant women are diagnosed with gestational diabetes and, 10% develop type 2 diabetes right after the pregnancy (Boulton, 2008). The risk of contracting this type of diabetes increases with the increase in age. Several morbidities are associated with diabetes. These include dyslipidemia, obesity, hypertension, diabetic foot ulcer, kidney disease, and cardiovascular diseases. This dissertation will deal with Diabetic Foot Ulcers (DFU). Up to 5% of diabetes patients will develop DFU and 15% of them develop the complication. DFU is characterized by red sores which develop on the patient’s foot (Boulton, 2013). Managing DFU is important for improving the quality of life of the patients and, it begins with wound assessment.

Wound assessment involves identifying and incapacitating obstacles to healing and is essential to the development of wound treatment systems. The elements that influence the healing of a wound are sufficient oxygen supply and the presence of infections. A supporting reference should be included here

Thorough wound assessment involves conducting a general review of the patient’s health and locally identifying the history and the characteristic of the wound (Eagle, 2009, p.20).This will guide the physician in the appropriate treatment to help attain rapid healing of the wound. The main aim of assessing the general health is to discover and eradicate factors which may disturb the process of healing.

Features that may affect the process of wound remedy include the age of the patient. As people age, there are at a risk of going through physiological alterations that puts them at a risk of poor wound healing. Some common changes related to age that affects wound healing are the reduced skin elasticity. Degradation of the dermal layer and the collagen fibers causes the skin to become loose for the old people. These two elements often provide flexibility, strength, and helps tissues recover to its initial state (Eagle, 2009, p.22). If a patient with diabetic foot ulcer is old, the tissues of his leg will be less elastic and thus make it difficult to the area affected to return to its natural color and shape. Slow collagen replacement is also another factor that can hinder wound healing (Bakker, Apelqvist &Schaper 2012, p.228) Collagen is essential for tissue regeneration and the cellular development in the entire dermis area. Age-related diseases like cardiovascular disease and the presence of diabetes will also affect the wounds since the blood supply to the foot will be affected.

Another factor that affects the wound healing process is the presence of a disease and the use of medication. If the diabetic individual is under some medications which affect the formation or functions of platelets the healing wound will be further affected. Glucocorticoid Steroids often used as anti-inflammatory means have significant effects on the healing of wounds (Sen, 2009, p.7).  This medication inhibits the formation of granulation tissues and leads to reduced wound contraction. It also prevents the formation of hypoxia-inducible factor-1 which is a key element in healing wounds. Non-steroidal anti-inflammatory medications are also proved to have negative effects on wound healing

Another general health element to be considered is obesity. The frequency of obesity has continued to rise among the entire population. Obesity increases the risk of various health conditions and risk of diseases. Among the complication it has is reducing the wound healing process. If the diabetic foot ulcer patient is obese, there are chances that the wound healing will be impaired. A supporting reference should be included here

Obese individuals often have skin complications which include infection of wounds and increased tension on wounds. Wound tension affects the oxygen supply to the wound and increases pressure in the tissues (Markova &Mostow, 2012, p.110). Alcohol consumption is also an examination taken by the physician. Alcohol reduces wound healing ability and increases the chances of contracting infections. Diabetic foot ulcer patient exposure to alcohol reduces the patient’s resistance and intoxications caused by ethanol causes the infections. Ethanol also affects the proliferative process of healing

The sex hormones in the aged individuals is also an important health factor to examine. Aged males have a slow wound healing ability as compared to aged females. The female estrogens and the male androgens contribute to the wound healing process (Baranoski &Ayello, 2008). The difference in the expression of genes in the young and old people wound healing is affected by estrogen. Estrogen affects some genes which are responsible for tissue regeneration, inflammation, and epidermal function. Androgens, on the other hand, negatively affect wound healing. Moreover, stress levels of an individual will have impacts on wound healing (Baranoski &Ayello, 2008). Stress causes deregulation in the body’s immune system. It also affects the hormones needed for wound healing and reduces pro-inflammatory cytokines level in the wound sites. Additionally, stress results in negative emotions which will result in negative effects on the physiological processes and the health of the individual. Diabetic foot ulcer patients need to avoid stressors.

After the general patient assessment, the next step is making an accurate assessment of the wound to identify local elements that could be affecting it. This involves reviewing the history of the wound and looking at the characteristics of the wound. The characteristics include the condition of the wound bed, the presence of pain, and its location, depth, and size. In assessing the wounds, a physical examination is conducted on the skin, neurological system, musculoskeletal systems, and the vascular systems. Visual inspection of the skin also takes place. Systolic blood pressure can also be measured in the arms and ankles to check for peripheral arterial disease (Sen, 2009, 15). Neuropathy, on the other hand, can be identified by symptoms such as muscle cramps, and stabbing pains. Neuropathy Disability score is also another test that can be used. Another assessment means measuring limb temperature and vibration perception. Whatever method is chosen, there is the need for correct classification of the problem to facilitate correct treatment.

Wound assessment will include, observations and measurements of the wound bed, the presence of pain, and its location, depth, and size, skin, integrity in general, blood supply to the area, associated symptoms such as muscle cramps, and stabbing pains.

You have discussed ulcers, their causes and assessment. You needed to include further supporting references for the content covered. You should have also drawn on more epidemiological statistics around incidence both locally in Oman and the GCC states and wider international comparisons.

1.2 Dissertation Aim

To explore the assessment of diabetic foot ulcers and role of nurse.

1.3 Dissertation Question

What is the right approach to assess wounds in diabetic foot ulcers?

According to the aim, the dissertation will answer what causes the complication, Your aim is focussed on assessment not causes you could be clearer here.

the dissertation question by exploring the strategies involved in this sector.

1.4 Search Strategy.

In order to find the most appropriate literature to achieve the aim, a comprehensive search is required. Holland and Reese advocate clear identification of search terms and inclusion/exclusion.

It involved searching for the keywords like diabetic foot ulcers, wound healing, tissue regeneration, proliferation, and inflammation. The search engine used was Google scholar. The databases used were Medline Plus and PubMed. The articles used were initially ten but later narrowed down to five. Exclusion and inclusion criteria were used in the literature selection. Under the inclusion criteria, the articles used were the English articles, articles that guide on understanding diabetic foot ulcers, articles that deal with the management, assessment, and classification of foot ulcers, articles that describe the elements of wound healing, and articles that explain the process of wound assessment.

Key Words

Inclusion

Exclusion

 Diabetic foot ulcers, wound healing

Tissue regeneration, proliferation, inflammation

English

Data range

Geography

The study name for this research is known as Wound Assessment Project and was carried out in 2017 with the aim of identifying whether the wound assessment tools utilized by nurses all over are relevant for that purpose. We aimed at identifying high-quality practices to be used by nurses in the wound assessment procedures. The wound assessment tools were evaluated against the international literature developed on wound assessment. When the criteria was disagreed, a wound specialist was consulted to help in coming up with the final decision. The optimum wound assessment tool was identified by analyzing the components it assesses. This includes the characteristic and the details of the wound, patient’s details, wound measurement, tissue type, exudate, surrounding skin, pain, and the signs of infections. Other components of the tools used that we were interested in include documentation, communication and continuity of care, ease of use,  the setting of goals for healing and planning care, monitoring the healing process, and guiding practice.

The study group was composed of the wound assessment tools, and we selected the tools from those already in use by nurses, those published and those that are unpublished. We eventually used ten tools, the Sessing Scale, National Wound Assessment Form (NWAF), Applied Wound Management (AWM), Wound Assessment and Management System (WAMS), Leg Ulcer Measurement Tool (LUMT), and Pressure Ulcer Scale (PUS) for Healing. The other tools include the Sussman Wound Healing Tool (SWHT), Bates-Jenson Wound Assessment Tool (BWAT), and the T.I.M.E Wound Assessment Tool (TWAT).  To obtain the results of our study, we used the audit tool development approach. We developed our own measurement tool since no audit toll existed. The measuring tool measured the quality of each wound assessment tool. The results of the study had the most reliable tool as AWM, followed by NWAF, TWAT, WAMS, BWAT, PUSH, LUMT, SWHT, and lastly the Sessing Scale.  I am not sure what you are discussing here, a wider project that you have completed or part of a study within the research that you will discuss?

Chapter Two: Literature Review

Introduction
A literature review is important in the creation of an academic thesis and the writing of a dissertation. It does not only include searching for relevant information, but it also involves thorough description, a summary of information, and the explanation of the purpose of the literature. Literature review can be defined as an element of research which gives a detailed analysis of the recent publications depending on the topic of interest. It facilitates the research question and guides researchers in their research process. Literature Review examines the evidence present on the topic of interest to find solutions to the research problem. Additionally, it enables researchers to base their arguments on some evidence hence thus clarifying the research question. For this dissertation, systematic reviews and Random Control Trials are research studies that have contributed to the findings and evidence used. The articles selected cover some major themes:

Causes of Diabetic Foot Ulcer
Wound Assessment of Diabetic Foot Ulcers
Treatment of the wound
This is quite a brief theme and you haven’t really explored or analysed any studies.

Causes of Diabetic Foot Ulcer.
Diabetic Foot Ulcer is a complication that arises in individuals with Diabetes Mellitus. The condition is likely to affect 15% of the total diabetic individuals. It is a serious complication which could lead to amputation. The condition leads to the breakage of the skin tissues thus exposing the layers below it (American Diabetes Association, 2015, p. 97). It mainly affects the balls of the feet or the big toes. Any individual with diabetes is susceptible to the condition, but those who take good care can escape this. The healing process of the wounds formed is often impaired, and this poses a great risk to an individual. Poor blood circulation, high blood pressure, and damage in the nerves are some factors that slow down the healing of the wounds. The two main causes of the ulcer are neuropathy and the peripheral vascular disease. Neuropathy is characterized by loss of the sensory nerves in the areas around the wound. Peripheral vascular disease, on the other hand, leads to the inadequate blood supply in the foot. Infections worsen the state of foot ulcers and lead to amputation.

Wound Assessment of Diabetic Foot Ulcers.
Assessment of the wound that is formed as a result of Diabetic Foot Ulcers is significant in classifying the wound and effectively managing or treating the situation. Just as wound assessment requires, the general health of the patient needs to be reviewed after which the assessment of the real wound takes place. The study by Ward

date of study?

 proved that nutritional assessment is important before all other factors are looked into.The causes and the duration of the ulceration are essential points. In the assessment process, a physical examination involves carefully examining the skin, the musculoskeletal systems, the neurological system, and the vascular system. It involves identification of the temperature sensation, discernment of a feigning pain, and assessment of the pressure (Eagle, 2009, p. 18).  A biothesiometer can also be used to determine the vibration perceptions. Furthermore, this assessment should consider identifying the nature of the deep tendon reflexes and the position sensor.

  The dermatological examination involves visually inspecting the skin of the feet and the entire leg and an examination of the toenail. Visual inspection should also reveal the maceration and the peeling off of skin. The visual examination reveals a lot of details about the wound. The factors that physician aim at getting include the size of the wound, age of the wound, site of the wound, wound bed, depth, the necrotic tissues, infection, pain, and the surrounding skin. You need to include supporting literature here and explore the research findings

During all the presentations, the size of the wound matters. The wound margin needs to be identified, and the surface area determined. Physicians, however, need to be careful with the methods they use in assessing the wound.  Research by Flanagna1 suggested that the linear method of measuring the surface area of the wound. Research by Shaw et al. also proves this. The curving, positioning, and the limb tapering will affect the accuracy. The edge of the wound will inform the physician of the etiology and the history of the wound. Venous leg ulcers, for example, have edges that are gently sloping. Arterial ulcers, on the other hand, have averted edges. Also, the site of the wound is important to note. Diabetic Foot Ulcers often arise in the regions where their abnormal blood pressure distribution. Additionally, the wound bed needs to be identified (Eagle, 2009, p. 20).  Where the granulation tissues are healthy, the color of the skin is pink. If they are unhealthy, dark red color is seen. Over granulation could also occur and it signifies that the wound in non-healing or that there is an infection. If the wound is chronic, it will be covered by a yellow or white tissue. If necrotic tissues are present, they need to be removed since they attract pathogens.

Moreover, the depth of the wound needs to be assessed to find out the progress of the wound.  The appropriate clinical measures need to be utilized in this procedure. If sinuses are present, then surgical procedures are required. The state of the ski surrounding the wound is also important. Maceration is often a sign that the dressing did not appropriately control the wound exudate. The presence of infections also needs to be identified since all open wounds are susceptible to it.  You are not supporting your discussion with any references or evidence. You seem to be purely describing approaches to assessment.

The signs of an infected Diabetic Foot Ulcer is the odor, bleeding, redness, pain, swelling, abnormal granulation tissues, and slow healing process. The type and the nature of pain should also be noted to facilitate effective treatment.

A study by Gunes and Bilgin in 2014 (590) was carried out to show the effectiveness of three methods used to measure the surface area of wounds. The methods include planimetry, acetate tracing, and linear approximation.65 individuals were measured using these methods and grouped into large and small groups.  The same study was also carried out by Oien et al. (165) where they analyzed 50 wounds and grouped them. The two methods planimetry and acetate tracing were approved. Linear approximation exaggerated the size of the wound.  You have provided slightly more detail here but still not sufficient depth. Where these two studies exactly the same? consider sample size and compare and contrast the results there will be some differences. There are different sample sizes, how were the participants found, a convenience sample? you need to comment on the methodology as well as the results.

Additionally, another study which involves no contact with the wound while measuring surface area was carried out by Samad et al. (138). Digital planimetry and contact tracing were tried during this study. The results proved that the digital planimetry was more accurate, but it emphasized that since no contact is used high-quality images need to be used. Thawer et al. (50) also compared the contact planimetry and digital planimetry using 38 animals and 45 human being and found out that both techniques were okay, but the digital one had some error on measurements. Explore further, what degree of error?

Moreover, research by Wendelken et al. (270) on digital planimetry and acetate tracings were similar to the findings by Samad et al. All the research emphasized the need for continuous assessments of the wounds.

Wound assessment involves identifying and incapacitating obstacles to healing and is essential to the development of wound treatment systems. The elements that influence the healing of a wound are sufficient oxygen supply and the presence of infections. Thorough wound assessment involves conducting a general review of the patient’s health and locally identifying the history and the characteristic of the wound (Eagle, 2009, p.20).This will guide the physician in the appropriate treatment to help attain rapid healing of the wound. The main aim of assessing the general health is to discover and eradicate factors which may disturb the process of healing.

Treatment of the wound.
After proper assessment and classification of the wound, its management is important. The most common method used to treat diabetic foot ulcers is known as debridement. This method involves removing necrotic tissues and surface debris from chronic wounds.  It promotes the manufacture of the granulation tissues hence facilitating the healing process. Surgical debridement is also known as the sharp method and involves the use of a scalpel to remove the dead tissues (American Diabetes Association, 2015). Proper care is required to avoid damaging the healthy tissues. Enzymatic debridement involves using enzymes such as collagenase to eliminate the necrotic tissue and maintaining the healthy tissues. Autolytic debridement entails the usage of dressings to create a moist environment hence clearing the devitalized tissues. You need supporting references here

Another treatment method is off-loading. It is important to off-load the affected area for the ulcers to heal.  Research shows that plantar pressures lead to plantar ulcers. Foot deformities and neuropathy reduce off-loading. Inadequate off-loading is also known to slow the healing process of the ulcer. It could also create recurrent ulcers when not done effectively. The most utilized off-loading method is known as the Total Contact Cast. They spread the plantar pressures all over the feet and allows the body to rest as restricted activity occurs.  Removable Cast Walkers help to support the limb hence providing total protection. Moreover, another method exists known as the half shoes, but it is associated with walking difficulties.

 Negative pressure wound therapy is a new treatment for the ulcers. It involves the use of a special pump to exert pressure to collect the discharge from the wound. Another way of managing the wounds is by the dressing method. The ulcers heal faster when it is moist since it has fewer infection complications (American Diabetes Association, 2015).  You need to explore the research underpinning this approach to treatment. How much faster do the ulcers heal? you state that there are fewer complications, what approaches was this method compared to. There is an opportunity here to compare and contrast findings as well as offering a more analytical discussion.

Patents need to be educated on how to take care of their wounds and the appropriate ways of dressing it. Other treatment options available include the use of growth factors, use of bioengineered skin substitutes, utilizing extracellular matrix proteins, use of hyperbaric oxygen, and the use of MMP Modulators.

Hyperbaric Oxygen Therapy (HBOT) has been suggested as an effective treatment for diabetic foot ulcers despite being expensive. A study by Duzgun et al. (517) compared standard wound care with HBOT with 100 patients. The results were that HBOT showed high healing rates. How much higher, you need to discuss the findings.

Additionally, a study by Lindahl et al. (1000) which was carried out on 16 patients showed that in six weeks HBOT reduced the size of the wounds.

Some research doctors have also suggested some new ways that they think would be efficient in the treatment of diabetic foot ulcers. Who? identify the studies that you are referring to.

 The research program tested the extraction of the cells of the skin from the region that is affected by the ulcers. The researchers were professors from the University of Tufts, and their idea was based on the fact that they can revert the cells of the skins and reprogram the skin genetically to return it to its embryonic state (American Diabetes Association, 2015). This process entirely changes the cells of the skin. The new cells heal faster unlike the old ones with the ulcers. This proposal was published in a book known as Cellular Reprogramming.

The second research deals with the epigram of the ulcer cells. It was also carried out at the University of Tufts. This method was found significant since it entailed the protein fibronectin. The protein fibronectin has an impact on the complications of diabetes. It deals with the breakdown of the tissues. Protein fibronectin, therefore, means that the protein will gather and inhibit the healing process of the wound (American Diabetes Association, 2015). The epigram of the ulcer cells hence means that the role of fibronectin is reduced and the cells will be reprogrammed to the embryonic cells that would begin the healing process. This research was written in the journal Wound Repair and Regeneration. You should refer to the author not the Journal.

The professors involved are also analyzing the models to determine how effective the modified or the grown cells are. The head of the second research, Anna Maione date of publication? 

 claimed that the lack of the effective wound-healing models prevents the development of operational therapies. The required models need to work the same way as the extracellular matrix which is significant in the repair of wounds. She also claimed that the 3D models that they were developing would be essential in the testing of the new proposals that they had. The researchers believe that the use of the skin cells in their research would reduce the use of animals for testing. The Scotland Glasgow Caledonian University researchers utilize skin cells donated in their search for the treatment drugs for the diabetic wound ulcers.

Summary of the Literature Review.
  The first theme briefly explains the causes of the wound that is the ulcer. Diabetic Foot Ulcer is a complication that arises in diabetic patients, and it entails slow healing process of the wound.  The second theme is the main theme, and it talks about the assessment of the wounds in Diabetic Foot Ulcers. Wound assessment is an important aspect of the management of Diabetic Foot Ulcers. It involves examining the general health and history of the patient and then the characteristics of the wound (American Diabetes Association, 2015).  Some of the characteristics include pain, depth, the age, availability of infections, the size of the wound, among others.  Upon assessing the wounds, it is important to correctly classify the wound to ensure the correct treatment is used. The two major classifications are the neuroischemic foot and the neuropathic foot. Proper classifications are done after which the treatment methods are applied. Some major methods used are debridement, off-loading, and dressing. There are, however, other effective methods.

Your summary is an opportunity to compare and contrast the research findings, summarising the chapter and making links to your service improvement.

 

Recommendation for local service improvement.
According to the results and information obtained from the literature review, proper health care and cooperation from the patients plays a big role in managing the problem. Patients need to be more educated in ways that can avoid contracting the complication (American Diabetes Association, 2015). The appropriate Wound Assessment Tools need to be utilized in the local community for the wound assessment problems to be managed effectively. Just like our research has identified, Applied Wound Management is the best wound assessment tool, and it should thus be utilized to improve the welfare of the community. Additionally, appropriate methods need to be used by nurses while assessing wounds, for example, using digital planimetry and avoiding linear measurements since they exaggerate the size of the wounds. Also, patients in the community should consider using HBOT as their treatment means despite being expensive since it has been proved to work effectively. The next chapter will explain the importance of leadership services and theories are used to implement the wound assessment tools and strategies in the healthcare centers in our local communities.

 

 

 

 

 

 

Chapter Three: Leadership and Service Improvement. All chapters should start on a new page.

 

 3.1 Service improvement in the Healthcare Sector.

The healthcare system needs to ensure improved services if it has to offer the best care to its clients. Researching in healthcare professional training is one way in which the services can be improved. I am unsure of your meaning here.

Explicitly, service improvement involves altering the attitudes, the practices and the knowledge of the healthcare practitioners to better the quality of care given to the patients. Granville (2006) describes service improvement as the interaction between successful tools and proper leadership. Service improvement can also be defined as the projects aimed at improving the quality of service offered to patients. Changing services offered is a complex process, and it requires adequate planning, evaluation, and implementation procedures (Sullivan, 2012). This, therefore, requires an effective leader for every service that is to be changed. According to clinicians, service improvement involves improving the healthcare processes to offer a better quality for patients. You need to include supporting references here.

The National Health Service Foundation (NHS) is an organization that directs the development of healthcare services in the United Kingdom. Its goals are providing the best service to the patients. The NHS center for improvement and innovation was founded to demonstrate the benefits of service improvement (National Health Service, 2015). The organization published a framework that healthcare organization utilizes when dealing with service improvement.  Additionally, a study in Australia by Greenfield et al. (335) proved that changes in the services provided in the healthcare require an effective management that can deal with the challenges and the resistance that accompany the changes. Ho was this proved, there is an opportunity here to discuss these findings in more depth.

 It was developed to show the importance of service improvement in the healthcare center. It also has additional publications that guide on the quality and service improvement in healthcare centers to guide various professionals and healthcare organizations.  

The service improvements in the healthcare centers were introduced by the Ministry of Health in the United Kingdom. Reference?

 Oman was in power that time, and since his resurgence in the 1970’s, the Ministry of Health in the region developed a five-year strategy to improve services in the healthcare institutions and to overcome all the challenges faced. You need to reword this opening to your sentence.

He also outlined a vision for 2050 that would affect the healthcare centers. He wanted to ensure that the medical services and the care available for the Omani people was competent, safe, and of high quality (Ministry of Health, 2014). He looked into some specific details about the healthcare services in the region. These were factors such as the leadership, how services are delivered, and the available finance and human resources. The NHS thus explained the importance of service improvement and how leadership was significant for the implementation of such improved services. An effective and a proactive leadership was identified as the best means to implement the aims of the vision 2050 and the aims of Oman health services (Ministry of Health, 2014).

The Department of Health and Human Services (HHS) in the US explains quality improvement as the consistent and continuous activities that increase efficiency in the healthcare services and the targeted patients. Reference?

Some priorities were outlined by the agency (SULLIVAN, 2012).The first one is making the services more patient-centered, safe, and accessible. It also aims at supporting the interventions that are proven to deal with the environmental and the social issues.  Another purpose is reducing the cost of the services provided.

Leadership in healthcare and service improvement.

Leadership is significant in every successful project of service improvement in the healthcare sector since the leaders will deal with the planning, implementation, and the maintenance of the new strategies (SULLIVAN, 2012). Barr and Dowing (2015) stated that any undertaking to make change in the clinical practice is advantageous: along these lines. It is required to reveal a change in the way assessing wounds in general and diabetic foot ulcers in specific.

Effective leadership creates positive efforts in the training and the experience of the healthcare providers. Leadership can be defined as the influence that an individual has on others to accomplish the targets and the objectives set by an organization (SULLIVAN, 2012). This definition, however, excludes some important aspects of leadership such as teamwork and motivation. Service improvement, on the other hand, can be defined as the strategies, projects, and activities aimed at bettering and maintaining the quality of services given to patients who in the various healthcare institutions. Quality is the case whereby there is an increased desire and likelihood of the outcomes of health services consistent with the professional safety and ensures the safety of the patient their experiences. Reference?

In the past years, there has been the need to define and recognize the contributions of leadership in a healthcare organization. Collective leadership is thus aimed at ensuring success in the goals of a healthcare organization.  Can you identify when this was recognised? You need to be including supporting references within your discussion.

Every healthcare practitioner should thus aim at creating and taking a leadership role so that the tasks and aims of the organization are met. Leadership in the healthcare organization can be linked to the implementation of the appropriate wound assessment tools in the organization (sullivan, 2012). You need to explore wider literature in your discussion not just Sullivan.

The nurses involved with wound assessment need to make proper and appropriate decisions that will ensure that the best tools are used in practice. The nurses also have to be knowledgeable and skillful for a service improvement strategy to be effective.

 For a successful service improvement, a clear and better understanding of the leadership styles and theories is essential for the healthcare practitioners. Change and improvement in any sector of life are often challenging, but in any healthcare organization, it is more difficult since it depends on the organizational culture and issues, the beliefs of the staff, the need to adapt to new changes, characteristics and the skills of leadership present in the healthcare organization (SULLIVAN, 2012). Dealing with the beliefs of the staff is the most challenging tasks since they need to be convinced that a problem exists in the organization and the proposed change to improve the services is essential in ensuring the success of the healthcare organization. An examination by Greenfield in Australia prove that for any service improvement to be successful leadership that will overcome resistance is needed.

You need to explore these findings in more depth

Leadership Theories.
The focus of discussion has been the merits and the merits of the different leadership theories. A worldwide controversy on whether leaders are made or born is the basis of the various leadership theories. The most common leadership theories include the contingency theory, the great man theory, trait theory, and the behavioral theory (Hierbert et al. 2001). The trait theory states that leaders are made or born with some qualities that are essential in making them effective leaders. It was created between the 1930s and the 1940s by Gordon Allport. The traits often outlined include responsibility, intelligence, honesty, fairness, and creativity among other traits. It deals with the study of the social, physical, and mental characteristic of individuals so that the combination of the characteristics of several leaders. Studies have shown that analysis of the traits of the current leaders helps in the identification of the traits of leaders. Identify and explore the studies that you refer to here.

The great man theory states that leaders are born. It was created in the 19th century and was not identified with any scientific certainty or any human characteristics.  It was created by Thomas Carlyle who was a teacher and a writer who studied the influential heroes. The individuals are always destined to become leaders. It also believes that various challenging situations will result in the rise of a leader who will deal with the situation (Hierbert et al. 2001). The behavioral theory, on the other hand, believes that there are two types of leaders, those who focus people and those who focus on tasks. It was developed around the 1940s to 1950s to correct the trait theory and thus focused on the behaviors of leaders rather than their mental, social, and physical characteristics. This theory divided leaders into two groups. The first group is made up of leaders who concerned with people and the second group is made up of leaders concerned about the tasks of individuals. The styles of leading are obtained from the experience of the individual. Contingency theory states that no one way can be pointed to the appropriate leadership strategy (Hierbert et al. 2001). It was developed in the 1960s.  Leadership involves utilizing the most effective strategy for every situation that comes up. There is no single way to that can be identified as the appropriate style of leadership. You need to relate the discussion more closely to your service improvement and the leadership theory that will be followed.

Leadership Styles.
The leadership theories act as a basis for the formation of leadership styles. The most common leadership styles include the transactional and the transformational leadership styles. They are both used in the healthcare practice (KIPPENBERGER, 2002). They are both as a result of effective leadership, and they contribute to the job satisfaction of the healthcare practitioners. Under the transactional leadership, the leader and the follower both agree on certain goals to be attained with the exchange of the leader’s acknowledgment (KIPPENBERGER, 2002).  Bass thinks that this style works for the regulation of the management and the position of a manager. This kind of a leader only deals with issues when they arise and using the policies that guide the issue. It is associated with the traditional ways of managing change in the organization. It is established to be operational in the controlling of emergencies and quick services.  Transactional leaders are passive leaders who manage change in the organization according to the hierarchical authority.

Transformational leadership style, on the other hand, is the style mostly used in healthcare organizations. It identifies the requirements of the organization and the followers are then encouraged to use their maximum effort to accomplish the objectives of the organization (kippenberger, 2002).  Trust, and a positive relationship is maintained between the leader and the followers. Nurses are thus encouraged to use this style during the wound assessment, for example, the administrations of the healthcare need to ensure that the optimal wound assessment techniques are utilized in their facilities (kippenberger, 2002).  Transformational leaders smoothen the change in a slow and effective manner since their concerns are mainly about themselves before they think of their interests. They utilize total professional engagement in attaining the visions of the organization, and they solve the problems that arise in the organization by forming teams. They also recognize the success of their subordinates as their own success, and this helps them to support the subordinates. The transactional style can, however, be used to maintain the authority of the leaders of the healthcare institution whereas transformational style used to motivate the practitioners.

Service improvement is linked to the leadership styles and theories and is useful in the introduction of the best wound management tools in the healthcare centers of our local communities. The discussion below thus focuses on the introduction of the best wound management tools and strategies in our healthcare centers.  We will use the transformational leadership and the RAPSIES model to outline the process used in the service improvement (Gopee 2010).

Introduction of the best wound management tools in the local practice.
There is a need for change in the wound assessment techniques hence an effective strategy is important in introducing the tool. Gopee 2010 states that the effective method of implementing change is through the use of the RAPSIES Model. You need to relate the discussion more closely to your service improvement and the leadership theory that will be followed.

Recognition- The first step of the model is recognition. Before making any changes to the services provided, it is important to identify the need for change and the positive impacts it will create. The leader must also identify whether the change is aligned with the beliefs of the community. The leaders should also identify whether the service will play an effective role in the service providence given to patients (Gopee & Galloway, 2014). Just like the SMART (Specific, measurable, attainable, reachable, and time-framed) framework works, the leaders need to ensure that the new model suits all the employees and the culture of the organization.  About the dissertation aim, recognition is important in identifying whether the appropriate and most effective wound assessment tools are used.  Reword this sentence doesn’t flow well.

Linking the new service to this step, the wound assessment tools would not negatively affect the culture of the organization, and it is anticipated that it would make the diabetic wound ulcer management easier (Kelly, 2012).The leaders often review the evidence that the new model works and inform all the members of the organization about how the model works. The leader should be able to deal with all the comments that he receives from the employees. The leaders should also be aware of the challenges that are likely to affect the new change and this include financial issues, leadership style, staff engagement, motivation, and the organizational culture.

 Analysis- The second step is known as the analysis.  The leader analyses all the available resources including the people and the equipment that would be needed for the implementation of the change. This is where all the available options are identified and also the factors which influence the change identified (Gopee & Galloway, 2014). There is a wide range of wound assessment tools, for example, the National Wound Assessment Form (NWAF), Applied Wound Management (AWM), Wound Assessment and Management System (WAMS), and the Leg Ulcer Measurement Tool (LUMT) among others. The leader could also conduct a SWOT (Strength, weaknesses, opportunities, and threats) to confirm the changes necessary for the services to be improved. How would you assess the need for change? you would need to look at patient outcomes as well as nurses ability.

 The nurses are important in creating excellent customer services, and thus competent nurses should be available to implement the new model to be utilized in the healthcare organization.

Preparation- The third step is the preparation. This comes after the identification of the most effective tool. Our research identified that the best wound assessment tool is the AWM. It is thus important to prepare to begin using this tool.  Whose research?

This stage also begins with the appointment of the change agent who will explain to all the stakeholders about the new models and the expected outcomes. The leader should be open-minded, confident, active, a good listener, and experienced about the new model to be implemented in the organization (Kelly, 2012). Competent physicians and nurses will be the change agents to utilize the new changes that would be present in the organization. The patients treated using the new model should be aware of the new tools to ensure that they cooperate and fully involve themselves in the treatment process.

The Tuckman model which is often used for team development will be utilized in the new proposal. The model is often used before the launch of a training program in an organization. It consists of four stages that assist a leader in the creation of the effective team. The steps include formation, norming, storming, and performing. The forming stage involves the selection of all the agents that will offer the services important for the new model to perform effectively (Gopee & Galloway, 2014). They will be introduced to the new setting and the new members important in the effective performance of the model. The selected team will depend on the instructions and the guidance of their leaders. The leader needs to trust and inspire the team for cooperation to be portrayed. The next step is the storming stage (Kelly, 2012).The members highly question the new model. Many members will try to utilize their previous experiences and others will stop their participation in the implementation of the new model. Many conflicts. The leader should be keen on the assessment of the strengths and the weaknesses of the team members. The physicians will be allocated various roles according to their capabilities. You need to consider what staff you would want in the team, what skills and attributes would be required?

The performing and the norming stages will offer solutions and suggestions to the leaders. The model will appear as an operating unit. The team at this stage avoids conflicts and ensure that they aim at accomplishing their roles and responsibilities. Suggestions will be accepted if they are meant to facilitate the implementation of the new model aimed at service improvement. For our wound assessment model, the required nurses will be allocated, and the suitable strategies will be utilized for AWM to operate in the organization.

 Strategy- The firstth step is the where a strategy is chosen for the implementation of the selected tool. Wolper 2010 states that the best strategy is the Plan, Do, Study, Act (PDSA) strategy. Using this strategy, finances and adequate resources are required to implement a pilot study, do this change first in one clinical area, evaluate its success then disseminate the findings to other clinical areas. This stage shows that effective planning and careful management is important for the new model (Gopee & Galloway, 2014). The PDSA is adopted to explain the changes and understand why service improvement is important in the local healthcare organizations. The framework is also cheap since it requires minimal resources to utilize. It effectively manages the change barriers, and it can be used in the small-scale analysis.

 Implementation- The fifth step involves the implementation stage where the tool is put into practice, and the challenges and resistance facing it are overcome. The environment is one of the factors that influences the changes to be implemented in a healthcare organization. A cooperative and trained team is also important during this stage for active participation in implementing the tools and the strategies. The PSDA framework will be used to test the effectiveness of AWM in the local healthcare organizations. The framework needs to be utilized at the appropriate time to reduce the mistakes that could arise.

 Plan- The sixth stage is planning where all the stakeholders of the new tool are involved. The practitioners will assess the tool, and when they accept it as efficient, it can be used on the patients.  During this stage, the management of the healthcare organization needs to be more involved in the various affairs of health issues for them to gain more support in their new service improvement tools (MoH, 2010). A proposal file is created and useful graphs are used and also the indicators of the existing problems in the local society are identified. I presume this will be some sort of audit of patients presenting with ulcers to a specific clinical area or service? you need to be clear what you will do in this service improvement.

A design strategy analyzed with the SMART goals should also be prepared at this stage. The stakeholders will be informed about the expectations and the objectives of the model. The project action plan will be created for the organization to successfully utilize the new model. Effective communication is important to keep the team members on track and to make them creative enough to ensure that the strategy is effective.

Do- The second stage is the do step which involves carrying out wound assessment using the new tool, AWM. A study will be carried out after the tool is in use for some time and the outcomes stated. The practitioner will then act by involving all the stakeholders the progress seen in the organization due to the new changes. Evaluation is then conducted to check whether the tool accomplished its objectives. Sustainability will then follow whereby the effective tool will be monitored and maintained for effective service provision (Gopee & Galloway, 2014).  The nurses will carry out their duties with the help of the training they would have obtained regarding the new tools introduced. The most qualified, and experienced nurses will use the model to treat the selected patients.

 Study- After the new model is used for about three months, the leaders need to study and make inferences on the outcomes. The success of the model or the new tool AWM will be determined by how effective it has worked on the patients treated in the organization (Gopee & Galloway, 2014).  Questionnaires could also be provided to the previous patients to assess what that has to say about the new wound assessment tool. As well measuring areas such as healing time & reduction is wound size, not just the patient experience. The leader will keep records of whether the new tool achieved its objectives or not. The strengths and the weaknesses of the wound assessment tool will also be identified.

Act- During this stage, the leader will write a report on how the tool was implemented in the local healthcare organizations. If it succeeded, it could then be utilized in all the healthcare organizations that deal with the diabetic wound assessment and treatment. Its success at the local level will determine whether it will be utilized nationally.

Evaluation- This stage shoes whether the new tool introduced achieved its objectives or not. It also encourages the supporters of the new services to continue offering support for the utilization of the new tool. The physicians will assess the impacts that the new tool will have in the healing of the wounds of their patients (Gertler et al. 2012). The assessments will show the significance of all the stakeholders in operation and the success of the new tool.  

Sustaining- This involves keeping the AWM in functioning. The barriers that are likely to affect its achievement of its set objectives are eliminated. The necessary human resources, financial resources, and the healthcare equipment will be assessed to ensure that they are sufficient to ensure the continued use of the new wound assessment tool (Kerridge, 2012c).  Important judgments need to be made on how the patients benefit from the use of the model. The team members still need reinforcement to ensure that they do not lose hope or fail to encourage and support the new strategies aimed at improving service management. The new tool would not succeed without the help of the team members.

 

 

 

 

 

 

 

 

 

 

Chapter Four: Conclusion.

Type 2 diabetes is prevalent in the world today, and this increases the cases of diabetic foot ulcers. The effective management of the diabetic foot ulcers begins with the proper wound assessment. Wound assessment involves examining the general health of the patient and then examining the characteristics of the wound to determine the treatment methods to use. The literature review of this dissertation explains the appropriate approaches to be used in the wound assessment process (American Diabetes Association, 2015). Hyperbaric Oxygen Therapy and use of Digital planimetry are the techniques that are found to be most effective. The most effective wound assessment tool identified is the Applied Wound Management Tool. This dissertation suggests that this tool needs to be implemented in the local healthcare services.

The PSDA strategies and the RAPSIES models were used to explain the process that would be utilized in the introduction of the more effective services in the local healthcare organizations. Transformational leadership was also identified as the most effective form of leadership to be utilized in changing the services used in the various local healthcare organizations. The effective leadership styles will be utilized in the implementation of the new wound assessment tools, however, challenges should still be anticipated. Challenges are likely to arise from due to change in the culture of work, human nature, change in the organizational structure and also doubt and problems with the patients. The transformational leaders are, nevertheless, expected to deal with such challenges effectively to ensure that the best services are offered to the patients in the healthcare organizations. 

Your conclusion needs to be more reflective of the main body of work and include reference to key authors and evidence.

PLEASE check all the references and do them properly according to HAVARD referencing style with the missing details, eg. Date of publication, location of publication,

References

American Diabetes Association, 2015. Standards of medical care in diabetes—2015 abridged for primary care providers. Clinical diabetes: a publication of the American Diabetes Association, 33(2), p.97.

Bakker, K., Apelqvist, J. and Schaper, N.C., 2012. Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes/metabolism research and reviews, 28(S1), pp.225-231. The Netherlands

Baranoski, S. and Ayello, E.A., 2008. Wound care essentials: Practice principles. Lippincott Williams & Wilkins.

Bilgin M., & gunes U.Y. (2013). A Comparison of 3 wound measurement techniques effects of pressure ulcer size and shape. Journal of Wound, Ostomy and Continence Nursing. 40, 590-593.

Boulton, A.J., 2008. The diabetic foot: grand overview, epidemiology, and pathogenesis. Diabetes/metabolism research and reviews, 24(S1).

Boulton, A. J. M. (2013). The Diabetic Foot. London, Elsevier Health Sciences. http://search.ebscohost.com/login.aspx?direct=true&scope=site&db=nlebk&db=nlabk&AN=652124.

Duzgun, A. P., SATIR, H. Z., OZOZAN, O., SAYLAM, B., KULAH, B., & COSKUN, F. (2008). Effect of Hyperbaric Oxygen Therapy on Healing of Diabetic Foot Ulcers. The Journal of Foot and Ankle Surgery. 47, 515-519.

Eagle, M., 2009. Wound assessment: the patient and the wound. Wound Essentials, 4, pp.14-24.

Flanagan M. (2003). Improving accuracy of wound measurement in clinical practice. Ostomy/Wound Management. 49, 28-40.

Gertler, P. Martinez, S. Premand, P. Rawlings, L. and Vermeersch, C. 2011. Impact Evaluation in Practice. Washington: The World Bank. 

Granville, G. 2006. What does the service improvement literature tell us and how can it make a difference to implementation? .Gillian Granville Associates.

Greenfield, D. Nugus, P. Travaglia, J. and Braithwaite, J. 2011. Factors that shape the development of interprofessional improvement initiatives in health organizations. British Medical Journal Quality and Safety 20, pp. 332-337.  

Gopee, N. 2010. Practice teaching in healthcare. Los Angeles: SAGE.

Gopee, N. and Galloway, J. 2014. Leadership & Management in Healthcare. 2nd ed. Los Angeles: Sage. 

Hiebert, Murray, and Bruce Klatt. The Encyclopedia of Leadership: A Practical Guide to Popular Leadership Theories and Techniques. New York: McGraw-Hill, 2001. Internet resource.

Kelly, P. 2012. Nursing Leadership and Management. 3rd ed. Delmar: Cengage Learning.

Kerridge, J. 2012c. Leading Change: 3 -Implementation. Nursing Times 108(6), pp. 23-25.

Kippenberger, T. (2002). Leadership styles. Oxford, Capstone Pub.

Londahl M., katzman P., nilsson A., & hammarlund C. (2010). Hyperbaric oxygen therapy facilitates healing of chronic foot ulcers in patients with diabetes. Diabetes Care. 33, 998-1003.

Markova, A. and Mostow, E.N., 2012. US skin disease assessment: ulcer and wound care. Dermatologic clinics, 30(1), pp.107-111.

MoH. 2010. Primary health care policies. Sultanate of Oman: Primary Health Care Affairs Department.

Ministry of Health.2014. Oman Health Vision 2050. 1st ed. Muscat: MOH. 

National Health Service. 2015. about the National Health Service (NHS) in England – NHS Choices [Online]. Available at: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/overview.aspx [Accessed: 3 May 2015].

Oien RF, HÅkansson A, hansen Bu, & bjellerup M. (2002). Measuring the size of ulcers by planimetry: a useful method in the clinical setting. Journal of Wound Care. 11, 165-8.

SAMAD, A., HAYES, S., FRENCH, L., & DODDS, S. (2002). Digital imaging versus conventional contact tracing for the objective measurement of venous leg ulcers. Journal of Wound Care. 11, 137-140.

Sen., C.K., 2009. Wound healing essentials: let there be oxygen. Wound repair and regeneration, 17(1), pp.1-18.

SULLIVAN, E. J. (2012). Effective leadership and management in nursing. Boston, Pearson.

Thawer Ha, houghton PE, woodbury MG, keast D, & campbell K. (2002). A comparison of computer-assisted and manual wound size measurement. Ostomy/Wound Management. 48, 46-53.

Wendelken, M., berg, W., lichtenstein, P., markowitz, L., comfort, C., & ALVAREZ, O. (2011). Wounds Measured from

Digital Photographs Using Photo-digital Planimetry Software: Validation and Rater Reliability. Wounds: a Compendium of Clinical Research and Practice. 23, 267-275.

Wolper, L. 2010. Health care administration: managing organized delivery systems. 5th ed. Ontario: Jones and Bartlett. 

Appendix.

Definitions

Words

Definition

Diabetic foot ulcer

It is a complication of diabetes that arises when the layers below the skin are exposed due to skin tissue breakage.

Wound assessment

An examination of the various aspects of a wound.

Proliferation

It is the multiplication of cells in part of the skin or body.

exudate

It is a fluid which contains high amounts of proteins and is deposited on the surface of tissues.

Wound management

A comprehensive care on a wound.

Knowledge

In your introduction You have discussed ulcers, their causes and assessment. You needed to include further supporting references for the content covered. You should have also drawn on more epidemiological statistics around incidence both locally in Oman and the GCC states and wider international. You have included an aim and a question for your work.  Your aim is focussed on assessment not causes, you could be clearer here on your focus for the work. You go on to discuss the search strategy, this could be more structured. On page 10 you have included a section on a wound assessment project I am not sure what you are discussing here, a wider project that you have completed or part of a study within the research that you will discuss?

In the literature review you highlight a range of literature but do not add any depth to the discussion which is a major omission within your work. You appear to have chosen an appropriate service improvement but it is not fully clear what you will do, how the change will be developed, implemented and evaluated. At present you are demonstrating a limited level of knowledge of your topic area.

Analysis

The level of analysis across your work is poor. in your literature review you highlight studies but fail to explore them in any depth. On page 12 you mention two studies one by Flanagan 2003 and another by Shaw et al 2007. There is no real discussion or analysis of the findings.You need to explore these findings in some depth and offer some critical analysis. You should consider what the researchers set out to find, the sample size, how the data was collected, what the results were, how the findings compare to other studies. On page 13 you refer to two studies Gunes and Bilgin 2014 and Oien et al 2002. Where these two studies exactly the same? consider sample size and compare and contrast the results there will be some differences. There are different sample sizes, how were the participants found, a convenience sample? you need to comment on the methodology as well as the results. You need to be exploring your research findings in some depth.

Synthesis

There is a lack of synthesis within the work. You need to compare and contrast the literature in chapter 2, identifying key findings that support your proposed change in chapter 3. In your service improvement You need to relate the discussion more closely to your proposed change. You discuss leadership styles and approaches which is good. You chose RAPSIES model to structure your work with PDSA. You needed to briefly compare these to other approaches to demonstrate your knowledge. There was also some confusion with the ‘Plan ‘being the first stage of PDSA not the sixth stage of RAPSIES. Your proposed change needs more clarity in terms of what you will do, how you would measure success and patient outcomes.

Evaluation

There is insufficient evaluation of the literature in both your literature review and chapter 3. Try to consider the strengths and weaknesses of what you read in more depth and make judgements on their relevance. Your summary in chapter two is an opportunity to compare and contrast the research findings, summarising the chapter and making links to your service improvement.Your conclusion needs to be more reflective of the main body of work and include reference to key authors and evidence.

Presentation

You have a number of referencing errors in the work and reference list. You have some language errors which at times detracts from your discussion. You need to pay attention to presentation across the work.

unfortunately your work has not achieved a pass at this attempt. To improve the work seek guidance from your supervisor. I Would suggest the following:

That you include further literature in your introduction to identify the scope of the problem both locally and internationally. Draw on supporting statistics to underpin your discussion and include wider references. In the literature review you need to explore the research in much more depth. You need to discuss the findings as well as the research approaches such as sample, how the data was collected, what were the findings and how they compare to other studies. In chapter 3 link your discussion of leadership approaches , styles and implementation models much more closely to your service improvement. Keep your change simple, what do you want to change, what staff and leadership are required to achieve it, how will you introduce the change, how will you measure and evaluate success. I would suggest a pilot with a small group of patients. You need to be more analytical in your writing. Please feel free to email me with any questions that you have or with any points that you would like me to clarify.