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Interview

An interview with

Richard White Oxford Wound Centre which proved immensely valuable. The rest is history.

What challenges have you faced as a wound care specialist?

email: [email protected] Professor of Tissue Viability, University of Worcester

What made you go into tissue viability? It was almost by accident. I had been working in experimental dermatology and the project was closed. An opening came in wound care: being 1990, ‘tissue viability’ as such was in its infancy at that time. I suppose that knowing something about skin made me a suitable candidate but I knew nothing of matters such as pressure ulceration and modern wound dressings! I had seen large numbers of leg ulcers and factitious wounds in dermatology out-patients; this helped me get started. Our standard wound care at that time involved gauzes and so-called non-adherent dressings, and zinc paste or ichthopaste bandages, applied as the ‘Unna’s boot’. We regularly used silver nitrate solution to burn back hypergranulation. I had seen Granuflex and Comfeel hydrocolloids but knew nothing of this strange new dressing type. Times have now changed—hopefully everywhere in the UK has moved forward substantially. The Journal of Wound Care was begun in 1992 and proved a very useful asset. I read this regularly and spent a lot of time at the

What are the biggest concerns for patients with chronic wounds and how can wound care professionals rise to the challenge? For me this is easy—it is poor care, and inconsistent care. The fundamentals of chronic wound care are far from universally applied (in the UK that is). I still see the need to persuade clinicians to wash patients’ legs and feet, even in the presence of ulcers. Properly done, it is not at all harmful, has no crossinfection risk, and offers great relief and comfort to the patient. In patients with venous ulcers especially, skin care is essential— yet few clinicians will make the time to moisturise and to remove scale before re-bandaging. Lack of time is usually cited as the reason, but why administer only part of the treatment? It wouldn’t happen with other disorders, so why do leg ulcer patients have to suffer? The needs of mental health patients with wounds must also be considered. Such is the nature of this area that acute wounds become chronic due to patient interference. The whole field of mental health in the UK is in

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Richard White

Mainly from a teaching and research perspective, getting the discipline ‘up to speed’ with biological and physiological aspects of wound healing. There are also numerous struggles regarding standards of care, fashionable topics, product availability, evidence, and funding along the way. In terms of products, once I became aware of moist wound healing and observed for myself just how effective hydrocolloids could be, I was converted. In the subsequent decades, I have tried to persuade clinicians that antiquated ‘therapies’ such as eosin (for maceration!), proflavine ribbon gauzes and creams, and potassium permanganate were to be resigned to history for wound care. However, there are pockets of resistance and someone will now surely let me know that these are ‘miracle cures’. As in every other area of health care, there is still much to be done.

Community Wound Care June 2014 Journal of Community Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 22, 2015. For personal use only. No other uses without permission. . All rights re



need of reorganisation, funding, research and education. Tissue viability in mental health is woefully neglected. Furthermore, the development of sepsis in chronic wound patients is a largely unexplored topic. We speak glibly of patients with pressure ulcers developing septicaemia and bacteraemia, yet there are no data on incidence and prevalence. What is the scale of this problem and what can be done to avoid sepsis—in all patients with wounds? What clinical; outcomes are obtained in patients with infected ulcers of categories 3 and 4? We need to know.

How can health professionals ensure that national and local guidelines are implemented in clinical practice? Firstly, there are local guidelines all over the country; not every organisation needs its own, why reinvent the wheel? The same applies to formularies too! National guidelines such as Scottish Intercollegiate Guidelines Network (SIGN) and the National Institute for Health and Care Excellence (NICE) are excellent. Others are variable and usually out of date. The Royal College of Nursing (RCN) has been quiet on this topic of late. Those ‘guidelines’ and ‘best practice statements’ written to support commercial interests are usually valueless. If practitioners are wary of litigation, then follow guidelines from authoritative sources.

© 2014 MA Healthcare Ltd

In what ways are you working to improve patient care? By writing, teaching, and agitating. The title of Professor has given me some leverage to say what I think, and to articulate what many nurses want to say but dare not. I have taken this upon myself to do; it doesn’t always win friends and influence people, but I do get lots of positive feedback. It is also in my nature to speak out about misleading articles and arrogant pontification. Evidence has been high on my agenda: clinicians do need to know what the current evidence is, and importantly, what it means for their clinical practice. ‘Best evidence’ is always going to be subjective, so reviews of all of the available evidence, with guidelines, is my preference. Thankfully, NICE have adopted this approach with considerable acclaim from practitioners, educators, societies and industry. The various societies have an important role to play, but sometimes I feel they are too reserved. I am currently working with the Wound Care Alliance UK (again!) and the Sepsis Trust, in whatever way I can to raise awareness. Last year I began a close liaison with the Association of Personal Injury Lawyers (APIL) with the aim of raising awareness on pressure ulcer avoidance and care. It just might be the case that litigation is the only way to move pressure ulcer care forward. We probably knew all we needed to reduce the incidence of ulcers by 1980, yet the same problems keep occurring. The fact that health-care trusts set aside funds in mitigation for malpractice and negligence is morally appalling. It is tantamount to accepting an attrition rate for category 3 and

Interview: Richard White

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4 pressure ulcers as but one example. The emphasis on reducing surgical site infections and readmissions seems to be having an impact. The same enthusiasm, and penalties, need to be applied to pressure ulcers.

What are your views on ‘no avoidable pressure ulcers’? This is, I believe, the single most important issue for UK tissue viability at present. Ethically, we must proceed as if all pressure ulcers are avoidable until circumstances dictate otherwise. It is inadvisable to predict ‘unavoidableness’ in any patient.

What do you enjoy about your role? Freedom to write, speak and meet with a remarkable sector of our health-care system. When one compares wound care in the UK between 1990 and today, the progress has been enormous. The dedication of most people in tissue viability is wonderful. I am getting older and my health care needs are increasing—tissue viability problems may be lying in wait for me, so in one way it is selfish!

What advice would you give to budding wound care professionals? Embrace the field, as there is abundant room for improvements in practice and research. Enrol on a UK masters degree course if you can. Times are, however, tough in the NHS at present, and there are many disillusioned TVNs.

What do you expect to see in wound care in the next 10 years? I am currently researching the last century of wound care— from 1914 and the start of the Great War through to today. In some respects we have made little progress, although, thanks to industry, we now have a vast array of good products to help. In 1914 it was Gamgee tissue, iodine and the knife. Now we have hundreds of dressings and devices with which to aid healing. On the UK front, I would like to see tissue viability unite under one umbrella, to speak with one voice. I have argued for the specialty to link with a medical discipline such as dermatology. However, this has met with little enthusiasm on either side! For tissue viability to thrive I believe such a link will be essential. In purely wound care terms, the various specialties such as diabetes and vascular have already established a general high standard of care. My concerns are for the community patients: what will happen with the new clinical commissioning groups? Will GPs acknowledge that wounds can take skill and time to heal, or will costs be everything? CWC

Community Wound Care June 2014 Journal of Community Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 22, 2015. For personal use only. No other uses without permission. . All rights re

An interview with Richard White.

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