Volume 27 Number 2

Key messages

• Australian patients reported higher confidence in self-management of surgical wounds after discharge than Dutch and Swedish patients.
• Clear instructions on removing wound closure materials were strongly linked to patients’ post-discharge wound management but were frequently missing from discharge education.
• Patients requiring wound-related readmission faced greater challenges with self-management, indicating that standardised discharge education is insufficient for more complex wounds.

Introduction

Despite advances in surgical techniques, perioperative care, and operating room environment, surgical site infections (SSI) remain a significant cause of morbidity and mortality due to delayed or complicated wound healing.¹ A systematic review and meta-analysis of 499,594 patients identified that 11% of general surgical patients will develop an SSI within 30 days post-operation.² Up to 6% of patients will be readmitted for SSIs³, and a single case of SSI can cost up to $30,000 depending on its severity.^4,5 Consequently, surgical wound complications, including SSIs, account for almost 4% of healthcare costs, and that proportion is rising.

Given that many SSIs occur after patients are discharged from the hospital, experts suggest that patient participation in surgical wound care may be instrumental in reducing SSIs.⁶ Patients affected by SSIs have ardently expressed that they want to be more involved in their care, yet, they also highlighted that they lack understanding of ‘normal’ wound healing and warning signs.^7,8 This makes it difficult for patients to participate in self-management wound care practices.

Evidence suggests that discharge education can increase patients’ ability to self-manage once home.⁹ However, Gillespie et al,¹⁰ found that only 27% of patients received postoperative wound education in surgical wards. Furthermore, a recent meta-analysis of perioperative care bundles used to prevent SSIs highlighted that patient education was only included in five out of 18 studies.¹¹ This all points to the lack of prioritisation of patient discharge education.

Overall, there is a gap in surgical wound care discharge education that undermines patient-centred care (PCC).¹² Internationally, PCC has received considerable attention over the last decade,¹³ with countries like Australia, the Netherlands and Sweden actively prioritising PCC.^14–16 Delivering discharge information that aligns with patients’ preferences is a practical way to operationalise PCC, while also ensuring patients understand their wound care instructions, resulting in safer transitions from hospital to home. Findings of a review including 36 studies suggest that surgical patients want clear, timely and multimodal discharge information, such as written and verbal formats covering self-care and complication management, to feel adequately prepared for recovery after hospital discharge.¹⁷ Although general discharge education is well-documented, there remains a lack of understanding regarding surgical patients’ specific experiences and preferences regarding wound care education at discharge.

Thus, we aimed to describe patients’ experiences and preferences for surgical wound care discharge education across three countries, and to examine factors associated with their ability to manage their surgical wound following hospital discharge. The study addresses the following questions:

1. What are surgical patients’ experiences of wound care discharge education, including their opportunities to participate in wound care decisions?
2. What are surgical patients’ preferences for the delivery of wound care discharge education?
3. To what extent are surgical patients able to manage their wounds at home following discharge?
4. What factors predict patients’ ability to self-manage their surgical wound care at home?

This study was conducted across Australia, the Netherlands, and Sweden. These countries offer diverse healthcare systems, discharge practices, and models of postoperative care, providing a valuable comparative framework. A multinational approach enables the identification of both shared and context-specific factors influencing wound self-management, including patient education, access to follow-up care, and cultural attitudes toward health responsibility. By examining patients’ experiences across these varied settings, the study enhances the generalisability of findings and contributes to the development of internationally relevant strategies to reduce wound-related complications. This approach also supports the design of tailored interventions that reflect the realities of different health systems and patient populations.

Methods

Study design

A multinational cross-sectional study, reported as per the Consensus-Based Checklist for Reporting of Survey Studies (CROSS).¹⁸

Survey development

The 18-item SWAPP-Q¹⁹ was used to explore participants’ experiences of and preferences for surgical wound care discharge information, according to the following themes:

Experiences:

1. Wound care discharge education (10 items)

2. Participation in wound care decisions (3 items)

3. Patients’ ability to manage their surgical wound to prevent wound complications (1 item)

Preferences:

4. Preferences for discharge education delivery (4 items)

The questionnaire was developed based on a literature review. After face validity and content validity testing with an international group of health consumers, clinicians and researchers, the questionnaire was pilot tested with seven Australian health consumers to ensure the questionnaire was acceptable to administer via telephone. The original questionnaire was developed in English and then translated into Dutch and Swedish using forward-backward translation. In Sweden, two English-speaking Swedish natives translated the questionnaire, while in the Netherlands, one English-speaking Dutch native did the same. In both countries, the translation was back translated by a native English-speaking medical professional fluent in Swedish or Dutch.

Setting and population

Study sites included two European university hospitals (Netherlands and Sweden) and two metropolitan tertiary hospitals in Australia. This study was conducted across varied surgical wards within the hospitals. Patients were eligible to participate if they were adults (18+), who consented, underwent any type of planned or emergency surgery, and were available for an interview via phone (14±3 days post-surgery/discharge) or mail. This timeline aligns with evidence that 75% of post-operative complications occur within 14 days of discharge home.²⁰ Patients receiving end-of-life care or with cognitive impairments were excluded. The target sample was 900 patients (300 patients per country).

Recruitment and data collection

Trained researchers in each country recruited participants from surgical wards in their hospitals. If participants gave verbal and written informed consent, their demographic data, phone number and/or email address were collected, and the survey was administered by telephone in Australia and the Netherlands, and by mail in Sweden. Data was managed using country-specific web systems: Australia used Research Electronic Data Capture software (REDCap); the Netherlands used Castor®, and Sweden used KI Survey (Sunet Survey). All systems complied with relevant legal and ethical standards and used secure, access-restricted databases. Participants were de-identified using coded study IDs before data was shared with the Australian site for analysis.

Data analysis

Data were exported into SPSS (Version 30) for cleaning and analysis. Responses marked as “missing,” “not reported,” or “did not respond” were labelled as missing data. “Not applicable” responses were defined as indicating that the question was irrelevant to the participant’s post-surgery care and were treated as a separate category for descriptive analysis. These responses were later grouped with missing data for consistency in comparative analysis. Likert-type scale responses were binarised (strongly agree/agree = Yes | neutral/disagree/strongly disagree = No) to improve interpretability and reduce multicollinearity. Descriptive statistics were used to compute absolute (n) and relative (%) frequencies of categorical variables, and the means and standard deviations (SD) of normally distributed continuous variables. Survey items with multi-response options, primarily related to patients’ preferences, were descriptively analysed as percentages of “yes” versus “no” responses for each question.

Univariate analyses were conducted using Chi-square tests for categorical variables and t-tests for continuous variables (such as age). For variables with multiple categories (such as Country), post-hoc Chi-square tests with Bonferroni correction were applied to control for multiple comparisons.

A binary logistic regression model was used to identify predictors of patients’ ability to manage their surgical wounds at home. A model-building approach was used, and independent variables were selected based on significance in univariate analyses (p≤0.05) and theoretical relevance. Independent variables included: country (with Australia as the reference group), participant age, hospital re-admission, wound closure via adhesive glue, wound not closed, and information delivery (how the wound should be cleaned, signs of infection, when and how wound closure methods are removed, and use of physical materials like brochures). Independent variables were binarised based on researchers’ judgements: No = 0 and Yes = 1.

The dependent outcome measure was patients’ ability to manage their surgical wounds at home. This outcome originally was on a 5-point Likert-type scale ranging from 1=strongly disagree to 5=strongly agree. Like the original survey, this outcome was also non-normally distributed; to maintain consistency, this variable was also dichotomised like all other Likert-type scale responses in this survey. Multicollinearity was assessed using Variance Inflation Factor (VIF) and tolerance values, with no concerns detected.

To assess confounding, binary logistic regression models were used to compare Australia versus Netherlands and Sweden versus Netherlands. Changes in the country’s odds ratios (ORs) were examined before and after adjusting for potential confounders. Statistical significance was set at p<0.05.

Ethics

The Ethics Review Committee of each hospital and the Australian university involved reviewed the proposed study and provided ethics approval (Australian hospital: HREC/2020/QGC/64063; Australian university: 2020/880; Swedish hospital: Dnr 2022-05580-01). In the Netherlands, it was concluded that the Medical Research Involving Human Subject Act (WMO) did not apply to this project (reference number W21_440 #21.489).

Patient and public engagement

The Guidance for Reporting Involvement of Patients and the Public (GRIPP2) checklist was used to report consumer engagement in this study²¹ (See Appendix 1). One consumer has been engaged from survey development through to manuscript development.

Results

Individual screening, participation and completion rates are shown in Figure 1. In total, 520 participant responses were analysed. Missing data was 0.6%; 3.5% including Not Applicable responses.

 

Figure 1. Flowchart of the response to the survey

 

As shown in Table 1, the mean sample age was 56 years (SD 19.2) and more women overall participated. Swedish participants were generally older and more educated, with 70.3% holding university degrees. In Australia and Sweden, most participants underwent general surgery, while nearly half of the Dutch participants had orthopaedic or trauma surgery. Most of the procedures fell into these two groups. Across all countries, stitches were the most common surgical wound closure method.

 

Table 1. Participant demographics and surgical characteristics by country.

 

Patients’ experiences of wound care discharge education, including their opportunities to participate in wound care decisions

Table 2 shows that across all countries, most patients received wound care discharge education on follow-up appointment scheduling (n=439; 84.4%) and who to contact with questions about the wound (n=443; 85.2%). These instructions were frequently given verbally, with opportunities for questions (n=386; 74.2%), and approximately half of all participants received supplemental printed materials (n=234; 45.0%).

 

Table 2. Experiences of wound care discharge education.

 

Appendix 2, Table A2 presents survey results on patients’ experiences of participation in wound care decisions, with no variables reaching statistical significance in subsequent analyses. Most Australian and Dutch participants reported that medical and nursing staff discussed surgical wound-related treatment options; however, 32 (43.2%) Swedish participants disagreed. Across all countries, staff were generally reported to have discussed wound care pain management options (n=412; 79.4%), but when asked if they were invited to participate in decision-making, 244 participants (46.9%) responded ‘no’.

Patients’ preference for the delivery of wound care discharge education

Full survey results on patients’ discharge education preferences are presented in Appendix 2, Table A3. Across all countries, most participants preferred to receive printed materials (n=315; 60.6%) and verbal instructions with opportunities to ask questions (n=450; 86.5%) from medical staff (n=387; 74.4%) and nurses (n=377; 72.2%). Most participants wanted this information at discharge (n=416; 80.0%), with follow-up appointments scheduled as outpatient visits at their local hospital (n=312; 60.0%).

Patients’ ability to manage their wounds at home following discharge

Table 3 shows patients’ self-reported ability to manage their surgical wound and prevent complications at home. In Australia, 244 participants (90.4%) could care for their wound at home, compared to 101 Dutch participants (57.4%) and 64 Swedish participants (86.5%). Among Dutch respondents, 43 (24.4%) selected “Not Applicable”. When these “N/A” responses are excluded in later inferential analyses, the proportion of Dutch participants reporting positive wound care ability increases to 75.9%, indicating a narrower gap between countries than the descriptive results initially suggested.

 

Table 3. Patients’ ability to care for wound at home.

 

Factors influencing patients’ ability to self-manage their wound at home

Thirty-six candidate variables were tested at the univariate stage; ten with p≤0.05 were simultaneously entered into the binary logistic regression model (Table 4). The full model containing all 10 predictors was statistically significant (χ²=32.80; [10, N=520], p<0.001), indicating that the model was able to distinguish between participants who reported they were and were not able to manage their surgical wound at home. The model explained between 11% (Cox and Snell R-sq) and 21.1% (Nagelkerke R-sq) of the variance and correctly classified 87.9% of cases.

 

Table 4. Binary logistic regression analysis for predictors of patients’ ability to manage their surgical wound at home.

 

Table 4 shows three independent predictors of patients’ ability to manage wound care at home. Australians were 4.3 times more likely than Dutch participants to report successful wound care management (OR=4.25, 95% CI [1.82–9.90], p<0.001). Conversely, wound-related readmission to hospital decreased the odds of self-managing wound care by 82.7% (OR=0.17, 95% CI [0.04–0.82], p=0.027), indicating that complications requiring hospital readmission are strong negative predictors of wound care ability. Finally, participants who received instructions on removing wound closure materials, like stitches and tape, were 3.6 times more likely to manage their wound care at home (OR=3.62, 95% CI [1.45–9.05], p=0.006), than those who did not receive this information.

While Australia remained a strong predictor after adjustment, Sweden’s association disappeared after adjustment. This suggests that Sweden’s univariate association with wound care ability was likely influenced by the fact that no Swedish participants had open wounds, a factor associated with lower wound care ability. Consequently, this absence of open wounds may have led to an overestimation of Sweden’s wound care performance.

Discussion

In this multinational cross-sectional study, we described patients’ experiences of and preferences for wound care discharge education, and examined the factors associated with patients’ ability to care for surgical wounds at home across three countries. We found that most participants received verbal discharge instructions regarding follow-up and wound care. While pain management was commonly discussed by staff, nearly half of the participants felt excluded from decision-making, and most preferred both verbal and printed information from medical staff. We found three variables were independently associated with wound care ability: the country in which treatment occurred, receipt of wound closure removal instructions, and readmission due to wound complications. The following discussion explores the results of the regression analysis in more depth.

The strongest predictor of wound care ability was the country of treatment. Australian participants were more likely to report successful wound self-care than their Dutch counterparts, while Sweden did not remain significant after adjustment. Prior research suggests that 91% of Australians feel confident in managing their health, even when formal health literacy is variable.²² This confidence may also reflect practical differences in post-operative care. For instance, many Australian participants’ wounds were closed with adhesive glue, which typically requires less maintenance than sutures or staples and may partly explain their higher reported self-care ability. Another plausible explanation is that healthcare structures and discharge practices influence patient behaviour, as reported in other studies.^23–26 Both the Netherlands and Sweden offer integrated, hospital-led care pathways with structured follow-up to support patients after hospital discharge.^27–29 In contrast, Australia’s model decentralises healthcare. After discharge patients are expected to take greater responsibility for navigating their own care, choosing between public or private services for support.³⁰ Systems with more formal aftercare pathways, such as those in Sweden or the Netherlands, may foster expectations of professional involvement, making patients less inclined to be autonomous in their wound care.³¹ While this level of system trust can reduce the burden of managing wounds, it may also contribute to passivity and situate patients as dependents within profession-led pathways, rather than collaborators. Together, structural features of the healthcare system and resultant role expectations appear to condition how patients approach self-care; however, further cross-cultural investigation is recommended.

Our findings also reinforce the idea that not all discharge education is equally effective or consistently provided. Among the several education topics assessed, the most significant predictor of independent wound care was the instructions on the timing and manner of removing wound closure materials; yet this information was among the least provided. Only two-thirds of participants who managed their wound at home reported receiving these instructions, making its overall delivery rates the lowest across all three countries. One reason for this gap may be that staff assume sutures or staples will be removed by professionals, making detailed instruction unnecessary. Yet prior research shows that half of patients discharged without complete education were also unaware of the purpose of their follow-up appointments³²; and missed appointments are a recognised issue in surgical aftercare.³³ Thus, omitting these kinds of instructions introduces avoidable risk. Furthermore, without clear instructions, patients may delay or attempt removal incorrectly,³⁴ which increases the risk of SSIs, healing complications and prolonged dependence on clinical support.^35,36 Yet, when provided clear wound care instructions at discharge, 97% of patients successfully removed sutures at home without any major complications,³⁷ showing their capability to self-manage wounds. Therefore, discharge education should emphasise instructions for wound closure removal, as patients can manage this care safely when given proper guidance.

We found that participants who were readmitted for wound-related complications were significantly less likely to report confidence in managing their own care. Among those who managed their wounds independently, readmission was rare (3.2%), compared to nearly four times higher among those who struggled (11.8%). Although this might suggest poor self-care led to complications, evidence shows the relationship is more complex. Complications such as infection, dehiscence, or delayed healing can occur for reasons outside a patient’s control and often require professional intervention beyond home-based care.³⁸ This raises a critical question: are patients readmitted because they struggled with wound care, or do they struggle because the wound became unmanageable? Studies show that even informed patients can be overwhelmed by early complications without adequate support.^31,34 Similar patterns have been observed in chronic wound care, where higher wound complexity correlates with poorer self-management and greater reliance on clinical care.^39,40 If this is the case, then patients readmitted for wound complications face a dual challenge: they are more likely to have dealt with a difficult recovery, and less likely to gain confidence in managing it. In this context, readmission reflects unmet care needs, not personal failure. Therefore, discharge pathways should recognise that complications can undermine even well-prepared patients. Providing accessible, early points of contact for support may prevent avoidable readmissions and help sustain patient confidence in wound care.

This pattern was also evident among participants with open wounds, who were significantly more likely to report difficulty managing care at home. Although the sample was small (n=16), those with open wounds were nearly five times more likely to struggle (10.5%) than those with closed wounds (2.2%). Open wounds often follow complex procedures and require care beyond routine inspection, which can overwhelm patients after discharge. Prior research shows that managing open or complex wounds often requires ongoing support, especially when frequent dressing changes or the visual severity of the wound make independent management challenging.^31,41 Structured follow-up systems, such as those in the Netherlands, are designed to address these needs through coordinated aftercare and home nursing support.⁴² Yet, despite this strong infrastructure, our findings showed both the highest proportion of open wounds and the lowest rates of wound care ability in the Netherlands. As noted earlier, some of this pattern may reflect patient reliance on professional care within Dutch and Swedish healthcare systems. However, it also suggests that even well-integrated systems can struggle if clinical demands exceed what can reasonably be managed at home. Moreover, research shows that many patients receive the same guidance at discharge regardless of wound type.⁴³ While this reflects efforts to standardise wound care education, our findings highlight that standardisation alone cannot meet the differing demands of individual wounds. Discharge education should therefore combine basic instructions with tailored guidance for complex or open wounds. Such an approach would equip patients with the means to manage their care safely and reduce the risk of postoperative complications.

Limitations

While this study offers novel insights into the factors influencing wound care self-management, we acknowledge some limitations. First, the cross-sectional design limits causal inference, as associations cannot confirm directionality between predictors and wound care ability. Second, sampling and response rates varied across sites, which may affect generalisability. Sample sizes were smaller in Sweden, and 43 Dutch participants who had been discharged selected ‘Not Applicable’ when asked about wound self-care at home, as their wounds were already healed by discharge. While these cases were valid, their exclusion reduced the analytic sample and may have influenced between-country comparisons. Third, the final logistic regression model excluded 238 out of 520 cases due to listwise deletion in SPSS. This volume of missing data limited the feasibility of multinomial approaches and required a binary logistic model to maintain stability. Although the model was statistically significant and correctly classified most cases, its explanatory power was limited. This is typical for logistic regression models, where pseudo-R-sq values tend to be modest. The high classification accuracy was likely influenced by outcome imbalance, as most participants reported being able to manage their wound. Listwise deletion may have further limited the model’s capacity to identify key predictors. Future research should consider using approaches that can handle incomplete data without excluding large portions of the sample.

Finally, certain contextual factors may have influenced participants’ responses but could not be fully captured. Differences in wound type, surgical specialty, or hospital setting were not controlled for and may affect wound care expectations. Dutch participants, for example, were more likely to undergo orthopaedic or trauma surgery in academic hospitals, which in the Netherlands are reserved for complex cases rather than routine procedures. This differs from Australia and Sweden, where academic hospitals perform a broader range of surgeries. As a result, the Dutch sample may reflect more complex wounds and structured discharge routines, influencing both wound characteristics and expectations of self-care.

Conclusion

This study shows that patients’ ability to manage surgical wounds at home is significantly influenced by the healthcare context in which they receive care, and the discharge instructions they receive. Across contexts, readmission rates and open wounds further highlighted the limits of standardised education, with patients suffering from complications when their clinical needs exceeded these limits. Together, these findings reveal a broader pattern: what patients are taught, given, and expected to manage within their context may influence their recovery. Thus, to truly facilitate patient self-management of their surgical wounds, practical information supported by discharge systems that recognise and accommodate varying levels of need are required, thereby advancing truly patient-centred care.

Implications for clinical practice

• Patients need clear, specific instructions on when and how to remove wound closure materials.
• Standard discharge information does not meet the needs of patients with open or complex wounds.
• Written instructions should accompany verbal education to reinforce confidence in home wound care.

Further research

• Research is needed on how healthcare system structures, discharge practices, and cultural expectations shape patients’ roles in wound care.
• Future analyses should explore whether certain surgeries or wound types create heavier post-discharge care demands.

Acknowledgments

We thank the nursing students at the Amsterdam University of Applied Sciences, and RN Michiel Pardieck for the inclusion of patients in the Netherlands. We thank RN Sani Kreca and RN Jose Boerrigter MSc for the coordination of the project. Furthermore, we thank Charly Durlacher MD and Brian Cleaver MD for the backward translations of the Dutch and Swedish questionnaires, respectively.

ORCID IDs

Kita Liosatos 0009-0004-9837-1156
Anne M Eskes 0000-0003-1605-0195
Georgia A Tobiano 0000-0001-5437-0777
Ami Fagerdahl 0000-0002-9170-581X
Eva Torbjörnsson 0000-0003-0720-4981
Annette Erichsen 0000-0002-4785-8544
Joan J Carlini 0000-0002-0446-9215
Brigid M Gillespie 0000-0003-3186-5691

Conflicts of interest

The authors declare no conflicts of interest.

Funding

The is research was enabled by an EMWA Research Grant in Wound Care, supported by ConvaTec. The funder had no role in the study design, data collection, analysis, interpretation or manuscript preparation.

Author(s)

Kita Liosatos*¹ BNurs (Hons), Anne M Eskes^1,2 PhD, Georgia A Tobiano^3,4 PhD, Ami Fagerdahl⁵ PhD, Eva Torbjörnsson^5,6 PhD,
Annette Erichsen^7,8 PhD, Joan J Carlini⁹ PhD, Brigid M Gillespie^1,3,4 PhD

¹School of Nursing and Midwifery, Griffith University, 1 Parklands Dr, Southport, 4222, Gold Coast, Australia
²Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health, Amsterdam, Netherlands
³NHMRC Centre of Research Excellence in Wiser Wound Care, Griffith University, Brisbane, Australia
⁴Gold Coast University Hospital, Gold Coast Hospital & Health Service, Gold Coast, Australia
⁵Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
⁶Department of Perioperative Care, Södersjukhuset, Stockholm, Sweden
⁷Institute of Health and Care Sciences, University of Gothenburg, Göteborg, Sweden
⁸Sahlgrenska University Hospital, Göteborg, Sweden
⁹Bond Business School, Bond University, Gold Coast, Australia

*Corresponding author email kita.liosatos@outlook.com

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