SCIENCE, PRACTICE AND EDUCATION professionals ascertain that they are both confident and competent in managing STs, 3 as older adults are at a heightened risk of skin frailty due to the aggregated effect of a combination of intrinsic and extrinsic factors. 4 According to the International Skin Tear Advisory Panel (ISTAP) classification system, STs can be clas- sified into three types. Type 1 refers to no skin loss; in this type of ST, there is no skin loss, and the linear or flap tear can be repositioned to cover the wound bed. Type 2 refers to partial skin loss; here, there is a partial flap loss that cannot be repositioned to cover the wound. Type 3 refers to total flap loss; in this case, there is a total flap loss that exposes the entire wound bed. 1 According to Van Tiggelen et al., 5 STs are often misdiagnosed. These injuries are generally under- recognised and typically tend not to be well reported within clinical practice. To improve healthcare pro- viders’ knowledge and apply best practices, 1 early and more accurate identification of STs is encouraged, followed by proper classification and documentation of the wound and its cause. Furthermore, LeBlanc et al. 1 suggested that clinical practices implement an evidence-based treatment protocol. The Payne-Martin ST classification system, published in 1990, was the first to be developed. The system classified STs into three categories and five types. The classification was driven mainly by the morphological characteristics of the epidermal wound. 6 Payne and Martin acknowledged some concerns with respect to the definitions included in their original classification system and later updated the definition of STs and other definitions used within the system accordingly. 7 Furthermore, in evaluating the quality of their sys- tem, they identified three criteria, internal validity, external validity and utility (usefulness), and claimed that, whilst the first two were well demonstrated, they were concerned about the latter. 7 According to White, 8 one of the reasons why such criteria were not being met was the lack of awareness and use within care facilities, at least in the case of Australia. In an attempt to improve this, an Australian group of authors led by Professor Keryln Carville 9 developed the Skin Tear Audit Research (STAR) ST classifica- tion system, with the modified Payne and Martin system as a basis. 9 A study was conducted to obtain consensus for the use of the STAR tool and to ensure its availability for use in research. 9 Limited literature is available, however, on the use of the STAR tool in the field. With the aim of continuing to improve on the exist- ing system, the newly developed ISTAP ST classifica- tion system consists of three types of wounds (also inclusive of photographic aids). In the next phase, ISTAP tested the system’s intra-reliability by request- ing the panel members evaluate and group photos of 30 lesions that had been extracted from a validated photograph database. 10 The panel was then asked to re-evaluate the same photos two months later, and the results of both tests were compared and analysed. The system’s inter-observer reliability was then tested through the involvement of 327 clinical nurses by requesting the participants classify the same 30 pho- tos. The results from the external participants were then compared to those of the panel members and analysed. 10 While there are a number of existing ST classification systems, awareness and use of them is limited. 5 This is also the case in Malta, where the use of such tools in the identification, classification, prevention, assess- ment and management of ST has not been adopted in clinical practice. According to Chang et al., 11 nurses have a tendency to overlook STs as a type of wound until they deteriorate or become problematic to man- age. 11 One nurse working in a geriatric rehabilita- tion hospital in Malta observed that a pressure ulcer staging system was often used incorrectly to classify and document STs. This can lead to misdiagnoses, the under-reporting of STs’ incidence, inappropriate management and inconsistencies in ST assessment and documentation. 11 The current study sought to address this issue and to identify aspects of the pre- vention and management of STs that needed further education using the ISTAP ST classification tool to assess the level of knowledge and the possible impact on outcomes for patients at risk of developing an ST. OBJECTIVES OF THE STUDY The main aim of the study was to investigate the cur- rent level of registered nurses’ knowledge of the iden- tification, classification, prevention, assessment and management of STs. The intention was to identify gaps, so as to design an appropriate education pro- gramme to improve nursing staff members’ skills in the assessment, prevention and identification of STs, increase their awareness, improve their knowledge and facilitate the appropriate management of STs. JOURNAL OF WOUND MANAGEMENT OFFICIAL JOURNAL OF THE EUROPEAN WOUND MANAGEMENT ASSOCIATION 110
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