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“Compulsory training would help every HCA spot moisture lesions”

Healthcare assistants need more training to distinguish between moisture lesions and pressure ulcers

Newton (2010) stated: “Pressure ulcer prevention is not complex, nor should it be made to be. Maintaining the integrity of patients’ skin is a fundamental and essential element of care, for which all healthcare professionals are accountable”. And yet, every year up to 20% of patients nursed in hospital in England and Wales are affected by pressure ulcers (Whitlock et al, 2011). As well as the cost to health, the treatment costs for the NHS are substantial – they are estimated to be 4% of NHS expenditure.

Health professionals are often confused about the difference between a pressure ulcer and a lesion that is caused by the presence of moisture, resulting from urinary or faecal incontinence. Distinguishing between the two, however, is of clinical importance as prevention and treatment strategies are very different.

Developed in 2004 at St Vincent’s Medical Center in Florida, and introduced in Wales in 2009, the SKIN (Surface, Keep moving, Incontinence and nutrition) bundle is a systematic approach to help reduce incidences of pressure ulcers and ensure improved moisture management. But, as a dermatology nurse, I believe reducing pressure ulcer incidence and improving moisture management are neither being acknowledged properly nor appropriately addressed by pressure ulcer training and management. I am also concerned that, unless we address the staff level mix and train healthcare assistants to recognise and report moisture lesions, as well as offering good skin care, we will be unable to progress in achieving these aims. 

There are many changes to staffing levels and staff skill mix on the wards, most notably the replacement of qualified staff with HCAs. My main worry is that, as teaching is focused on qualified staff, HCAs are missing out. The danger is that, although in the frontline when it comes to observing patients’ skin and the changes occurring, they are not being trained to act on those changes.

My idea of best practice is to have compulsory training for all HCAs to help them recognise moisture lesions as well as pressure ulcers, to carry out the appropriate skin care and to report skin changes to ensure they are documented and communicated to health professionals.

Recently, I attended a study day for HCAs on pressure ulcers, moisture lesions and documentation. None of the attendees could differentiate a moisture lesion from a pressure ulcer, and they did not know how to manage or prevent a moisture lesion from occurring. Surely such study days should be considered by all hospitals? A trust’s tissue viability group could produce teaching packages to inform attendees; such training would help tackle the prevalence of pressure ulcers – most of which are avoidable.

Denise Elson is dermatology nurse specialist, Gloucester Hospitals Foundation Trust

Readers' comments (3)

  • From personal experience of care in the Bracknell area - district/community nurses and practice nurses also need urgent retraining in the identification of pressure sores/ulcers in elderly patients. Its not just HCAs who are totally unable to identify pressure sores, its also qualified nursing staff.

    Furthermore, district/community and practice nurses also need urgent update training in the early signs of infections, cellulitis and DVT. They managed to miss all of these in an elderly relative of mine in these last few weeks. Eventually requiring an emergency visit to hospital for correct diagnosis and for appropriate treatment to finally commence, after three weeks of considerable pain and distress.

    When relatives had raised the possibility of pressure sores, cellulitis, DVT and infections they were repeatedly, patronisingly dismissed by the nursing staff concerned! Had they been listened to by these qualified nursing staff, the patient wouldnt have been left in pain and distress for three weeks, the patients future long term recovery wouldn't have been compromised and the NHS would have been saved the expense of an emergency A&E attendance at the weekend. Let alone the distress this caused to the patient.

    Last but not least - communication systems need to urgently be put in place between district nurses/community nursing team and GP practices with regard to the care of such patients in respect of pressure sores, DVT, cellulitis and infections, rather than blissfully working in isolated silos - with no patient information whatsoever shared between them in a timely manner.

    When will we be able to get these basic tenets of care right? Its not rocket science!

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  • Its a sad fact that district nursing teams are as overworked and stressed as all other areas. I sympathise with Christine Chapman and her relatives negative experience with the district nursing team. Its is true to say that there are also many HCAs working unsupervised in their daily practices within the district teams. A close friend (who is one such HCA) told me of her isolation and the expectations of qualified nurses that she be able to recognise pressure sores and moisture lesions as well as cellulitis and just about everything else that a trained and experienced nurse ought to recognise. She has had next to no clinical training other and as she has an NVQ 3 she has been repeatedly told she should know all of this! Please, support HCAs as well as the qualified nurses to have structured accredited and relevant training.

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  • As a student nurse, and previously a healthcare assistant, I have never even heard of moisture lesions prior to reading this article! While in both roles I have had training in the recognition, grading, treatment, causes and prevention of pressure ulcers yet not one word has been said of moisture lesions so is it any wonder people are missing them?

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