Editor`s Opinion: Connecting the Dots to Improve Patient Care
Nothing in nature is isolated. Nothing is without reference to something else. Nothing achieves meaning apart from that which neighbors it. — Goethe (1749–1832)
When the goal is better patient care, understanding theories, concepts, and issues such as validity and reliability seems unnecessary— you just want to know what to do. Similarly, when a researcher wants to learn more about, for example, the role of fibroblasts in healing, spending precious time reading the results of a case study or the steps involved in the development of a conceptual framework to improve patient care may appear to be counterproductive. Goethe put these concerns in context when he wrote, “Nothing (in nature) achieves meaning apart from that which neighbors it.” Hence, the behavior of a fibroblast in a petri dish achieves meaning only if it can be connected to that which is clinically relevant — for example, a new theory about wound healing. And clinical interventions, assessments, and terminologies are meaningless unless someone has connected the dots to show they are valid (logically correct, relevant, and appropriate for achieving the desired goal) and reliable (consistent).
The processes involved in developing theories and testing concepts, validity, and reliability are arduous and lengthy. Funding opportunities for these ventures are generally more limited than those available for the evaluation of new treatments; results are less exciting even though crucial to practice and progress. Consider the exhaustive evidence review on topical antimicrobials by White, Cutting, and Kingsley in this issue of OWM. Examples of pre-clinical studies — nature in isolation — abound, but solid evidence supporting their clinical relevance remains limited. Similarly, Helberg and colleagues found considerable gaps between research and practice along with the ample “expert opinion” evidence in the pressure ulcer guidelines they reviewed. Reading the results of their study, one cannot help but wonder if universal implementation of existing guidelines is hampered by the plethora of unconnected dots and resultant lack of meaning. Of the hundreds of guidelines and algorithms — some evidence-based, some not — validity and ability to improve outcomes (with few exceptions) remain unknown. In other words, the dots between the literature and its interpretation by groups developing guidelines, consensus and recommendation documents, and patient outcomes have not been connected. Indeed, a number of variables used to describe wounds, the current dressing categories, as well as terms and theories such as bioburden, wound bed preparation, and critical contamination are adopted in clinical practice before their validity (relevance and appropriateness) or reliability have been established. For example, what percentage of clinicians, looking at the same wound and its history, would agree on an assessment of critical contamination? And if the terms are valid and can be reliably assessed, how do they relate to what we do? What do they mean in practice?
The theoretical framework described by Dr. Leach provides an excellent example of finding meaning by connecting the dots. We all know that chronic pain and discomfort drain our energy. We also know that leg ulcer patients often report pain, fatigue, and difficulty walking. By connecting the dots between existing venous ulcer treatment evidence, healing, and the universal law of energy conservation, the author helps us see how optimal care may affect the entire patient and his or her neighboring environment. The evidence has meaning that goes beyond existing preclinical and clinical data. The dots are connected through and by everyone involved in healthcare.
No one — regardless of practice setting, level of expertise, or interest — works in isolation. What we do always has reference to something someone else said or did. We are neighbors in our quest to improve care.
This article was not subject to the Ostomy Wound Management peer-review process.
