The Implementation Gap: Why Evidence-Based Wound Care Still Isn't Standard Practice with Michelle Barakat-Johnson

In this episode, Hayley sits down with Professor Michelle Barakat-Johnson, Joint Clinical Professor of Wound Care and Skin Integrity, Director of the Tissue Repair Institute, and Lead for Skin Integrity and Wound Care across Sydney Local Health District and the University of Sydney.

Together, they unpack one of wound care’s biggest challenges: closing the gap between evidence and implementation in wound care.

They explore why education alone isn’t enough, the barriers preventing evidence-based practice, the role of leadership and decision-making in driving change, and how clinicians can turn knowledge into meaningful improvements in patient outcomes. They also discuss the future of wound care, from implementation science and data-driven improvement to artificial intelligence and the Wound Care Command Centre. 

Resources Mentioned

Google Scholar

221444_IMBED_Toolkit_DIGITAL_V20.pdf

Wound Care Command Centre | Sydney Local Health District

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Transcript

SPEAKER_02 0:00

Welcome to Woundcare Unwrapped, the podcast that peels back the layers of wound care to uncover what's working, what isn't, and what needs to change. So let's unwrap it. Welcome to another episode of Wound Care Unwrapped. I'm Hayley Ryan, the Director of Wund Rescue, and this podcast is produced in partnership with Learn on the Move. In this episode, I'm joined by Professor Michelle Barricat Johnson, Joint Clinical Professor of Wound Care and Skin Integrity, Director of the Tissue Repair Institute, and lead for skin integrity and wound care across Sydney Local Health District and the University of Sydney. Michelle is a recognised leader in wound care research, implementation science, and advancing skin integrity at a systems level, with a strong focus on translating evidence into real-world clinical practice. Today we're going to unpack the gap between evidence and implementation, the challenges of driving change at scale, and what's really holding wound care back from progressing the way it should. So let's unwrap it. Welcome, Michelle. It's great to have you on Wound Care Unwrap. Oh, thanks, Haley.

SPEAKER_01 1:27

It's great to be with you this morning. So yeah, thank you.

SPEAKER_02 1:31

You've certainly done a lot of exceptional things in the wound world. You're certainly internationally recognized and such an honour to have you here today. I guess before we dive into some deeper questions and start unwrapping things, maybe you could tell us about your current role and what your focus is right now.

SPEAKER_01 1:51

Yeah, thank you. So my current role is a joint clinical professor at the University of Sydney and the Sydney Local Health District. So really my role, and I'm a clinical lead at the Sydney Local Health District. So my role is really much about that strategic focus of, you know, getting what we see in practice back into research and then from research evidence back into practice. So it's that whole ecosystem of you know, seeing what works on the ward, what doesn't, it's you know, real, real-time implementation, and it's also the then we, you know, whatever we find on the ward in clinical practice in the community in relation to wound care, we then take it back to well, where is the evidence and and you know, where is the evidence backing whatever we're doing? So I'm still involved in wound care. I do rounds with some of the clinicians and you know, really love to hear about the patient's perspective and also what's happening on the wards or in the community. Um, yeah, so really that's that's my what my role is currently.

SPEAKER_02 3:06

Yeah, I I love that you call it an ecosystem. It's really the circle of life, you know, what you're seeing on the floor and then what you're putting into that research, and then it continues. Love that you described it like that, Michelle. I guess um, let's get a little bit deeper about Michelle as a person. What really drew you into wound care?

SPEAKER_01 3:25

I it's funny because I got asked this a couple of weeks ago, and I remember one of my first postgrad. So I did my new grad at Royal Prince Alfred Hospital. It was great, rotated, had some wonderful staff that I worked with and great managers. Uh, then I um applied for a job at St. Vincent's Public Hospital, and it was on the plastics um ward, and I worked with this wonderful, amazing, or I worked for this wonderful, amazing nursing unit manager who had such a special interest in um wounds as a whole, obviously, because it's a plastic ward, but we also used to get patients who had really, really deep pressure injuries, like um you could put a fist in in that pressure injury, that's how deep it was. And she just, you know, she used to walk through um all the reasons why, you know, how you would treat it, what we were looking at, why she would use certain dressings, why you have to look at the whole, you know, body as a system and whether it's going to heal or not. And, you know, I really loved that passion she had, and I was really inspired by her. And that's actually how I got into wound care.

SPEAKER_02 4:38

Oh, I love that, Michelle. And probably a take-home message for our listeners today is you will get mentors in life that you will go, I can resonate with that or I'm interested in that. And they're the people that take you on the journey. So it's great that you found yours. Michelle, what do you think's been the biggest shift you've seen in wound care over your career?

SPEAKER_01 4:56

Yeah, that's actually a really good question because I I was thinking about this the other day. Another question where I was thinking about, um, if we think about where wound care was about, you know, two decades ago, or even a decade ago, it was really um thought of as this Cinderella specialist service, right? Um so you know, this Cinderella service, it's a specialty. Um, and you know, pe people who knew about wound care knew how to do wounds, and obviously those that didn't uh would would seek help. What we've actually seen over the past decade is this real push towards, you know, this clinical priority and a national and global priority around how we get prompt access to wound care for people in the community and how chronic wounds, for example, has actually become this global, you know, um priority. I mean, uh Haley, you we were talking a few months ago about how it how it took so long before we could actually get Medicare um recognize how important wound care is and be able to fund products. Um so I guess it's really shifted. It really has. And and for me, I've actually seen that over the past decade. Yeah.

SPEAKER_02 6:23

Thanks, Michelle. Look, it's an evolving place and it needs to be. We're dealing with people, so it completely makes sense. And wow, when you said two decades ago, I just went straight away and thought, yeah, I've been nursing for over two decades. So yes, thank you.

SPEAKER_01 6:39

And and and also, um, you know, on that, wound wounds are not just you can't get somebody who's got a wound and put them on a clinic specializing wounds, like you know, renal people who have renal issues go on to a renown, people who um have um you know cancer issues are treated by palliative care and cancer and and and so on. Wound care, it kind of spreads everywhere, doesn't it? So at some stage of your life as a nurse, you are going to see someone with wounds and you're going to look after someone with wounds. Um and you know, in the in the community, if you think about people in the community, that community nursing is the la a large part of their care is wound care. Um, and that's because it's you know it's an area where we discharge people that have either got chronic wounds or have had injuries in hospital or have actually injured themselves in the community. So yeah, so it's kind of definitely an area of um of interest now and definitely area of priority as well.

SPEAKER_02 7:48

All right, so we're going to start with a segment we call clinical confessions. So, Michelle, what is something you've seen in practice, heard, or maybe even read about that made you think, boy, we really need to talk about this.

SPEAKER_01 8:02

Look, I I I'm gonna have to go back. Yeah, I I for me it was very much around how we actually implement the evidence into practice. And um, you know, if I if I go back to as an example with pressure injury prevention in in my district, um, you know, in 2014, we had the highest incidents in New South Wales of pressure injuries, and we had put in strategies, um, you know, people were mandated to read the policy. We had education, we had a committee. Um, you know, we did a number of um, you know, we put in a number of strategies to reduce pressure injuries, but the incidents just kept going up and up and up. And, you know, I remember sitting on a committee thinking, yeah there's got to be something we're doing wrong. We've got um like all these amazing leads, we've got executives who were really keen to support, um, but there's got to be something that we're doing wrong. And and so I started to learn about um a framework called implementation science to to put it in um in you know, in lay terms, it's really about what is happening on the wall, you know, what is happening at in the organization, whether it's in the community hospital or what have you, outpatient, what is happening in that area um to really kind of unpack what exactly is going on and then put in interventions um in order to, you know, address the issue. And um that for me was a big turnaround because you know, like wound care, implementation science only became really it was only emerging 10 years ago when I look at pressure injury prevention, nobody knew much about it. But it was all around, you know, how do you actually take the evidence that you've read, put it into practice, then um get people on board, um, and then you know, scale it up to the rest of your organization or share it with other colleagues in different health settings and then you know, sustain it as well. I I think that for me was a really big move. And um, you know, from there I actually took that into being able to reduce the pressure injuries we had, you know, such the high incidents we had at Sydney Local Health District.

SPEAKER_02 10:35

So sometimes, you know, having all these great ideas, we all have them always as clinicians, um, but not having a framework back behind it doesn't always make it sustainable. So I'm glad you mentioned that. And I think building on that, Michelle, what's one piece of wisdom from you for our listeners today that we could be doing better right now that would actually change outcomes?

SPEAKER_01 10:57

Yeah, absolutely. Look, I think, you know, um we've got, I think it's about unpacking the problem, whether you're looking at a wound that's got an increased amount of exudate and you know, you've used a number of dressings, it isn't working, or you've tried a different treatment regime, it isn't working. It's really unpacking exactly what the root cause is. Like I remember this is earlier in um, you know, going back about 15 years ago, I was working in an acute setting, and I remember there was one of the staff members that was really passionate about reducing skin tears, and and they introduced this new protective dressing for high-risk patients so that they could reduce skin tears. Anyway, she organized a quick in-service, she stocked the product, and then she encouraged the staff to use it straight away. Um, and initially there was a lot of enthusiasm from staff, but what happened was within a few months, and then she went on holidays and what have you, the skin tear incidents just started increasing again. Um, and and you know, when we look deeper into the real issues, into what was happening in that setting, it wasn't actually the dressing product, it was actually manual handling practices, it was adhesive product use, and it was really limited staff awareness during that routine care. Um so that so my point is the dressing alone couldn't address those factors. So, you know, we had this individual, she ran with change without buying from others and without solving the root cause. And and for me, that's actually a really good reminder that, you know, even with well-intentioned changes, they don't actually stick unless you understand the root cause, and unless you also bring your other work colleagues along. Like where I've seen it work really, really well is you start small, you get a group together to unpack exactly what's going on. Even if it's you're looking after a patient and something's not working with their wounds, you you know, you you gather people around, we've always got this, you know, collegiality. Um, and then so you know, I I recall, like, I'll give you incontinence associated dermatitis when I first knew about that a decade ago. I had no idea what it was and what to do with it. And I went out there and I searched for the evidence, and then I got a small group of us together. I got registered nurses, wound clinical nurse consultants, quality improvement, you know, you name it, nursing unit managers, and we collected data over two wards. We just wanted to start small, and you know, because at that time we were looking at pressure injuries, and as you know, IADs get mistaken for pressure injuries. Anyway, we then collected the data and you know, we looked at the evidence and we also looked at our own local evidence. What were people saying, patients, nurses? Um, but then all of a sudden, what you have is you have you know, six to eight people on the same team, all driving change. So, you know, if you contrast contrast that to the skin tear story I just told, where we had one individual that was carrying it all on her shoulders and she had to chase everyone over and over again. Um, really, that you know, if you have these six people, you it's more effective than the one. But you you you start out by starting small, finding what the root cause is, um, and you know, bringing in your evidence. And we've kind of used that same approach, um, and it's worked every single time. Yeah.

SPEAKER_02 14:49

Yeah, great example. So then let's go back to the evidence. Do you think we have an evidence problem in wound care, or is it an implementation problem?

SPEAKER_01 14:59

Yeah, so look, we do we have great evidence in wound care, but you know, and no one disputes evidence. And I think as clinicians, we need to be seeking more evidence. We know that chronic wounds affect over 400,000 Australians. We know that it costs the Australian health system 3 billion annually. We know that the effect on the patient cannot be estimated. And, you know, as clinicians, we should be seeking more evidence, but what we've seen incredible frustration with evidence about evidence is where it's actually ignored in the health system. Um, so you know, let me give you another example. Um, and again, it brings in IAD, um, because this is currently happening now. So we uh we were successful with grant funding, um, we implemented a bundle of care for incontinence associated dermatitis across six health districts, um, multiple hospitals. It was called the embed study. And um, you know, we had credible clinical and financial benefit. We published it. And then, you know, we've got this push from procurement, for example, in um particular hospitals that that you know came along and um you know certain people ignored the evidence. So, you know, by taking part of that implementation bundle and then going for you know, going for a product that's a cheaper option with no research behind it, it really makes that so hard for folk for nurses who are really focused on relying on evidence because the people around them that are making the decisions, um and it's different to what they've experienced. Um, so you know, if you ask me if evidence is a problem, really I believe that the problem lies in the decision makers and it's making decisions about evidence. Um, so you know, and I see this time and time again. Um, you know, we need to get back to evidence-based decision making in healthcare. Um, we we know there's, you know, currently, unfortunately, we're quite constrained with finances all over Australia. Um, we haven't really recovered from COVID. Um, but we really shouldn't be experimenting on patients. We shouldn't be guessing on patients. Um, and I'm using that example because it's a real one today. And I, you know, the thing is, I'm I'm feeling quite frustrated about it. I know nurses get um frustrated. And what actually happens is then nurses are going to get disengaged because they'll see worse outcomes. And then next time you want to implement something that's evidence-based, in the back of their mind, they're going, Well, what's the point? I'm going to change this, and then six months' time, somebody's going to come and change it with no evidence. So, um, yeah, so ignoring evidence is actually an implementation problem, really.

SPEAKER_02 18:02

Yeah, I like how you've you've actually pinpointed that sometimes it does come down to the breakdown being within that decision making and even procurement, you know. This is where we can see some foundational governance issues that stop it for all. I mean, we've got guidelines, frameworks, policies readily available, but I'm going to throw the question back a little bit and say, what role is it or what um responsibility is it of the clinician to pick up those guidelines, frameworks and policies and read them and act on it. What are your thoughts there?

SPEAKER_01 18:33

Look, I believe as clinicians, nurses, we really need to be like information and knowledge is power, right? And I I think part of our nursing profession and and being clinician is when you read, you get that more not you get more knowledge. You then, and then it becomes a whole health system thing. It's not only benefiting you to have that knowledge, you're actually benefiting really the patient, their family, the health system, their colleagues, and so on. So um absolutely, you know, p pulling out it's not expected that we read the whole international guideline from front to back. The great thing about guidelines is they're there, they're based on best evidence. And when I want to find something out, that's my first go-to. And then obviously I unpack, you know, I unpack unpack evidence. You know, like recently I had um a CNC come to me and say, Oh, you know, I've got this problem on the ward, we've got an increase in IAD and so on. Um, what about I change from this to that? And I said to her, Look, have we actually looked at what the evidence is? You know, from what we've got as guidelines, from um what we see in research, and then our own local evidence. So for me, it's a three-way thing here. It's what is the what are the guidelines, international robust evidence telling us? What are some more research grade literature I can find on this? What is anecdotal and what is the anecdotal evidence and what is the evidence I can get from the hospital to then put that into practice? So absolutely, as a clinician, as a nurse, we really need to be, you know, keeping up to date with um with new initiatives.

SPEAKER_02 20:28

Yeah, absolutely it is. It's definitely the the wound care industry is evolving, you know. I've been uh in this area for 25 years. I can tell you I have seen everything from, you know, gauze-packed wounds to much more advanced products now. I I guess sometimes what we see is when the evidence doesn't make it to that operational level or that clinical level, our first jump to or go to is education. So I guess my question is: do you think we might be over relying a little bit on education as the only solution or as a solution? What do you think there?

SPEAKER_01 21:03

Yeah, no, that's actually a really good question. Look, if I think back, if you think about um when you go and you sit in an education session, um, you know, there's only bits and pieces that you come away from, right? There's only bits and pieces. So education should be used from from my perspective, education should be used as an adjunct to to other modalities of delivering that that, you know, delivering evidence. Um, because you know, I I remember I attended a whole workshop um going back last year, and and you know, I could only, and because your your mind's so busy and there's so much going on, I could only pull away some really, you know, two or three key points from that that gave me um it was really around impact. So education, if we could turn it around to make it more. you know, where you're actually using it in practice, you're actually here's the hands-on, here's the, you know, let's let's go and put this into practice or you know, turn it around so that the people that that are being educated are being questioned or being asked to actually develop the education themselves. Um, I think for for me, I think that works best in terms of, you know, getting that person that you're trying to educate to do the hands-on stuff and probably even develop the education package or be part of that as well.

SPEAKER_02 22:34

So, Michelle, do you think clinicians sometimes hide behind a lack of resources when actually it's about decision making and their own accountability?

SPEAKER_01 22:43

Yeah, that's that's actually a really good question. I believe that sometimes, unfortunately, in the current health system that we have, um, you know, despite every great intention for clinicians to have that decision making and want to be part of that decision making or want to be that, you know, that authority in decision making, sometimes the decision making is actually taken away from them. Um, and I see this quite a bit. And, you know, it's really hard when you're working with you're working in a facility or you're working on a ward where you don't have that ability to have that decision making. Um, and this is where, you know, I I mean that's actually happened with me in the past. I remember as me as a young nurse where I remember, you know, when I was just getting into wound care, I knew that betadine, you know, because betadine was used, betidine gauze, soaked gauze was used back then a lot. I just remember reading about it, knowing that the evidence was really all for applying betidine before surgery, for example, you know, or if you had a limb that was quite necrotic, you'd put betidine, but you wouldn't apply it on a granulating wound with with um gauze-soaked dressings. And I just remember feeling really frustrated because, you know, I was a I was a younger clinician, I knew this evidence, and I wasn't able to make any change. Um, so I think it really, it really comes down to the organization in which you work. I think there's great intentions from clinicians, um, you know, and I've worked with so many amazing clinicians to actually make that change, but sometimes their hands are tied. And, you know, it's about seeing, I've always, for me, what's worked really well for me is I try and associate myself with people who can make change or have some authority around change and you know, who are inspirational, and that's really, really worked for me in the past.

SPEAKER_02 24:45

You couldn't have said it better, Michelle. It's comes back to that empowering again. You know, how do we empower people to come on the journey to be the allies for the patient? So I think you've articulated that very well. Let's talk a little bit about your work now, your current work that you're working on in terms of research. From your work, Michelle, what do you see as the most exciting advancements or shifts you're seeing in your current research?

SPEAKER_01 25:10

Yeah, like uh that's actually a really good question. I'm really excited because um I'm establishing a tissue repair institute. Um, and that institute, the main aim or the main goal is to actually support clinicians and nurses and also support patients. Um, so supporting clinicians in research and getting that wonderful new evidence, innovation and what have you. And from that, um, as you know, Haley, we've we implemented the wound care command centre, so which is quite a big innovation, and being able to share that innovation, you know, and hoping, you know, we can implement that across Australia is so exciting because you have, you know, the way we're moving now is obviously artificial intelligence, digital applications. And we just, you know, with artificial intelligence and digital applications, we want to make sure that we're not taking that approach away from a person-centered approach because that can actually um that can actually be a barrier in itself. But the great thing about this, and um, you know, what's what I'm really energized about is that, you know, this whole system, it uses artificial intelligence, you have a digital application that is patient-facing, clinician-facing. It's um, you know, it the ability to share that with other districts and other organizations across the state, um, for me is really exciting. But the great thing is you're getting data analytics off it. So it's generating more evidence, it's generating more questions around evidence. Um, so yeah, that's I'm really excited about to see how that actually progresses.

SPEAKER_02 26:54

Well, it absolutely is exciting, Michelle, and you've done some amazing work in that area. We hope it can go across every healthcare environment in Australia. I'm looking forward to the changes. Um, let me ask you a final perky question. Uh, thinking about the novice nurse out there or the novice clinician that's listening in today, where do they find the research? If they're not affiliated with a university, how do they get access to research?

SPEAKER_01 27:20

That's a really good question. Uh, I just, interestingly enough, I just had um one of the clinicians ask me the exact same question yesterday. Um, I'm just uh mentoring them in writing up a journal article on case studies using a new wound gel. Um so yeah, absolutely. Look, if you're affiliated with a university, it's easier to get the research that you want. However, a lot of health districts have their own libraries, and if you send them a message, they can actually get the research, you know, whatever it is, the article that you know that you need. Um, I would say for the novice nurse, do a just quick Google search, and you might come across an abstract which doesn't have a full access, and that's you can actually ask your library or um your colleagues to actually pull out that information. But you know, there are readily um available um resources online. You've got the Amazing Wounds Australia, which has great resources for clinicians. Um, if you do a you know a Google search on wounds, a whole pile of other resources pop up. So it's just about just doing a quick search and you'll find that you'll actually get something. Yeah.

SPEAKER_02 28:38

You just gotta have to go down that little rabbit warren, but you do end up with some great resources. Even Google Scholar Michelle, you know, there's lots of things out there. Um great advice. If you've been trying to build your clinical knowledge, but just can't seem to find the time, this is definitely worth checking out. Learn on the Move makes learning simple again with short, free online modules that you can fit around your day, whether that's between visits, on a break, or at home. The content is all reviewed by local healthcare specialists, so you know it's relevant and practical. And there's really a broad range of topics from wound care and dementia through to diabetes, aged care, and lower limb conditions. It's generally one of those platforms you can jump into at any time. And if you want to learn and explore more, jump over to learnonthemove.org and sign up today. All right, Michelle. Look, we've um we we've gone through the the perky questions and we're going to finish with what we call a rapid fire where we unwrap whether something is true or false. It's a little bit of fun, but there's no time to elaborate. You have to think quick. So I'm hoping we can have a little fun. I will shoot some questions and you will say true or false. Does that sound okay? Sounds great.

unknown 29:57

Okay.

SPEAKER_02 29:58

Okay. See how I go.

SPEAKER_01 30:00

Because you know me, I like to elaborate. I like to elaborate. But anyway, I'll I'll I'll give it a go.

SPEAKER_02 30:07

Perfect. Let's kick it off. Evidence alone is enough to change clinical practice.

SPEAKER_00 30:13

False.

SPEAKER_02 30:15

Most healthcare systems are designed for prevention.

SPEAKER_00 30:20

False.

SPEAKER_02 30:21

Variation in practice is one of the biggest risks to patient outcomes.

SPEAKER_00 30:28

False.

SPEAKER_02 30:29

We measure wound care outcomes effectively in Australia.

SPEAKER_00 30:34

False.

SPEAKER_02 30:35

Implementation is harder than generating evidence.

SPEAKER_00 30:41

True.

SPEAKER_02 30:43

Leadership has a bigger impact than clinical skill on system change. Most pressure injuries are preventable.

SPEAKER_00 30:54

True.

SPEAKER_02 30:55

Data is best used effectively to drive wound care improvement. True. And the last one, healthcare systems, reward prevention. True. Great answers, Michelle. It was a little bit of fun. We got there in the end. I'd like to say a huge thank you to Professor Michelle Barakak Johnson for joining us today and hope to see you at the next podcast. Thank you so much, Michelle.

SPEAKER_01 31:22

Oh, thank you, Haley.

SPEAKER_02 31:23

Thank you for tuning in to this episode of Wound Care Unwrapped. You can find us on LinkedIn, Facebook, Instagram, and TikTok at Wound Rescue PtyLTD. A big thank you to our show partners at Learn on the Move. You can find more about them on the show notes. Woundcare changes when we start having better conversations. And that's why we believe it's about healing lives and not just wounds. Tune in for next week's episode of Woundcare Unwrapped.