Low-value wound care: Are nurses and physicians choosing wisely? A mixed methods study

Background: Choosing Wisely is an international movement that stimulates conversations about unnecessary care. The campaign created five recommendations including a statement that less wound care is sometimes better. Aims: The study aims to evaluate nurses' and physicians' adherence to the Choosing Wisely recommendations for acute wound care in the Netherlands and the barriers and facilitators to improve this. Design: This is a mixed methods study using a survey and interviews. Methods: The survey was completed by 171 nurses and 71 physicians from November 2017 to February 2018. A total of 17 nurses and 6 physicians were interviewed. Results: Awareness of the five recommendations ranged from 62% to 89% for nurses and 46% to 85% for physicians. However, up to 15% of the nurses and 28% of physicians were aware but did not adhere to the recommendations. Barriers to adhering were a lack of knowledge, the work environment and perceptions of patients' preferences. Repeated attention, cost-consciousness and an open culture facilitated the implementation. Conclusion: Although most nurses and physicians were aware of the recommendations, not all adhered to them. Increasing awareness is not enough for successful implementation. A tailored approach that removes the barriers is necessary, such as increasing knowledge about wounds and changing the work environment.


Summary statement
What is already known on this topic?
• Less wound care is sometimes better: cleaning wounds with tap water only, not bathing wounds, using simple bandages and not using bandages on wounds healing by primary intention leads to better wound care for lower costs.What this paper adds?
• Although the majority of nurses and physicians were aware of the Choosing Wisely recommendations for acute wounds, not all adhered to them.
• Awareness is not always sufficient for successful implementation, which requires a broader approach that targets the barriers.

The implications of this paper
• Implementation of these recommendations can be improved by increasing knowledge about wounds and wound care, changing the work environment, and verifying the patient's presumed preferences regarding wound care.

| INTRODUCTION
Overuse of low-value care has been recognized as a major problem in healthcare in recent years (Brownlee et al., 2017).Low-value care provides no benefit for the patient, wastes resources and can cause harm (Mafi & Parchman, 2018).In 2012, the US Choosing Wisely campaign was started to stimulate the conversation about unnecessary tests, treatments, and procedures (Levinson et al., 2015).Since then, the campaign has spread to more than 20 countries (Levinson et al., 2015).As part of this campaign, professional societies produce lists of recommendations that advise against practices used in their discipline for which there is evidence of overuse and significant potential harm or cost.
The Netherlands launched its Choosing Wisely campaign in 2013.
One of its lists presents five recommendations for acute wound care that are based on the multidisciplinary guideline Wound care from 2013 (Ubbink et al., 2015).The recommendations apply to acute wounds caused by surgery or trauma and are as follows.Adhering to these recommendations not only saves costs on saline, cleanser and bandages, it results in better wound care for the patient.Cleaning wounds with tap water leads to fewer infections than cleaning with saline (Fernandez & Griffiths, 2012).Also, there is no difference in wound healing between covered and uncovered wounds and between different types of bandages (Dumville et al., 2016).Hence, it is recommended to not use bandages on a wound closed by primary intention and if a bandage is necessary to use simple gauzes.Early removal of dressings from surgical wounds may even result in shorter hospital stays (Toon et al., 2015).Lastly, providing instructions to patients may reduce the risk of patientrelated surgical site infection through better wound care after discharge (Anderson et al., 2016).

| Aim
This study aimed to evaluate nurses' and physicians' adherence to the Choosing Wisely recommendations for acute wound care and the barriers and facilitators to improve this.

| Design
We performed a mixed methods study comprising of two components with equal priority.First, we performed a cross-sectional study using an online survey amongst nurses and physicians about the awareness of and adherence to the five recommendations.Second, we performed semistructured interviews with nurses and physicians about their perceived barriers and facilitators for adhering to the recommendations.With equal priority, each component provides an important contribution to the aim of the study.The benefit of this approach is that the survey gives us insight into the current awareness and practice, whereas the interviews gave us insight into the experiences and motives behind this.

| Setting
We evaluated the awareness of and adherence to the five Choosing Wisely recommendations for acute wounds in emergency and surgery departments in 96 hospitals in the Netherlands.Most hospitals, including those that participated in this study, are privately run but nonprofit.We included both outpatient and inpatient care in the surgery department.In the Netherlands, both nurses and physicians are involved in wound care.Generally, the physician determines the treatment policy and performs the surgical procedures, while the nurse provides the daily wound care and chooses the dressing.Both are involved in the patient's care directly at admission post trauma or during and after a surgical procedure.In addition, most hospitals have one or more nurses who are specialized in wound care, who are called wound care experts.Mostly they are trained as advanced nurse practitioners and serve as knowledge brokers.

| Survey
The online survey was developed in several feedback rounds with the authors of this paper.An expert group on acute wound care, including two nurses, two physicians and a patient representative, provided feedback on the survey to ensure the questions were clear and complete and they confirmed face validity.The survey can be found in Data S1.The link to the online survey was sent by email along with information on this study.To prevent socially desirable responses, we first asked the respondents about their current practices in wound care related to the recommendations, such as 'How do you clean an acute wound?'.Subsequently, we introduced the recommendations and asked for their awareness of and adherence to them.Also, questions on demographics such as age and current employment were included.We aimed to keep the survey length within ten minutes to complete.

| Participants
In November 2017, we asked all wound care experts that were employed in one of 69 Dutch hospitals and were registered with the Dutch Nurses Association, by e-mail if they were willing to participate in our study.In December 2017 and January 2018, a reminder was sent.Those who signed up were asked to complete the survey themselves and send the survey to 30 nurses in their hospital at random: 10 nurses from the emergency department, 10 from outpatient surgery and 10 from inpatient surgery.In addition, they were asked to send the survey to five physicians working at one of these three departments.When we received no or few responses from a hospital, we asked the wound care expert in question to repeat sending the survey.To reach more physicians, an open invitation to the survey was published in the newsletter of the Dutch Association for Emergency Department Physicians.At the end of the survey, respondents could leave their email address or phone number if they were willing to participate in an interview.Figure 1 shows the flow of our survey.

| Analysis
Data were analysed with SPSS 25.Descriptive statistics were used to describe the awareness and current practice of the nurses and physicians.Missing values were handled by pairwise deletion and correction for clustering within hospitals was not possible because of the low number of respondents per hospital.The response rate for emergency department physicians could not be calculated because the privacy law hampered us from seeing how many received the invitation.
The survey is reported using the STROBE checklist for cross-sectional studies (Data S2).

| Semistructured interviews
We developed an interview guideline for nurses and physicians by selecting themes that potentially influence adherence to the recommendations from the checklist for identifying determinants of practice (Flottorp et al., 2013).The expert group on acute wound care, including two nurses, two physicians and a patient representative, ensured all potentially relevant themes were included.The interview guide can be found in Data S3.

| Participants
Nurses and physicians who completed the survey and signed up to participate in an interview were contacted by a researcher.We used purposive sampling to select nurses and physicians from different departments and hospitals.An informed consent form was emailed, and oral consent was recorded.The primary researchers and two research assistants interviewed the participants telephonically, and all interviews were audio-taped.New interviews were scheduled until no new themes emerged and saturation was reached according to all interviewers.

| Analysis
The interviews were fully transcribed.Three researchers coded the interviews using an inductive thematic analysis (Braun & Clarke, 2006).In this approach, the analysis is data-driven, and themes are constructed without a pre-existing frame.The researchers started by giving initial codes to relevant quotes.Subsequently, all codes were grouped into categories and subcategories derived from the data through constant comparison and review.Three researchers coded the first four interviews independently and discussed the results until a consensus was reached.All subsequent interviews were coded by one researcher after which the codes were checked by another and discrepancies were discussed.In forming the categories, the researchers regularly discussed and rearranged the quotes and codes.This method with multiple coders and constant comparison and review ensured the validity of the themes that emerged.Atlas-Ti 8.0.34 was used for coding and analysing.More details can be found in the COREQ checklist for qualitative studies (Data S4).

| Ethical considerations
The research protocol was sent to the local Research Ethics Committee, which judged that ethical approval was not required under the National Law in the Netherlands (study number: 2017-3857).

| Survey
Wound care specialists from 14 hospitals (12 general and 2 university hospitals) responded to our request (response rate of 20% [14/69]) and were asked to forward the link to the online survey.In total, 171 nurses and 22 physicians responded.They were asked to complete the survey themselves, and by assuming they forwarded it to 30 nurses and 5 physicians per hospital, 434 nurses (including wound shown in Table 1. Figure 2 and Table 2 provide an overview of the awareness of and adherence to the Choosing Wisely recommendations for nurses and physicians. When asked about their current wound care practices, 65% of the nurses and 79% of the physicians report that they use tap water to clean an acute wound.However, 57% of both nurses and physicians (also) use saline or sterile water, which contradicts Recommendation 1.Only 1% of the nurses and 4% of the physicians soak acute wounds in cleanser, which is in accordance with Recommendation 2. Contradictory to Recommendation 3, 16% of the nurses and 49% of the physicians always use bandages on a wound healing by primary intention.Only 10% of both nurses and physicians use expensive bandages, and 86% of the nurses and 100% of the physicians give wound care instructions to the patient, which shows good adherence to Recommendations 4 and 5.
When we presented the recommendations, the percentage that report that they know them and adhere to them varied between 62% and 89% for nurses and 46% and 85% for physicians.In addition, 4%-15% of the nurses and 2%-28% of the physicians knew the recommendations but did not adhere to them.Recommendations 1 and 3 (do not clean with saline and do not cover wounds) were the least adhered to.Lastly, 3%-24% of the nurses and 13%-32% of the physicians did not know the recommendations.Nurses were unaware of Recommendation 1 (do not clean wounds with saline), whereas physicians were unaware of Recommendations 3 and 4 (do not cover wounds and do not use expensive bandages).The most frequent responses to the question of how implementation could be improved were education in wound care and improving wound care policy in their department.
Our results indicate that nurses from the emergency department are less likely to know the recommendations compared with the surgery department.However, due to the small number of emergency department nurses, this could not be tested for statistical significance.
The awareness of and adherence to the recommendations is likely to vary between hospitals, but this could also not be tested.The percentage of missing values for the questions regarding the awareness of and adherence to the recommendations varied from 9% to 12% of the initial respondents.

| Semistructured interviews
We interviewed 23 of the 53 survey respondents that offered to participate in an interview, which included 17 nurses and 6 physicians.
Eight interview participants worked at the emergency department, eight at the surgery department, three at multiple departments and four were wound care experts who also worked at multiple T A B L E 1 Characteristics of the respondents to the survey.Table 3 presents relevant quotes.

| Knowledge
Several nurses and physicians indicated that they did not know (some of) the recommendations, mainly 1 and 3 (do not clean with saline and do not cover wounds).In addition, we found that a lack of knowledge about wound care was a barrier to accepting and applying them.
According to the nurses and physicians, the wound care specialist can help to improve this knowledge.Soaking a wound in a cleanser used to be common practice, but according to the participants, it is now well known that this impairs wound healing.The participants have reported that the fact that this subject was regularly brought to their attention has helped to achieve this.

| Attitude
Some participants needed to see the scientific evidence that underpins Recommendations 1 and 3 (do not clean with saline and do not cover wounds) in order to trust them.Others needed to experience for themselves that cleaning with tap water does not result in more infections.Furthermore, some found it important to act cost-conscious while others did not.Nurses and physicians agree that wound care instructions are important for optimal healing, which motivates them to adhere to Recommendation 5 (do teach patients).
The patient's comfort is also very important to them, which sometimes leads to them using more expensive bandages.

| Habits
As with many behaviours, habits are hard to change.For Recommendations 1 and 3 (do not clean with saline and do not cover wounds), T A B L E 2 Current wound care practice and awareness of and adherence to the Choosing Wisely recommendations.

| Practical work environment
The work environment plays an important role in adhering to Recommendations 1, 4 and 5 (do not clean with saline wounds, do not use expensive bandages, and do teach the patient).Whether a nurse or physician chooses tap water or saline depends for a big part on which is closer by or easier to use.Some reported that tap water is difficult to obtain in their department, while the bottles with saline are easily accessible.The type of that they use depends on what is available on the dressing cart.According to the nurses and physicians, reminders in their work environment and the fact that adhering to Recommendations 2 and 3 saves time (do not soak and cover wounds) facilitate their implementation.

| Social environment
Generally, physicians leave the choice of wound care products to the nurse, but they sometimes ask nurses to deviate from Recommendations 1 to 4 (do not clean wounds with saline and do not use expensive bandages), for example, to use expensive bandages instead of simple gauze.Some nurses subsequently discussed this with the physician and sometimes they decided together to follow the recommendation.The participants indicated that an open culture in which it is possible to give feedback to colleagues helps to adhere to the recommendations.In some departments, wound care and the prices of bandages were regularly discussed.

| Policy
Regarding the wound care policy in their department, some nurses and physicians had work instructions that were outdated and conflicted with the recommendations.Others did not describe wound care or were unclear.Some nurses and physicians even stated that they did not know the work instructions in their department.

| Patient
Nurses and physicians reported that they often use bandages or clean wounds with disinfectant or saline because they assume that this is what their patients prefer.They also report that when they explain why a wound care practice is not necessary, patients generally accept this.

| DISCUSSION
This study demonstrates that the majority of nurses and physicians are aware of the five Choosing Wisely recommendations for acute wounds.Recommendations 1 and 3, regarding cleaning acute wounds and covering closed wounds, are the least known.Several nurses and physicians that are aware of the recommendations do not adhere to them in practice, especially for Recommendations 1 and 3. Further implementation is important, as adhering to the recommendations improves the quality of wound care and reduces costs (Ubbink et al., 2015).We found seven categories of barriers and facilitators that can be used to improve implementation: knowledge about wound care, attitude, practical and social environment, habits, the (expected) preferences of patients, and policy.
The results indicate a lower implementation of the recommendations in emergency care nurses, and this is recognized in a study in Spain (Osorio et al., 2019).The authors suggest that decision making and avoiding low-value care might be harder for this department (Osorio et al., 2019).For some subjects, we found a discrepancy between the reported current practice and adherence to the recommendations.For example, a few physicians soak acute wounds in cleanser, and all of them provide wound care instructions to the patient, but 13% and 19% of the physicians are not aware of Recommendations 2 and 5 (do not soak wounds and do teach the patient).It is possible that respondents were not aware of the specific recommendations but nevertheless were used to delivering care according to them.The percentage of respondents that were not aware might T A B L E 3 Quotes from the interviews.therefore be an overestimation.It should be noted that we have not assessed wound care practices before the release of the recommendations, so it is unknown how much the Choosing Wisely campaign has contributed to their implementation.
An evaluation of Choosing Wisely recommendations amongst nurses in Spain also found that implementation is done well, but there is room for improvement.Seven of the 38 recommendations they evaluated needed further implementation.The recommendation with the greatest participant disagreement (21%) was Recommendation 5 'covering a closed wound' (Osorio et al., 2019).The following literature also supports our finding that there could be a gap between being aware of the recommendations and applying them in daily practice.A study in Spain found that even though nurses agree with a recommendation, adherence can be low (Osorio et al., 2019).
Only part of the US physicians sees the campaign as a legitimate source of guidance (Colla et al., 2016).In Canada, 88% of the physicians were aware of the campaign, but only 30% were able to describe ≥3 of the recommendations (Stern et al., 2017).Even when clinicians are aware of the limited value of a care practice, they can remain confined by a set of structural forces beyond their control (Montini & Graham, 2015).Clinicians also deviate from a guideline intentionally, often for valid reasons such as contra-indications and patient preference (Arts et al., 2016).Our study showed that indeed the (expected) preferences of patients are one of the reasons for nurses and physicians to practice wound care that is medically not necessary.However, the other reported reasons, such as habit and practical environment, should be targeted to support clinicians to provide only valuable care.

| Limitations and strengths
The strength of our study is the mixed methods design that allows us

| CONCLUSIONS
This study showed that for these recommendations, increasing awareness is not enough for successful implementation.Even for recommendations that appear to be easy to implement, like these for wound care, several barriers can hinder physicians and nurses to adhere to them.It is therefore important to identify the barriers and facilitators and target those in a tailored approach to implementing Choosing Wisely recommendations (Eskes et al., 2020;Hanrahan et al., 2015).tailored approach that removes the barriers is necessary.

•
It is unknown to what extent this is known and practiced by nurses and physicians and what barriers and facilitators they experience in practicing this.

1.
Do not clean the wound with saline; cleaning is only necessary in case of a dirty open wound, and lukewarm tap water is sufficient.2. Do not soak the wound in cleanser; soaking the wound in cleaning products such as washing soda or bath products increases the risk of infection and slows down the healing.3. Do not use bandages on a wound closed by primary intention; covering a surgically closed wound does not reduce the risk of infection and changing bandages can be painful.A bandage is only necessary when the wound leaks, when clothing creates friction, or when the patient does not want to see the wound.4. Do not use expensive bandages when gauze suffices; a nonadhesive gauze suffices for most wounds.Additional dressings can be applied to leaking wounds.For skin transplants, hydrocolloid or film is recommended.5. Do not discharge a patient without giving instructions; a patient with a surgically closed wound may take a short shower 24 h after surgery.Instruct the patient on what to do when signs of infection appear and when and how they can return to normal activity.The development of the underlying guideline and selection of these five Choosing Wisely recommendations is described by Ubbink et al. (2015).
Ubbink guideline and the five Choosing Wisely recommendations were disseminated amongst wound care experts (nurses specialized in wound care who are registered with the Nurses Association) and by the developing organizations through websites and newsletters.It is unknown to what extent the five recommendations are currently known by nurses and physicians, to what extent they adhere to them and why.This study aimed to evaluate nurses' and physicians' awareness of and adherence to the five Choosing Wisely recommendations for acute wounds and their perceived barriers and facilitators for implementation in the Netherlands.

F
I G U R E 1 Flowchart of survey respondents.care specialists) and 70 physicians received the invitation to the survey.The response rates were 39% (171/434) for the nurses and 31% (22/70) for physicians.The invitation in the newsletter for emergency department physicians yielded an additional 49 responses from 30 hospitals, of which 21 hospitals were not yet reached through the wound care specialists.In total, 171 nurses and 71 physicians from 35 hospitals responded to our survey.Respondent characteristics are departments.The mean age was 41 years, and 65% of the participants were female.The interviews lasted on average 22 min (range 12-38 min).We identified seven main categories of barriers and facilitators: knowledge, attitude, habits, practical environment, social environment, policy and expected preferences of the patient.Below we describe the barriers and facilitators for each category from nurses and physicians together because of the large overlap in responses.
participants indicated that they learned to use cleaners and bandages during their education and many have done this for years.Their habit facilitates adhering to Recommendation 5: most nurses and physicians routinely provide wound care instructions to the patient.F I G U R E 2 Awareness of and adherence to the Choosing Wisely recommendations.
to integrate the results of the survey with the interviews.By knowing to what extent nurses and physicians know and follow the recommendations and why, we are able to formulate recommendations regarding further implementation.A limitation of our study is that there might be selection bias.Probably, wound care specialists that have spread the recommendations in their hospital were more likely to contribute to our study.Also, although we tried to reduce selection bias by introducing the survey as an assessment of current wound care practices and not yet mentioning the recommendations, nurses and physicians that are interested in wound care are probably more likely to both know the recommendations and respond to our survey.Therefore, our survey results are probably an overestimation of the implementation.Possible selection bias could not be monitored because we had no insight into the e-mail database of the Nurses Association and the Association for Emergency Department Physicians.A second limitation is the possibility of socially desirable responses in the survey and the interviews.Nurses and physicians might have found it hard to admit they were not aware of the recommendations or do not follow them and why.This could also have led to an overestimation of the adherence.

Further
research into the costs and harms associated with low-value wound care could help to establish the need for change, for example, by analysing hospital data (Badgery-Parker, Pearson, Chalmers, et al., 2019; Badgery-Parker, Pearson, Dunn, & Elshaug, 2019).In addition, further research should explore the patient's preferences regarding these recommendations.Although most nurses and physicians are aware of the Choosing Wisely recommendations, some of them do not adhere to the recommendations in practice.The recommendations regarding cleaning acute wounds and covering closed wounds are the least known and adhered to.Increasing awareness is not enough for the successful implementation of these Choosing Wisely recommendations, and a