Leg ulcer care is complex, and a lack of understanding by managers and funders about its management can cause unnecessary costs and harm care, says Irene Anderson
Wound care is a complex specialty, and requires a vast range of skills and knowledge on how to assess and manage patients. It comes with the potential to do harm and incur costs.
Managers may not be aware of issues around specific wound types and their treatment. Patients may be at risk if the person delivering treatment does not have the skills to do this, or know how to conduct continuous assessment.
Redistribution of resources and staffing may lead to staff carrying out care for which they are not competent. In these circumstances, educational processes, competence frameworks and support should be put in place, and there should be expert leadership from people with relevant knowledge and skills.
There are no national competencies or standards for leg ulcer management, although the RCN Leg Ulcer Guidelines (RCN, 2006) serve as a framework for the components of leg ulcer care.
Leg ulcer training can be provided in house, by commercial companies or by higher education institutions. Questions we need to ask about education centre on course content and the qualifications, experience and teaching ability of those delivering such courses.
Many decisions are made on the basis of clinical presentation, so experience should be gained in real life situations; using models and simulations may not develop skills and test competencies on the intricacies of the type of skin and leg shapes many patients have. The person responsible for signing off these competencies needs to be prepared and qualified for this.
At the Leg Ulcer Forum conference in April 2010, interim results were presented from an RCN survey of community nurses. Early findings show that about a quarter of nurses have not had leg ulcer training in the past three years, some for much longer. Considering leg ulcer care takes up over half of a community nurse’s caseload, this is a concern.
More practice nurses are becoming involved in leg ulcer care. This is fine if the nurse has the skills and time and space is allowed for this. However, we often hear this is not the case and that patients are being treated for months without any progress being made.
It is pointless to blame practice nurses: the problem is a lack of recognition by managers and funders about leg ulcer management and the benefits of training and support.
Prevention is better than cure, but funding for leg ulcer prevention is not seen as a priority. People with signs of vascular disease, venous or arterial, and those with chronic oedema would benefit from a proactive service offering assessment and prevention strategies.
More leg ulcer clinics are needed to concentrate expertise, costs and logistics in one place. This would drive up care standards, develop more centres of excellence and reduce the isolation many patients feel.
Quality frameworks allow us to work more closely with patients and demonstrate that our work is effective, professional and makes a difference.
The financial climate means we have rethink how we approach the management of people with leg ulceration and related conditions. Improvements in care will be driven by skilled and knowledgeable practitioners. This relies on quality education that is focused on quality care, and patient outcomes must be inherent in the quality measurements.
IRENE ANDERSON is a reader in learning and teaching in healthcare practice and module leader for leg ulcer theory and practice and complexities in leg ulcer management courses at the University of Hertfordshire, and chair of the Leg Ulcer Forum
RCN (2006) Clinical Practice Guidelines: The nursing management of patients with venous leg ulcers. London: RCN Institute.