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Practice comment

Costs can be cut by providing high quality training in leg ulcer care


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



Readers' comments (3)

  • Richard White

    I cannot over-emphasise the importance of Irene Anderson's article. In my experience, the current state of awareness of best practice for leg ulcer patients is very poor. Community nurses especially need to be aware of the need to reduce oedema, wash legs, care for the skin, as well as recognise the condition of the wound. This is not happening to the degree that it should, or for delivery of quality care.

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  • As nurses, it is vitally important to know what we are aiming for, by gaining a differential diagnosis, then treating according to best practice. It is evident that for some, it is task oriented, where a clean dressing is all that is done without assessment and reassessment. It could be helped by employers providing regular training updates, instead the cutbacks continue.

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  • I worked in a trust where the tissue viability nurse was on top of everything, she personnally ran leg ulcer updates and new courses for new nurses constantly throughout the year!
    I now work for a trust that has a tissue viability nurse that isn't so hot therefore standards fall maybe if more tissue viability nurses were employed, there would not be such a decrepency in standards.
    Also, can I please say don't point the finger at community nurses, ( Mr Richard White in particular) The need to highlight oedema care along with compression should be addressed on the wards. Many a time there has been in consitancey of care because the ward nurses do not know enough about compression, let alone give a patient with leg ulcers skin care! I feel us community nurses need to be prasied for a good job done in very demanding time!

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