Usability of Standards for Scaffolding in a Health Sciences Programme: A feasibility Study.

BACKGROUND: Standards contribute to comprehensive and programmatic implementation of educational strategies, such as scaffolding. Although the development of educational standards follows a rigorous consensus approach, they are socially constructed and could result in varied interpretations by users. Reports of varied implementation of standards in health professions education underscore the need to test the developed standards for scaffolding in health sciences programmes. Usability entails determining whether a product like standards works as intended under the expected conditions and contexts. This study aimed to describe the usability of standards for scaffolding in a health sciences programme through a pilot study. METHODS: A multi-method design employing user and expert-based usability evaluation techniques sought to describe the usability of the standards for scaffolding in a three-year pre-registration nursing programme. The user sample of nurse educators drawn from the programme, conducted a self-assessment on scaffolding practices in the programme using a developed standards checklist. For the expert sample, three-panel members with an understanding of the discipline and programme context were purposively sampled. These panelists studied the users' self-assessment reports before completing an author-generated heuristics checklist to support or refute any of the standards. Descriptive statistics, comparative and content analysis were applied to analyse data from users' interviews and expert's completed heuristics checklist, determining the standards' usability, and identifying the usability flaws or strengths. RESULTS: The users had three or more years of teaching experience in the competency-based curriculum for nursing. The experts shared an average of 16 years of experience in teaching in higher education, and seven years of experience in quality assurance and programme accreditation. The four standards had a usability score of above average (68%). Seven usability strengths and four usability flaws were identified. Usability flaws related to misinterpretation of some criteria statements and terminologies, multiple meanings, and users' challenges in generating evidence for some criteria. CONCLUSIONS: The pilot study revealed the context-based 'truth' regarding the fidelity of a health sciences programme evaluation on scaffolding, as well as identifying the ideal contextual conditions in which the standards for scaffolding health sciences programmes would work best. The identified usability flaws highlighted the need for further revisions of the standards. Future research on the feasibility of the standards in other health sciences programmes and contexts is recommended.

Mindfulness-based interventions to support wellbeing of adults in low socio-economic settings: a realist review.

BACKGROUND: Mindfulness as a modality involves training the innate human capacity for present-moment awareness with a view to cultivating a more harmonious and integrated life experience, especially in the face of hardship. Over the past four decades, the field of mindfulness has grown rapidly. Despite a substantial body of literature outlining the many benefits of mindfulness practice within a range of contexts and populations, the authors noticed that studies addressing the adaptation, application and value of mindfulness-based interventions (MBIs) for adults within socio-economically challenged setting were scant. To address this gap, we conducted a realist review of studies pertaining to MBIs within low socio-economic settings, to determine the extend and nature of research in this sector and culminating in a program theory which may be useful for the design of interventions going forward. METHODS: We selected realist review as the methodology as it is well suited to investigating the complex nature of social interventions. The value of realist review is that the exploration of the causal relationships between the mechanisms (M) within a specific context (C) towards particular outcomes (O) offers a deeper understanding of the intervention which may assist in more effective delivery going forward. The review follows the guidelines presented by the Realist and Meta-narrative Evidence Synthesis - Evolving Standards project. RESULTS: Of the 112 documents identified, 12 articles met the inclusion criteria. Of these 12 studies, 10 were conducted in the United States, with little representation across the rest of the globe. The interventions described in these articles were varied. We identified mechanisms that offered beneficial outcomes for participants across a range of contexts, with indications of how interventions might be adapted towards greater accessibility, acceptability, and feasibility within communities. CONCLUSION: By reviewing the various programs in their respective contexts, we developed a program theory for implementing socio-culturally adapted MBIs in low socio-economic settings. In the future, this program theory could be tested as a means to create a sense of wellbeing for people living in low socio-economic settings.

Doctoral Contribution to Nursing Science in Sub-Saharan Africa: A Document Review.

Nursing science is at serious risk of extinction. The lack of funding for research, absence of healthcare policies underpinned by nursing science, and general lack of understanding of nursing metaparadigms all contribute to the stunted growth in nursing science. Doctoral research is a platform for the development and refinement of nursing science. The purpose of this qualitative retrospective document review was to describe the doctoral contribution to nursing in sub-Saharan Africa (SSA). Electronic dissertations for doctoral degrees in nursing within a 5-year period from universities in SSA were included. The extracted data comprising the purpose of the studies, the models used in the studies, and the studies' contributions to nursing science were analyzed against a knowledge contribution framework. In total, 166 documents were included, mostly from South African universities, with a predominant focus on developing models, frameworks, and strategies within nursing practice. Only 17% of the studies applied grand nursing theories or models, with the rest of the studies applying theories from other disciplines. The contribution to nursing science from the doctoral studies was poor. The low uptake of nursing models in doctoral research in SSA may significantly contribute to the lack of refinement of nursing science within SSA. Structured approaches focused on integrating the nursing metaparadigms, theories, and models and fundamental underpins for doctoral education in Africa are essential to influencing the refinement of nursing science.

Twelve tips for creating online learning units for the health professions in low-and middle-income countries.

Health professions educators in low-and middle-income countries are often sceptical about developing online learning units. This scepticism stems from the belief that online programmes are limited in developing clinical competence, and there are concerns about digital proficiency and resource availability. A social constructivist approach in designing online work-based learning units may overcome such scepticism. In this article, we use our experience in developing an online learning unit for healthcare education to suggest 12 tips for developing online learning units in a low-and middle-income context. The tips are nested in a 'promoting theory-practice integration framework' and include context, establishing communities of learning and practice, establishing foundational knowledge, practise in a work-based environment, and showcasing attainment of learning outcomes. By integrating the guidelines and framework, healthcare educators will be better equipped to develop online learning units and contribute to learning.

Standards for Scaffolding in Health Sciences Programmes: A Delphi Consensus Study.

Introduction: Health sciences programmes operate in complex, unpredictable contexts, underscoring the need for comprehensive scaffolding of the learning processes. Yet, the scaffolding approaches remain fragmented, and lack a shared approach to how programmes could integrate scaffolding across the curricula. The literature argues that standards result in the comprehensive implementation of educational practices. There are no reported standards related to scaffolding practices in these programmes. OBJECTIVES: To develop standards for scaffolding in health sciences programmes utilising a consensus approach through a modified Delphi Technique. METHODS: Following the recommendations on Conducting and REporting of DElphi Studies (CREDES), an online modified Delphi technique was applied. Evidence on the application of scaffolding in health sciences programmes, obtained through an integrative review, was synthesised to draft standards. Using purposive and snowball sampling, an international panel from diverse geographical and professional backgrounds refined and validated the standards. Descriptive statistics was utilised to analyse demographic data and consensus agreements to include standards and criteria. Qualitative analysis of textual comments ensured the synthesis and inclusion of critical divergent views and additions. RESULTS: A total of 22 experts from around the globe agreed to participate in the study and one did not complete Delphi surveys. Most experts (n = 18) held a PhD; and an average of 19 years of teaching in health sciences programmes. Four standards and 27 criteria were included after achieving consensus during the two Delphi surveys rounds. The included standards focused on four areas: structuring and sequencing educational activities, resources/tools for scaffolding, structuring the programme and instructional strategies to support learning. CONCLUSION: The principle-based standards developed in this study could direct and support scaffolding practices in health sciences programmes. The standards' emphases on macro-, meso- and micro-scaffolding present numerous opportunities for designing and applying contextually sensitive scaffolding strategies at every level of curriculum implementation.

Educators' ability to use concept mapping as a tool to facilitate meaningful learning.

Background: Meaningful learning is enhanced when concepts are visually differentiated, linked to or nested under other concepts, resulting in integrative reconciliation of knowledge and understanding. Competence in using concept mapping as a strategy to support students towards meaningful learning, is essential.Aim: The aim of the study was to describe the nature of the concept maps drawn by educators after a symposium on concept maps to transfer educational knowledge to the classroom.Design: A quantitative descriptive cross-sectional design was used to explore the nature of concept maps drawn by educators after having attended a workshop on concept mapping.Methods: The authors developed a checklist based on the principles of a good concept map to assess and describe to what extent the concept maps drawn by the participants, aligned with general principles on creating a concept map appropriate to enhance meaningful learning. During a symposium, participants were introduced to the advantages, principles and requirements for concept mapping. Sixty-two (62; 100%) participants drew concept maps. Using a checklist based on the principles of good concept mapping, we assessed concept maps from 22 (35.4%) volunteers to explore the extent to which the concept maps aligned with general principles necessary to enhance meaningful learning.Results: Criteria for a good concept map include the graphical presentation and establishing relationships between these concepts. The network-style concept map was used by the majority (68%) of the participants. Only 9% used the spoke concept map. The graphical presentation of concepts and the relationships between these was limited. Only 41% of the maps were understandable, while 36% made sense in the context of the chosen topic.Conclusions: Well-designed concept maps can add value to and improve educator teaching and student learning. Not all educators in this study understood what a good concept map is. Visualisation offered by concept maps assist in recognising how new knowledge can link with, and build on, existing knowledge.

Health sciences educator's simulation debriefing practice needs: A mixed methods study.

BACKGROUND: Simulation debriefing influences learning from healthcare simulation activities. Health sciences educators must be competent in conducting simulation debriefing for healthcare students. A structured faculty development intervention for health sciences educators must be informed by educator needs to enhance its utility. This paper describes the needs of health sciences educators regarding simulation debriefing at a faculty of health sciences. MATERIALS AND METHODS: A parallel convergent mixed methods study design was applied on a selected population of 30 health sciences educators at the University (x) who integrate immersive simulation for first- to final-year students in their undergraduate programs. The Objective Structured Assessment of Debriefing tool underpinned observations which informed the quantitative strand of the study, while semi-structured interviews were conducted as part of the qualitative strand. Descriptive statistics and thematic analysis were used to analyze the data. RESULTS: Health sciences educators struggled to establish the learning environment for simulation (median 1), facilitate learning (median 3), and evaluate their debriefing activities. However, they were able to apply an appropriate approach toward simulation (median 4). They identified the need to be educated on the fundamentals of simulation-based education. CONCLUSION: A continuing professional development program must be developed aimed at transforming approaches toward facilitating learning, explaining the fundamentals of simulation-based education, modeling of best-practices related to debriefing, and applying appropriate strategies for evaluating debriefing activities.

Scaffolding in Health Sciences Education Programmes: An Integrative Review.

The complexity of health sciences programmes justifies scaffolding to support students in becoming competent health professionals. This article reports on an integrative review that aimed to describe the application of scaffolding in health sciences programmes. Twenty-nine sources, inclusive of theoretical and empirical studies, were reviewed. The sequencing of educational activities, the application of scaffolding tools or resources, frameworks for applying scaffolding, modelling, and fading represented the application of scaffolding in health sciences programmes. Awareness of the application of scaffolding in health sciences programmes could contribute to enhancing competence development among students when applied across all learning platforms.

A concept analysis on the transfer climate in health sciences education.

The transfer of learning is complex, with factors such as transfer climate influencing students' transfer of learning. This transfer climate will shape a student's experiences during work-integrated learning and can be modified to enhance the transfer of learning. However, studies on transfer climate are mainly reported from a human resource development context and the outcomes may not be transferable to health sciences education. Furthermore, there is no uniformity in defining and measuring transfer climate. Rodgers' evolutionary concept analysis approach was used to describe the antecedents, attributes, and consequences of a positive transfer climate. An information specialist assisted in developing a Boolean search string and searched 15 databases to identify relevant sources. In total, 156 relevant articles were selected from 1448 sources. Data were charted and thematically analyzed. Antecedents comprise interpersonal relationships and theory-practice correlation. The presence of student support, training programs, student characteristics, clinical facilitator characteristics and a well-resourced clinical environment are the attributes of a positive transfer climate and act as learning transfer mediators. Transfer climate consequently influences student, educational, and organizational performance. A conceptual definition for transfer climate was then proposed. It was subsequently concluded that developing competent healthcare professionals and providing support to students depend on the synergy and good working relationship between health services and educational institutions. The insights into modifiable elements to enhance transfer climate could benefit health sciences educators in reconsidering their clinical training models to ensure sufficient support during students' clinical placements to meet the demands for a better-qualified healthcare workforce.

A supportive clinical learning environment for undergraduate students in health sciences: An integrative review.

BACKGROUND: The clinical learning environment is a platform where theory and practice should be integrated in a safe environment. However, many students experience the clinical learning environment as "stress provoking", because this environment is not always supportive. OBJECTIVE: The aim of the article is to report on a study that synthesized the evidence on strategies for providing a supportive clinical learning environment for undergraduate students in health sciences. DESIGN: The integrative review followed the methodology of Whittemore and Knafl (2005). DATA SOURCES AND REVIEW METHODS: We searched MEDLINE with Full Text, CINAHL with Full Text, Academic Search Ultimate, PsycINFO, Health Source: Nursing/Academic Edition, ERIC, Africa-Wide Information, OpenDissertations, CAB Abstracts, MasterFILE Premier, SocINDEX with Full Text, SPORTDiscus with Full Text and PsycARTICLES. Other data sources included grey literature and reference lists. The filtering process, quality appraisal and data extraction were carried out by at least two independent reviewers. Thematic analysis was used to analyse the data. RESULTS: The search yielded 500 studies, of which nine studies met the inclusion criteria. The generated data culminated in a clinical learning environment mindmap that highlights, firstly, a network of carefully selected supporters who may have specific clinical responsibilities while supporting undergraduate students in clinical learning. Secondly, the relationship between the student, student supporter and clinical staff should create a sense of belonging, self-efficacy and self-directedness. This relationship is influenced by the roster, the ratio of students to student supporters, and appropriate learning opportunities. Thirdly, higher education institutions and healthcare providers should support students and student supporters through formal partnerships. CONCLUSIONS: The synthesis of the evidence provided new insights regarding creating and maintaining supportive clinical learning environment strategies for undergraduate students in health sciences. These strategies may be implemented in innovative ways to provide students with the best clinical learning opportunities.

Infection prevention and control practices of non-medical individuals in a neonatal intensive care unit: A Donabedian approach.

OBJECTIVE: To describe the infection prevention and control practices of non-medical individuals in a neonatal intensive care unit, using the Donabedian model. DESIGN: We used an observational descriptive qualitative approach, collecting data over 38 h of non-participant, unstructured observations. An interprofessional observational team recorded their observations. SETTING: Observations were collected in the neonatal intensive care unit of a regional hospital in Gauteng, South Africa. PARTICIPANTS: We observed non-medical individuals involved in the day-to-day operations related to infection prevention and control in a neonatal intensive care unit, specifically the cleaners and laundry staff, maintenance and technical services, and significant others. Individuals were selectively observed due to their proximity and convenient presence in the neonatal intensive care unit at the time of observation. MEASUREMENTS AND FINDINGS: Data were deductively analysed and categorised into Donabedian's pre-existing structure- process- outcome framework. Themes that evolved were the absence of policies and procedures, inadequate written information, unsuitable physical layout of the neonatal intensive care unit, non-adherence to hand hygiene, lack of personal protective equipment, poor cleaning practices, poor service delivery and unavailability of documented evidence on cleaning routines, delivery of supplies and infection prevention and control training. KEY CONCLUSIONS: In the neonatal intensive care unit, non-medical individuals did not adhere to infection prevention and control measures. The absence of standard operating procedures may contribute to cross contamination and an increase in hospital acquired infections. IMPLICATIONS FOR PRACTICE: Infection prevention should be regarded as an interprofessional team effort and requires situational awareness. The infection prevention control practitioner and unit manager should collaborate with support services and significant others to ensure that these individuals have appropriate knowledge about and adhere to infection prevention control practices in a neonatal intensive care unit. The infection prevention control committee should be expanded to include support staff managers. Orientation programmes should be implemented to raise the awareness of non-medical individuals about the important role they play in infection prevention and control.

Clinical placement models for undergraduate health professions students: a scoping review.

BACKGROUND: Clinical learning is fundamental to undergraduate health professions students. There are several calls for the transformation of health professions education, which have direct implications on clinical learning. Clinical placement models provide structure to clinical learning. Therefore, this scoping review could contribute to supporting curriculum transformation to enhance learning in the clinical environments for undergraduate health professions students. OBJECTIVES: This scoping review identified the characteristics of research evidence related to mapping the purpose, methodologies used, outcomes, and specific recommendations associated with clinical placement models in undergraduate health professions education. DESIGN: A scoping review method was used in this study. A search string developed from the title of the review was used to search online databases to identify research published between January 2000 and March 2020. RESULTS: Forty-eight articles reporting on ten clinical placement models were included in this review. The majority of these articles originated from Australia and predominantly report on nursing. The aims of these articles aligned with the evaluation of the implementation of a clinical placement model. Seven categories of outcomes of the clinical placement models are reported namely, relationships, influence, environment, facilitation, inputs, knowledge scores, and student perceptions. CONCLUSIONS: As clinical learning is fundamental to undergraduate health professions education, clinical placement models should prioritise the development of competence among undergraduate students. Insights into outcomes reported in literature could guide educators in fostering optimal learning in students who may then be able to influence community health outcomes positively.

Towards Continuing Interprofessional Education: Interaction patterns of health professionals in a resource-limited setting.

There are challenges related to collaboration among health professionals in resource-limited settings. Continuing Interprofessional Education initiatives grounded on workplace dynamics, structure and the prevailing attitudes and biases of targeted health professionals may be a vehicle to develop collaboration among health professionals. Workplace dynamics are revealed as health professionals interact. We argue that insights into the interaction patterns of health professionals in the workplace could provide guidance for improving the design and value of CIPE initiative. The study was conducted through rapid ethnography and data were collected from non-participant observations. The data were transcribed and analysed through an inductive iterative process. Appropriate ethical principles were applied throughout the study. Three themes emerged namely "Formed professional identities influencing interprofessional interaction", "Diversity in communication networks and approaches" and "Professional practice and care in resource limited contexts". This study revealed poor interaction patterns among health professionals within the workplace. These poor interaction patterns were catalyzed by the pervasive professional hierarchy, the protracted health professional shortages, limited understanding of professional roles and the lack of a common language of communication among the health professionals. Several recommendations were made regarding the design and development of Continuing Interprofessional Education initiatives for resource-limited settings.

Stakeholders' perceptions of family-centred care in the intensive care unit: An associative group analysis.

AIM: To explore different stakeholders' including nurses, health care professionals and family member's perceptions of ideal family-centred care in an intensive care unit. RESEARCH DESIGN AND METHODS: We used a mixed method approach to identify perceptions of family-centred care with 60 stakeholders of equal numbers who voluntarily participated in the study. Data were collected over one month using an associative group analysis method. The responses were ranked, scored, thematically themed and weighted. SETTING: A 23 bed adult intensive care unit in an urban private hospital in South Africa. FINDINGS: According to the stakeholders' responses, ideal family-centred care should be built around communication based on expectations and engagement. In addition, the physical environment should allow for overall comfort and spiritual care must be incorporated. CONCLUSION: Stakeholders had similar perceptions on the main themes however; nuances of different perspectives were identified showing some of the complexities related to family-centred care. Spiritual care was highlighted by the family members, revealing the need to broaden the care perspectives of healthcare providers.

Development of a conceptual framework for a Person-centred Nurse Residency Programme.

Newly Qualified Professional Nurses (NQPNs) require support while transitioning from student to professional nurse. Nurse residency programmes guided by competent facilitators provide such support. We developed a conceptual framework for a Person-centred Nurse Residency Programme. This qualitative interpretive descriptive study was conducted in three phases. In phase 1, we assessed the support needs of purposively selected NQPNs as well as senior professional nurses. Data were collected using multiple methods and analysed during a consensus workshop held in Phase 2. In Phase 3, we developed a conceptual framework which was validated by six nurse education experts. The final framework comprised of four domains: learning outcomes, learning processes, learning environment, prerequisites of the facilitator, and was underpinned by the educational theories of constructivism and person-centeredness. Advocates of nurse residency programmes should recognise that these domains are interrelated and aim to achieve person-centred support for NQPNs.

WhatsApp as a support strategy for emergency nursing students during the COVID­19 pandemic

Students in emergency nursing had already commenced their postbasic training at universities when the Higher Education Institutions were compelled to discontinue face-to-face contact with students and switched to various online modes of delivering content and facilitating learning in response to the government's hard lockdown rules. Health services assumed students reverted to fulltime staff, while students envisaged completing the postbasic programme. In addition to the stressors all frontline workers encounter, these students had academic-related stressors. This short report aims to describe the use of WhatsApp™ as a support strategy for emergency nursing students during the COVID-19 pandemic. The lecturer initiated a WhatsApp™ group, including all students and the clinical facilitators from various healthcare facilities. The communication stream from 1 March to December 2020 was exported in a Portable Document Format, followed by thematic analysis to identify the support provided. Support for emergency nursing students during the COVID-19 was multifaceted and included system, academic and emotional support. WhatsApp™ as a strategy to provide support to students during the COVID-19 pandemic served its purpose but could add to additional workload for the lecturer at odd or inconvenient hours.

Optimising simulation learning experiences for mature, postgraduate nursing students.

Mature students do not always approach learning activities according to expected adult learner behaviour. In addition, they may have never experienced simulation as a learning opportunity before. This creates a unique opportunity for nurse educators to contextualise education principles that are most applicable to mature students' learning needs. Education action research was conducted with two groups of mature postgraduate students, using nominal and focus groups to optimise their simulation learning experiences. Results showed that mature students should be thoroughly oriented beforehand about simulation practice and what is expected of them during participation. Through scaffolding and a succession of at least six to 10 simulation sessions, learner independence and adult learner behaviour can be developed. Begin with less complex scenarios before moving to ones that are more complex - this will prevent cognitive overload. Keeping the simulation environment as authentic and reliable as possible will promote suspension of disbelief. A non-punitive debriefing model is essential for enhancing student engagement and motivating improved performance in follow-up simulation learning sessions. If nurse educators stay open and responsive to the learning needs of mature students, the advantages of learning through simulation can be realised fully.

Social norms as possible causes of stillbirths.

OBJECTIVE: High stillborn rates are a concern in developing countries. Hence, this article aims to describe the sociocultural norms contributing to the high number of stillbirths as perceived by mothers, significant others, midwives and records of the Pregnancy Problem Identification Programme (PPIP). DESIGN & SETTING: A multimethod qualitative descriptive study was conducted in a district in the Free State, South Africa. Each of the five sub-districts has a district hospital where most pregnant women give birth. Eighty per cent of the community is black of which about a quarter live in poor conditions below the poverty line. PARTICIPANTS: The first author conducted unstructured in-depth interviews with 36 mothers and their significant other who gave birth to a stillborn. She also extracted relevant data from the PPIP record of each mother. A skilled moderator conducted three focus group interviews with a convenience sample of midwives. The data were inductively analysed to identify subthemes under the central theme of social norms. KEY CONCLUSIONS: The authors concluded that traditional practices, traditional role players (traditional healer, mother-in-law, partner), abuse, and prescriptive social norms might contribute to stillbirths. Pregnant women are oppressed as they adhere to traditional social norms and are unable to make independent, informed healthcare decisions. The midwives, who are mostly female, may find it difficult to empower pregnant women because they are under the same social oppression as their clients. IMPLICATIONS FOR PRACTICE: It is imperative that healthcare providers consider social determinants of health, including social norms, when providing healthcare, especially to pregnant women as some social practices may have detrimental outcomes for the mother and/or baby.

The Ears of a Hippopotamus: Quality of Venous Leg Ulcer Care in Gauteng, South Africa.

OBJECTIVE: To describe venous ulcer care and wound care practices in Gauteng, a province of South Africa, according to the Donabedian structure-process-outcome quality improvement model. METHODS: Forty-eight facilities were selected randomly from public and private wound care practices in Gauteng. Structured interviews were conducted with care providers via questionnaire to assess the structural aspects of the Donabedian model. Within these facilities, investigators randomly selected 160 patient files and extracted data using a checklist to assess processes implemented and outcomes reached for patients who had previously presented with lower-leg venous ulcers. RESULTS: Facilities lack the necessary equipment to perform vital assessments. Handheld Dopplers were available in 66% (n = 48) of the facilities. Sixty-one percent (n = 48) of the personnel at the facilities indicated that they had no formal wound care training. Although the majority of files (92%, n = 147) indicated that an assessment tool was used, many elements were not evaluated comprehensively according to the best available evidence. Aspects such as smoking, body mass index, and anemia were assessed in fewer than 30% of the patients. Distinguishing between superficial and deep infection and the accompanying overuse of antimicrobials and antibiotics were among the challenges identified. Further, 71% of patients received compression therapy, although the ankle-brachial pressure index of only 30% of patients was known. In 27 cases (17%), the outcome was amputation. CONCLUSIONS: From this survey, it is evident that not all clinicians providing wound care in Gauteng are adequately trained or fully implementing best practice guidelines, and the consequences are detrimental to patients, particularly in terms of amputation. This article highlights the need for improved legislation and regulation for practitioners who deliver wound care services.