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Do nurses use evidence-based care in the management of venous leg ulcers?

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This study examined the type of nursing care and advice given to patients with venous leg ulcers by community nurses and compared their practice with evidence

Venous leg ulcers are common among patients in community settings, yet there is evidence to suggest that there is a discrepancy between evidence and practice in leg ulcer treatment. Past research has concluded that nurses’ knowledge of compression therapy and leg ulcer management in general is insufficient.

 

Key points

There is a discrepancy between evidence and practice in leg ulcer treatment

Patient education was often not given by nurses

Nurses who find leg ulcer care unrewarding are less likely to deliver patient education

Pain is a major problem among patients with leg ulcers and is undertreated

A change of focus is needed from the goal of wound healing to the management of leg ulcers as a long-term condition

 

The study

This study aimed to: describe venous leg ulcer care in the community in the areas of compression, pain management and lifestyle advice; and to identify factors that predict whether community nurses gave lifestyle advice to patients.

A self-administered questionnaire was completed by 789 nurses. Two focus groups with a semi-structured format were also conducted. The first group consisted of a sample of six nurses involved in the home care of patients with leg ulcers in the previous two weeks. The second group had, in addition, followed a specialised wound/leg ulcer education programme. The nurses reported data for 435 patients.

Key findings 

Because of the self-reporting design of the study, the researchers acknowledge that the nurses may have given answers reflecting more the expected way of working than what was actually done. However, as the results did not give an optimistic view of care, this was probably not a significant effect.

Three types of leg ulcer care were studied: compression therapy; pain; and lifestyle advice.

Compression therapy

Despite the evidence supporting the use of compression therapy, this intervention was applied to only 58% of patients.

Long-stretch or elastic bandages were mainly used in mobile patients. Of the ess mobile patients, 20% were treated with short-stretch or inelastic bandages, even though research recommends that elastic bandages are used for patients who are immobile.

Single-layered compression was used most often, although research suggests that multi-layered bandages are more effective. 

Pain

Pain was a major problem and was present in 83% of the patients.

One in three of these received analgesics, with only half of these taking them as prescribed. The authors question whether the acceptance of pain as a normal outcome among patients could have influenced their intake of analgesics.

As nurses can underestimate levels of pain, the problem might be even larger. The study’s data indicated that pain management was inadequate with pain being undertreated.

Lifestyle advice

Patient education was often not given, despite this being an important role of the community nurse. Half of the nurses who did provide lifestyle advice relating to the leg ulcer, mainly talked about leg elevation, promoting physical activity and optimising nutrition.

Previous research has shown that health education in community nursing is embedded within daily work and often not recorded. This may explain why the nurses did not report giving lifestyle advice.

Nurses who perceived themselves to have adequate leg ulcer knowledge and skills were 3.75 times more likely to give lifestyle advice than those who said they lacked such knowledge and skills. Nurses who found leg ulcer care unrewarding, rarely successful or difficult also gave statistically significantly less advice than those who found it rewarding, successful and not difficult.

The findings suggested that nurses under 30 years of age in particular might need support in providing patient education.

Conclusion

This study, carried out in Belgium, revealed that patients with leg ulcers receive less than optimum care and patient education.

The key concerns highlighted were the limited knowledge and skills about wound care issues and leg ulcer-related health education.

Pain assessment and monitoring should be integrated into the daily practice of community nurses, and they need to determine whether patients are taking their pain medication as prescribed.

In 30% of patients with venous leg ulcers, healing is neither easily nor quickly achieved. The authors therefore suggest that nurses think about the leg ulcer as a long-term condition. Treatment should be adapted to meet the patient’s lifestyle and the emphasis put on learning to live with and manage this long-term condition, rather than healing being the goal. This approach could help reduce feelings of hopelessness among nurses and lead to better patient education.

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