Volume 26 Number 3

Key messages

Community-based compression bandaging improves venous leg ulcer healing rates, reduces costs, and eliminates transport barriers for patients.

Structured training equips community nurses with the skills and confidence to deliver compression bandaging, expanding their scope of practice and improving service delivery.

Implementing compression bandaging in community settings decreases reliance on tertiary care, promoting a cost-effective and sustainable approach to healthcare delivery.

Introduction

Venous leg ulcers (VLUs) are chronic wounds defined as open lesions between the knee and ankle that persist for over four weeks due to venous disease.^1,2 A systematic review identified 13 key interventions for VLU management, assessing their effectiveness and safety. This included leg elevation, mobility, compression stockings for prevention, and compression bandages or stockings for treatment. Other listed interventions were low-level laser therapy, leg ulcer clinics, pentoxifylline, skin grafting and superficial vein surgery for treatment and recurrence prevention. Additionally, therapeutic ultrasound and topical negative pressure were considered for their role in VLU management.^2,3,4,5

Compression therapy is the standard of care for VLUs.^5-8 The goals of compression therapy include edema management, venous reflux improvement, and enhanced healing.^7,9 The two most commonly used compression therapy systems are compression bandages and compression hosiery/stockings.⁹ Most VLU patients often start with compression bandaging and progress to compression hosiery for maintenance once their VLU has healed.¹⁰ Effective compression therapy requires consistent application, patient adherence, and proper exudate management to maintain therapeutic pressure, improving comfort, compliance and healing outcomes.^9,11

Community nursing services are essential for delivering healthcare in home settings. Led by dedicated nurses who collaborate with patients, families, and other healthcare professionals, these services provide holistic and personalised care. They encompass a wide range of activities, including health assessments, medication management, wound care, chronic disease management, health education, and palliative support.¹² The transition of services from tertiary hospitals to primary care has expanded access to specialised treatments, while alleviating the strain on tertiary healthcare facilities.^12,13 Globally, community nursing bridges hospital and home care, ensuring continuous, holistic support for optimal patient outcomes.

In Singapore, compression bandaging has traditionally been confined to tertiary care due to the lack of trained community nurses.¹⁴ This contrasts with countries like Ireland and the United Kingdom (UK), where both tertiary and community nurses provide this service, improving accessibility and continuity of care.^15-17 Addressing this gap was the driving force behind this study.

The absence of community-based compression bandaging services in Singapore has contributed to a high reliance on tertiary care, as reflected in a retrospective study showing that VLU patients on compression therapy incurred median costs of S$451.20 (US$333.26) and required more outpatient visits to tertiary hospitals than those not on compression therapy. Frequent commutes, often two to three times a week, were costly and inconvenient, with higher rates of emergency admissions and hospitalisations among patients receiving compression bandaging.¹⁸ This placed a significant burden on both patients and the healthcare system. In a tertiary outpatient clinic in Singapore, 150 VLU patients requiring compression bandaging were treated weekly, with treatment durations lasting 12 weeks to a year. This resulted in frequent travel for patients and caregivers, and substantial demand for the tertiary care nursing staff.

Addressing the lack of trained community nurses providing  compression bandaging became impetus for this project. Guided by the IRLM, the study aimed to improve access to and expand community-based compression bandaging services. The specific objectives were, firstly, to implement compression bandaging for patients with VLUs in the community and, secondly, to evaluate patient and nurse perspectives on satisfaction, confidence and outcomes.

Methods

This was a quasi-experimental study in which the IRLM framework was used to systematically plan, implement and evaluate the compression bandaging service in the community (Figure 1). A single academic tertiary hospital, Singapore General Hospital (SGH), and the largest home healthcare provider in Singapore, the Home Nursing Foundation (HNF) were involved in this project. Patients were included if they had an active VLU requiring compression therapy and were medically stable for community-based care. Patients with complex VLUs requiring debridement or with active wound infections were excluded. Active infection was defined by swelling, pus, discharge and systemic signs such as fever or necrotic/sloughy tissue hindering healing.¹⁹ Since community care nurses in Singapore do not perform sharp debridement due to the lack of emergency resources to manage potential bleeding in home settings, these cases were excluded from the study.

 

Figure 1. IRLM: Implementation of compression bandaging service in the community

 

This paper discussed the four IRLM domains:²⁰

1. Determinants
2. Implementation strategies
3. Mechanisms of action, and
4. Outcomes.

Many implementation research projects lack a clear rationale for selecting and testing key aspects together, with limited tools available to address this gap.^20,21 To enhance rigor and transparency in adopting evidence-based interventions, the IRLM was developed and guided the implementation of compression bandaging in our community project. The intervention involved the development of a structured training program by the tertiary wound care nurses to equip the community nurses with the skills to perform two and four layer compression bandaging in the community.

Ethical considerations

This study conformed to the ethical guidelines of the Declaration of Helsinki and was approved by the SingHealth Centralised Institutional Review Board (Reference number: 2020/2104).

Determinants

Determinants influence the success of community-based compression bandaging for VLU patients. Key enablers (moderating factors) include structured training and competency, strong collaboration between tertiary and community care nurses, and the involvement of vascular surgeons and medical social workers (MSWs). On the other hand, major challenges and barriers include financial constraints and a lack of community nurse expertise in compression bandaging.

Intervention characteristics

Community nurses initially found two and four layer compression bandaging challenging due to limited experience (barriers). Establishing this service necessitated substantial investment in training and logistics. This included regular meetings with the bandage supplier and community leaders. The development and preparation of training materials by tertiary wound care nurses took nearly a month, reflecting the time and effort dedicated to this project. A team of 15 community nurses underwent ten weeks of competency training, which included theory lessons, practical classroom sessions, and clinical attachment at the tertiary hospital. Refer to Table 1 for training content.

 

Table 1. Training content for community nurses

 

Inner setting

Under the inner setting, we discussed the organisational and structural factors within HNF that influence the success of community-based compression bandaging. It encompasses aspects such as the organisational openness to change and capacity to support new interventions. Leadership support, communication and coordination between the tertiary and community team, and revising the current workflow and processes help to facilitate the adoption of the new service in the community.

A collaboration between tertiary and community care teams facilitated the transition of compression bandaging for VLU patients. Tertiary wound care nurses, and vascular surgeons identified suitable patients and ensured continuity of care through standardised referral workflows. Leadership support from vascular surgeons and nursing administrators fostered nurse commitment, improving adherence and patient outcomes. Effective communication, especially during the pilot phase, ensured a smooth transition and addressed challenges proactively.

Outer setting

Under the outer setting, we highlight the external influences such as policies, regulations and healthcare systems that influence the successful adoption of community-based compression bandaging. Community nurses lack expertise in performing compression bandaging due to lack of training and resources. With external funding and trained vascular nurses available, there was an opportunity to bridge this gap. By introducing compression bandaging in the community and fostering collaboration between tertiary and community care teams, community nurses can expand their skills and improve patient outcomes.

Characteristics of individuals

The implementation of community-based compression bandaging involved diverse stakeholders, including VLU patients, community nurses, tertiary wound care nurses, and vascular surgeons whose characteristics influenced the intervention.

Patients: VLU patients often preferred tertiary care due to established trust, familiarity and rapport with hospital staff. Privacy concerns, discomfort with home visits and inadequate living conditions contributed to reluctance toward community-based care, posing challenges in service transition.

Tertiary wound care nurses: Motivated to address a critical service gap, these nurses played a pivotal role in training and service expansion. Their adaptability and proactive approach overcome logistical challenges, ensured consistent care standards.

Community care nurses: Eager for professional development, community nurses embraced training and confidence-building activities. Despite initial skill gaps in compression bandaging, hands-on practice and training progressively enhanced their competence.

Vascular surgeons: Vascular surgeons referred patients to community care nurses for compression bandage changes, actively supporting the initiative. This collaboration boosted the nurses’ confidence, while increasing patient awareness and reassurance about safely continuing compression bandaging in the community.

Process

The implementation of community-based compression bandaging followed a structured process to ensure quality, accessibility and continuity of care.

Referral process: Patients were identified by wound care nurses and vascular surgeons in tertiary care with MSWs engaged to assist with financial support. Clear workflows and communication channels ensured seamless transitions, timely follow-ups and reduced miscommunication. Vascular surgeons and specialty nurses reassured patients about the quality of community-based care to improve adherence.

Financial aid: Community-based services reduced consumable costs (S$30–50 versus S$60 in hospitals). MSWs facilitated subsidy applications, ensuring continued financial support for eligible patients.

Supply coordination: Community nurses streamlined the workflow for procuring, storing and transporting compression bandaging supplies to patients’ homes, ensuring efficient supply management and continuity of care. Tertiary wound care nurses provided guidance as needed, fostering collaboration to maintain continuity in compression bandaging services.

Implementation strategies

Implementation strategies involve providing support, making adjustments, and introducing interventions within the system to promote the adoption of evidence-based interventions into regular care practices.²⁰

Formation and partnership

SGH and HNF established a collaborative partnership to enhance community-based wound care. This multidisciplinary team comprises nurse researchers, administrators, a community nurse lead and a wound and vascular specialist. They reviewed and streamlined protocols, improved coordination and continuation of care. SGH researchers provided expertise in research, while HNF nurses offered insights into patient needs. The inclusion of a specialised wound care nurse strengthened evidence-based protocols, driving innovation and improving care for patients with VLUs.

Training

Training incorporated the use of PicoPress® to ensure the compression bandages deliver optimal sub-bandage pressure.²² The UrgoK2® (20–30mmHg) and PROFORE® (30–40mmHg) compression systems were used for training and delivered the adequate compression pressure.²³ Hands-on practice, paired with constructive feedback from trainers, enabled community nurses to improve their bandaging techniques and skills. Competency was validated after ten successful independent applications of each technique. To maintain proficiency, a master community nurse trainer implemented a Train-the-Trainer model,²⁴ supported by yearly competency reviews and supplier-led refresher training, ensuring ongoing proficiency.

Financial assistance

SGH and HNF MSWs streamlined financial aid and supply coordination. During the trial, SGH’s Needy Patient Fund fully covered costs, ensuring accessible, affordable care with the help of SGH’s MSWs, while the HNF’s MSWs created a new service code as part of their billing process.

Materials and consumables

To ensure a consistent supply of compression bandages and wound dressings, HNF developed a new workflow for ordering and stocking these essential items. Subsequently, HNF’s MSW and finance teams secured Ministry of Health (MOH) approval for subsidised consumables, ensuring the patients received financial support for procedures and supplies in the community.

Mechanisms of action

These are processes through which an implementation strategy works to achieve desired outcomes. These may involve changes in key factors, immediate outcomes, the strategy itself or a mix of these.²⁰

Self-efficacy and recognition of community nurses

Hands-on practice with trainer feedback refined community nurses’ compression bandaging skills, boosting their confidence and efficacy. Recognised for their competency, they gained patient trust and reinforced their professional role in community care.

Outcomes

Outcomes are the results of intentional efforts to introduce new treatments, practices or services. They serve as indicators of implementation progress or intermediate steps toward service or clinical goals.²⁰

Reach

Of the 27 patients who initially agreed to community-based compression bandaging (mean age 72.6±12.2 years, equal male/female distribution), 48.1% required walking aids, while 25.9% were independent or wheelchair-bound. Hypertension was the most common comorbidity (62.9%). Most received  two layer (62.9%) or four layer (37.0%) compression. The mean baseline wound area was 12.33±19.01cm squared, with VLUs mainly on the shin (37.0%) (Table 2).

 

Table 2. Demographic data of VLU patients in community care and tertiary care centre, ^aChi-square, ^bFisher’s Exact Test, ^cMann–Whitney U test

 

By week twelve, 12 patients discontinued due to non-adherence (n=4), hospital readmission (n=2), or preference for tertiary care (n=6). Among the 15 who continued, nine completed follow-up and had complete ulcer healing. Mean wound area decreased significantly from 15±22.32cm squared to 5.3±10.15cm squared (p=0.003), with a median healing time of five weeks (range: 2–12 weeks) (Table 3). Most (77.8%) required caregiver assistance, and two layer compression was the preferred modality for home care (77.8%).

 

Table 3. Demographics of VLU patients with healing status at 12 weeks, ^aChi-square, ^bFisher’s Exact Test, ^cMann–Whitney U test

 

Implementation and feedback

Nearly half of the patients (44.4%, n=4) expressed confidence in community nurses’ competence in compression bandaging, highlighting reduced travel time and costs. More than half were satisfied with home-based compression care (Figure 2).

 

Figure 2. Patients’ experiences with community compression bandaging

 

Fifteen community nurses completed the training, 14 out of 15 HNF nurses participated in the survey post-training. All tertiary wound care nurses (n=7) from SGH also provided feedback on community-based compression bandaging. Community nurses had 3–14 years of experience, while tertiary care nurses had 2–42 years.

Among community nurses, 71% (n=10) found the training comprehensive, while 78% (n=11) considered the materials adequate. Nearly half (43%, n=6) strongly agreed they could apply theoretical knowledge to practice, and 50% (n=7) viewed compression bandaging as a valuable addition to their practice (Figure 3). All tertiary care nurses (100%, n=7) endorsed community-based compression bandaging as both beneficial and cost-effective. (Figure 3).

 

Figure 3. Community nurses’ experiences with compression bandaging

 

Service/clinical/patient

A collaborative partnership with the vendor fostered a continuous learning environment for community nurses through regular training and in-service programs. This approach addressed initial training needs, while supporting ongoing professional development, ensuring proficiency in the latest compression bandaging techniques. Consequently, community nurses improved their proficiency, enhancing the quality of care delivered.

No adverse events, such as skin breakdown, necrosis, infections, or increased lower limb pain, were reported from compression bandaging provided by community nurses. Patients demonstrated positive outcomes, including a significant median reduction in wound surface area of -2.27cm squared (p=0.003). Among the 26 patients, 11 from the community care setting and 5 from the tertiary care setting received financial aid. Out-of-pocket costs were calculated for those who did not receive any financial assistance. In the community care group, patients had a median consumable cost of S$339.50 (min–max: S$290.00–S$684.00). In contrast, those receiving care from the tertiary care had a median consumable cost of S$281.80 (min–max: S$120.00–S$585.00).

Notably, patients in tertiary care were eligible for supplementary financial support beyond standard aid, which is an option unavailable in the community care setting. Therefore, the median consumable cost from the tertiary care group was lower than the community care group. For transportation costs, this study included expenses related to visits to tertiary care for VLU management. In the tertiary care group, the median transportation cost was S$20.00 (min–max: S$12.20–S$493.00), which included public transport expenses. In comparison, the community care group had a median transportation cost of S$18.00 (min–max: S$1.20–S$40.00). Notably, community care patients still incurred transportation costs when they required treatment for their VLUs at the tertiary care facility.

Despite these benefits, financial disparities posed challenges. Full subsidies in tertiary care were unavailable in community schemes, requiring patients to partially cover dressing material costs, deterring some from transitioning to home-based care. The consumable costs reported were calculated before MOH subsidies. From October 2023, MOH approval extended these subsidies to include nursing procedure fees and consumables, making community-based care more financially accessible.

Challenges

Despite the potential time and commuting cost savings, patients accustomed to full financial subsidies in tertiary care were hesitant to transition to home-based compression bandaging. This reluctance stemmed largely from the disparity in subsidy structures: tertiary care is provided with comprehensive financial support, while community-based schemes are offered with only partial subsidies. Patients were also required to independently cover the cost of dressing materials, further discouraging them from opting for home care.

As a result, many VLU patients preferred attending outpatient clinics in tertiary care settings, where full financial coverage eliminated out-of-pocket expenses. This preference highlights a critical barrier to the adoption of community-based services. Addressing these financial disparities and aligning subsidy structures between tertiary and community care is essential to improving the accessibility and feasibility of home-based compression bandaging, especially for patients from diverse socioeconomic backgrounds.

Discussion

This implementation project represents a pioneering collaboration between Singapore’s largest tertiary care centre with a community healthcare provider, demonstrating the feasibility and benefits of expanding compression bandaging services into community settings. Similar to a UK project aimed at enhancing VLU care services and staff training,²⁵ our initiative focused on improving staff confidence and training in compression management for VLU patients in the community.

By addressing a critical gap in healthcare access for VLU patients, the project enabled comprehensive wound care to be delivered at home. Despite initial challenges, such as patient hesitancy and the need to build specific competencies among community nurses, the outcomes were encouraging. Among the 15 patients who completed the intervention, nine achieved complete ulcer healing, and feedback highlighted positive perceptions of community nurse competency and care effectiveness.

When compared to the study conducted on VLU management in primary care, the authors highlighted different perspectives between VLU patients and clinicians.²⁶ Patients emphasised the need for earlier specialist referrals, vascular assessments and compression therapy. Clinicians, however, relied on clinical judgment rather than guidelines, and often managed the VLUs with topical dressings alone. However, in our study, the patients are managed with both topical dressings and compression bandaging. A qualitative study in Australia identified factors influencing VLU guideline implementation in primary care.²⁷ Conducting a similar study could identify challenges affecting our nurses and patients in the community before implementing compression therapy.

The training program played a pivotal role in this success, enhancing the skills and self-efficacy of community nurses. It also fostered collaboration between tertiary and community care teams, facilitating resource-sharing and integration of services. Financial assistance mechanisms and streamlined workflows further reduced patient burden, improving accessibility and easing cost-related barriers. These findings underscore the importance of establishing robust support structures, ongoing professional development and clear communication pathways to sustain and scale community-based healthcare initiatives.

This project highlights the transformative potential of decentralised healthcare models in improving patient outcomes, increasing access to care, and achieving cost savings. The successful implementation of community-based compression bandaging reinforces the importance of interprofessional collaboration, research and strategic planning in delivering equitable, high-quality healthcare. This initiative offers a replicable framework for extending specialised care into community settings, ultimately enhancing quality of life and promoting healthcare equity for patients with complex medical needs.

Limitations

One of the key limitations includes the small that limits the study’s generability. A larger sample size would provide more robust evidence for the effectiveness and scalability of this approach. Additionally, the study did not assess the long-term sustainability of community-based compression bandaging and its impact on tertiary care workloads. Specifically, changes in hospital resource utilisation, staffing requirements and the potential redistribution of workloads between tertiary and community care were not evaluated. However, the research team and SGH vascular nurses are monitoring referrals to the community.

Second, the financial implications for both patients and healthcare systems were incompletely addressed. Although the study compared costs between community and tertiary care, we did not conduct cost effective analysis.

Another limitation was the absence of an integrated communication system between tertiary and community care settings. The lack of shared medical records hindered consistent updates on patient progress, creating potential gaps in care continuity. While tertiary care patients can seamlessly coordinate bandage changes with vascular surgeon consultations, community nurses at HNF relied on messaging platforms to communicate with specialists, which often delayed access to timely clinical input. Furthermore, the absence of a telehealth consultation framework exacerbated these challenges, requiring patients to attend tertiary outpatient appointments to consult with their vascular surgeons. Establishing an integrated communication and telehealth infrastructure could significantly enhance the efficiency and accessibility of community-based care.

Lastly, this study did not capture patient-reported outcomes (beyond satisfaction surveys) in sufficient depth to assess their broader quality-of-life improvements. Factors such as pain management, mobility and psychological well-being are some of the important aspects of VLU treatment, which were not extensively explored. Mechanisms for peer support should be assessed and integrated into the community to help VLU patients with goal setting, compression adherence and social interaction. Furthermore, a review reported a lack of trials on interventions promoting adherence to compression therapy for VLUs.²⁸ Future research should address these patient-centered metrics to provide a more comprehensive evaluation of community-based compression bandaging.

Implications for nursing and health policy

The success of community-based compression bandaging for VLUs underscores the transformative potential of decentralising specialised healthcare services. By extending care beyond tertiary settings, this model improves access, addresses barriers in service delivery, and enhances overall healthcare equity and efficiency. These findings underscore the need for investment in key areas: aligned subsidy structures, comprehensive training programs, and sustainable funding models for community-based care initiatives. Empowering community nurses through training and clear policies reduces tertiary care strain and enhances care quality and access.

To ensure scalability and sustainability, policymakers need to prioritise the integration of telehealth platforms, streamlined referral systems, and shared electronic health records to bridge communication gaps between care settings. Further research is necessary to assess the long-term clinical and economic outcomes of community-based compression bandaging, including its potential to optimise resource utilisation, improve patient-reported outcomes, and create cost-efficient healthcare solutions. By addressing these areas, community healthcare systems can evolve to meet the growing demand for specialised, patient-centered care.

Conclusions

Implementing community-based compression bandaging in Singapore proves the feasibility and benefits of decentralising specialised care. This initiative reduced barriers to access, supported cost-effective care delivery and empowered community nurses to take on expanded roles, ensuring continuity and quality of care. Collaborative partnerships between tertiary and community care providers, underpinned by the IRLM, were essential in overcoming challenges and fostering an environment of innovation and shared responsibility.

This project illustrates the importance of strategic planning, interprofessional collaboration and evidence-based methodologies in addressing complex healthcare needs. By building on this foundation, healthcare systems can adapt to better serve patients with chronic conditions, promoting equitable care delivery and enhancing patient outcomes across diverse care settings. The success of this initiative offers a scalable framework for other regions seeking to bridge gaps between hospital and community healthcare, paving the way for more sustainable and patient-centered healthcare delivery systems.

Acknowledgments

We sincerely thank the following individuals and teams for their invaluable support and contributions to this project: Dr Ng Yi Zhen (Program Manager, A*STAR), Dr Christina Tiong (CEO, Home Nursing Foundation), Dr Kjersti Marie Blytt (Postdoctoral Fellow) for her insightful comments, and the dedicated nurses from HNF: Ms Hayaty Abdullah, Ms Nur Shafurah Hamzah, Ms Chitra Kumarasamy, Ms Wong Wenming Cathy, Ms Siti Mariam Mohamed Amin, Ms Kok Candace Kwai Huong, Ms Fazrina Ahmad, Ms Chong Yuk Fong, Ms Shahfadzillah Jaafar, Ms Choo Fang Yi Carolyn, Ms Joan Christina Hendriks, Ms Tan Yee Cher Sharon, Ms Veejayakumar. Thanks also to our research coordinators: Ms Raden Nurheryany and Ms Nurliyana Agus. We also extend our gratitude to our Wound, Ostomy, Continence Nurses, represented by Ms Tan Wei Xian, Ms Chong Hui Ru and Ms Angela Liew, and the medical social workers: Mr Brandon Ow Yong, Ms Christine Lim, and Ms Yeda Ko. And to vascular surgeon Prof Chong Tze Tec and team, and chief nurses A/Prof Tracy Ayre from SingHealth Group and Ms Ng Gaik Nai from SGH.

We would like to thank the SGH DMC Clinic Nurses: NC Vir Kaur Gill, ANC Tuang Juan Jang Gracia, SSN Nur Farhana Binte Mohd Ali, PEN Ong Li Li, PEN Teo Mui Huay, PEN Hadigah Bte Mohammed, PEN Nur Amaliyyah Binte Mohd Mocktar.

Conflict of Interest

The authors declare no conflicts of interest.

Funding

This research was supported by the Agency for Science, Technology and Research (A*STAR) under its Industry Alignment Fund—Pre-Positioning Programme (IAF-PP) grant number H1901a0LL9 as part of the Wound Care Innovation for the Tropics (WCIT) Programme.

Author contributions

All authors reviewed and extensively edited the manuscript and approved the final version.

Author(s)

Fazila Aloweni¹ M.Sc (HRM), Nanthakumahrie Gunasegaran*² M.Sc (ClinLead), Wee Ting Goh³ B.Nurs, Hafidah Saipollah⁴ B.Nurs, Shin Yuh Ang⁵ MBA (Health Management)
¹Nursing Division, Singapore General Hospital, Singapore
²Nursing Division, Singapore General Hospital, 10, Hospital Boulevard, SingHealth Tower, Level 15, 168582, Singapore
³Nursing Division, Singapore General Hospital, Singapore
⁴St Luke’s ElderCare, Singapore
⁵Nursing Division, Singapore General Hospital, Singapore

*Corresponding author email nanthakumahrie.gunasegaran@sgh.com.sg

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