Editorial
Advances in nursing research on wounds: achievements, opportunities and challenges
Los avances de la investigación enfermera sobre heridas: logros, oportunidades y retos
Pedro L. Pancorbo-Hidalgo
Departamento de Enfermería, Facultad de Ciencias de la Salud, Universidad de Jaén, Comité director GNEAUPP, EWMA council, Spain
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Pancorbo-Hidalgo" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Pedro L." "apellidos" => "Pancorbo-Hidalgo" "email" => array:1 [ 0 => "pancorbo@ujaen.es" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Enfermería, Facultad de Ciencias de la Salud, Universidad de Jaén, Comité director GNEAUPP, EWMA council, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Los avances de la investigación enfermera sobre heridas: logros, oportunidades y retos" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">For nursing research on wounds I would like to propose four questions for the structuring of this editorial article.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Is it relevant to research on wounds from a nursing discipline?</span><p id="par0010" class="elsevierStylePara elsevierViewall">Wounds are an alteration to health and have always been present in human history. Ever since the first written history of humanity there are always been references to people who have suffered from wounds and to their treatments.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We should recall that the skin is the largest organ in the human body and is the interface or means of contact with the exterior. It is therefore constantly exposed to aggressions of different types that may lead to injury of tissues, epidermis and dermis, which we call a wound. The biological recovery process of healing is a highly effective mechanism for restoring tissue integrity but is frequently interrupted in its inflammatory phase, leading to chronic wounds. Nowadays we prefer to call these wounds of difficult healing or delayed healing.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Many factors, including the progressive ageing of the population have led to an increasing number of people suffering from chronic wounds. The impact of chronic wounds on peoples’ quality of life is very high, physically, psychologically, emotionally and socially. In extreme cases these people may refer to their daily live as “a living hell”,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> and their care requirements are intense.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Caring for people with wounds has evolved in different ways in different countries, historically and above all, during the last century. In the European and North American context, three groups may be considered. There are some countries where medical professionals are those regularly in charge of wound treatment (e.g. Germany, Austria, France), others where it is mainly the nurses who treat wounds (e.g. Spain, Italy, Sweden). Finally, in some countries, like the U.S.A. and United Kingdom a mixed model could be described, with participation from both professional groups. In Spain there is a solid historical tradition of wound care within the nursing profession, which began in the last century with the figure of the” practitioner” who performed a primary healthcare role in the community.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In the last few decades, the figure and area of competencies of the wound specialist nurse has been developed in several countries.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In Spain this has been reflected in the creation of the figure of the Advanced Practice Nurse, in caring for people with chronic wounds,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> which began in Andalusia and extended to other health systems.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In this context it is clear that professional care for people with wounds falls within the competence area of nurses. This practical activity quickly generates questions such as, what is the best form of treating this type of wound? How can these injuries be prevented? What product improves the healing process? New forms of as of yet unavailable knowledge were required for this, which led to the need to obtain it through research.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">What has the wound research context been in Spain?</span><p id="par0030" class="elsevierStylePara elsevierViewall">In Spain it is believed that nursing research began, in a more or less regulated manner, after the establishment of the university qualification of the Nursing Diploma in 1977. Research on wounds was among the first issues to be covered, highlighting pressure ulcers for their high frequency in hospitals. For many years small, very local studies were conducted, with no financing and published in journals with very limited distribution.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> During this period a pioneering role was played by the journal ROL on nursing which was (almost the only) means of distribution of these studies, although it is true that shortly afterwards many other journals appeared. Gerokomos was outstanding as the journal specialising in wounds and Enfermería Clínica as the journal with a high international impact, playing a leading role in the extension of nursing research.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Two characteristics mark nursing research on wounds during this period. The first is the lack of support offered by health institutions – when not outright obstruction – to these research studies conducted by nurses, especially in hospitals. The second is the lack of collaboration between care professionals and teachers in the University Schools of Nursing, for developing research. For many years they followed parallel but completely separate paths.</p><p id="par0040" class="elsevierStylePara elsevierViewall">From here, two agents have played a major role over the last 30 years in developing and evolving the area of wounds: healthcare product companies and scientific wound societies.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Several companies in the healthcare product sector for the treatment or prevention of skin wounds promoted and supported many of the studies conducted by nurses by financing them. These were usually in the form of clinical case histories. Research studies mainly aimed at presenting results on the use of these products in congresses and scientific workshops, with the purpose of product familiarisation. Obviously apart from purely scientific interests other more commercial ones were present but it cannot be denied that thanks to the context of an absolute lack of grants and financing, this helped to drive nurses’ research on wounds. This cooperation between companies and research groups has become consolidated, although discreetly in Spain. However, it is a major pillar of development, provided that it is carried out ethically and transparently.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Several Spanish scientific associations have also played a major role in fostering research on wounds. Initially in the nursing discipline and more recently in a multidisciplinary fashion. This activity has been built up through congresses and workshops, as forums for spreading research results. Also through publication in specialised journals and the creation and diffusion of documents and guidelines for communicating scientific evidence to professional clinical practice. Without wishing to present an exhaustive list, we should mention the outstanding role of the Grupo Nacional para el Estudio y Asesoramiento sobre Úlceras por presión y heridas crónicas (GNEAUPP) (national study and consultation group on pressure ulcers and chronic wounds) created in 1994; together with the Asociación Nacional de Enfermería Dermatológica e Investigación del Deterioro de la Integridad Cutánea (ANEDIDIC) (national association of dermatological nursing and research into skin integrity impairment); the Asociación Española de Enfermería Vascular y heridas (AEEVH) (the Spanish association of vascular nursing and wounds); la Sociedad Española de Heridas (SEHER) (the Spanish Society of Wounds) and the European Wounds Management Association (EWMA).</p><p id="par0055" class="elsevierStylePara elsevierViewall">Another major landmark in the drive for research on wounds from the viewpoint of care (and research into nursing in general) was access to doctorate studies.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Since 2005 different doctorate programmes have been established in Spanish universities which offer access to nursing qualifications. In many cases these programmes have a multidisciplinary approach within the health sciences. Over the last 15 years, in both programmes with specific lines of research into wounds and others with more general lines of research, numerous doctoral theses by nurses have been defended on different aspects of care for people with wounds, in Spanish universities, leading to a large number of scientific publications. The incorporation of a growing number of nurses with doctorates in health centres and hospitals will most probably have a high impact on the number and methodological quality of research projects on wounds, and also the transference of these research results, as evidence to modify clinical practice.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">How has research on wounds in Spain evolved?</span><p id="par0060" class="elsevierStylePara elsevierViewall">Research on wounds, from very different approaches, has experienced a notable improvement in methodological quality and in the complexity of research projects undertaken. A transition has taken place from small observational studies and clinical cases some years ago, to larger projects with robust experimental designs, multicentre studies and the participation in international projects. Projects have also been widely developed for the creation and validation of different methods and instruments required for clinical investigation. Quantitatively there has also been a considerable increase in the number of projects undertaken and results published. For example, the scientific production of articles recorded in Pubmed within the Nursing journal category and with at least one Spanish author, with the descriptor “Pressure ulcer” progressed from 1 article in the 2000 – 2010 decade to 38 articles in the 2010 – 2020 decade. The descriptor “leg ulcer” progressed from 1 article in the 2000 – 2010 decade to 22 articles in the 2010-2020 decade. In both cases percentile increases were notable. If we consider the publication in journals in the Ibero-American area, in Spanish and Portuguese, in the Scielo Citation Index repertoire there is a total of 101 results of articles published during the 2000 to 2020 period with the descriptors “wounds” or “ulcers” with a growing constant throughout this period.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The specific themes covered in these research studies published are highly diverse and cover epidemiology; theoretical models; diagnostic methods and wound classification; patient assessment; physiopathological aspects; and prevention, procedures and products for the treatment, education and training of health professionals. If we consider the whole scientific production, wounds would be among the health issues or problems with the greatest research development and which have helped to generate evidence to modify clinical practice. Several of the research results carried out in Spain have had a major international impact and have been included in clinical practice guidelines. On example is the effectiveness of hyper-oxygenated fatty acids in the prevention of skin lesions and pressure ulcers<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> or the theoretical explanatory model of dependence-related skin lesions.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">What are the future challenges?</span><p id="par0070" class="elsevierStylePara elsevierViewall">Research is a dynamic and unstable field, like a conveyor belt where, if you stop, you go backwards. Advances in research on wounds from the science of care have been noteworthy, but major challenges remain. I would underline three of them: <ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0075" class="elsevierStylePara elsevierViewall">Creating and especially maintaining stable research groups with institutional recognition at the same level as groups of other areas of knowledge, which are pluridisciplinary in nature and which aim at training new researchers. These groups could be affiliated to universities, research institutes or healthcare centres, but, in any event, participation from clinical researchers is necessary. The existence of clear and differentiated lines of research focusing on wounds is highly recommendable. At present in Spain there are already several groups which meet and comply with these characteristics, but the challenge is to achieve their consolidation and increase their number.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0080" class="elsevierStylePara elsevierViewall">Access to powerful sources of financing for research which lead to the development of large-scale projects. This implies participation in bids for research projects both nationally and within Europe, such as the 2020 Horizonte plan. The challenge is to increase the number of projects presented and the final rate of successfully won projects. Wounds, as a specific health problem, are not considered among the priorities of these bids, but it is possible to fit in the projects on wounds among wider issues which are priority, such as the ageing of the population, the development of new technologies and the development of e-health.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0085" class="elsevierStylePara elsevierViewall">Increase the degree of multidisciplinary collaboration both in the groups and research projects, maintaining specific contribution from nursing science. Collaboration on an equal footing needs to be maintained with other areas of knowledge both with regards to health and to technologies in the research design, planning, execution and diffusion. These projects may be led by nurses. Researchers with sufficient skills already exist today, although projects led from other areas of knowledge may also be used. This type of collaboration provides the opportunity to address complex problems and at the same time greatly increase the opportunities to obtain finance in competitive bids. Some of the possible lines of development could be: new biological skin replacement and wound treatment materials ;(in collaboration with areas of pharmaceutical technology, biotechnology, biochemistry and the engineering of materials); biosensors for wound treatment (with computer technology, engineering and biotechnologies); wearables for the prevention of wounds in clinical environments (with engineering and computer sciences) and e-health or tele-medicine in wound management. One challenge to address which is required for the development and piloting of this type of project is the incorporation of the science of care perspective and access to clinical environments.</p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">The key to addressing these challenges is to leverage the accumulated experience and training skills of nursing research on wounds.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Is it relevant to research on wounds from a nursing discipline?" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "What has the wound research context been in Spain?" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "How has research on wounds in Spain evolved?" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "What are the future challenges?" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pancorbo-Hidalgo PL. Los avances de la investigación enfermera sobre heridas: logros, oportunidades y retos. Enferm Clin. 2021;31:67–70.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anecdotario histórico de las heridas crónicas: personajes ilustres que las han padecido" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "FP García Fernández" 1 => "P López Casanova" 2 => "PL Pancorbo Hidalgo" 3 => "J. 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