In this guest editorial, Janine Michaelides discusses her motivation for improving the care of patients by raising the profile of tissue viability in Cyprus.

'Where do I begin' sums up how I felt in October 2000 when I decided to undertake a distance-learning course in wound management. This decision was born out of my frustration with the lack of specialist knowledge in tissue viability and wound management in Cyprus, where there was no wound management society or access to tissue viability specialists; nurses were simply doing what they could, to the best of their ability, with the limited resources available.

Palliative care in Cyprus

Working as a nurse in palliative care for a local charity, I am presented with a range of different wounds, including fungating tumours, radiotherapy-induced skin reactions and pressure ulcers, all of which cause additional distress to this group of cancer patients.

The desire to improve things was an absolute necessity for me as these patients are often labelled as being beyond help. I felt our patients deserved better care and I knew that to alter this situation I had to have the knowledge to enable me to make that change.

I realised that to provide high-quality, evidence-based care in the area of wound management I would have to start studying again and I was very fortunate that my organisation (The Cyprus Association of Cancer Patients and Friends) agreed to sponsor me for a Diploma in Professional Studies in Wound Care.

In Cyprus, there is as yet no primary healthcare system, which poses a number of obstacles. For patients leaving hospital there is no discharge planning and patients are often referred to our palliative care service by themselves, their family, friends or sometimes their doctors.

The lack of community care means that I am often both the palliative care nurse and the district nurse rolled into one. In addition, many of the doctors work autonomously and prefer to control all aspects of care themselves, including wound care. This is where I feel I need to be able to convince the medical profession that I have the necessary understanding and skills to have an impact.

Introducing a pressure ulcer risk assessment tool

Through self-directed learning I have gained sufficient knowledge on the physiology of wound healing to be able to disseminate this to my colleagues. As part of my first assignment, I composed a wound questionnaire to ascertain the level of collective knowledge within my organisation. The results obtained confirmed that there were inconsistencies across areas of our wound care practice and, in particular, highlighted the need for a pressure ulcer risk assessment tool.

In order to select the most suitable tool for our service, I undertook a literature search on the different assessment scales available and then discussed my findings with my colleagues. We agreed that we would use the Waterlow Pressure Sore Risk Assessment Tool  as this addresses more of the categories applicable to our group of patients, it is easy to understand and simple to use.

In the absence of any documented risk assessment, the introduction of this tool was seen to be both beneficial for patients and to provide the necessary evidence for quality of care.

To support its introduction, I am in the process of implementing teaching sessions for nurses on the importance of risk assessment, which should be used as part of an holistic approach to care, with regular reassessment; all too often, as nurses we fill in the form and file it away. However, there is no point in using a risk assessment tool if we do not reassess at regular intervals or as the patient's situation changes.

In the palliative care setting a great majority of patients are at risk simply due to their underlying condition and we need to be more aware of this and provide appropriate preventative measures. I believe that if nurses are involved in decision making from the beginning, this will increase the chances of compliance. I see my role as providing the necessary support and guidance, as well as evaluating the effectiveness and acceptability of the tool by the nurses.

Home care and pressure ulcer prevention

My next goal is to raise awareness among families on the prevention of pressure ulcers in the home. This is an area where advice is desperately lacking despite the fact that it is mainly family, friends or other non-healthcare professionals who provide care at home. Also, a great majority of patients are discharged back in to the community with pressure ulcers.

I believe that providing appropriate information for carers is an effective way of preventing pressure ulcers from developing in the first place. I would hope this information would be accessible to the general public as well as to my patients by ensuring the pamphlets are distributed in hospital and in palliative care. The carers can also apply this guidance to the inpatient setting where they are all too often relied on to do a lot of the basic care.

My aim of producing a pamphlet that is easy to understand and simple to use is about to become a reality. If I can reach some of the providers of care and influence them, it will have been a worthwhile initiative.

Achievements and future goals

In May 2004, I was also instrumental in organising the first Wound Care Conference for Cancer Patients in Cyprus. This was a highly rewarding experience and the feedback from participants was extremely positive.

In the nine years since I started my distance-learning course, I feel I have achieved a great deal and I am now involved in teaching within local hospitals, hospices and my own organisation. I still have a long way ahead of me and a great deal more projects to undertake, but I am certain it will prove to be immensely satisfying.

Indeed, a recent case has inspired me to take further action. A 73-year old lady with diabetes was admitted to the local hospital and developed small pressure ulcers on both heels. These ulcers quickly deteriorated due to poor circulation, which was further compromised by her leg bandages being applied to tightly (Fig 1).

Fig 1 Patient with diabetes who subsequently underwent bilateral below-knee amputation

By the time the patient was referred to me, the extent of the necrosis was such that the only option was for the patient to have a bilateral below-knee amputation.

This was an extremely distressing case and has prompted in me a desire to develop a wound care society in Cyprus where the public and healthcare professionals can have access to specialist knowledge and information free of charge. It is a huge task that will require a great deal of specialist input, but it is my aim to raise standards of wound management in Cyprus and to make a difference for patients.

Author details:

Janine Michaelides, RGN, ONC, Dip Mgt, Lymphoedema, Dip H.E. Wound Management, Palliative Care Nurse - Home Care, The Cyprus Association of Cancer Patients and Friends, Limasol, Cyprus

If you would like to contribute an article about your own experiences in raising the profile of tissue viability in your country or in setting up a wound care society, please contact Wounds International editorial team at info@woundsinternational.com