Empowering Palliative Wound Care in Long-Term Care Facilities: A Comprehensive Nursing Competency for Palliative Wound Care
Article information
Abstract
Purpose
The importance of wound care as a part of end-of-life care is rising due to aging populations and increased chronic disease prevalence. This study developed a comprehensive competency framework on palliative wound care for nursing staff within long-term care facilities (LTCFs).
Methods
The study utilized a three-phased exploratory methods approach involving topic modeling, expert interviews, and a Delphi survey.
Results
Four key competencies emerged regarding nursing competency for palliative wound care in LTCFs: (1) building partnerships with patients and caregivers, (2) an individual approach to wound treatment based on understanding the patient's situation, (3) a holistic approach through shared information and cooperative decision-making, and (4) integration of wound management knowledge within end-of-life care.
Conclusion
This framework supports developing targeted training programs for nurses to improve the quality of life for terminally ill patients in LTCFs.
INTRODUCTION
The importance of end-of-life care is increasing due to the aging population and the rise in the prevalence of chronic diseases. According to the Organization for Econo-mic Cooperation and Development (OECD), the number of people requiring end-of-life care is projected to reach 10 million by 2050, up from 7 million in 2019 [1]. In South Korea, the number of hospice facilities increased from 56, serving 73,759 patients in 2012, to 191, serving 96,619 patients receiving end-of-life care by 2022 [2]. Furthermore, the Ministry of Health and Welfare aims to increase the number of hospice institutions to 360 and raise the hospice utilization rate from 25% in 2023 to 50% by 2028. [3].
In terminally ill patients, blood flow to the skin is re-duced due to circulatory system damage, and both nutritional status and immune function are compromised, making it difficult to maintain skin integrity [4]. This increases the risk of developing pressure injuries, surgical wounds, lymphedema, and leg ulcers, which can significantly diminish a patient's quality of life by causing pain, anxiety, odor, exudate, and bleeding [4]. In the United States, it is reported that at least one-third of the approximately 1 million hospice patients suffer from such injuries [5]. Injuries among terminally ill patients are a tragic issue for nearly 1 million hospice patients and millions of frail older adults with chronic illnesses [6]. The utilization of long-term care facilities (LTCFs) by terminally ill patients has been on the rise. This is evidenced by the increasing proportion of terminally ill or severely ill patients among long-term care insurance beneficiaries [2]. Therefore, it has become essential for nursing staff in these care facilities to possess adequate competencies in palliative wound care.
Palliative wound care refers to nursing care primarily focusing on wound management for terminally ill patients [7]. Unlike traditional wound care, palliative wound care requires a different approach that emphasizes managing wound-specific symptoms to ensure patient comfort rath-er than aiming for healing [7]. The goal is to maintain and improve the individual's quality of life and prevent further suffering [7,8]. Palliative wound care involves the complex task of managing wounds and assessing and sup-porting the patient's psychological and emotional well-being, necessitating appropriate nursing competencies [8]. Studies have shown that when proper palliative wound care is provided, overall patient satisfaction and health outcomes significantly improve [7-9]. Palliative wound care extends beyond wound management; it also addresses the psychological and social challenges faced by terminally ill patients and their families [7,9,10]. This type of care maintains the patient's dignity and helps them live the remainder of their lives more comfortably [7,8]. Therefore, to enhance the efficiency of palliative wound care, nurses need to possess various competencies that can be developed through continuous education and training.
In particular, LTCFs offer personalized nursing care to individuals with chronic illnesses, disabilities, or those requiring assistance with daily activities, emphasizing patient comfort and respect for individuality [9,10]. Unlike the aggressive treatments often given to terminal patients in general hospitals, end-of-life care in LTCFs focuses on maintaining patients' quality of life and dignity [9]. These facilities provide prolonged care with limited resources, and nurses receive specialized training to build patient trust [10]. This suggests that palliative wound care in LTCFs requires different nursing competencies than in hospitals.
While studies highlight the importance of palliative wound care, more systematic reviews are needed to address nurses' competencies and educational needs [7,8,11,12]. This study aims to review the competencies required for palliative wound care in LTCFs and develop a framework to guide practice. Framework development in nursing involves creating a conceptual model to address specific practice issues [13]. A framework for palliative wound care will help nurses improve wound management, enhance comfort, and uphold patient dignity at the end of life. It will also serve as the basis for educational programs, improving the overall quality of care by reducing complications and discomfort [4-6].
METHODS
This study employed a three-phase exploratory approach to develop a comprehensive framework for palliative wound care competencies [13]. In the first phase, topic modeling and a literature review established the theoretical foundation by identifying key components of palliative wound care. The second phase involved in-depth interviews with LTCF nursing staff to integrate practical experiences and refine the model's structure. In the final phase, a Delphi survey validated the essential competencies and finalized the model through expert consensus. The study developed a competency framework by com-bining theoretical insights and practical knowledge, confirmed via quantitative methods.
1. Phase 1: Literature-Based Topic Exploration
1) Data collection
We searched the relevant literature in four online databases (PubMed, EMBASE, CIHNAL, Web of Science) to identify theoretical evidence for general palliative wound care. The search term comprised related keywords such as wound care and end of life. The search was conducted based on the title or abstract of the document and studies published up to July 2020. Only literature written in En-glish was included, and after removing 14,056 duplicates and studies without abstracts, 5,880 studies were reviewed. Studies that were inappropriate for the topic were ex-cluded (n=4,872), and 1,008 were included in the final analysis. The detailed data collection process for topic modeling is available in Supplementary Materials 1.
2) Data analysis
Topic modeling infers topics by clustering words with similar meanings to find topics in unstructured literature [14,15]. This method helps integrate theoretical knowledge and extract critical components from a large body of literature [14,15]. This study used the NetMiner 4 program (version 4.4.2.c, Cyram Inc., Seoul, Korea) for data analysis, including data preprocessing, topic modeling, and in-terpretation of results [16]. First, in data preprocessing, text was extracted through morphological analysis, con-verting text into meaningful minimum units by separating endings, particles, and affixes, and the parts of speech of the extracted words were designated as nouns to identify the main concepts. Researchers independently reviewed the extracted words, and a dictionary consisting of defined words, thesaurus, and stop words was built to organize the words that were to be analyzed. In topic modeling, the documents were classified and clustered into topic groups using the Latent Dirichlet Allocation (LDA) technique, and each topic was extracted and visualized for examination [17]. Next, in interpreting the results process, each topic was named after the top keywords, and documents for each topic were exploratorily reviewed. Based on the analyzed results, five wound care experts evaluated the clarity and consistency of each topic to confirm its validity using a 5-point Likert scale.
2. Phase 2: Practical Insights Through Expert Interviews
1) Participants
Based on the theoretical basis derived through the previous steps, we explored the empirical evidence provided by nursing staff through interviews. In-depth interviews with experts are useful when you want to understand an expert's opinions, experiences, and knowledge on a specific topic or issue in detail [18]. In this study, we purposively recruited ten expert wound care nurses for palliative wound care in LTCFs. The selection criteria were those who had worked at an LTCF for over 5 years and worked as a wound care nurse for over 3 years. The participants' general characteristics were an average age of 43.70±3.96, and all were female. Their average working experience in an LTCF was 13.80±4.15 years, and the average working experience as a wound care nurse was 8.10±3.11 years (Table 1).
General Characteristics of Participants of the In-Depth Interviews and Delphi Survey
2) Data collection
The interview questions were structured based on the themes derived from the previous phase. The questions were: “ What psychological and ethical competencies should nurses have to provide life-centered well-dying support for patients and caregivers?”(Topic 1), “ What technical skills and emotional empathy should nurses demonstrate in local wound care focusing on symptom relief and emotional care?”(Topic 2), “ What collaborative and adaptive competencies should nurses possess to implement effective strategies through diverse treatment approaches?” (Topic 3), and “ What professional competencies and hu-manitarian approaches are required of nurses in providing wound care during the death process?”(Topic 4). Interviews were conducted from August to September 2020. A researcher with theoretical and practical knowledge of palliative wound care conducted the interviews in comfortable environments, such as clinics or quiet cafes, chos-en by the participants. The interviews continued until theoretical saturation was reached. Each interview was recorded and lasted approximately 60 minutes. In cases where additional information was needed, follow-up interviews were conducted in person or by phone, resulting in an average of 1.5 interviews per participant.
3) Data analysis
The in-depth interviews were analyzed using content analysis methods. The analysis was carried out in five stages [19]. First, the unit of analysis was determined by setting the entire interview as the scope of the analysis. Second, meaning units were identified by selecting phras-es, sentences, or paragraphs from the text that held sig-nificant relevance to the research topic: competencies in palliative wound care nursing. Third, a condensation process was conducted, where the selected meaning units were condensed into key messages, simplifying the participants' lengthy explanations into concise core content. Fourth, coding was performed by assigning specific codes or labels to the extracted meaning units, grouping data with similar meanings. Finally, categories and themes were derived by organizing the codes into categories and subcategories, representing the major themes or patterns of the research. These categories and themes were then used to identify the study's key findings.
4) Trustworthiness
To ensure the study's rigor, factual value, applicability, consistency, and neutrality were considered [18]. To increase the factual value, we created a comfortable atmos-phere for the interviews by engaging in mutual intro-ductions and light conversation before the interviews, and immediately after them, the recorded content was tran-scribed and checked repeatedly. To increase applicability, we selected participants who could provide specific state-ments about palliative wound care and had them confirm the researchers' content analysis results. To increase consistency, the researchers derived results from several dis-cussions while maintaining the purpose of the study and sought advice from a nursing professor with experience in qualitative research. To maintain neutrality, the researchers' subjective judgment was minimized during the interview, and efforts were made to prevent the researchers' subjectivity and prejudice from becoming involved during the data analysis process.
3. Phase 3: Validation Through a Delphi Survey
1) Participants
In this phase, a Delphi survey was used to verify wheth-er the preliminary items of the frame were suitable for improving the palliative wound care competencies of LTCF nursing staff. The Delphi survey method allows respond-ents to express their opinions freely, and a structured survey form is used to repeatedly collect opinions and change those opinions when necessary [20]. This study comprised a group of 20 experts in LTCFs. Participants were recruited by posting an announcement at the Korean Wound Care Society's academic conference. The selection criteria included having at least three years of experience as a wound care nurse in an LTCF and having experience in palliative wound care. The participants' general characteristics were an average age of 53.25±6.32 years, and all were female. Their average working experience in an LTCF was 18.30±4.91 years, and all had wound care experience in LTCFs (Table 1).
2) Data collection
The draft for the Delphi survey consisted of the items and sub-items derived from the previous stage. The Delphi survey was conducted from September to October 2020. In principle, the Delphi research process is performed until experts mutually agree. To this end, the survey can be repeated up to the fourth stage, but if the experts reach a consensus in the second stage of the survey, the sub-sequent survey can potentially be more meaningful [21,22]. Since, as a result of the survey's second stage, this study found little disagreement in expert opinions, the final content was composed based on the second stage. The questionnaire employed a 5-point Likert scale for each item to evaluate its importance and validity.
3) Data analysis
The suitability of the items was judged by calculating the content validity ratio (CVR) and coefficient of variation (CV) [23,24]. The CVR value is calculated as CVR <0 if less than 50% of the expert panel responds that it is valid, CVR=0 if 50% of the expert panel responds that it is valid, and CVR=1 if everyone responds that it is valid [23]. In this study, items with a CVR value of .44 or higher were judged to have content validity [23]. Stability was analyzed by CV value; when the CV value was 0.5 or less, the panel's consensus was judged high [24]. By analyzing the content validity and stability of the previous stage of the survey, the content of the next stage was revised, and open-ended questions were included to collect additional opinions. Data were analyzed using the SPSS 25.0 program.
4. Ethical Considerations
This study adhered to the ethical principles outlined in the Declaration of Helsinki and was approved by the ** Institutional Review Board (KUIRB-2019-0294-01). All participants in the in-depth interviews and Delphi surveys were provided with a detailed description of the study and written informed consent forms, with the assurance of anonymity. All personal data collected during the study were anonymized and securely handled, prioritizing the rights and safety of the research participants.
RESULTS
1. Phase 1: Theoretical Knowledge through Previous Research Review: Topic Modeling
Through the topic modeling of 1,008 documents dealing with palliative wound management in LTCFs, four topics containing 10 top keywords each were extracted (Supplementary Materials 2). Keywords for each topic were analyzed to identify key terms, and their relationships were examined by reviewing related abstracts and documents to determine the central theme of each topic. The context and patterns in which the terms were used together were identified in this process. Based on these key terms and their relationships, each topic was interpreted and as-signed a concise and representative name (Figure 1). A content validity survey was conducted with five wound care nurses to validate the appropriateness of each topic name. The survey results indicated that on a 5-point scale, Topic 1 scored 4.25±0.50, Topic 2 scored 4.50±0.58, Topic 3 scored 4.25±0.50, and Topic 4 scored 4.50±0.58, confirming their validity.
Results of the topic modeling.
Topic 1, “ Life-centered well-dying support for patients and caregivers,” expresses the importance of identifying the needs of patients and their families for wound care, focusing on their quality of life, and helping them maintain dignity and comfort. It suggests that nurses need to be equipped with psychological and ethical competencies to effectively support patients and their families in achieving a dignified, life-centered end-of-life experience. Topic 2, “ Local wound care focusing on symptom relief and emotional care,” is centered on relieving symptoms such as pain and exudate caused by wounds and providing emotional support. It also concentrates on local wound care, such as dressings. Relieving symptoms and improving quality of life were shown to be necessary. It suggests that nurses should possess technical proficiency and the ca-pacity for emotional empathy to effectively focus on symptom relief and emotional care in localized wound management. Topic 3, “ Effective strategy through diverse treatment approaches,” emphasizes the multidisciplinary management of complications, metastasis, and recurrence through various therapeutic methods, including surgery, chemotherapy, and flap surgeries. This approach highlights the need for strong collaboration among healthcare professionals and the ability to adapt treatment plans based on the patient's evolving condition. Finally, Topic 4, “ Wound care along with the death process,” addresses the patient's death and related factors and symptoms. It im-plies that nurses need to be proficient in pain relief techni-ques and possess the skills to support families, ensuring comprehensive wound care during the end-of-life phase.
2. Phase 2: Experiential Knowledge through Expert Experience: In-depth Interviews
Four key categories were identified through expert interviews regarding the practical aspects of LTCFs’ palliative wound management capabilities.
1) Category 1. Building partnerships with patients and caregivers
It is essential to reflect the opinions of patients and their guardians in all processes related to managing the patient's wounds and to form a trusting relationship with them.
(1) Understand the direction of care that takes into account patient preferences
When setting goals for wound care, the needs of the patient and caregiver should be identified, and the beliefs, at-titudes, expectations, cultural norms, and interpersonal dynamics related to the desired scope of care should be considered. “ Especially when performing palliative wound care, we first talk a lot with the patient or guardian. So we should set goals for active treatment, maintenance, or comfort before starting.” (Participant 3)
(2) Ability to communicate to understand emotions
A treatment strategy should be developed based on this by exploring what's in the hearts of the subject and/or their caregiver through communication that examines their probable feelings of despair and alienation ahead of death. “ Even though he was close to death because he had major problems with his vitals, such as breathing, when-ever his caregiver came to visit him, the caregiver showed little interest in other things and always complained about the wound dressing. I did not understand initially, but when I talked to the caregiver, he felt less sorry if the patient's visible parts were clean. After understanding that part, I started to pay more attention to the time when the caregiver came as much as possible.” (Participant 2)
(3) Creating an environment to empower family members in wound care
Because palliative wound care often does not aim at healing, it can require treatment over a long period and, therefore, should be done with a caregiver's assistance. In other words, the patient and the family become the main targets of wound care. Therefore, we need to help them do it to the extent possible and create an environment for it. “ If the caregiver is dressing by the bedside directly or going home, it is important to educate the caregiver about wounds, but in many cases, the caregiver is older. In those cases, we will set it up and educate them in the simplest way possible so the caregiver can use it comfortably.” (Participant 10)
2) Category 2. An individual approach to wound treatment based on understanding the patient's situation
In palliative wound care, it is necessary to comprehensively evaluate each patient's wound and physical and psychological condition and provide customized care.
(1) Knowledge and understanding of wound-related symptoms
Because various wounds may appear at the end of life, knowledge about them is essential, and it is necessary to adjust to the patient's situation and provide optimal treatment. “ Wound care knowledge is fundamentally important in palliative care. You can modify and apply the basics to suit the audience if you know the basics. So, we need to keep studying this and using it in practice.” (Participant 2)
(2) Setting wound treatment priorities and methods based on the patient's condition
Since palliative wound care is often not aimed at healing, symptoms should be approached according to the patient's situation and needs, economic and social situation, and emotional issues, all of which can determine the number of dressings and methods. “ We do not always say that the patient needs to change position every two hours, but we change the time according to systemic conditions such as breathing, and if the pain is too severe, we strategically devise a method of reducing the number of dressing changes.” (Participant 4)
(3) Continuous reorientation through disease-based wound monitoring
For patients receiving palliative wound treatment, the wound's progress varies depending on their disease and can change daily, significantly affecting wound healing. Continuous monitoring is necessary from a perspective based on individual situations, and it is essential to prevent worsening through continuous correction of direction. “ Patients with palliative wounds often experience drastic changes in their overall condition. The wound then often gets worse as well. Therefore, the direction of wound treatment should be continuously changed while looking at the progress of the disease.” (Participant 3)
3) Category 3. A holistic approach through shared information and cooperative decision-making
Information sharing between staff in palliative wound care is essential for providing integrated and consistent patient treatment through multidisciplinary teamwork. This requires fully utilizing each person's expertise via regular meetings and an efficient information delivery system.
(1) Collaboration-based approach with various medical staff within the facility
In LTCFs, where various medical staff care for patients, palliative wound care decisions should be based on clinical knowledge. This knowledge must be shaped comprehensively by sharing and integrating the experiences of each expert, making team-based cooperation essential. “ Because the patient's condition changes daily, we need to share information about the wound and various patient information, discuss priorities, and approach accordingly. That is why it is essential to cooperate and build and utilize a system.” (Participant 7)
(2) Consideration and understanding of the current institution's acceptable range of care
Since resources are limited within LTCFs, exploring available resources and defining their limits is necessary. “ Because it is a facility, care is more limited than in a hospital. So, it is essential to discuss with the medical staff and patient caregivers how much we can do, do our best within those limits, and intervene to ensure that patients receive appropriate care if they go beyond that range.” (Participant 2)
(3) Ability to communicate with and use nearby medical facilities
Because there are limited resources within nursing facilities, it is essential to overcome limitations and ensure continuity by linking them with the necessary resources. “ If a case is beyond our capabilities, connecting with nearby hospitals or local doctors is crucial. Building good relationships in advance through regular meetings or collaboration ensures effective communication for such ex-changes.” (Participant 6)
4) Category 4. Integration of wound management knowledge within end-of-life care
Integrating wound management knowledge with the death process in palliative wound care focuses on maintaining quality of life and minimizing pain through wound management even while the patient is dying.
(1) Understanding end-of-life care
It is necessary to provide care tailored to the patient's life cycle by integrating knowledge of wound management with an understanding of end-of-life care. This should include pain management, symptom relief, and emotional and spiritual support. “ Unlike general wound management, palliative wound management requires integrated knowledge of end-of-life care, including understanding the physical and mental challenges that may arise, to develop effective wound management strategies and achieve desired outcomes.” (Participant 5)
(2) Understanding different approaches through com-parisons of weakened skin
The wound-healing process of end-of-life patients is greatly affected by skin changes caused by aging and diseases. For this reason, new wounds often form, and the healing period is often much longer. Therefore, it is necessary to take a strategic approach based on understanding this and finding ways to minimize the impact. “ Elderly patients have weakened skin, requiring careful consid-eration in wound care. For end-of-life patients, caregivers should use alternatives to adhesive dressings or tape, such as fixation.” (Participant 1)
3. Phase 3: Integration and Field Validity Review: Delphi Survey
Table 2 shows the statistical results for each round of the Delphi survey. Most items met the CVR standard of 0.44 or higher, but some did not; therefore, we collected opinions from participants, renamed them, and added subcategories. In the second round, which reflected their views, an item called “ ethical considerations based on respect for dignity” was added to emphasize ethical competency. In addition, “ ability to communicate with and use nearby medical facilities” was changed to “ ability to communicate with and use nearby resources” due to the majority's opinion that it should include not only medical facilities but also all available resources in the surrounding area, such as community resources. It was renamed “ balance between end-of-life care and wound care” in response to the opinion that “ understanding end-of-life care” requires the ability to use not only end-of-life care knowledge but also wound care knowledge in an integrated manner. Similar-ly, “ knowledge and understanding of wound-related symptoms” was renamed as “ understanding and application of wounds and disease-related symptoms” with the opinion that it should include knowledge of wounds and the patient's disease-related symptoms. As a result of the second round, the CVR values were all above 0.44, which confirmed that they were all suitable, and the stability was confirmed to be below 0.5, confirming that no further in-vestigation was needed. After going through each step and agreeing on all items, an outline of the framework for the LTCFs’ palliative wound care capabilities emerged (Figure 2).
Results of the Delphi Survey
Nursing competencies for palliative wound care at long-term care facilities.
A high-level framework describing the core competencies of nursing staff for palliative wound care in LTCFs was agreed upon through a sequential literature review, qualitative interviews, and a Delphi survey. It consists of four main categories of LTCF palliative wound care capabilities. The first category suggests that creating a cooperative environment through physical and verbal communication with the target patients and their caregivers is essential. The second category emphasizes the need for strategic capabilities to set priorities and directions for wound treatment and continuously monitor them based on the patient's symptoms and overall condition. The third category suggests that the ability to communicate well with and utilize resources within and outside the facility is essential to overcoming the limitations of LTCFs. The fourth category demonstrates the need for integrated thinking capabilities based on balanced thinking informed by a comprehensive understanding of end-of-life care and wound management. It also demonstrates respect for dignity in treating wounds by understanding the characteristics of that part of the life cycle called dying.
DISCUSSION
This study systematically analyzed the competencies of nursing staff required for palliative wound care in LTCFs and presented a framework based on this. Through this, the core competencies of LTCF nursing staff for palliative-wound management were presented, and the areas required for palliative wound management in LTCFs were shown. Previous studies have presented general guide-lines for wound care or palliative care and discussed the importance of some types of palliative wound care within them [4-6,8,10,12]. However, our study focused on palliative wound care and studied the competencies of nursing staff in LTCFs, the most common location for end-of-life care, thus directly presenting a way to improve the quality of nursing care in LTCFs.
In this framework, the emphasis is not only on wound care but also on the care of patients at the end of life. The importance of patient-centered and individualized approaches in categories 1 and 2 was also emphasized in a study by Meier and Brawley [25], which showed that an individualized approach that reflects the needs of patients and families is essential in hospice palliative care and that it improves the patient's quality of life [25,26]. Palliative wound care in categories 1 and 2 well reflects the emphasis on the importance of end-of-life care. In addition, the findings of a study by Fernando and Hughes [27] are well reflected in category 3, which emphasizes that multidisciplinary teamwork is essential for improving the quality of care of hospice patients. As shown in Category 4, wound management in end-of-life care focuses on preserving the patient's quality of life and dignity, aligning with previous research emphasizing the ethical responsibility to respect autonomy and dignity [7,9]. Continuous education and the development of assessment tools to enhance nursing competency are effective in strengthening the competencies of nursing staff and increasing patient satisfaction in LTCFs [28-30]. Based on this, we suggest that they should be integral to developing appropriate education and establishing a system to improve the quality of palliative wound care in LTCFs.
Building partnerships with patients and caregivers is based on building trusting relationships and establishing effective communication, for which scenario-based learning that improves verbal and non-verbal communication, including active listening, empathy, and cultural sensi-tivity, is proposed [31]. Additionally, a route for partic-ipation in the patient planning and decision-making proc-ess should be provided through a caregiver support program for patient-and family-centered care education. An individualized approach based on understanding the patient's situation requires understanding the patient's symptoms and condition and strategic priority setting and monitoring. To increase these competencies in LTCFs, clinical decision-making workshops, such as case-based learning, can improve how nursing staff assess patients' conditions, set priorities, and select wound care interventions tailored to individual needs [32]. An integrated approach through collaboration with medical staff requires cooperation between staff at various facilities and effective communication with external resources. Periodic multidisciplinary team training opens up not only knowledge but also communication and allows us to find effective methods for a system of communication. It also improves networking with external healthcare providers and local resources through external partnership training. Integrating knowledge in end-of-life care and wound management is ach-ieved through training emphasizing comprehensive, patient-centered care, addressing physical, emotional, social, and spiritual needs.[33]. Experienced palliative wound nurses guide less experienced staff through mentoring programs, ensuring they learn to provide care that meets all patients' physical, emotional, and spiritual needs [34,35]. Providing mentoring will help develop and provide guidance and resources needed to apply integrated wound care and end-of-life care practices.
Several limitations should be considered in this study. The literature search, interview, and Delphi survey sam-ples used in this study may have been limited to specific regions or settings, affecting the generalizability of the results. To minimize these limitations, we refined the search terms during the literature analysis process and searched as comprehensively as possible using several online databases. Additionally, to avoid selection bias during the purposeful sampling of interview and survey participants, we recruited competent participants capable of providing diverse, rich opinions and who had established successful, creative careers at LTCFs.
CONCLUSION
This study systematically analyzed the nursing staff capabilities required for palliative wound management in LTCFs and presented a framework based on this. Four main categories were derived: building partnerships with patients and caregivers, an individual approach to wound treatment based on understanding the patient's situation, a holistic approach through shared information and cooperative decision-making, and integration of wound management knowledge within end-of-life care.
This study highlights the importance of developing innovative, patient-centered approaches and fostering inter-disciplinary collaboration to enhance nursing staff competencies in palliative wound management within LTCFs. By leveraging advanced clinical practices and integrating tailored care strategies, we can better address the unique challenges of end-of-life care, especially with the aging population and the prevalence of chronic diseases. Improving these competencies will lead to better patient outcomes and higher quality of care. Future research should focus on developing and validating educational programs based on the framework while exploring innovative tech-nologies and methods to optimize management and care standards.
Notes
CONFLICTS OF INTEREST
The authors declared no conflict of interest.
AUTHORSHIP
Study conception and design acquisition - Chang S-O and Lee Y-N; Data collection - Choi Y-R, Kim D and Lee Y-N; Data analysis & Interpretation - Chang S-O, Choi Y-R, Kim D and Lee Y-N; Drafting & Revision of the manuscript - Chang S-O and Lee Y-N.
DATA AVAILABILITY
The data that support the findings of this study are available from the corresponding author upon reasonable request.
