VOL: 98, ISSUE: 44, PAGE NO: 49
Karen LayFlurrie, RGN, DPSN, is a staff nurse, Windsor Wing Day Hospital, Hemel HempsteadObjective
The objective of Reynolds (1999) was to determine the effect of a compression bandage training programme on nurses' knowledge, confidence and competence and to assess the level of skill maintained over time.
This quantitative study was undertaken by a leg ulcer specialist who recruited a sample of 25 community nurses and assessed their compression bandaging skills before and after a bandage training programme and at follow-up six to 10 weeks later. Nurses who had previous formal bandaging training using a pressure monitor or were involved in other research were excluded from the sampling frame.
Confidence and competency were self-assessed, using a questionnaire containing a mixture of closed questions and attitude scales. Bandaging proficiency was tested using an Oxford pressure monitor to record sub-bandage pressures for each nurse using two types of bandages, one with a geometric pattern (bandage B). One healthy volunteer was used throughout the study.
All subjects underwent the same training programme and had the opportunity to practise with the pressure monitor before retesting. The resulting sub-bandage pressures were then converted to give each nurse a 'bandage proficiency score' - good, adequate or poor. The proficiency score achieved was then compared with the nurse's self-assessment of bandaging competency.
Of the 25 subjects recruited, 23 took part in the study. Eleven of these were D grades, nine E grades and three G grades, and they had community experience of between less than 12 months to five years. Eighteen returned for follow-up six to 10 weeks later. All but one had previously been taught how to apply compression. All had used bandage A and 19 bandage B. The median quantity of bandages applied by the nurses over the preceding month was estimated to be between five and nine.
Before training 21 (95%) rated their knowledge of compression bandaging as adequate or good. After training this had risen, with 18 (78%) rating their knowledge as good or very good. At follow-up six to 10 weeks later 11 (39%) rated their knowledge as adequate and seven (61%) as good.
Sixteen (69%) subjects felt 'reasonably confident' in applying both bandages. Before training a greater confidence level was recorded for bandage B than bandage A. No significant difference in confidence levels was found at follow-up for either bandage.
Before training 22 (96%) subjects assessed themselves as adequate or good in applying bandage A, and 18 (78%) in applying bandage B. No significant difference was recorded after training or at follow-up.
- Bandage A: before training the mean ankle pressure achieved was within the 'adequate' range, while three (13%) subjects achieved a good proficiency. However, after training those attaining a good proficiency increased to 11 (49%). This was not maintained at follow-up, as just one nurse achieved a good proficiency score. Fifteen nurses produced higher calf than ankle pressures, with three (13%) producing calf pressures within the correct range of 21-28mmHg. Calf pressures achieved after training and at follow-up showed no significant improvement. However, a significant improvement in graduation proficiency was recorded after training, with 19 (82%) nurses producing adequate or good graduation. This proficiency decreased significantly at follow-up, with nine (50%) achieving this level of graduation.
- Bandage B: before training eight (35%) subjects achieved a mean ankle pressure within the good proficiency range, which increased to 20 subjects after training. Ten nurses produced pressures at the calf that were lower than at the ankle. This did not alter significantly post-training. No significant differences in mean pressures were produced at follow-up. In graduation proficiency 13 (56%) of subjects achieved adequate or good graduation, which increased to 21 (91%) after training but fell to 10 (55%) at follow-up.
Actual proficiency and self-rating of competence
- Bandage A: before training competency was self-rated as 'adequate' by 22 (96%) subjects, with seven (30%) achieving an adequate or good score. At follow-up all 18 subjects rated themselves adequate or good, with eight (44%) achieving these scores.
- Bandage B: before training 12 (52%) subjects had adequate or good scores, increasing to 91% after training. At follow-up 55% had adequate or good competency scores. There was no significant difference between the self-rating scores or actual proficiency recorded during the study.
Discussion and conclusion
Nurses tend to achieve sub-therapeutic bandage pressures when applying compression bandaging. There is a propensity for them to overestimate their confidence and competency compared to their actual proficiency. The use of bandages with geometric designs assists practitioners in achieving therapeutic graduation pressures. While training in compression bandaging also improves proficiency, such skills are not necessarily maintained over time.
The study has identified that the maintenance of compression bandaging skills is an important area for further research if nurses are to provide effective leg ulcer management. Furthermore, it highlights that nurses' perceptions of their competency in bandaging may differ from their actual performance, which is an area that has been largely neglected in former studies.
As Reynolds concedes, there was a high negative response rate from G-grade nurses, with the majority being D and E grades. Although this could be attributed to reluctance on the part of G grades to appear inadequate in front of junior staff or lack of time within their workload, the overall sample is biased and does not accurately reflect the target population, which limits the extent to which the results may be generalised.
Proficiency may have been further influenced by the amount of bandaging practice the subject undertook between the original study and follow-up, which is not detailed. Reynolds also mentions the possibility of that subjects may have behaved differently when being observed (the Hawthorn effect), and this may have affected their degree of bandaging proficiency.
While the extent to which the findings of the paper reviewed can be generalised, it is clear that some nurses are unable to produce therapeutic bandage pressures when applying compression. Training in the underlying theory and practical application of compression bandages is an essential component in the education of nurses whose clinical practice encompasses leg ulcer management.
A study such as this demonstrates that monitoring and ongoing support of those nurses undertaking compression therapy must be sustained if patients are to receive optimum care.
- This was written as part of the Principles of Wound Management course in part-fulfillment of a BSc Hons in Tissue Viability at the University of Hertfordshire.